India has achieved major organisational and technological successes but the health system’s performance is abysmal. This cannot be attributed to poverty. It is poor health that places India 134th in the Human Development Index although on GDP, it is a success. Globally, in terms of Life Expectancy at Birth, India is positioned at 132; 124 in maternal deaths; 143 in Infant deaths and 145 in child deaths under-five years of age even though 50 to 75 per cent of new-born and maternal deaths are preventable. India fares worse than Bangladesh, China, Nepal and Sri Lanka. There is an urgent need to reduce the overall disease burden.
Government data say 18 per cent of illnesses in rural areas and 10 per cent in urban population do not receive any form of health care, while only 23 per cent of surgical patients receive free care. Medical attention at hospitals and health centres before death is particularly low at 34 per cent (including 12 per cent in private) and 38 per cent by individual health professionals. However, the disparity is wide – Tamil Nadu (34 per cent with 15 per cent in private) and Kerala (74 per cent with 34 per cent in private). Non-availability of health professionals and financing are key factors for such inequities (see graphic).
Health professionals in India range from doctors, nurses and allied health staff including pharmacists, and technicians to the frontline Auxiliary Nurse Midwives (ANM) and male health workers. The health sector is the 2nd largest employer (education being 1st).
The present low salary structures for health professionals compared to other civil servants, recruitment delays and poor working conditions have resulted in understaffing, low staff morale and low quality of services.
Government facilities continue to face high staff shortage as over 85 per cent specialist doctors, 75 per cent doctors, 80 per cent lab technicians, 53 per cent nursing and 52 per cent ANM posts are vacant across states. Health professionals are increasingly opting for the private sector: 80 per cent of doctors and 26 per cent of nurses. In the post-independence era, the private health sector has grown from 8 per cent of hospitals to 93 per cent.
The WHO Global Atlas of Health Workforce advocates the critical threshold of 23 doctors, nurses and midwives per 10,000 populations and identifies 57 countries, including India, as facing a crisis. According to WHO (2012), the doctor-nurse density in India is 19 with 6.5 doctors (global average 14.2), 13 nurses and midwives per 10,000. However, this varies widely from 10 in Bihar to 65 in Chandigarh. Very low (10-15) -Bihar, Uttar Pradesh, Jharkhand, Rajasthan, Assam and Meghalaya; Low (16 -20) - Chhattisgarh, Madhya Pradesh, Gujarat, Tripura, Haryana and Odisha ; Moderate (21- 23) - Haryana, Andhra Pradesh, Jammu & Kashmir, Karnataka, Uttaranchal ; Manipur and Tamil Nadu ; Good (24 - 35) -West Bengal, Himachal, Punjab, Nagaland and Maharashtra ; High (36 - 65) - Delhi, Goa, Kerala, Mizoram, Sikkim, Puducherry and Chandigarh.
Further, only 26 per cent of doctors reside in rural areas to serve 72 per cent of the population. The urban density of doctors is nearly four times and nurses three times that of rural areas. The supply of doctors, nurses and allied health professionals is a pervasive challenge. In 2007, the Planning Commission Task Force recommended a five-fold increase in public spending on health workforce development. The resultant initiatives of the XI Plan led to increase of ANM schools by 425 per cent, nursing schools by 170 per cent, nursing colleges by 330 per cent and medical colleges by 50 per cent.
At present, 193 of 642 districts have a medical college, 45 per cent of medical colleges are located in the South, 21 per cent in the West, 17 per cent in the North, 10 per cent in the East, with 5 per cent in Central area and a low 3 per cent in the Northeast. Also, 46 per cent Indians living in the seven states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Rajasthan, Uttaranchal and Uttar Pradesh have only 27 per cent of total medical colleges.
Similarly in nursing, 154 districts in 23 states with high maternal and child deaths have neither nursing school nor colleges. The four southern states have 63 per cent of nursing schools in contrast to 20 per cent in the poorly performing seven states.
For-profit colleges
A large number of private colleges are run for profit with serious shortages in faculty, infrastructure and quality of education. Fees here are significantly higher. Also, 88 per cent of all nursing institutions are in the private sector.
India has 355 medical colleges which annually produce over 44,000 doctors, 22,000 specialists, besides 21,500 dentists from 290 dental colleges, 1.2 lakh nurses from 2,400 nursing schools and 1,500 colleges, 30,000 ANMs from 1,300 schools and 70,542 pharmacists from 1,211 schools and colleges. We are still grappling with severe shortage of doctors, nurses and midwives.
The Health Ministry says two lakh doctors out of the 7.5 lakh registered and six lakh nurses out of 10.7 lakhs are not working. The High Level Expert Group of the Planning Commission (2012) said by 2022, excluding private sector hospitals the need would be for 4.2 lakh doctors (allopathy), 2.1 lakh specialists, 16.2 lakh nurses, 8.3 lakh ANMs and 4.5 lakh male health workers, among others. But annual admission capacities cannot achieve the targets.
The way forward
For the next 15 years, start new medical colleges, nursing and paramedical institutions, only in states with very low density, preferably in the government sector; reorient medical, nursing and paramedical education, increasing enrolment from districts facing shortages; devise standardised accreditation and licensing systems in private institutions; annual recruitments to attract medical professionals to the government sector.
(Dr. D. Thamma Rao is Senior Advisor, Public Health Foundation of India, New Delhi)
