Workforce problems at rural public health-centres in India: a WISN retrospective analysis and national-level modelling study

Abstract

Background Rural India has a severe shortage of human resources for health (HRH). The National Rural Health Mission (NRHM) deploys HRH in the rural public health system to tackle shortages. Sanctioning under NRHM does not account for workload resulting in inadequate and inequitable HRH allocation. The Workforce Indicators of Staffing Needs (WISN) approach can identify shortages and inform appropriate sanctioning norms. India currently lacks nationally relevant WISN estimates. We used existing data and modelling techniques to synthesize such estimates. Methods We conducted a retrospective analysis of existing survey data for 93 facilities from 5 states over 8 years to create WISN calculations for HRH cadres at primary and community health centres (PHCs and CHCs) in rural areas. We modelled nationally representative average WISN-based requirements for specialist doctors at CHCs, general doctors and nurses at PHCs and CHCs. For 2019, we calculated national and state-level overall and per-centre WISN differences and ratios to depict shortage and workload pressure. We checked correlations between WISN ratios for cadres at a given centre-type to assess joint workload pressure. We evaluated the gaps between WISN-based requirements and sanctioned posts to investigate suboptimal sanctioning through concordance analysis and difference comparisons. Results In 2019, at the national-level, WISN differences depicted workforce shortages for all considered HRH cadres. WISN ratios showed that nurses at PHCs and CHCs, and all specialist doctors at CHCs had very high workload pressure. States with more workload on PHC-doctors also had more workload on PHC-nurses depicting an augmenting or compounding effect on workload pressure across cadres. A similar result was seen for CHC-specialist pairs—physicians and surgeons, physicians and paediatricians, and paediatricians and obstetricians–gynaecologists. We found poor concordance between current sanctioning norms and WISN-based requirements with all cadres facing under-sanctioning. We also present across-state variations in workforce problems, workload pressure and sanctioning problems. Conclusion We demonstrate the use of WISN calculations based on available data and modelling techniques for national-level estimation. Our findings suggest prioritising nurses and specialists in the rural public health system and updating the existing sanctioning norms based on workload assessments. Workload-based rural HRH deployment can ensure adequate availability and optimal distribution.

Human resource shortage in India’s health sector: a scoping review of the current landscape

“…1 ). Study characteristics [ 10 , 16 – 102 ] are described in detail in Supplementary Table 2 . The first research question was addressed in 30.6% of studies ( n = 27) whereas 69.3% of studies ( n = 61) addressed the second research question.…”

“…The thematic analysis of data regarding the second research question yielded five kinds of HRH-related problems that are causing a scarcity of HRH in India. The outcomes of each study are described in Supplementary Tables 3 and codes identified under each theme is shown in Supplementary Table 4 [ 10 , 16 – 102 ]. A summary of these themes is provided in Table 2 below:…”

“…of studies References 1. Inadequate HRH production Due to an inadequate number of healthcare educational institutions in India, there is a lack of healthcare professionals 10 [ 65 , 66 , 74 , 75 , 80 , 81 , 88 , 102 ] The current medical colleges are also underfunded and underequipped, which results in substandard training of healthcare professionals 3. Job dissatisfaction Poor physical work conditions, autonomy, unhealthy relations with colleagues, boss and management 39 [ 10 , 16 , 18 , 19 , 22 , 24 , 26 – 28 , 30 , 34 , 39 , 41 , 43 , 46 , 51 , 53 , 54 , 58 , 59 , 61 – 66 , 71 , 75 , 78 , 81 , 84 , 88 , 89 , 91 , 92 , 94 , 96 , 99 , 102 ] Inadequate salary, no opportunities for promotion, no respect, and non-recognition leads to dissatisfaction …”

A novel comprehensive Tuberculosis (TB) control programme methodology based on the nexus of participatory action research inspired public health and precision treatment approach

“…In India, the general health of the people in rural populations is inferior to that of urban populations (31); rural areas tend to have shorter life expectancies and high mortality rates due to infectious diseases like tuberculosis (TB)(32). Despite these adverse statistics, while 72.2% of Indian people reside in rural areas, only 40.8% of healthcare workers are available for rural areas (33). Thus, it is imperative that public health management of rural populations in developing countries improves..…”

Government Strategy in Tackling Poor Access to Public Service in India

“…As a result of public health systems' failure to offer access to high-quality care, private healthcare systems have developed at the same time, with their proportion of the market increasing steadily and gradually over time. As a result of the incapacity of public health systems to offer access to high-quality treatment, private healthcare systems have developed at the same time, with the continuous and gradual growth of private healthcare services over the last several decades (Nair et al, 2022).…”