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Strategy for New India at 75:Inclusion- Human Resources for Health

  • On 15th August 2022, independent India will turn 75. In the lifespan of nations, India is still young. The best is surely yet to come. India’s youthful and aspirational population deserves a rapid transformation of the economy, which can deliver double-digit growth, jobs and prosperity to all.
  • The purpose of this, ‘Strategy for New India @ 75’, is to define clear objectives for 2022-23 in a  diverse range of 41 areas that recognize the progress already made; and challenges that remain; identify binding constraints in specific sectors; and suggest the way forward for achieving the stated objectives. 
  • The Strategy document has disaggregated the 41 sectors under four sections: drivers, infrastructure,  inclusion, and governance. 
  • The first section on drivers focuses on the engines of economic performance – in macroeconomic terms with chapters on growth and employment.
  • The section also discusses strategies for the doubling of farmers’ incomes; boosting Make in India; upgrading the science, technology and innovation ecosystem; and promoting sunrise sectors like fintech and tourism.
  • An annual rate of growth of 9 per cent by 2022-23 is essential for generating sufficient jobs and achieving prosperity for all. Four key steps, among others, have been spelled out for achieving this GDP growth rate. These are:

a. Increase the investment rate as measured by gross fixed capital formation (GFCF) from present 29 per cent to 36 per cent of GDP by 2022. About half of this increase must come from public investment which is slated to increase from 4 per cent to 7 per cent of GDP. Government savings have to move into positive territory. This sharp increase in the investment-to-GDP ratio will require significantly higher resource mobilization efforts as elaborated in the chapter on Growth.

b. In agriculture, emphasis must shift to converting farmers to ‘agripreneurs’ by further expanding e-National Agriculture Markets (e-NAMs) and replacing the Agricultural Produce Marketing Committee  (APMC) Act with the Agricultural Produce and Livestock Marketing (APLM) Act. The creation of a unified national market, a freer export regime and the abolition of the Essential Commodities Act are essential for boosting agricultural growth.

c. A strong push would be given to `Zero Budget Natural Farming (ZBNF) techniques that reduce costs,  improve land quality and increase farmers’ incomes. This is a tested method for putting environmental carbon back into the land. Therefore, ZBNF allows India to significantly contribute to reducing the global carbon footprint.

d. To ensure maximum employment creation, codification of labour laws must be completed and a massive effort must be made to upscale apprenticeships.

  • The second section on infrastructure deals with the physical foundations of growth. A lot of progress has been made across all infrastructure sectors. This is crucial to enhancing the competitiveness of Indian business as also ensuring the citizens’ ease of living. Three key steps, among others, are:

a. Expediting the establishment of the Rail Development Authority (RDA), which is already approved. RDA  will advise or make informed decisions on an integrated, transparent and dynamic pricing mechanism for the railways. Investment in railways will be ramped up, including by monetising existing railway assets.

b. The share of freight transported by coastal shipping and inland waterways will be doubled. Initially,  viability gap funding will be provided until the infrastructure is fully developed. An IT-enabled platform would be developed for integrating different modes of transport and promoting multi-modal and digitised mobility.

c. With the completion of the Bharat Net programme in 2019, all 2.5 lakh gram panchayats will be digitally connected. In the next phase the last mile connectivity to the individual villages will be completed. The aim will be to deliver all government services at the state, district, and gram panchayat level digitally by  2022-23, thereby eliminating the digital divide.

  • The section on inclusion deals with the urgent task of investing in the capabilities of all of India’s citizens. The three themes in this section revolve around the various dimensions of health, education and mainstreaming of traditionally marginalized sections of the population. While there are multiple dimensions and pathways  contained in the chapters in this section, four key steps, among others, are:

a. Successfully implementing the Ayushman Bharat programme including the establishment of 150,000  health and wellness centres across the country, and rolling out the Pradhan Mantri Jan Arogya  Abhiyaan.

b. Upgrading the quality of the school education system and skills, including the creation of a new innovation ecosystem at the ground level by establishing at least 10,000 Atal Tinkering Labs by 2020.

c. As already done in rural areas, affordable housing in urban areas will be given a huge push to improve workers’ living conditions and ensure equity while providing a strong impetus to economic growth.

d. Implementing strategies to achieve regional equity by focusing on the North-East region and successfully rolling out the Aspirational Districts Programme.

  • The final section on governance delves deep into how the tasks/business of government can be streamlined and reformed to achieve better outcomes. It involves a sharp focus on ensuring accountability and a shift to performance-based evaluation.
  • The government will revamp its data systems and analysis so that all policy interventions and decision-making are based on evidence and real-time data. This will yield efficient and

targeted delivery of services and justice to those who need them the most.

  • Three key steps, among others, are:

a. Implementing the recommendations of the Second Administrative Reforms Commission as a prelude to appointing a successor for designing reforms in the changing context of emerging technologies and the growing complexity of the economy.

b. A new autonomous body, viz., the Arbitration Council of India, may be set up to grade arbitral institutions and accredit arbitrators to make the arbitration process cost-effective and speedy, and to pre-empt the need for court intervention.

c. The scope of the Swachh Bharat Mission may be expanded to cover initiatives for landfills, plastic waste and municipal waste and generating wealth from waste.

  • To achieve the goals of New India in 2022-23, it is important for the private sector, civil society and even individuals to draw up their own strategies to complement and supplement the steps the government intends to take. With the available tools of 21st-century technology, it should be possible to truly create a mass movement for development. With the Sankalp of all Indians, India will have Siddhi.

Check out our previous blogs on the Strategy for New India at 75:

Objectives

  • Achieve a doctor-population ratio of at least 1:1400 (WHO norm 1:1000) and a nurse-population ratio of at least 1:500 (WHO norm 1:400) by 2022-23.
  • Ensure availability of paramedics and doctors as per Indian Public Health Standard (IPHS) norms in high-priority districts by 2020 (National Health Policy, 2017).
  • Deploy mid-level providers (MLPs) to manage the primary healthcare system.
  • Generate at least 1.5 million jobs in the public health sector by 2022-23, a large number of which will employ women.

Current Situation

  • India’s health workforce is characterised by a diversity of providers delivering services in allopathy and alternative systems of medicine like Ayurveda, homeopathy, Unani and Siddha.
  • As of March 2017, there were 10.23 lakh allopathic doctors registered with the Medical Council of India or state medical councils. Assuming 80 per cent availability, it is estimated that around 8.18 lakh doctors may actually be available for active service. This gives a doctor-population ratio of 1:1613. The current nurse-population ratio is 1:588.
  • Due to the suboptimal quality of training offered by several institutions that have mushroomed over the years, limited career prospects and poor working conditions, especially in the private sector, there is a significant shortage of skilled nurses in the country.
  • Moreover, the distribution of doctors and nurses across the country is uneven. Urban areas have four times as many doctors and three times as many nurses as compared to rural areas. Medical and nursing colleges are concentrated in a few states, e.g., Andhra Pradesh, Karnataka, Tamil Nadu, Kerala, Gujarat and Maharashtra.
  • There are also severe shortages in the category of allied health professionals (AHPs) including medical lab technicians, optometrists and radiologists. For instance, as of March 31, 2016, there was a shortfall of 13,659 lab technicians at primary health centres (PHCs) and community health centres (CHCs) across India.
  • Similarly, there was a shortfall of 3645 radiographers at CHCs. The absence of a central regulatory authority for AHPs has resulted in the mushrooming of institutes/ colleges without affiliation or recognition, giving rise to quality issues for this category of health professionals as well.
  • As far as specialists are concerned, a large number of posts are vacant all over the country. According to estimates, India needs close to 0.5 million additional specialists. Ayushman Bharat has triggered the need for even more human resources for health (HRH). There is also an acute shortage of medical faculty. Of the 1,830 faculty posts across six All India Institutes of Medical Sciences (AIIMS), approximately 583 (31 per cent) had been filled up until July 2017.
  • The government has made several efforts to address the shortage and quality of HRH in the country. These include the passage of the National Medical Commission (NMC) Bill, 2017 by the Union Cabinet, addition of 15,364 undergraduate and 9,855 postgraduate seats in medical colleges as well as increasing the superannuation age of doctors to 65 years in the Central Health Service, among other measures. Steps have also been taken to address the shortage of specialists through the system of diplomas from the College of Physicians and Surgeons (CPS), for instance.

Constraints

  • The regulatory system (Medical Council of India, Nursing Council of India) has failed to ensure adequate availability and quality of health professionals.
  • There is an inadequate capacity to train doctors, especially specialists and super-specialists.
  • Private practice by medical faculty in teaching institutions is rampant in several states, compromising on the commitment to teaching and institutional clinical work.
  • Many state and private medical/nursing/dental colleges have poor infrastructure.
  • There is no comprehensive and consistent HRH policy.
  • Workforce shortages and uneven distribution of doctors, nurses, specialists and allied health professionals plague the sector.
  • The quality of health professional training and adherence to standards is sub-optimal, including in the private sector.
  • Health professionals in the public sector are inadequately compensated and motivation levels are extremely poor. Fair compensation in the private sector, e.g., for nurses, is also a challenge.
  • There is a paucity of data on HRH in the country.

Way Forward

  1. Reform the governance of medical, nursing, dentistry, and pharmacy education in the country
  • Enact the NMC Bill, 2017.
  • Revamp the AYUSH, nursing, dentistry and pharmacy councils along the lines of the NMC Bill, 2017.
  • Establish a Council for Allied Health Professionals to ensure standardization of education and putting in place quality control mechanisms for educational institutions, teaching methods, clinical protocols and workforce management.
  • Put in place an updated curriculum for medical and allied professions that keeps pace with the changing dynamics of public health, policy, and demographics.
  • Establish a nursing school in every large district or cluster of districts with a population of 20-30 lakhs as per the National Health Policy,2017.
  • Take steps to revamp the regulatory system of nursing education, ensure quality training in nursing schools, develop specialties in nursing, develop centres of excellence in nursing and enhance the stature of government nurses.
  • Take steps to stop private practice by faculty of government teaching institutions by providing attractive salaries and incentives.
  1. Enhance production of doctors (especially specialists and super- specialists)
  • While some steps have been taken, the system of Diplomate of National Board (DNB) and Diplomas from CPS, may be expanded. This will help to address the shortage of specialists in the country.
  • Link at least 40 per cent of district hospitals with medical colleges.
  • Meet faculty shortages in new AIIMS with an active search strategy, visiting/adjunct faculty system (from India and abroad), and other methods.
  • Create pathways for the training of doctors in specialties and super-specialties at private hospitals (certification, short courses, exchange programmes, etc.)
  • Utilize extensively and incentivize district hospitals for formal (DNB/CPS diploma) and informal specialty training of doctors and nurses.
  • Provide opportunities for training in specialized/cutting edge areas at the best centres in the world for faculty of national institutions of excellence (NIEs) (AIIMS, PGIMER, JIPMER, NIMHANS) and of state medical colleges of repute.
  • Create conditions to facilitate the import of doctors, especially those of Indian origin, working abroad.
  • Consider deploying teachers from universities abroad as visiting professors at AIIMS/NIEs.
  • An enabling framework for the deployment of doctors and specialists from the private sector to government hospitals on a visiting/honorary basis may be developed and piloted.
  1. Develop a comprehensive HRH policy in states
  • To enable the formulation of a comprehensive HRH policy in states for all categories, develop a model policy covering issues pertaining to staff recruitment, retention, transfer, incentive structures for posting in difficult areas including access to housing facilities, performance management and competency-based career tracks for professional advancement.
  1. Skill and deploy non-physicians and other health providers
  • Develop plans for training a full range of allied health professionals such that it meets national requirements as well as creates a surplus for placements abroad.
  • Create a cadre of primary healthcare practitioners by introducing a three-year competency-based dynamic course for primary, community and family medicine.
  • Place 150,000 skilled and independently certified MLPs to manage the health and wellness centres to be operationalized over the next five years.
  • Explore some specific task-shifting opportunities like developing a cadre of nursing practitioners and physician assistants.
  1. Generate data on HRH, track progress
  • Generate comprehensive real-time data on forecasting, production capacity, and skill mix as well as general trends with respect to the key categories of HRH in the country.
  • By 2019, put in place a system for tracking progress against the stipulated HRH requirements.
  • Ensure meeting country commitments and targets under the Global Strategy on HRH.
  1. Engage private sector for skilling and training HRH
  • Establish partnerships with medical device manufacturers as part of the Skill India and Make in India programmes to identify skill gaps and design appropriate curricula for training programmes.
  • Partner with private hospitals/private medical practitioners to skill technicians, nursing and para-nursing as well as paramedical staff under the National Skill Development Corporation’s Healthcare Sector Skill Council.