The Human Resource Story of

Rural Healthcare in India

(Concerns and Challenges)

Group – 8Vivek MahajanDeepak DassKumar AnshumanVishadJai Prakash

Evolution of rural healthcare system in India

Bhore Committee : • In 1943, the Government of British India constituted a Health Survey and Development Committee,

under the chairmanship of Sir Joseph.W. Bhore, to survey the existing medical facilities and health conditions and suggest the course of future developments.

• The Bhore Committee established an important concept – that the health of the people is the responsibility of the state.

V year Plans :• The First Plan (1951-56) While the first PHC set up in October 1952 and a total of 725 PHCs were

established by the end of the Plan period.• The Second Plan (1956-61) stressed the need for more rural health infrastructure, increasing output

of human resources, particularly more auxiliaries, as doctors were reluctant to serve in rural areas.

The National Health Policy (1983):• Approach for effective primary health care to involve large scale transfer of knowledge, simple skill

and technologies to Health Volunteers, selected by the communities and enjoying their confidence. The quality of training of these guides/workers would be of crucial importance to the success of this approach.

The National Health Policy (2002):• Aimed to decentralize public health system by establishing new infrastructure in deficient areas and

increased spending to primary health care.

National Rural Health Mission (NRHM), 2005:• One of the priority areas is increasing and improving human resources in rural areas. • The Mission seeks to bring about reduction in child and maternal mortality; ensure universal access

to public services for food and nutrition, sanitation and hygiene and access to public health care services/integrated comprehensive primary health care; prevention and control of communicable and noncommunicable diseases; population stabilization, gender and demographic balance and revitalization of local health traditions.

Sub–Centres (SCs) : The SCs is the most peripheral health unit and contact point between the primary health care system and the community. Each SC has one Female Health Worker / ANM (Auxiliary Nurse Midwife) and one Male Health Worker. One Female Health Assistant (Lady Health Visitor LHV) and one male health assistant supervise six sub centre, SCs are assigned to perform task related to components of primary health care. They are provided with basic drug for minor ailments needed for taking care of essential health needs of population.Primary Health Centres (PHCs) : PHCs remain the first contact between village community and Medical Officer. They are manned by a Medical Officer supported by 14 paramedical and other staff. It acts as a referral unit for 6 sub-centres. It has 4-6 beds for patients.

Community Health Centres (CHCs) : CHCs are manned by four medical specialist i.e. Surgeon, Physician, Gynaecologist and Pediatrician supported by 21 paramedical and other staff. It has 30 in-door beds with one OT, X-ray, labour room and laboratory facilitites. It serves as a referral centre for 4 PHCs and also provides facilities for obstetric care and specialist consultation.

Sub-CentresSub-Centres 1,45,272

Primary Health CentresPrimary Health Centres 22,370

Community Health Community Health CentresCentres

4,045

Source: GOI RHS Bulletin 2010

A structural outline of Rural Public Health Care system in India

Challenges and Concerns

Shortage in rural health workforce

India’s health infrastructure and allocation of health workers is anchored on population-size based norms rather than the specific health needs and demands at the community level.

Three-fourths of 0.7 million graduate doctors legally permitted to practise as qualified doctors operate in and around urban areas, thus catering to just 28 per cent of the country’s population and leaving the rural folk underserved or totally neglected in terms of basic health care.

Source: ‘Health at a Glance 2010—OECD Indicators, Organisation for Economic Co-operation and Development statistics .”

Health Expenditure of various countries as percentage share of their GDP, 2009

0.00% 2.00% 4.00% 6.00% 8.00% 10.00% 12.00% 14.00% 16.00% 18.00%

Portugal

N Zealand

Korea

Poland

Mexico

Turkey

UK

USA

Japan

India

Rural Population per Doctor

0 10000 20000 30000 40000 50000 60000

Puducheri

A & N Islands

Lakshadweep

Sikkim

J & K

Arunachal Pradesh

Goa

Karnataka

Mizoram

Maharastra

Meghayala

Haryana

Tripura

Manipur

Daman & Diu

Rajasthan

D & N Haveli

Kerala

Chandigarh

Andhra Pradesh

Uttaranchal

Chattisgarh

Punjab

Nagaland

Gujarat

West Bengal

Madhya Pardesh

Total

Bulletin on Rural Health Statistics (BRHS) of the Ministry of Health and Family Welfare, there are (as of March 2008)

Manpower in PHCs

0 5 10 15 20 25 30 35 40 45

Without Doctor

Without Techncians

Without Pharmacist

% of PHCs

c

Percentage of sanctioned post of specialists' vacant

0 10 20 30 40 50 60

Total

Surgeon

Obstetricians &Gynaecologists,

Physician

Paediatrician

Source: Frontline Volume 27 - Issue 04 :: Feb. 13-26, 2010

Shortfall in Manpower in PHCs

0 10000 20000 30000 40000 50000 60000 70000 80000

MPW(F)/ANM

MPW(M)/HW(M)

LHV/HealthAssistants(F)

Health Assistant(M)

Number

Perenctage of Sub Centres functioning without ANMs or/and HW(M)

0 5 10 15 20 25 30 35 40 45

Without Both

Without HW(M)

Without HW(F)/ANM

Percentage

Source: Frontline Volume 27 - Issue 04 :: Feb. 13-26, 2010

Workforce Development, Deployment, Performance and ManagementWorkforce Development, Deployment, Performance and Management

• Presently, for several categories of health workers there are no clear cut job descriptions.

• Qualifications and eligibility criteria for different cadres of health workers need to be reviewed in relation to their job descriptions.

• Information suggests that doctors are reluctant to be posted in rural areas as they feel isolated and cut off from the medical mainstream.

• Incentives should be enhanced to address the current shortage of critical medical personnel, particularly doctors, in remote and rural areas.

• Absenteeism of health workers from their positions further aggravates the already short supply of staff.

• Working conditions of health workers are poor as facilities are chronically understaffed and ill equipped with the basic supplies.

• Representation of women in medical institutions has been poor, at less than half that of males.

• Presently Senior policy makers in the health care system are not exposed to effective management techniques as well as, tools for strategic decision making in the health sector.

Education, training and professional developmentEducation, training and professional development

•Medical education has often been criticized for failing to equip health workers to undertake primary health work.

•Increasing specialization and super specialization in the curative fields. has little impact on the health services in rural areas.

•In the 6th V year plan it was admitted that doctors and paramedics were reluctant to serve in rural areas and that their training was not adapted to the needs of rural areas. To counter this situation, upgraded departments of preventive and social medicine were set up in medical colleges with facilities for postgraduate education, to provide a social orientation to the education and training of medical graduates. However these became the least favoured departments in terms of funding, authority and prestige.

•The nursing education has also witnessed shortfalls in the quality of education due to inadequate infrastructure, insufficient budgets,, lack of commitment and accountability in educators and insufficient hands-on training for students.

•There is no separate council to guide the training of laboratory technicians.

Planning and Strengthening of Human ResourcesPlanning and Strengthening of Human Resources

•Currently there is no clear system of projecting the future supply of human resources vis-à-vis the population’s need and demand.

•Promotional opportunities for ANMs and paramedical staff are particularly limited.

•There are no rewards for good work or clear expectations on work roles and feedback and proper performance appraisals.

• In the absence of systematic monitoring and supervision systems, health workers do not receive appropriate and timely performance appraisals or constructive feedback.

•All of this has resulted in a demoralized and poorly motivated health workforce with low public accountability.

Some unanswered questions

Is the current system of medical education meeting the objectives of public healthcare in rural areas?

Can we create a cadre of providers of basic health services willing and able to live and work in rural areas?

How can we better look after the needs of our human resources if we want them to look after the health needs of our populations with commitment and motivation?

Job Satisfaction Scale Case Study

Sample Size : 07 [03 PHC doctors; 02 ANM; 02 HW(M)]

Methodology : • Measurement of Job Satisfaction using The Warr 15 item Job

Satisfaction Scale

• The scores range from (1) ``I'm extremely dissatisfied`` to ``I'm extremely satisfied`` (7) with higher scores indicating higher levels of job satisfaction.

• The questionnaires were distributed to each participant with full instructions for completion.

• To ensure confidentiality, participants were not required to give their name or any information that could identify them.

Aspect of job I’m extremely dissatisfied

I’m very dissatisfied

I’m moderately dissatisfied

I’m not sure

I’m moderately satisfied

I’m very satisfied

I’m extremely satisfied

1 2 3 4 5 6 7

The physical work conditions

(5) (2)

The freedom to choose your own method of working

(4) (2) (1)

Your fellow workers

(3) (2) (2)

The recognition you get for good work

(3) (3) (1)

Your immediate boss

(4) (1) (2)

The amount of responsibility you are given

(5) (2)

Your rate of pay

(6) (1)

Your opportunity to use your abilities

(7)

Industrial relations between management and workers in your firm

(7)

Your chance of promotion

(4) (1) (2)

The way your firm is managed

(6) (1)

The attention paid to suggestions you make

(1) (6)

Your hours of work

(3) (4)

The amount of variety in your job

(6) (1)

Your job security

(1) (6)