Universal Health Coverage is a goal of many governments and organizations around the globe. One of the main criteria for achieving it is having an ample number of human resources designated to health-related jobs, such as doctors, nurses, midwives, dentists, and pharmacists. The World Health Organization (WHO) discusses HRH in their 2006 report. Things have only marginally improved since then.
Medical resources are only one piece of the puzzle of Universal Healthcare. There are four dimensions that countries must consider: availability, accessibility, acceptability and quality (AAAQ). Countries have to have adequate medical resources in order to be a respectable country seeking UHC. Additionally, these medical resources must be accessible at all times – including remote areas and evenings. Furthermore, these resources need to be diverse so as to appeal to everyone. Further, the people providing these resources must be trained in all aspects of their work. Finally, most importantly, the quality of care needs to be high-quality training, thus negating any possible compromises for patients.
A new study has found a family of four indices to measure shortages in health care for nurses. The availability deficit is the scarcity of trained nurses compared to the number required. When the current nurse density is equal to the number needed, there’s no shortage or surplus–that would be zero. The shortage index is positive when there’s a shortage and negative when there’s not enough. The accessibility deficit measures how many rural areas receive too few nurses compared to urban ones. Standards are higher in rural areas, so they need more nurses than urban ones do. The acceptability deficit measures the imbalance between male and female nurses. Finally, the quality deficit is a measure of how many qualified doctors are available versus quacks.
The 2011 census found that nurses, pharmacists, and dentists are in short supply in India. However, ANMs and AYUSH practitioners are showing significant surpluses. Compared to the standards set by commissions with higher authority, access to these professions is not up to par. All SAR graphs included showed some form of accessibility deficit, with nurses being well-supplied. While most graphs suffered from deficits in both acceptability and quality, pharmacists seemed to be doing better in those areas. All graphs had an optimistic bias, which is ironic considering that the profession shortcoming was positive.
One study found that, from 1981 to 2011, all of the deficit indices showed a general decreasing trend, with the exception of accessibility. Availability decreased for all cadres, with the exception of pharmacists and Australian Ayurvedic Medicine practitioners who saw an increase in availability of about 75% in 2011 compared to 1981. In terms of accessibility deficits, those values are almost constant from 1981 to 2011 at less than 1% change. Exceptional improvement in accessibility was observed among ANM professionals. Acceptability deficits pretty much stayed the same over the years, but they did show small decreases through time.
The amount of policy attention focused on the AAAQ dimensions has increased over time, from just 13 recommendations in 1981 to 120 in 2011. Policy makers have largely neglected acceptability, with no recommendations in 1983 and only 10 of 120 recommendations in 2011. The NHPI has largely focused its recommendations on physicians for three decades, leaving other HRH professions to suffer. There are also policy mismatches: In discussing accessibility, the 2017 policy does not provide relevant recommendations for dentists facing a critical deficit. Quality-related recommendations focus disproportionately on physicians, who suffer from a lower quality deficit than pharmacists and nursing cadres, highlighting a lack of continuity across NHPI policies in AAAQ dimensions.
In the current National Health Policy, there is no separate department for human resources. We believe a multidimensional approach to data-driven holistic assessment will allow it to meet the country’s human resource needs more effectively.
This article has been written by Vidhi Wadhwani, a sophomore at Gujarat College of Surgeons (GCS) Medical College and Research Fellow with Association for Socially Applicable Research (ASAR) and by Siddhesh Zadey. He is also a co-founder and director at ASAR and commission member with Lancet Citizens’ Commission for Reimagining Health System.