By T Sundararaman
Focus needed on medical education and training: I will focus based on a very specific area, that is on human resources for health. There seems to be a lack of confidence in our ability to run a robust public health system. The government officers seem to see it as an opportunity to outsource the jobs rather than taking the trouble of running a public health system across the country. One of the reasons why people resist the notion of a universal public provisioning of healthcare systems is an inability to manage the problems of the human resources for health.
I have studied the human resources problems of the public health system from the 10th Five Year plan (2002-2007) when privatisation became the order of the day. Most of the policy questions being raised about the public health workforce are based on the assumption that it has an inherent problem. A senior IAS office tried to explain the government’s plan for right to health. His response was what with your workforce, is there any accountability.
This has become a bottleneck, but the point is that actually all these problems have viable solutions, but are not market-based solutions. But they do need creative and innovative ways to solve these open problems. The problem is in attracting and retaining staff in public services, especially in rural and remote areas. The problems are in improving workforce performance, skills, and motivation. The health workforce is the largest sector and can absorb more students than those graduating in India’s medical education system.
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Universal basic income vs universal employment
As the world is becoming increasingly technology driven and automated, labour will be replaced in a major way. The number of healthcare staff needed in proportion of the India’s population means heavy investment. Instead of thinking of a universal basic income, one can do much better if we think of universal employment where the caregiving part of the economy will become a major employer.
Though the doctors and nurses are the central point of the discussion, a large number of people will get employed in the sector. The team has to work together from the non-health support staff to medical practitioners to deliver quality healthcare. In terms of adequacy, we have a norm of 44.5 skilled health workers per 10,000 people. We are not talking about the non-health support workers here, but 44.5 doctors, nurses, and midwives. It’s not the last word on it, but it definitely gives you a guiding principle.
If we go by that you will need 80 per 10,000 population and for a population of 1.3 billion, we need about 13 lakh doctors as well as 39 lakh nurses and midwives. And associate health professionals will be about 20 lakh. This is the employment potential of the sector. There is a huge resistance in providing this in the public sector — because of economic reasons, management reasons, and governance reasons. The medical education system needs to be developed in a planned way.
One interesting aspect is that we really don’t know exactly the number of doctors and staff we have. I’m not going into this whole didactic session, but we have used extrapolation of data which is not updated on a regular basis. You can see that the range goes up 6.4 per 10,000 to 20.8. These numbers can give us a sense of the sector. You have a high skew across the states and within the state.
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Investment in medical education
There is a mismatch between where your investment in medical education is going and where there is a requirement of medical professionals. We made a presentation to the economic advisory commission in 2019 in which we examined state by state. If you look at the aggregate for India, there is no shortage of professionals.
Unfortunately, there is no way of systematically transferring professionals from excess states to deficit states. There was a time when nurses from Kerala would get employed in the north, but that doesn’t happen because of several reasons. Nurses from Kerala are now going abroad, not to other states. We have studies from Maharashtra that show a recruitment deficiency, or the ability to recruit available people graduating from medical education institutions to fill the positions in the government.
Even the so-called most developed countries have very similar problems. This is not some inevitable problem, but a manageable problem that can be solved through educational interventions, regulatory interventions, financial incentives, and management and social support. We are talking about the ASHAs, nurse practitioners, mid-level healthcare providers, the Aayush persons retrained and the traditional doctors. You are talking of generating new professional boundaries. Regulatory intervention does not work for a number of reasons or works in a very limited space.
There are other mechanisms that have given better results. You have monetary compensation for work, but management support and a positive practice environment are the most effective steps. So, there is a whole policy and what works well is a bundle of interventions. It is a matter of selection, training, professional boundaries, payment, and working environment that needs to be packaged to get things right.
The crisis of confidence is a big issue. And there is also a crisis of motivation and a highly crowed environment. People pay Rs 2 crore for post-graduation and then are pushed into the urban areas, catering to a very small segment of the population that can pay. There are a number of ways to make things work, but not without a robust public sector. What does not work is the public private partnerships.
The government can do it, some non-governmental organizations that are dedicated also can do it. But as a system of outsourcing will never work. There are issues about how we deal with community health workers, a one million strong workforce. There is a whole number of challenges that can be overcome, but the solutions that are pushed these days are not viable.
(Dr T Sundararaman is Former Executive Director, NHSRC Delhi and Global Chairperson of Peoples Health Movement. This article is a reproduction of his speech at a webinar organised by Policy Circle.)