Human Resources for Health

Dr. D. Thamma RaoAdvisor - Public Health (Human Resources)

National Health Systems Resources Centre, NRHMNew Delhi

Bangalore 10 Dec. 2010 Health System Goals• Improve Health Care Accessibility• Reduce Health Inequalities• Be Responsive to User’s Needs

HRH is the Critical Factor For Health Care Accessibility - Equity -

Quality

Health Sector Planning & H R H Development

1946 Bhore - Every Citizen to Secure Adequate Health Care

Committee

1961 Mudaliar “ - Infrastructure Development & Cadres at Primary level

1963 Chaddha “ - Health Worker /10000 Pop. M&F & PHC - Lab Asst., FP Worker

1966 Mukerjee “ - Review of Staff Pattern for Fly Planning, NMED etc

1967 Jungal “ - United Cadre, Org. & HR Integration

1974 Kartarsingh“ - M P W Concept for Fly Planning

1975 Srivastava “ - Medical Education & Support Manpower

Cadre of Health Assistants, VHG ….

Training Curriculum - MPHWS, HA & LHV

1983 Bajaj “ - Essential Educational Infrastructure, Carrer Prospects ..

2000 GoI - National Population Policy - Decentralised Planning

2005 “ - N R H M

2007 “ - Task Force Report -Planning for HRH (Planning Commission)

H R H - Norms

H R H

Providers - Professional, Technicians, Auxillaries , PH specialists …

Managerial & Supportive - Policy makers, Administrators, Statisticians,

Researchers …

HRH are not just individuals but integral part of TEAMS – each one Contributing different Skills and Performing different functions

HRH determines - What Service, When, Where, What extent, priority…

Of Late, We are witnessing Growing Challenges to

maintain required numbers, distribution & quality to meet the changing health care needs

Human Resources for Health

H R H Diversity

Rigorously trained Specialists & Super-specialists

General Duty Doctors - Allopathy, AYUSH, Dentists

Physiotherapists, Occupational therapists, Speech therapists..

Nurses - General, O Ts, ICCUs, ICMUs, IRCUs, Post- Operative,

Paramedics - Pharmacists, Radiographers, Optometricians, Counsilors, Medical Social Workers ……

Technicians – Laboratory (Pathology, Microbiology, Biochemistry) OT, ECG, EEG, EMG, USG, CT, MRI, RT, NMT, Audiometry, …

Dressers, Nursing orderlies, OT Attendrs, Stretcher Bearers…

Drivers, Cleaners, Cooks, Clerical Staff, Managers

Informal HR – TBA, Bone setters, Traditional healers...

Invisible H R H - Preventive Health Care

ANM (Auxillary Nurse Midwife) & Health Worker (Male)

Lady Health Visitor & Health Assistant (Male)

Public Health Nurse & Health Inspector

Paramedical Worker & Non-Medical Supervisor

Insect Collectors & Entomologists

Cold chain mechanics & Cold Chain Officers

Food Inspectors & Drug Inspectors

Deputy C M H O & D C M H O

Health Programme Managers – District & State Levels

Workforce Management

Numerical Adequacy

Workforce Performance

Capacity Building

Skill Mix

Health System’s Vital Ingredient - H R H

HRH in India (%) - Census 2001

Traditional HWs, 51318, 3%

Pharmacists 11%239276

Midwives 13 % 277655

Nurses 25 % 545933

Dentists 22962 1 %

Total 21,68,223

Other HW, 155177, 7%

Doctors (Allopathy) 31 % 676756

Physicians (AYUSH) 9 % 196488

0

2500

5000

7500

10000

757377

1043363

608788

681692

Doctors

Nurses

MidwivesPharmacists

2009 2009 2009 2009

National Health Profile, MOHFW, Govt. of India 2009

HRH in India

H R H - Density (Per 10,000 Population) World Health Statistics 2007- WHO

DoctorsNurses &Midwives

Pharmacists Lab. Tech.

Other HRH

India 0.6 1.3 0.6 0.02 1.13

China

1.6 1.03 0.3 0.16 0.93

Cuba 5.9 7.4 - 0.07 2.75

U S A 5.5 7.7 0.7 2.30 16.1

U K 1.7 5.6 0.6 0.34 3.79

Specialists at CHC 3 Doctors at PHC 3 Nurses at PHC 2nd ANMs at SHCs0

20000

40000

60000

80000

100000

120000

140000

160000

3550

2030817371

5789

3138123982

34290

25079

67110 67110

145272

NRHM - HR Vision & Achievements 2009 (for Existing Health Centres)

2007 March 2009 Target 2012

1951 1961 1971 1981 1991 2001 2007

217 2071 3043 4,510725 25655,112 5740

20450 22842 23,39128,489

51,405

1,30,9581,37,311

1,45,894

CHC

PHC

SHC

2009

Primary Health Care Facilities - Growth

H R H Requirements (as per IPHS norms for year 2011)

CategoryHRH for

Existing SHC, PHC & CHC

HRH forSHC, PHC & CHC as per IPHS

Required 2009

Short fall2009

Required2011

Short fall 2011

1 Doctors (Allopathy) 53,354 28,356 2,00,607 1,75,609

2 Nurses 67,651 10,676 3,00,910 2,43,935

3 A N M s 2,91,788 1,00,869 5,54,276 3,63,357

4 Pharmacists 60,312 39,345 1,22,593 1,01,626

5 Lab. Technician 60,312 47,408 1,22,593 1,09,689

Total 5,33,417 2,26,654 13,00,979 9,94,216

H R H Availability & Health Care Outcomes (DLHS-3)

Uttar P

rades

hM

P

Bihar

Rajas

than

Jhar

khand

Chhattis

garh

Orissa A P

Karnat

aka

Wes

t Ben

gal

Tamiln

adu

Pondich

erry

Kerala

Goa

0

10

20

30

40

50

60

70

80

90

100

1316

1014 14

1620 21 21

24 23

54

3842

30

36

41

49

54

59 62

67

77 76

8380 80

90

72 72

58

65

48

59

71

54

47

3735

25

13 13

HRH Child Immunisation (1-2 yrs) DLHS-3 IMR SRS

States

Population Quality perceived

to be GOOD

Health Worker Density (/10000 Popu.–

Census 2001)

Health Care Out-Comes

MMR

IMR

NFHS - 3 (2005-06)

DLHS- 3 (07-08)

SRS (04-06)

SRS (04-06)

(Lakhs)

Per Bed

DLHS-3 (07-

08) HRH(all)

Doctor Allopathy

Nurse &

ANM

ANC (min.3

)

Deliveries

by HRH

Full

Immunisation

Children S R S S R S

India 2,315 19.5 6.1 7.4 52 47 44 54 254 55

1 U P190

35,646 35 13 6 3 27 27

23

30 440 69

2 Bihar 936 4,163 16 10 4 3 17 2933

41 312 58

3 Rajasthan 645 1,977 37 14 4 5 41 4127

49 388 65

4 M P 687 3,392 37 16 5 6 41 3340

36 335 72

5 Jharkhand 302 5,494 44 14 4 6 36 2834

54 312 48

6 Orissa 397 2,724 61 20 3 13 62 4452

62 303 71

7 A P 824 2,351 37 21 8 8 85 75 46 67 154 54

8Karnatak

a 576 1,163 49 21 7 8 80 70 55 77 213 47

9West

Bengal 870 1,734 49 24 7 6 62 48 64 76 141 37

10Tamil Nadu

661 1,391 45 23 6 10 96 91 81 83 111 35

11Pondicher

ry 12 352 73 54 11 29 98 99 89 80 20 25

12 Kerala 338 1,217 66 38 6 19 94 99 75 80 95 13

NB: DLHS -3 Children 12-35 months

HRH Density & Health Care Outcomes

Full vaccination in Children - Low & High performing districts in states DLHS -3

State Average Lowest Highest Difference HRH

1 Bihar 41Jamui 17 Kaimur

22Muzaffarpur 57 Saran

65 48 10

2 UP 30 Budaun 11 Etah

12

Pratapgarh 59 Deoria

7261 13

3 Rajasthan

49Alwar 27 S.Madhopur

29Banaswara 87 Dungarpur

88 59 14

4 Jharkhand

54Girdih 22 Godda

28Lohardaga 81 E. Singh

Bhumi 82 60 14

5 MP 36Damoh 11 Tikargarh

14

Ujjain 74 Balaghat

7564 16

6 Orissa 62Rayagada 27 Malkangiri

35

Jajapur 82 Baleshwar

8356 20

7 Karnataka

77Raichur 50 Bijapur

51Kolar 95 Kodagu

96 46 21

8 A P 67Srikakulam52 Nellore

53Rangareddy 81 Karimnagar

82 30 21

9West Bengal

76 U.Dinajpur 55 Murshidabad62

Bankura 92 Hugli 93 38 24

10 Tamil Nadu

83Madurai 60 Theni

61Viluppuram 95 Nagpattinam

95 35 23

11 Kerala 80Malapuram62 Palakkad

65Alappuzha 92 Thiruvnthpuram 93 31 38

D

Inequities within the States

Equitable Distribution & Quality - Essential for health care provision

U PM

P

Bihar

Rajasth

an

Jharkhand

Chhattisg

arh

Oris

sa A P

Karn

ataka

Wes

t Ben

gal

Tamiln

adu

Pondicher

ry

Ker

ala

Goa

0

20

40

60

80

100

120

35 37

16

37

4449

61

37

49 4945

73

6671

1316

1014 14 16

20 21 2124 23

54

3842

92 92

79

9390

94 9287 86

96 97100

85

96

Good Quality HRH Personnel Available

HR - Quality & Accountability – Consumer’s Perceptions (DLHS-3)

Districts

Total Prioritised

Institutional Deliveries (< 80%) - 485 216

Full Immunisation in Children (<85%) - 358

177

TB Control (NSPCDR of < 60 %) - 243 99

Malaria (API >1.9) or Kala-azar cases - 200 102

Leprosy (PR >1.0) – 53 53

Health inequities across States, Districts & Social Groups

Health Care Challenges Across States

Challenge States

1 TB Cases - HighAndhraPradesh, Assam, Bihar, Gujarat, Jharkhand, Tamilnadu, West Bengal & U.P.

2 Malaria - HighAP, Arunachal, Assam, Bihar, Chattisgarh, Jharkhand, Karnataka, Maharashtra, Meghalaya, M.P, Orissa, Rajasthan, West Bengal & U.P.

3 DiabetesDeli, Goa, Kerala, Tamilnadu, Tripura & West Bengal

4Immunisation Full in Children

Bihar, Jharkhand, M.P, Rajasthan & U.P.

5Children < 3 Yrs Under Weight

Assam, Bihar, Chattisgarh, Gujarat, Haryana, Jharkhand, Karnataka, Maharashtra, M.P, Orissa, Rajasthan, West Bengal & U.P.

6 Infant Mortality Assam, Bihar, Chattisgarh, M.P, Orissa, Rajasthan& U.P.

7 Maternal Mortality

Assam, Bihar, M.P, Orissa, Rajasthan & U.P.

8 High Fertility Rate

Bihar, Chattisgarh, Jharkhand, M.P, Rajasthan & U.P.

Health Policy Planning &

Implementation

Architectural Correction of Health Systems

Bottom-up Planning Approach

Need Based Planning Provision of Essential H R H &

Infrastructure - Service Guarantees as per IPHS

- Contractual Staff (2nd ANM, Nurses, LT ...Drs.)

- ASHAs

Convergence of all Vertical Programmes

National Rural Health Mission

SDH / CHC

120,000 populatio

nNurses, MOs,

Specialists

Obst./Anaest./Pedia/Med/SurP H C

30-40 Villages 30,000 Population

3 Nurses + LHV + Pharmacist + Lab. Tech. + MOs (Allopath)+MO

(AYUSH)

S H C 5 -6 Villages 5000 Population

Auxiliary Nurse Midwives (Regular + Contractual) & Health Worker (Male)

Community Level (Village) 1,000 Population

ASHA (Accredited Social Health Activiist) + AWW (ICDS)

Vision – National Rural Health Mission (India)

SDH – Sub District Hospital CHC - Community Health CentrePHC - Primary Health CentreSHC – Sub Health CentreLHV – Lady Health VisitorAWW - AnganWadi Worker

NRHM Achievements 2007-2010

Infrastructure up-gradation of - 28,686 SHCs,

5,407 PHCs, 4,937 Block PHCs 444 Dist. Hosp.

Additional Human Resource provided in Govt. sectorOver 8,20,000 ASHAs,

48,104 ANMs, 3,295 Pharmacists,

26,253 Nurses, 8,782 Doctors, 2,474 Specialists ..

Indicator

Performance

Progress2007-08 2008-09

1 Out Patients 1,21,37,284 1,49,63,492 23 %

2 In-Patients 14,41,845 19,62,679 36 %

3 Deliveries 1,84,367 3,12,354 69 %

4 MTPs 14,546 11,932 18 %

5 Operations - Major 1,02,852 1,53,298 49 %

6 Operations - Minor 1,45,832 1,84,298 26 %

Performance of IPHS Institutions

BANKURA

Priyadarshini FBNC,Jaipur

Bridge the gaps between HRH Availability

and Unmet Needs of the

Community

Increase HRH in Rural Areas.

Provision of essential HRH, Infrastructure

& Service Guarantees - Indian Public Health

Standards

HRH Skill Up gradation for ensuring

services

Eliminate quackery in the Villages

Supportive Supervision of HRH

HRH Thrust of NRHM in India

New Cadre of Rural Practioners for Hilly/ tribal areas

- Bachelor of Rural Medical Practioners course 3 ½ years - Diploma in Medicine & Rural Health Care – Assam State Rural Health Regulatory Act in

2004

Enhancement of MBBS seats in Medical Colleges 150 to 250 per year

Doubling of PG Medical Seats (Specialist Doctors)

Central Government Support for new institutes

Midwifery & Nursing - increased from 1,646 to 5,222 (2005-06 to 2010-11)

Exclusive Council for HRH Educational Institutions

HRH initiatives in India

• Appropriate

skills

• Training

• Leadership

• Systems

Support

• Work

environment

• Remuneration

• Numeric

adequacy

• Social outreach

Human Resource Inputs

Competence

Coverage

H R objectiv

es

Quality

Equitable Access

Health Care Outcomes

Performance

Motivation

Healthy INDIA

Efficiency

H R H Performance

Difficult area incentive : Assam, Andhra Pradesh, Jharkhand, Uttarakhand, Bihar, J&K, Madhya Pradesh, Haryana, Himachal Pradesh, Karnataka, Kerala, Orissa, Arunachal Pradesh, Meghalaya, Mizoram, Nagaland, Sikkim, Tripura, Gujarat, Punjab, Tamil Nadu.

Tribal area incentive : Andhra Pradesh, Himachal Pradesh, J&K, Karnataka, Madhya Pradesh, Maharashtra, Nagaland, Rajasthan, Tamil Nadu.

Conflict area incentive: Andhra Pradesh, Chhattisgarh,

Jharkhand, Maharashtra, Orissa

Provision of Incentives

Skill

ANM Schools (n=24, 36 & 61)

Nursing Schools (n=25, 30 & 67)

Nursing College B.Sc. (n=49 & 27)

Independently Independently Independently

Bihar

Chattisgarh

Orissa

Uttarakhand

Bihar

Chattisgarh

Orissa

Chattisgarh

Orissa

Uttarakhand

Child care

Immunisation 8 25 25 9 15 17 30 24 15 2

New Born Resuscitation

6 21 18 0 13 0 23 17 9 0

Maternal care

Conducting Delivery 6 13 12 5 18 13 20 3 12 0

Ante Natal Care 8 17 23 14 20 24 32 25 11 5

Post Natal care 11 29 24 19 18 27 39 41 16 3

Family Welfare

IUD Insertion 5 0 25 5 13 0 21 5 14 1

Quality of MCH Trainings in Nursing & Midwifery Institutions

( Bihar, Chattisgarh, Orissa & Uttarakhand )

Making the Best Use of Available Limited HRH

• Achievements –

• Over Burdened Health Workers Stood Up to meet

Increased Demands

• Pooling of Resources at District Level

• Decentralisation of Powers to Districts

• Incentives for Good Performance

• Constraints –

• Inadequate Managerial Support & Supervision

• Indicators for HR & Governance • Norms for Accountability• Divergent characteristics of Population & Health

Workers• Conflict of Interests - Private Practice

Summary of HR H Issues in the States

Buildings and equipments made available and HRH left out..

Distributional imbalances - geographic, institutional and occupations

Qualitative imbalances - mismatches, under-qualification etc

Sanctioned Posts are < Requirements for Existing Health Facilities

Vacancies in Sanctioned Posts - Adhoc Contractual Appointments

Lack of H R H Mgt. Inf. Systems & Mechanisms for HR Planning Inadequate Managerial Support & Supervision of H R H

Lack of Accountability & Short-falls in Managerial Skills

Inadequacies in Training Capacities & Wastages

Lack of medical/ nursing/ paramedical institutions to generate additional H R H HRH Losses - Poor Working Conditions & Low Pay

Non- implementation of fair Postings & Transfers, Career Paths, Incentives, NPA

31

• HR Division or Cell for HR management - With senior level

officers with technical & administrative backgrounds.

• Should have the powers to change the HR rules.

• Should review, plan and monitor HR situation

• All India public health / medical / specialist / GDMOs cadres

on par with other central services (IAS, IPS,IRS…..) for

postings at the district and state levels

• Public health qualification (1-2) years must be made

mandatory for PH positions, who will supervise and direct PH

programs including primary health care.

• Large hospitals may have professionally qualified hospital

managers.

Policy changes needed – HRH Management

32

HRH Development, Trainings and Deployment are in State sector as the Heath Services Delivery and Implementation of Programmes are by the States / UTs.

Substantial Policy changes required to improve HRH and this needs high level of Political Advocacy

Are we ready for that ? Dileep IIM Ahmedabad

Health Systems

Population of Indian States & Other CountriesSource : UN Population Prospects 2005 & RGI Population Estimates 2006

Thank YOU

Dr. D. Thamma Rao Advisor (Public

Health)New Delhi, India

Deeds, Not words shall speak me

- John Fletcher

thammarao@gmail.com

37

Key HRH Issues at Health Facilities

FRUs / PHCsRegular anaesthetist and LSAS trained MO avaialable but

anaesthesia apparatus unavailable in OTs at the District Hospital.

Mismatch between EmOC and LSAS trained personnel - .Pathologist posted at a facility where no lab is available. No partogram used in Labor rooms. SHCsPoor utilization of services under RI on Wednesday at sub

centre. Essential drugs, functional toilets, power supply not

available. Lack of coordination between Regular\Contractual ANM. Contractual ANM unaware of her duties and responsibiities.Records (EC register etc) not maintatined. Inadequate use/lack of availability and awareness of

guidelines for utilization of untied funds.

38

Key Issues--TrainingNon implementation of CTPs at district level. Training institutions needs strengthening of physical

infrastructure, development of faculty,Lack of training in essential newborn care &

treatment/ stabilization of Sick Newborns for the existing MOs/Staff Nurses/ANMs.

Training on IUD/Minlap/SBA/IMEP/ARSH/ Immunisation particularly for contract staff needs urgent focus.