So many, yet few: Human resources for health in India

Monitoring the Family Health Centres in Kerala, India: Findings from a facility survey

Introduction

Kerala, a south Indian state, has often been cited globally as a model for better health outcomes at low cost but faces unique challenges in achieving Universal Health Coverage (UHC). To propel the efforts in achieving UHC, the Government of Kerala announced the "Aardram" health reform initiative, emphasising improving the quality of primary care service delivery. The reforms started in 2017, and in the first stage, 170 of 848 Primary Health Centres (PHCs) were upgraded to Family Health Centres (FHCs). The facilities were provided with additional doctors, nurses, and paramedical staff; the working hours were extended, and the range of services offered increased. In support of these processes, we carried out a facility assessment to assess differences between upgraded FHCs and existing PHCs.

Materials and Methods

We conducted a facility-based cross-sectional assessment in eight primary care facilities of Kerala, FHC (N=4) and PHCs (N=4) from June to October 2019. A structured questionnaire covering utilisation and coverage of selected priority services for various populations and health outcome data was filled out by health staff to report data for the financial year 2018-19. Data were analysed in Microsoft Excel spreadsheets for easy analysis and replication by state stakeholders.

Results

Coverage indicators such as full antenatal care and full immunization coverage were not appreciably different in FHCs as compared to PHCs. However, key reform-related differences were observed. On average, FHCs had 0.8 medical officers and one staff nurse per 10,000 population, whereas PHCs had 0.7 medical officers and less than 0.4 staff nurses per 10,000 population, even as the size of populations served by these human resources varied greatly across both types of facilities. The number of outpatient department visits per 10,000 population annually was 11,343 persons in FHCs and 9,580 persons in PHCs. FHCs also provided additional services such as screening for depression and chronic obstructive pulmonary disorders.

Conclusion

Aardram primary healthcare reforms are still in their early days and appear to be associated with improved service coverage at the institutional level. However, some patterns are uneven: reforms should be carefully documented, and population-level impacts monitored over time.

Human Resources for Health in Haryana, India: What can be Done Better?

Introduction

Health systems in developing countries suffers from both input and productivity issues. We examined the status of three domains of human resources for health, i.e., availability and distribution, capacity and productivity, and motivation and job-satisfaction, of the health-care workforce employed in the public health system of Haryana, a North Indian state.

Methodology

The primary data were collected from 377 public health facilities and 1749 healthcare providers across 21 districts. The secondary data were obtained from government reports in the public domain. Bivariate and multivariate statistical techniques were used for evaluating district performances, making inter-district comparisons and identifying determinants of motivation and job-satisfaction of the clinical cadres.

Results

We found 3.6 core health-care workers (doctors, staff nurses, and auxiliary nurses-midwives) employed in the public health-care system per 10,000 population, ranging from 1.35 in Faridabad district to 6.57 in Panchkula district. Around 78% of the sanctioned positions were occupied. A number of inpatient hospitalizations per doctor/nurses per month were 17 at the community health center level and 29 at the district hospital level; however, significant differences were observed among districts. Motivation levels of community health workers (85%) were higher than clinical workforce (78%), while health system administrators had lowest motivation and job satisfaction levels. Posting at primary healthcare facility, contractual employment, and co-habitation with family at the place of posting were found to be the significant motivating factors.

Conclusions

A revamp of governance strategies is required to improve health-care worker availability and equitable distribution in the public health system to address the observed geographic variations. Efforts are also needed to improve the motivation levels of health system administrators, especially in poorly performing districts and reduce the wide gap with better-off districts.

Are informal healthcare providers knowledgeable in tuberculosis care? A cross-sectional survey using vignettes in West Bengal, India

BACKGROUND

India accounts for one-quarter of the world's TB cases. Despite efforts to engage the private sector in India's National TB Elimination Program, informal healthcare providers (IPs), who serve as the first contact for a significant TB patients, remain grossly underutilised. However, considering the substantial evidence establishing IPs' role in patients' care pathway, it is essential to expand the evidence base regarding their knowledge in TB care.

METHODS

We conducted a cross-sectional study in the Birbhum district of West Bengal, India. The data were collected using the TB vignette among 331 IPs (165 trained and 166 untrained). The correct case management was defined following India's Technical and Operational Guidelines for TB Control.

RESULTS

Overall, IPs demonstrated a suboptimal level of knowledge in TB care. IPs exhibited the lowest knowledge in asking essential history questions (all four: 5.4% and at least two: 21.7%) compared with ordering sputum test (76.1%), making a correct diagnosis (83.3%) and appropriate referrals (100%). Nonetheless, a statistically significant difference in knowledge (in most domains of TB care) was observed between trained and untrained IPs.

CONCLUSIONS

This study identifies gaps in IPs' knowledge in TB care. However, the observed significant difference between the trained and untrained groups indicates a positive impact of training in improving IPs' knowledge in TB care.

Implementing a health labour market analysis to address health workforce gaps in a rural region of India

BACKGROUND

Human Resources for Health (HRH) are essential for making meaningful progress towards universal health coverage (UHC), but health systems in most of the developing countries continue to suffer from serious gaps in health workforce. The Global Strategy on Human Resources for Health-Workforce 2030, adopted in 2016, includes Health Labor Market Analysis (HLMA) as a tool for evidence based health workforce improvements. HLMA offers certain advantages over the traditional approach of workforce planning. In 2018, WHO supported a HLMA exercise in Chhattisgarh, one of the predominantly rural states of India.

METHODS

The HLMA included a stakeholder consultation for identifying policy questions relevant to the context. The HLMA focused on state HRH at district-level and below. Mixed methods were used for data collection and analysis. Detailed district-wise data on HRH availability were collected from state's health department. Data were also collected on policies implemented on HRH during the 3 year period after the start of HLMA and changes in health workforce.

RESULTS

The state had increased the production of doctors but vacancies persisted until 2018. The availability of doctors and other qualified health workers was uneven with severe shortages of private as well as public HRH in rural areas. In case of nurses, there was a substantial production of nurses, particularly from private schools, however there was a lack of trusted accreditation mechanism and vacancies in public sector persisted alongside unemployment among nurses. Based on the HLMA, pragmatic recommendations were decided and followed up. Over the past 3 years since the HLMA began an additional 4547 health workers including 1141 doctors have been absorbed by the public sector. The vacancies in most of the clinical cadres were brought below 20%.

CONCLUSION

The HLMA played an important role in identifying the key HRH gaps and clarifying the underlying issues. The HLMA and the pursuant recommendations were instrumental in development and implementation of appropriate policies to improve rural HRH in Chhattisgarh. This demonstrates important progress on key 2030 Global Strategy milestones of reducing inequalities in access to health workers and improving financing, retention and training of HRH.

Discriminatory Impact of the COVID-19 Pandemic on Women Physicians

The impact of gender and women's traditional roles in society has been particularly pronounced during the coronavirus disease 2019 (COVID-19) pandemic. We conducted an online survey to evaluate the impact of the COVID-19 pandemic on domestic responsibilities among Indian physicians to look for gender-based differences by collecting data regarding domestic work and childcare, changes in work patterns, and lack of domestic help during the pandemic and the resultant nationwide lockdown. Through this study, we reported the results of a nationwide survey and showed how gender gaps exist, even within highly qualified professionals such as physicians, and how the COVID-19 pandemic has widened this gap. Our study showed statistically higher contribution by women physicians as compared to men not only in the increased domestic work, but also when it came to childcare and education. More women than men were forced to take additional leave and quit their jobs due to the increased domestic responsibilities.

In addition to highlighting the difficulties faced by the physician community as a whole due to nonavailability of domestic help and childcare facilities, this survey demonstrated the intense challenges women physicians face as they try to navigate the work–life balance dilemma by providing care to their families as well as patients. Our study highlighted the need to re-examine the specific challenges faced by women physicians and identify means to support and empower them.

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

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.

Developing Clinical Decision Support System using Machine Learning Methods for Type 2 Diabetes Drug Management

BACKGROUND AND OBJECTIVES

Application of artificial intelligence/machine learning (AI/ML) for automation of diabetes management can enhance equitable access to care and ensure delivery of minimum standards of care. Objective of the current study was to create a clinical decision support system using machine learning approach for diabetes drug management in people living with Type 2 diabetes.

METHODOLOGY

Study was conducted at an Endocrinology clinic and data collected from the electronic clinic management system. 15485 diabetes prescriptions of 4974 patients were accessed. A data subset of 1671 diabetes prescriptions of 940 patients with information on diabetes drugs, demographics (age, gender, body mass index), biochemical parameters (HbA1c, fasting blood glucose, creatinine) and patient clinical parameters (diabetes duration, compliance to diet/exercise/medications, hypoglycemia, contraindication to any drug, summary of patient self monitoring of blood glucose data, diabetes complications) was used in analysis. An input of patient variables were used to predict all diabetes drug classes to be prescribed. Random forest algorithms were used to create decision trees for all diabetes drugs.

RESULTS AND CONCLUSION

Accuracy for predicting use of each individual drug class varied from 85% to 99.4%. Multi-drug accuracy, indicating that all drug predictions in a prescription are correct, stands at 72%. Multi drug class accuracy in clinical application may be higher than this result, as in a lot of clinical scenarios, two or more diabetes drugs may be used interchangeably. This report presents a first positive step in developing a robust clinical decision support system to transform access and quality of diabetes care.

Do health policies address the availability, accessibility, acceptability, and quality of human resources for health? Analysis over three decades of National Health Policy of India

BACKGROUND

Human Resources for Health (HRH) are crucial for improving health services coverage and population health outcomes. The World Health Organisation (WHO) promotes countries to formulate holistic policies that focus on four HRH dimensions-availability, accessibility, acceptability, and quality (AAAQ). The status of these dimensions and their incorporation in the National Health Policies of India (NHPIs) are not well known.

METHODS

We created a multilevel framework of strategies and actions directed to improve AAAQ HRH dimensions. HRH-related recommendations of NHPI-1983, 2002, and 2017 were classified according to targeted dimensions and cadres using the framework. We identified the dimensions and cadres focussed by NHPIs using the number of mentions. Furthermore, we introduce a family of dimensionwise deficit indices formulated to assess situational HRH deficiencies for census years (1981, 2001, and 2011) and over-year trends. Finally, we evaluated whether or not the HRH recommendations in NHPIs addressed the deficient cadres and dimensions of the pre-NHPI census years.

RESULTS

NHPIs focused more on HRH availability and quality compared to accessibility and acceptability. Doctors were prioritized over auxiliary nurses-midwives and pharmacists in terms of total recommendations. AAAQ indices showed deficits in all dimensions for almost all HRH cadres over the years. All deficit indices show a general decreasing trend from 1981 to 2011 except for the accessibility deficit. The recommendations in NHPIs did not correspond to the situational deficits in many instances indicating a policy priority mismatch.

CONCLUSION

India needs to incorporate AAAQ dimensions in its policies and monitor their progress. The framework and indices-based approach can help identify the gaps between targeted and needed dimensions and cadres for effective HRH strengthening. At the global level, the application of framework and indices will allow a comparison of the strengths and weaknesses of HRH-related policies of various nations.

Cervical cancer screening status and implementation challenges: Report from selected states of India

BACKGROUND

Cervical cancer contributes to 6%-29% of the cancers in India. Although the Government of India in 2010 integrated cancer screening within the National Programme for the prevention of Non-communicable Diseases, only 22% of women aged 15-45 years had undergone examination of the cervix by 2016. This prompts the question regarding the organisation of the program's implementation and service delivery and regarding challenges that may explain poor screening uptake.

METHODS

Semi-structured interviews were held with program managers and implementers in seven districts of three selected States of India. The data analysis looked at program content, the organisation of screening delivery, and the challenges to the implementation of the program, considering six theoretically derived dimensions of public health capacity: leadership and governance, organisational structure, financial resources, workforce, partnerships, and knowledge development.

RESULTS

Participants perceive the existing capacities across the six domains as insufficient to implement the CCS program nationwide. A context specific implementation, a better coordination between the program and district health facilities, timely remuneration, better maintenance of data and a strong monitoring system are possible solutions to remove health system related barriers.

CONCLUSION

The study provides evidence on the practical challenges and provides recommendations for strengthening the capacities of the health system.

Health System Contact and Awareness of Zoonotic Diseases: Can it Serve as One Health Entry Point in the Urban Community of Ahmedabad, India?

One Health (OH) is emphasized globally to tackle the (re)emerging issues at the human-animal-ecosystem interface. However, the low awareness about zoonoses remain a challenge in global south, thus this study documented the health system contact and its effect on the awareness level of zoonoses in the urban community of Ahmedabad, India. A community-based household survey was conducted between October 2018 and July 2019. A total of 460 households (HHs) were surveyed from two zones and 23 wards of the city through cluster sampling. A structured, pilot-tested, and researcher-administered questionnaire in the vernacular language was used to collect the information on demographic details, socio-economic details, health-seeking behavior for both the humans and their animals, human and animal health system contact details and the participants' awareness on selected zoonotic diseases based on the prioritization (rabies, brucellosis, swine flu, and bird flu). Out of 460 surveyed households, 69% of HHs and 59% of HHs had a health system contact to the human and animal health system respectively at the community level. There are multiple health workers active on the community level that could potentially serve as One Health liaisons. The investigation of the knowledge and awareness level of selected zoonotic diseases revealed that 58.5%, 47.6%, and 4.6% know about rabies, swine and/or bird flu, and brucellosis, respectively. The mixed-effect linear regression model indicates that there is no significant effect on the zoonotic disease awareness score with the human health system contact; however, a minimal positive effect with the animal health system contact was evident.

Diagnostic Accuracy of a Two-Stage Sequential Screening Strategy Implemented by Community Health Workers (CHWs) to Identify Individuals with COPD in Rural India

Purpose

Undiagnosed Chronic Obstructive Pulmonary Disease (COPD) results in high morbidity, disability and mortality in India. Effective strategies for active COPD screening in community settings are needed to increase early identification, risk reduction and timely management. The objective of this study was to test the diagnostic accuracy of a sequential two-step screening strategy to detect COPD, implemented by community health workers (CHWs), among adults aged ≥40 years in a rural area of North India.

Patients and Methods

Trained CHWs screened all consenting (n=3256) eligible adults in two villages using the Lung Function Questionnaire (LFQ) to assess their COPD risk and conducted pocket spirometry on 268 randomly selected (132 with high risk ie LFQ score ≤18 and 136 with low risk ie LFQ score >18) individuals. Subsequently, trained researchers conducted post-bronchodilator spirometry on these randomly selected individuals using a diagnostic quality spirometer and confirmed the COPD diagnosis according to the Global Initiative for Obstructive Lung Disease (GOLD) criteria (FEV₁/FVC ratio <0.7).

Results

This strategy of using LFQ followed by pocket spirometry was sensitive (78.6%) and specific (78.8%), with a positive predictive value of 66% and negative predictive value of 88%. It could accurately detect 67% of GOLD Stage 1, 78% of GOLD Stage 2, 82% of GOLD Stage 3 and 100% of GOLD Stage 4 individuals with airflow limitation.

Conclusion

COPD can be accurately detected by trained CHWs using a simple sequential screening strategy. This can potentially contribute to accurate assessment of COPD and thus its effective management in low-resource settings.

Size, composition and distribution of health workforce in India: why, and where to invest?

BACKGROUND

Investment in human resources for health not only strengthens the health system, but also generates employment and contributes to economic growth. India can gain from enhanced investment in health workforce in multiple ways. This study in addition to presenting updated estimates on size and composition of health workforce, identifies areas of investment in health workforce in India.

METHODS

We analyzed two sources of data: (i) National Health Workforce Account (NHWA) 2018 and (ii) Periodic Labour Force Survey 2017-2018 of the National Sample Survey Office (NSSO). Using the two sources, we collated comparable estimates of different categories of health workers in India, density of health workforce and skill-mix at the all India and state levels.

RESULTS

The study estimated (from NHWA 2018) a total stock of 5.76 million health workers which included allopathic doctors (1.16 million), nurses/midwives (2.34 million), pharmacist (1.20 million), dentists (0.27 million), and traditional medical practitioner (AYUSH 0.79 million). However, the active health workforce size estimated (NSSO 2017-2018) is much lower (3.12 million) with allopathic doctors and nurses/midwives estimated as 0.80 million and 1.40 million, respectively. Stock density of doctor and nurses/midwives are 8.8 and 17.7, respectively, per 10,000 persons as per NHWA. However, active health workers' density (estimated from NSSO) of doctor and nurses/midwives are estimated to be 6.1 and 10.6, respectively. The numbers further drop to 5.0 and 6.0, respectively, after accounting for the adequate qualifications. All these estimates are well below the WHO threshold of 44.5 doctor, nurses and midwives per 10,000 population. The results reflected highly skewed distribution of health workforce across states, rural-urban and public-private sectors. A substantial proportion of active health worker were found not adequately qualified on the one hand and on the other more than 20% of qualified health professionals are not active in labor markets.

CONCLUSION

India needs to invest in HRH for increasing the number of active health workers and also improve the skill-mix which requires investment in professional colleges and technical education. India also needs encouraging qualified health professionals to join the labor markets and additional trainings and skill building for already working but inadequately qualified health workers.

Human Resources for Health in India: Strategic Options for Transforming Health Systems Towards Improving Health Service Delivery and Public Health

Introduction:

The health workforce is the channel for delivering health interventions to populations. A critical mass of health professionals is necessary to manage a health system and is often a crucial limiting factor in the delivery of quality health services. India’s current situation, juxtaposed with its medium-term and long-term HRH (human resources for health) requirements, necessitates reassessing the policy levers that are available at the national level.

Objective:

To suggest strategic options to recommend India’s way forward to meet challenges related to health service delivery and public health with an HRH focus.

Methodology:

We reviewed and compared studies from different countries which focused on strengthening HRH at the national level. A two-step approach towards identifying and selecting HRH strategic options was adopted: desk review and discussions. A list of strategic options for reforming the current state of HRH in India was developed on the basis of lessons learnt from the review. These options were then scored and plotted on a grid (for innovation, disruption, difficulty of implementation, budget for implementation, importance and time period for implementation) in discussion with experts.

Result:

Based on the lessons learnt, eight strategic options were suggested for India: instituting a national HRH body; developing partnership models for the public sector and the private sector; setting benchmark HRH ratios; allocating at least 2.5% of the GDP to health; allocating at least 25% of all development assistance for health to HRH; halving the current levels of disparity in health worker distribution between urban and rural areas; evaluating HRH support through the National Health Mission (NHM); and maintaining a live register of HRH.

Conclusion:

The research is timely as India moves towards the implementation of the Sustainable Development Goals (SDGs) with a particular focus on universal health coverage (UHC) and Ayushman Bharat Yojana. The suggested strategic options for the way forward shall help India in dealing with the current health crisis to emerge with a strong public health system.

Approaches to motivate physicians and nurses in low- and middle-income countries: a systematic literature review

Poor health worker motivation, and the resultant shortages and geographic imbalances of providers, impedes the provision of quality care in low- and middle-income countries (LMICs). This systematic review summarizes the evidence on interventions used to motivate health workers in LMICs. A standardized keyword search strategy was employed across five databases from September 2007 -September 2017. Studies had to meet the following criteria: original study; doctors and/or nurses as target population for intervention(s); work motivation as study outcome; study design with clearly defined comparison group; categorized as either a supervision, compensation, systems support, or lifelong learning intervention; and conducted in a LMIC setting. Two independent reviewers screened 3845 titles and abstracts and, subsequently, reviewed 269 full articles. Seven studies were retained from China (n = 1), Ghana (n = 2), Iran (n = 1), Mozambique (n = 1), and Zambia (n = 2). Study data and risk of bias were extracted using a standardized form. Though work motivation was the primary study outcome, four studies did not provide an outcome definition and five studies did not describe use of a theoretical framework in the ascertainment. Four studies used a randomized trial-group design, one used a non-randomized trial-group design, one used a cross-sectional design, and one used a pretest-posttest design. All three studies that found a significant positive effect on motivational outcomes had a supervision component. Of the three studies that found no effects on motivation, two were primarily compensation interventions and the third was a systems support intervention. One study found a significant negative effect of a compensation intervention on health worker motivation. In conducting this systematic review, we found there is limited evidence on successful interventions to motivate health workers in LMICs. True effects on select categories of health workers may have been obscured given that studies included health workers with a wide range of social and professional characteristics. Robust studies that use validated and culturally appropriate tools to assess worker motivation are greatly needed in the Sustainable Development Goals era.

'One Health' Actors in Multifaceted Health Systems: An Operational Case for India

The surging trend of (re)emerging diseases urges for the early detection, prevention, and control of zoonotic infections through the One Health (OH) approach. The operationalization of the OH approach depends on the contextual setting, the presence of the actors across the domains of OH, and the extent of their involvement. In the absence of national operational guidelines for OH in India, this study aims to identify potential actors with an attempt to understand the current health system network strength (during an outbreak and non-outbreak situations) at the local health system of Ahmedabad, India. This case study adopted a sequential mixed methods design conducted in two phases. First, potential actors who have been involved directly or indirectly in zoonoses prevention and control were identified through in-depth interviews. A network study was conducted as part of the second phase through a structured network questionnaire. Interest and influence matrix, average degree, network density, and degree of centralization were calculated through Atlas.Ti (ATLAS.ti Scientific Software Development GmbH, Berlin, Germany), UCINET (Analytic Technologies, Lexington, KY, USA) software. The identified actors were categorized based on power, administrative level (either at the city or district level), and their level of action: administrative (policy planners, managers), providers (physicians, veterinarians), and community (health workers, community leaders). The matrix indicated that administrative actors from the district level were ‘context setters’ and the actors from the city level were either ‘players’ or ‘subjects’. The network density showed a strength of 0.328 during the last outbreak of H5N1, which decreased to 0.163 during the non-outbreak situation. Overall, there was low collaboration observed in this study, which ranged from communication (during non-outbreaks) to coordination (during outbreaks). The private and non-governmental actors were not integrated into collaborative activities. This study concludes that not only collaboration is needed for OH among the sectors pertaining to the human and the animal health system but also better structured (‘inter-level’) collaboration across the governance levels for effective implementation.

Market competition and demand for skills in a credence goods market: Evidence from face-to-face and web-based non-physician clinician training in rural China

Background

Non-physician clinicians (NPCs) providing services in functionally private markets account for a large share of the workforce in the primary care system in many low-income and middle-income countries. Although regular in-service training is believed to be crucial to updating NPCs’ professional knowledge, skills, and practices, participation rates are often low. Low participation may result from the “credence good” nature of the market for primary care: if patients are unable to observe quality improvements from training, NPCs have weaker incentives to participate. Empirical evidence is limited on the relationship between market competition and NPC participation in-service training as well as how participation varies with the type of training available.

Methods

The study uses a dataset of 301 NPCs from three prefectures in Yunnan, a province in southwest China, collected in July 2017. Logistic regression is used to estimate the relationship between competition and NPC’s participation in in-service training. We assess the relationship between participation and both the quantity of competition (number of competitors in the same village and surrounding villages) and the quality of competition (proxied using characteristics of competing clinicians).

Results

In 2016, nearly two thirds of NPCs participated in face-to-face or web-based in-service trainings at least once. Specifically, 58 percent of NPCs participated in face-to-face in-service trainings, and 24 percent of NPCs participated in web-based in-service trainings. The quantity of competitors is unrelated to participation in in-service training. The quality of competition is not related to face-to-face training but has a significant positive relationship with participation in web-based training.

Conclusions

Web-based trainings may be a better approach to increase NPC skills in developing country primary care markets.

Cost-Effectiveness of Therapeutic Use of Safety-Engineered Syringes in Healthcare Facilities in India

BACKGROUND

Globally, 16 billion injections are administered each year of which 95% are for curative care. India contributes 25-30% of the global injection load. Over 63% of these injections are reportedly unsafe or deemed unnecessary.

OBJECTIVES

To assess the incremental cost per quality-adjusted life-year (QALY) gained with the introduction of safety-engineered syringes (SES) as compared to disposable syringes for therapeutic care in India.

METHODS

A decision tree was used to compute the volume of needle-stick injuries (NSIs) and reuse episodes among healthcare professionals and the patient population. Subsequently, three separate Markov models were used to compute lifetime costs and QALYs for individuals infected with hepatitis B virus (HBV), hepatitis C virus (HCV) and human immunodeficiency virus (HIV). Three SES were evaluated-reuse prevention syringe (RUP), sharp injury prevention (SIP) syringe, and syringes with features of both RUP and SIP. A lifetime study horizon starting from a base year of 2017 was considered appropriate to cover all costs and consequences comprehensively. A systematic review was undertaken to assess the SES effects in terms of reduction in NSIs and reuse episodes. These were then modelled in terms of reduction in transmission of blood-borne infections, life-years and QALYs gained. Future costs and consequences were discounted at the rate of 3%. Incremental cost per QALY gained was computed to assess the cost-effectiveness. A probabilistic sensitivity analysis was undertaken to account for parameter uncertainties.

RESULTS

The introduction of RUP, SIP and RUP + SIP syringes in India is estimated to incur an incremental cost of Indian National Rupee (INR) 61,028 (US$939), INR 7,768,215 (US$119,511) and INR 196,135 (US$3017) per QALY gained, respectively. A total of 96,296 HBV, 44,082 HCV and 5632 HIV deaths are estimated to be averted due to RUP in 20 years. RUP has an 84% probability to be cost-effective at a threshold of per capita gross domestic product (GDP). The RUP syringe can become cost saving at a unit price of INR 1.9. Similarly, SIP and RUP + SIP syringes can be cost-effective at a unit price of less than INR 1.2 and INR 5.9, respectively.

CONCLUSION

RUP syringes are estimated to be cost-effective in the Indian context. SIP and RUP + SIP syringes are not cost-effective at the current unit prices. Efforts should be made to bring down the price of SES to improve its cost-effectiveness.

Medical schools in India: pattern of establishment and impact on public health - a Geographic Information System (GIS) based exploratory study

Background

Indian medical education system is on the brink of a massive reform. The government of India has recently passed the National Medical Commission Bill (NMC Bill). It seeks to eliminate the existing shortage and maldistribution of health professionals in India. It also encourages establishment of medical schools in underserved areas. Hence this study explores the geographic distribution of medical schools in India to identify such under and over served areas. Special emphasis has been given to the mapping of new medical schools opened in the last decade to identify the ongoing pattern of expansion of medical education sector in India.

Methods

All medical schools retrieved from the online database of Medical Council of India were plotted on the map of India using geographic information system. Their pattern of establishment was identified. Medical school density was calculated to analyse the effect of medical school distribution on health care indicators.

Results

Presence of medical schools had a positive influence on the public health profile. But medical schools were not evenly distributed in the country. The national average medical school density in India amounted to 4.08 per 10 million population. Medical school density of provinces revealed a wide range from 0 (Nagaland, Dadra and Nagar Haveli, Daman and Diu and Lakshadweep) to 72.12 (Puducherry). Medical schools were seen to be clustered in the vicinity of major cities as well as provincial capitals. Distance matrix revealed that the median distance of a new medical school from its nearest old medical school was just 22.81 Km with an IQR of 6.29 to 56.86 Km.

Conclusions

This study revealed the mal-distribution of medical schools in India. The problem is further compounded by selective opening of new medical schools within the catchment area of already established medical schools. Considering that medical schools showed a positive influence on public health, further research is needed to guide formulation of rules for medical school establishment in India.

Access to women physicians and uptake of reproductive, maternal and child health services in India

BACKGROUND

Low availability of women physicians in rural areas can compromise women's health care seeking, where need can be greatest. We examined the associations between availability of women physicians and maternal and child health service utilization in India.

METHODS

We analyzed cross-sectional district-level data from all 256 districts in 18 states, from India's District-Level Household and Facility Survey (2012-13) and the National Family Health Survey (2015-16). Assessed measures included lady medical officers (LMOs) availability at Primary Health Centers (PHCs, which are largely rural serving), modern contraceptive use, antenatal care (ANC), skilled birth attendance (SBA), maternal postnatal care (PNC), infant PNC, and child immunization. Multilevel regression models nesting districts in states examined associations between LMO availability and health service utilization, adjusting for district-level socioeconomic status (SES) indicators (e.g., women's education, household water access), urbanicity, health insurance coverage and sampled PHCs (15 on average) within districts.

FINDINGS

Only 72 of 256 districts (28.1%) reported >50% of PHCs with LMOs. In multivariable models, LMO availability in PHCs was associated with higher district prevalence (%) of modern contraceptive use [β=0.04 (95% CI: 0.007, 0.08)], 4+ ANC [β =0.07 (95% CI: 0.008, 0.13)], skilled birth attendance [β=0.09 (0.03, 0.14) and maternal PNC [β=0.08 (95% CI: 0.03, 0.12)], but not infant PNC or child immunization.

INTERPRETATION

Higher district availability of women physicians is associated with higher maternal health care utilization but not child health care utilization. Improving gender parity in the physician workforce and rural women physician access may improve maternal health care use in India.

Comprehensive measurement of health system performance at district level in India: Generation of a composite index

There have been limited attempts at measurement of health system performance at decentralized levels in low- and middle-income countries. This study was undertaken to develop a composite indicator to measure health system performance at district level in India. Primary data were collected from 377 public health facilities in 21 districts of Haryana state in India using health facility surveys. In addition, 1700 health care providers and 800 clients visiting health facilities were interviewed. Routine health management information system data at district and state level were also analyzed. These data were used for computing 67 input and process indicators covering six health system building blocks. Indicators were normalized and aggregated to generate domain-specific and overall composite health system performance index (HSPI) for each district. Several sensitivity analyses were performed to assess robustness of results. Overall, Panchkula and Ambala districts were found to be the best performing in the state (with HSPI scores of 0.64 and 0.62 out of 1), while Mewat, Faridabad, and Palwal districts had the poorest performance (with HSPI scores of 0.46, 0.49, and 0.48 out of 1). Significant variation in performance was observed for each health system building block. Sensitivity analyses results showed that study findings were robust to variations in methods of aggregation of indicators. Our study provides a framework and methods to measure health system performance at district level in a comprehensive manner. The composite indicator provides a summary snapshot to benchmark performance, while building block and domain scores provide critical information for programmatic action.

Physician preferences for working in deprived areas: a systematic review of discrete choice experiment

Background: Physician shortages in rural areas is a universal concern, and most countries face this challenge. Many attributes influence the physician preferences about the choice of working location. The aim of this systematic review was to investigate which attributes were included in discrete choice experiment studies and which of them valued the most by physicians. Methods: The following databases were searched: PubMed, Embase, and Web of Science Core Collection. Further studies were retrieved from reference lists of included studies, and grey literature. Studies used discrete choice experiments methods to elicit preferences for working in the deprived area, focus on physicians or medical students, and published between 2000 and 2017 in the English language were included. Results: The literature search yielded 192 studies, of which 14 studies met inclusion criteria. The attributes and attribute levels were identified by literature review and qualitative research. The number of attributes varied from five to ten, and the most frequent number was six attributes. In most studies, maximum of sixteen different scenarios were given to the study samples. The "salary or income" attribute was the most important in fifty percent of the studies and the attributes related to "study and education" was at the next level. Conclusion: Financial attributes are not the only significant attributes considered by the physicians for deciding where to practice, but also the other non-financial attributes are important. It is suggested that based on the economic, social and cultural conditions of each country, a specific incentive package, including a set of financial and non-financial incentives, is developed to attract physicians to the deprived areas.

Retention of medical doctors and nurses in rural areas of Odisha state, India – a policy analysis

Purpose

Retention of medical doctors and nurses in remote and rural areas is a key issue in India. The purpose of this paper is to assess the relevant policies and provisions with respect to health care professionals, aiming to develop feasible retention strategies in rural areas of Odisha state of India.

Design/methodology/approach

The study employed documentary review and key informant interviews with policy elites (health planners, policy maker, researchers, etc.). The document review included published and unpublished reports, policy notifications and articles on human resources for health (HRH) in Odisha and similar settings. Throughout the study, the authors adapted World Health Organization’s framework to study policies relevant to HRH retention in rural areas. The adapted framework comprised of the four policy domains, education, regulation, financial incentives, professional and personal support, and 16 recommendations.

Findings

In Odisha, the district quota system for admission is not practiced; however, students from special tribal and caste (Scheduled Tribe and Scheduled Caste) communities, Socially and Educationally Backward Classes of citizens, and Persons with Disabilities have some allocated quota to study medicine and nursing. Medical education has a provision of community placement in rural hospitals. In government jobs, the newly recruited medical doctors serve a minimum of three years in rural areas. Doctors are given with location-based incentives to work in remote and difficult areas. The government has career development, deployment, and promotion avenues for doctors and nurses; however, these provisions are not implemented effectively.

Originality/value

The government could address the rural retention problems, as illustrated in the study and put in place the most effective policies and provisions toward recruitment, deployment and attraction of HRH in remote and rural areas. At the same time, implementation HRH strategies and activities must be rigorously monitored and evaluated effectively.

Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data

OBJECTIVES

We provide new estimates on size, composition and distribution of human resource for health in India and compare with the health workers population ratio as recommended by the WHO. We also estimate size of non-health workers engaged in health sector and the size of technically qualified health professionals who are not a part of the health workforce.

DESIGN

Nationally representative cross-section household survey and review of published documents by the Central Bureau of Health Intelligence.

SETTING

National.

PARTICIPANTS

Head of household/key informant in a sample of 101 724 households.

INTERVENTIONS

Not applicable.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome was the number and density of health workers,and the secondary outcome was the percentage of health workers who are technically qualified and the percentage of individuals technically qualified and not in workforce.

RESULTS

The total size of health workforce estimated from the National Sample Survey (NSS) data is 3.8 million as of January 2016, which is about 1.2 million less than the total number of health professionals registered with different councils and associations. The density of doctors and nurses and midwives per 10 000 population is 20.6 according to the NSS and 26.7 based on the registry data. Health workforce density in rural India and states in eastern India is lower than the WHO minimum threshold of 22.8 per 10 000 population. More than 80% of doctors and 70% of nurses and midwives are employed in the private sector. Approximately 25% of the currently working health professionals do not have the required qualifications as laid down by professional councils, while 20% of adequately qualified doctors are not in the current workforce.

CONCLUSIONS

Distribution and qualification of health professionals are serious problems in India when compared with the overall size of the health workers. Policy should focus on enhancing the quality of health workers and mainstreaming professionally qualified persons into the health workforce.

Shortage and inequalities in the distribution of specialists across community health centres in Uttar Pradesh, 2002-2012

Background

The onus of providing affordable access to specialist services in rural India primarily lies with publicly funded rural hospitals, also known as community health centres (CHCs). However, no studies have attempted to measure the change in the shortage and distributional inequalities of specialists in the publicly funded rural hospitals of Uttar Pradesh (India). This study attempts to fill that gap.

Methods

The study uses data from the three latest rounds of the District-Level Household Survey, covering a period of 10 years spanning from 2002 to 2012. Shortages were measured against the Indian Public Health Standards for CHCs, and inequalities were measured using Gini and Theil indices, with the latter decomposed to reveal the source of the inequalities. Negative binomial regression was applied to examine the association between facility characteristics and the availability of specialists in CHCs.

Results

The current shortage of specialists stands at 80.7% of the total requirement. Currently, 62.1% of CHCs are functioning without a specialist. The distribution of specialists across CHCs has become progressively uneven over the study period, as shown by the rise in the Gini index (from 0.41 in 2002–2004 to 0.74 in 2012–2013). Decomposition analysis reveals that the contribution of within-district inequalities to overall inequality remains high (85.4% of total inequality). About 50% of within-district inequality is contributed by only 20 districts, most of which belong to eastern and central Uttar Pradesh. The analysis of factors affecting the distribution of the current specialist workforce revealed that the number of available specialists at a CHC is positively associated with the availability of residences for doctors and regular electricity supply, and negatively associated with CHC location and the distance of the CHC from the district headquarters.

Conclusion

The findings suggest that Uttar Pradesh not only needs to recruit more specialists, but it also requires proper implementation of deployment and retention policies to ensure equitable access to specialist care for rural populations. Ensuring the availability of quality accommodations and basic amenities at all CHCs, as well as adequate transport and rural allowance, could help increase the chances of specialists staying in rural and far-off CHCs.

A framework for medical power in two case studies of health policymaking in India and Niger

Medical professionals influence health policymaking but the power they exercise is not well understood in low- and middle-income countries. We explore medical power in national health policymaking for child survival in Niger (late 1990s-2012) and emergency medicine specialisation in India (early 1990s-2015). Both case studies used document review, in-depth interviews and non-participant observation; combined analysis traced policy processes and established theoretical categories around power to build a conceptual framework of medical power in health policymaking. Medical doctors, mainly specialists, utilised their power to shape policy differently in each case. In Niger, a small, connected group of paediatricians pursued a policy of task-shifting after a powerful non-medical actor, the country's president, shifted the debate by enacting broad health systems improvements. In India, a more fragmented group of specialists prioritised tertiary-level healthcare policies likely to benefit only a small subset of the population. Compared to high-income settings, medical power in these cases was channelled and expressed with greater variability in the profession's ability to organise and influence policymaking. Taken together, both cases provide evidence that a concentration of medical power in health policymaking can result in the medicalisation of public health issues.

Reviewing reliance on overseas-trained doctors in rural Australia and planning for self-sufficiency: applying 10 years' MABEL evidence

BACKGROUND

The capacity for high-income countries to supply enough locally trained doctors to minimise their reliance on overseas-trained doctors (OTDs) is important for equitable global workforce distribution. However, the ability to achieve self-sufficiency of individual countries is poorly evaluated. This review draws on a decade of research evidence and applies additional stratified analyses from a unique longitudinal medical workforce research program (the Medicine in Australia: Balancing Employment and Life survey (MABEL)) to explore Australia's rural medical workforce self-sufficiency and inform rural workforce planning. Australia is a country with a strong medical education system and extensive rural workforce policies, including a requirement that newly arrived OTDs work up to 10 years in underserved, mostly rural, communities to access reimbursement for clinical services through Australia's universal health insurance scheme, called Medicare.

FINDINGS

Despite increases in the number of Australian-trained doctors, more than doubling since the late 1990s, recent locally trained graduates are less likely to work either as general practitioners (GPs) or in rural communities compared to local graduates of the 1970s-1980s. The proportion of OTDs among rural GPs and other medical specialists increases for each cohort of doctors entering the medical workforce since the 1970, peaking for entrants in 2005-2009. Rural self-sufficiency will be enhanced with policies of selecting rural-origin students, increasing the balance of generalist doctors, enhancing opportunities for remaining in rural areas for training, ensuring sustainable rural working conditions and using innovative service models. However, these policies need to be strongly integrated across the long medical workforce training pathway for successful rural workforce supply and distribution outcomes by locally trained doctors. Meanwhile, OTDs substantially continue to underpin Australia's rural medical service capacity. The training pathways and social support for OTDs in rural areas is critical given their ongoing contribution to Australia's rural medical workforce.

CONCLUSION

It is essential for Australia to monitor its ongoing reliance on OTDs in rural areas and be considerate of the potential impact on global workforce distribution.

Factors affecting medical students' interests in working in rural areas in North India-A qualitative inquiry

BACKGROUND AND OBJECTIVE

The shortage of doctors, especially in rural areas, is a major concern in India, which in turn affects the effective delivery of health care services. To support new policies able to address this issue, a study was conducted to determine the discouraging and encouraging factors affecting medical students' interests towards working in rural areas.

METHODS

This cross-sectional, descriptive qualitative study has been conducted in three states of North India. It comprised six focus group discussions, each consisting of 10-20 medical students of six government medical colleges. The verbatim and thematic codes have been transcribed by using a 'categorical aggregation approach'. The discussions were thematically analyzed.

RESULTS

Ninety medical students participated in the study. The discouraging factors were grouped under two broad themes namely unchallenging professional environment (poor accommodation facilities and lack of necessary infrastructure; lack of drug and equipment supplies; inadequate human resource support; lesser travel and research opportunities) and gap between financial rewards and social disadvantages (lower salary and incentives, social isolation, political interference, lack of security). Similarly, the encouraging factors were congregated under three main themes namely willingness to give back to disadvantaged communities (desire to serve poor, underprivileged and home community), broader clinical exposure (preferential admission in post-graduation after working more than 2-3 years in rural areas) and higher status and respect (achieving higher social status).

CONCLUSIONS

This qualitative study highlights key factors affecting medical students' interest to work in rural areas. A substantial similarity was noted between the factors which emerge from the current study and those documented in other countries. These findings will help policymakers and medical educators to design and implement a comprehensive human resource strategy that shall target specific factors to encourage medical students to choose job positions in rural areas.

Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health

Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.

Advancing the science behind human resources for health: highlights from the Health Policy and Systems Research Reader on Human Resources for Health

Health workers are central to people-centred health systems, resilient economies and sustainable development. Given the rising importance of the health workforce, changing human resource for health (HRH) policy and practice and recent health policy and systems research (HPSR) advances, it is critical to reassess and reinvigorate the science behind HRH as part of health systems strengthening and social development more broadly. Building on the recently published Health Policy and Systems Research Reader on Human Resources for Health (the Reader), this commentary reflects on the added value of HPSR underpinning HRH. HPSR does so by strengthening the multi-disciplinary base and rigour of HRH research by (1) valuing diverse research inferences and (2) deepening research enquiry and quality. It also anchors the relevance of HRH research for HRH policy and practice by (3) broadening conceptual boundaries and (4) strengthening policy engagement. Most importantly, HPSR enables us to transform HRH from being faceless numbers or units of health producers to the heart and soul of health systems and vital change agents in our communities and societies. Health workers' identities and motivation, daily routines and negotiations, and training and working environments are at the centre of successes and failures of health interventions, health system functioning and broader social development. Further, in an increasingly complex globalised economy, the expansion of the health sector as an arena for employment and the liberalisation of labour markets has contributed to the unprecedented movement of health workers, many or most of whom are women, not only between public and private health sectors, but also across borders. Yet, these political, human development and labour market realities are often set aside or elided altogether. Health workers' lives and livelihoods, their contributions and commitments, and their individual and collective agency are ignored. The science of HRH, offering new discoveries and deeper understanding of how universal health coverage and the Sustainable Development Goals are dependent on millions of health workers globally, has the potential to overcome this outdated and ineffective orthodoxy.

Setting the agenda for nurse leadership in India: what is missing

Background

Current policy priorities to strengthen the nursing sector in India have focused on increasing the number of nurses in the health system. However, the nursing sector is afflicted by other, significant problems including the low status of nurses in the hierarchy of health care professionals, low salaries, and out-dated systems of professional governance, all affecting nurses’ leadership potential and ability to perform. Stronger nurse leadership has the potential to support the achievement of health system goals, especially for strengthening of primary health care, which has been recognised and addressed in several other country contexts. This research study explores the process of policy agenda-setting for nurse leadership in India, and aims to identify the structural and systemic constraints in setting the agenda for policy reforms on the issue.

Methods

Our methods included policy document review and expert interviews. We identified policy reforms proposed by different government appointed committees on issues concerning nurses’ leadership and its progress. Experts’ accounts were used to understand lack of progress in several nursing reform proposals and analysed using deductive thematic analysis for ‘legitimacy’, ‘feasibility’ and ‘support’, in line with Hall’s agenda setting model.

Results

The absence of quantifiable evidence on the nurse leadership crisis and treatment of nursing reforms as a ‘second class’ issue were found to negatively influence perceptions of the legitimacy of nurse leadership reform. Feasibility is affected by the lack of representation of nurses in key positions and the absence of a nurse-specific institution, which is seen as essential for creating visibility of the issues facing the profession, their processing and planning for policy solutions. Finally, participants noted the lack of strong support from nurses themselves for these policy reforms, which they attributed to social disempowerment, and lack of professional autonomy.

Conclusions

The study emphasises that the nursing empowerment needs institutional reforms to facilitate nurse’s distributed leadership across the health system and to enable their collective advocacy that questions the status quo and the structures that uphold it.

Time motion study using mixed methods to assess service delivery by frontline health workers from South India: methods

BACKGROUND

In India, amidst the increasing number of health programmes, there are concerns about the performance of frontline health workers (FLHW). We assessed the time utilisation and factors affecting the work of frontline health workers from South India.

METHODS

This is a mixed methods study using time and motion (TAM) direct observations and qualitative enquiry among frontline/community health workers. These included 43 female and 6 male multipurpose health workers (namely, auxiliary nurse midwives (ANMs) and male-MPHWs), 12 nutrition and health workers (Anganwadi workers, AWWs) and 53 incentive-based community health workers (accredited social health activists, ASHAs). We conducted the study in two phases. In the formative phase, we conducted an in-depth inductive investigation to develop observation checklists and qualitative tools. The main study involved deductive approach for TAM observations. This enabled us to observe a larger sample to capture variations across non-tribal and tribal regions and different health cadres. For the main study, we developed GPRS-enabled android-based application to precisely record time, multi-tasking and field movement. We conducted non-participatory direct observations (home to home) for consecutively 6 days for each participant. We conducted in-depth interviews with all the participants and 33 of their supervisors and relevant officials. We conducted six focus group discussions (FGDs) with ASHAs and one FGD with ANMs to validate preliminary findings. We established a mechanism for quality assurance of data collection and analysis. We analysed the data separately for each cadre and stratified for non-tribal and tribal regions.

RESULTS

On any working day, the ANMs spent median 7:04 h, male-MPHWs spent median 5:44 h and AWWs spent median 6:50 h on the job. The time spent on the job was less among the FLHWs from tribal areas as compared to those from non-tribal areas. ANMs and AWWs prioritised maternal and child health, while male-MPHWs were involved in seasonal diseases and school health. ASHAs visited homes to provide maternal health, basic curative care, and follow-up of tuberculosis patients. The results describe issues related with work planning, time management and several systemic, community-based and personnel factors affecting work of FLHWs.

CONCLUSION

TAM study with mixed methods can help researchers as well as managers to periodically review work patterns, devise appropriate job responsibilities and improve the efficiency of health workers.

Heterogeneity in the background and earnings of nurses in India: evidence from a cross-sectional study in Gujarat

It is important to understand the service conditions of nurses because these influence nurses' motivations and ability to provide care. Although nurses are estimated to constitute 30% of India's health workforce, limited empirical information is available about them. This paper attempts to address this gap in research. A cross-sectional survey of 266 nurses in the state of Gujarat was conducted to understand the demographic characteristics, qualifications and employment features of nurses working in India's private and public health sectors. Descriptive and univariate analyses were performed using the collected information. A multivariate regression model was also estimated with monthly earnings as the dependent variable, and workplace, type of employment contract, caste background and years in the nursing workforce as independent variables. The three main findings presented in this article highlight considerable heterogeneity in the background and employment of nurses in India. First, 49% of nurses working in private hospitals and as temporary employees in public facilities belonged to historically disadvantaged social groups (deemed Scheduled Castes and Scheduled Tribes) and were estimated to earn 9% less than similarly qualified and practiced nurses from general caste categories (P = 0.02). Second, 18% of nurses working in private hospitals did not have formal nursing qualifications. Third, nurses working in private hospitals and as temporary employees in public facilities earned less than the minimum wage stipulated by the Government of India. Permanent public sector nurses were estimated to earn 105% more than private sector nurses with the same qualifications, years of work and caste background (P <  0.001). This study finds that the disproportionate presence of women and socially discriminated caste groups in the nursing workforce, coupled with the failure of governmental agencies to regulate the health sector, might help explain the low wages and lack of job security that most nurses in India contend with.

Causes, consequences, and policy responses to the migration of health workers: key findings from India

BACKGROUND

This study sought to better understand the drivers of skilled health professional migration, its consequences, and the various strategies countries have employed to mitigate its negative impacts. The study was conducted in four countries-Jamaica, India, the Philippines, and South Africa-that have historically been "sources" of health workers migrating to other countries. The aim of this paper is to present the findings from the Indian portion of the study.

METHODS

Data were collected using surveys of Indian generalist and specialist physicians, nurses, midwives, dentists, pharmacists, dieticians, and other allied health therapists. We also conducted structured interviews with key stakeholders representing government ministries, professional associations, regional health authorities, health care facilities, and educational institutions. Quantitative data were analyzed using descriptive statistics and regression models. Qualitative data were analyzed thematically.

RESULTS

Shortages of health workers are evident in certain parts of India and in certain specialty areas, but the degree and nature of such shortages are difficult to determine due to the lack of evidence and health information. The relationship of such shortages to international migration is not clear. Policy responses to health worker migration are also similarly embedded in wider processes aimed at health workforce management, but overall, there is no clear policy agenda to manage health worker migration. Decision-makers in India present conflicting options about the need or desirability of curtailing migration.

CONCLUSIONS

Consequences of health work migration on the Indian health care system are not easily discernable from other compounding factors. Research suggests that shortages of skilled health workers in India must be examined in relation to domestic policies on training, recruitment, and retention rather than viewed as a direct consequence of the international migration of health workers.

Leveraging the private sector for child health: a qualitative examination of caregiver and provider perspectives on private sector care for childhood pneumonia in Uttar Pradesh, India

BACKGROUND

The private health sector is a primary source of curative care for childhood illnesses in many low- and middle-income countries. Therefore ensuring appropriate private sector care is an important step towards improving outcomes from illnesses like pneumonia, which is the leading infectious cause of childhood mortality worldwide. This study aimed to provide evidence on private sector care for childhood pneumonia in Uttar Pradesh, India, by simultaneously exploring providers' knowledge and practices and caregivers' experiences.

METHODS

We conducted in-depth interviews with a purposive sample of 36 practitioners and 34 caregivers in two districts. Practitioners included allopathic doctors, AYUSH providers, and drug sellers. Caregivers were mothers of children under the age of five with symptoms consistent with pneumonia who had seen one of those practitioners. Interview transcripts were analyzed thematically.

RESULTS

Caregivers were generally prompt in seeking care outside the home, but many initially favored local informal providers based on access and cost. Drug sellers were not commonly consulted for treatment. Formal providers had imperfect, but reasonable, knowledge of pneumonia and followed appropriate steps for diagnosis, though some gaps were noticed that were primarily related to lack of (or failure to use) diagnostic tools. Most practitioners prescribed antibiotics and supportive symptomatic treatment. Relational and structural factors encouraged overuse of antibiotics and treatment interruption. Caregivers often had a limited understanding of treatment but wanted rapid symptomatic improvements, frequently leading to sequentially consulting multiple providers and interrupting treatment when symptoms improved. Providers were confronted with these expectations and care-seeking patterns.

CONCLUSIONS

This study contributes in-depth evidence on private sector care for childhood pneumonia in UP. Achieving appropriate care requires an enriched perspective that simultaneously considers the critical role of provider-caregiver interactions and of the context in which they occur in shaping treatment outcomes.

Health workforce metrics pre- and post-2015: a stimulus to public policy and planning

BACKGROUND

Evidence-based health workforce policies are essential to ensure the provision of high-quality health services and to support the attainment of universal health coverage (UHC). This paper describes the main characteristics of available health workforce data for 74 of the 75 countries identified under the 'Countdown to 2015' initiative as accounting for more than 95% of the world's maternal, newborn and child deaths. It also discusses best practices in the development of health workforce metrics post-2015.

METHODS

Using available health workforce data from the Global Health Workforce Statistics database from the Global Health Observatory, we generated descriptive statistics to explore the current status, recent trends in the number of skilled health professionals (SHPs: physicians, nurses, midwives) per 10 000 population, and future requirements to achieve adequate levels of health care in the 74 countries. A rapid literature review was conducted to obtain an overview of the types of methods and the types of data sources used in human resources for health (HRH) studies.

RESULTS

There are large intercountry and interregional differences in the density of SHPs to progress towards UHC in Countdown countries: a median of 10.2 per 10 000 population with range 1.6 to 142 per 10 000. Substantial efforts have been made in some countries to increase the availability of SHPs as shown by a positive average exponential growth rate (AEGR) in SHPs in 51% of Countdown countries for which there are data. Many of these countries will require large investments to achieve levels of workforce availability commensurate with UHC and the health-related sustainable development goals (SDGs). The availability, quality and comparability of global health workforce metrics remain limited. Most published workforce studies are descriptive, but more sophisticated needs-based workforce planning methods are being developed.

CONCLUSIONS

There is a need for high-quality, comprehensive, interoperable sources of HRH data to support all policies towards UHC and the health-related SDGs. The recent WHO-led initiative of supporting countries in the development of National Health Workforce Accounts is a very promising move towards purposive health workforce metrics post-2015. Such data will allow more countries to apply the latest methods for health workforce planning.

Next generation maternal health: external shocks and health-system innovations

In this Series we document the substantial progress in the reduction of maternal mortality and discuss the current state of science in reducing maternal mortality. However, maternal health is also powerfully influenced by the structures and resources of societies, communities, and health systems. We discuss the shocks from outside of the field of maternal health that will influence maternal survival including economic growth in low-income and middle-income countries, urbanisation, and health crises due to disease outbreaks, extreme weather, and conflict. Policy and technological innovations, such as universal health coverage, behavioural economics, mobile health, and the data revolution, are changing health systems and ushering in new approaches to affect the health of mothers. Research and policy will need to reflect the changing maternal health landscape.

Spirituality, Religiosity, and Health: a Comparison of Physicians' Attitudes in Brazil, India, and Indonesia

BACKGROUND

One of the biggest challenges in the spirituality, religiosity, and health field is to understand how patients and physicians from different cultures deal with spiritual and religious issues in clinical practice.

PURPOSE

The present study aims to compare physicians' perspectives on the influence of spirituality and religion (S/R) on health between Brazil, India, and Indonesia.

METHOD

This is a cross-sectional, cross-cultural, multi-center study carried out from 2010 to 2012, examining physicians' attitudes from two continents. Participants completed a self-rated questionnaire that collected information on sociodemographic characteristics, S/R involvement, and perspectives concerning religion, spirituality, and health. Differences between physicians' responses in each country were examined using chi-squared, ANOVA, and MANCOVA.

RESULTS

A total of 611 physicians (194 from Brazil, 295 from India, and 122 from Indonesia) completed the survey. Indonesian physicians were more religious and more likely to address S/R when caring for patients. Brazilian physicians were more likely to believe that S/R influenced patients' health. Brazilian and Indonesians were as likely as to believe that it is appropriate to talk and discuss S/R with patients, and more likely than Indians. No differences were found concerning attitudes toward spiritual issues.

CONCLUSION

Physicians from these different three countries had very different attitudes on spirituality, religiosity, and health. Ethnicity and culture can have an important influence on how spirituality is approached in medical practice. S/R curricula that train physicians how to address spirituality in clinical practice must take these differences into account.

The influence of training programs on career aspirations: evidence from a cross-sectional study of nursing students in India

BACKGROUND

Nurses form the largest share of India's health workforce. This paper explores the relationship between nurses' pre-service education and labor market aspirations. It investigates supply-side factors shaping students' career plans and studies the influence that nurse training institutes have on students' transition into the workforce.

METHODS

A cross-sectional survey of 266 nursing students and training administrators at 42 training institutes was conducted in 2014 in two Indian states, Bihar and Gujarat. Piloted questionnaires were used to collect information on the cost and quality of training programs, the background of students, and their career aspirations. Descriptive analyses and multivariate logistic regression analyses were conducted.

RESULTS

A multivariate model on students' post-graduation plans indicated that students whose institutes provided training in non-technical skills, such as communication and teamwork, were less likely to aim for public sector employment upon completing their training. Similarly, students who joined their training institute because they believed it to be the best place to access job opportunities were less likely to have intentions to seek public sector jobs. Students attending institutes that organized job fairs were also more likely to want to study further or seek private sector employment rather than seeking public sector employment. On the other hand, studying in Bihar and belonging to historically disadvantaged social groups (deemed Scheduled Castes and Scheduled Tribes by the Constitution of India) were factors positively associated with plans to seek public sector employment.

CONCLUSIONS

This study helps explain some of the supply-side factors driving the preference for public sector employment among nurses in India by highlighting the influential role of caste, state-level characteristics, and training programs on nursing students' post-graduation plans. It demonstrates that the strong preference for government jobs among nursing students is linked to the limited role training institutes play in connecting students with other potential employers. In addition, the study indicates that training in non-technical skills, such as communication, makes students more open to pursuing private sector jobs and advanced training programs.

Using 'appreciative inquiry' in India to improve infection control practices in maternity care: a qualitative study

BACKGROUND

Infections acquired during childbirth are a common cause of maternal and perinatal mortality and morbidity. Changing provider behaviour and organisational settings within the health system is key to reducing the spread of infection.

OBJECTIVE

To explore the opinions of health personnel on health system factors related to infection control and their perceptions of change in a sample of hospital maternity units.

DESIGN

An organisational change process called 'appreciative inquiry' (AI) was introduced in three maternity units of hospitals in Gujarat, India. AI is a change process that builds on recognition of positive actions, behaviours, and attitudes. In-depth interviews were conducted with health personnel to elicit information on the environment within which they work, including physical and organisational factors, motivation, awareness, practices, perceptions of their role, and other health system factors related to infection control activities. Data were obtained from three hospitals which implemented AI and another three not involved in the intervention.

RESULTS

Challenges which emerged included management processes (e.g. decision-making and problem-solving modalities), human resource shortages, and physical infrastructure (e.g. space, water, and electricity supplies). AI was perceived as having a positive influence on infection control practices. Respondents also said that management processes improved although some hospitals had already undergone an accreditation process which could have influenced the changes described. Participants reported that team relationships had been strengthened due to AI.

CONCLUSION

Technical knowledge is often emphasised in health care settings and less attention is paid to factors such as team relationships, leadership, and problem solving. AI can contribute to improving infection control by catalysing and creating forums for team building, shared decision making and problem solving in an enabling environment.

Perception and prevalence of work-related health hazards among health care workers in public health facilities in southern India

BACKGROUND

Health care workers (HCWs) are exposed to occupational related health hazards. Measuring worker perception and the prevalence of these hazards can help facilitate better risk management for HCWs, as these workers are envisaged to be the first point of contact, especially in resource poor settings.

OBJECTIVE

To describe the perception of occupational health hazards and self-reported exposure prevalence among HCWs in Southern India.

METHODS

We used cross sectional design with stratified random sampling of HCWs from different levels of health facilities and categories in a randomly selected district in Southern India. Data on perception and exposure prevalence were collected using a structured interview schedule developed by occupational health experts and administered by trained investigators.

RESULTS

A total of 482 HCWs participated. Thirty nine percent did not recognize work-related health hazards, but reported exposure to at least one hazard upon further probing. Among the 81·5% who reported exposure to biological hazard, 93·9% had direct skin contact with infectious materials. Among HCWs reporting needle stick injury, 70·5% had at least one in the previous three months. Ergonomic hazards included lifting heavy objects (42%) and standing for long hours (37%). Psychological hazards included negative feelings (20·3%) and verbal or physical abuse during work (20·5%).

CONCLUSION

More than a third of HCWs failed to recognize work-related health hazards. Despite training in handling infectious materials, HCWs reported direct skin contact with infectious materials and needle stick injuries. RESULTS indicate the need for training oriented toward behavioral change and provision of occupational health services.

Challenges to effective cancer control in China, India, and Russia

Cancer is one of the major non-communicable diseases posing a threat to world health. Unfortunately, improvements in socioeconomic conditions are usually associated with increased cancer incidence. In this Commission, we focus on China, India, and Russia, which share rapidly rising cancer incidence and have cancer mortality rates that are nearly twice as high as in the UK or the USA, vast geographies, growing economies, ageing populations, increasingly westernised lifestyles, relatively disenfranchised subpopulations, serious contamination of the environment, and uncontrolled cancer-causing communicable infections. We describe the overall state of health and cancer control in each country and additional specific issues for consideration: for China, access to care, contamination of the environment, and cancer fatalism and traditional medicine; for India, affordability of care, provision of adequate health personnel, and sociocultural barriers to cancer control; and for Russia, monitoring of the burden of cancer, societal attitudes towards cancer prevention, effects of inequitable treatment and access to medicine, and a need for improved international engagement.

Rural clinician scarcity and job preferences of doctors and nurses in India: a discrete choice experiment

The scarcity of rural doctors has undermined the ability of health systems in low and middle-income countries like India to provide quality services to rural populations. This study examines job preferences of doctors and nurses to inform what works in terms of rural recruitment strategies. Job acceptance of different strategies was compared to identify policy options for increasing the availability of clinical providers in rural areas. In 2010 a Discrete Choice Experiment was conducted in India. The study sample included final year medical and nursing students, and in-service doctors and nurses serving at Primary Health Centers. Eight job attributes were identified and a D-efficient fractional factorial design was used to construct pairs of job choices. Respondent acceptance of job choices was analyzed using multi-level logistic regression. Location mattered; jobs in areas offering urban amenities had a high likelihood of being accepted. Higher salary had small effect on doctor, but large effect on nurse, acceptance of rural jobs. At five times current salary levels, 13% (31%) of medical students (doctors) were willing to accept rural jobs. At half this level, 61% (52%) of nursing students (nurses) accepted a rural job. The strategy of reserving seats for specialist training in exchange for rural service had a large effect on job acceptance among doctors, nurses and nursing students. For doctors and nurses, properly staffed and equipped health facilities, and housing had small effects on job acceptance. Rural upbringing was not associated with rural job acceptance. Incentivizing doctors for rural service is expensive. A broader strategy of substantial salary increases with improved living, working environment, and education incentives is necessary. For both doctors and nurses, the usual strategies of moderate salary increases, good facility infrastructure, and housing will not be effective. Non-physician clinicians like nurse-practitioners offer an affordable alternative for delivering rural health care.

For more than love or money: attitudes of student and in-service health workers towards rural service in India

BACKGROUND

While international literature on rural retention is expanding, there is a lack of research on relevant strategies from pluralistic healthcare environments such as India, where alternate medicine is an integral component of primary care. In such contexts, there is a constant tug of war in national policy on "Which health worker is needed in rural areas?" and "Who can, realistically, be got there?" In this article, we try to inform this debate by juxtaposing perspectives of three cadres involved in primary care in India-allopathic, ayurvedic and nursing-on rural service. We also identify key incentives for improved rural retention of these cadres.

METHODS

We present qualitative evidence from two states, Uttarakhand and Andhra Pradesh. Eighty-eight in-depth interviews with students and in-service personnel were conducted between January and July 2010. Generic thematic analysis techniques were employed, and the data were organized in a framework that clustered factors linked to rural service as organizational (salary, infrastructure, career) and contextual (housing, children's development, safety).

RESULTS

Similar to other studies, we found that both pecuniary and non-pecuniary factors (salary, working conditions, children's education, living conditions and safety) affect career preferences of health workers. For the allopathic cadre, rural primary care jobs commanded little respect; respondents from this cadre aimed to specialize and preferred private sector jobs. Offering preferential admission to specialist courses in exchange for a rural stint appears to be a powerful incentive for this cadre. In contrast, respondents from the Ayurvedic and nursing cadres favored public sector jobs even if this meant rural postings. For these two cadres, better salary, working and rural living conditions can increase recruitment.

CONCLUSIONS

Rural retention strategies in India have predominantly concentrated on the allopathic cadre. Our study suggests incentivizing rural service for the nursing and Ayurvedic cadres is less challenging in comparison to the allopathic cadre. Hence, there is merit in strengthening rural incentive strategies for these two cadres also. In our study, we have developed a detailed framework of rural retention factors and used this for delineating India-specific recommendations. This framework can be adapted to other similar contexts to facilitate international cross-cadre comparisons.

Which doctor for primary health care? Quality of care and non-physician clinicians in India

The scarcity of rural physicians in India has resulted in non-physician clinicians (NPC) serving at primary health centers (PHC). This study examines the clinical competence of NPCs and physicians serving at PHCs to treat a range of medical conditions. The study is set in Chhattisgarh state, where physicians (medical officers) and NPCs: Rural Medical Assistants (RMA), and Indian system of medicine physicians (AYUSH Medical Officers) serve at PHCs. Where no clinician is available, Paramedics (pharmacists and nurses) usually provide care. In 2009, PHCs in Chhattisgarh were stratified by type of clinical care provider present. From each stratum a representative sample of PHCs was randomly selected. Clinical vignettes were used to measure provider competency in managing diarrhea, pneumonia, malaria, TB, preeclampsia and diabetes. Prescriptions were analyzed. Overall, the quality of medical care was low. Medical Officers and RMAs had similar average competence scores. AYUSH Medical Officers and Paramedicals had significantly lower average scores compared to Medical Officers. Paramedicals had the lowest competence scores. While 61% of Medical Officer and RMA prescriptions were appropriate for treating the health condition, only 51% of the AYUSH Medical Officer and 33% of the prescriptions met this standard. RMAs are as competent as physicians in primary care settings. This supports the use of RMA-type clinicians for primary care in areas where posting Medical Officers is difficult. AYUSH Medical Officers are less competent and need further clinical training. Overall, the quality of medical care at PHCs needs improvement.