Healthcare for all is probably India’s most ambitious and necessary dream. However, it would be impossible to achieve without an adequate number of well-trained and professionally content health workers placed to serve the socio-demographically diverse people spread across the vast subcontinent. Our governance and policymakers recognize the importance of health workers in India’s health system and broader society. India has voluntarily adopted achieving 45 allopathic doctors, nurses and midwives per 10,000 people as one of its ten health-related Sustainable Development Goals (SDG) targets.
Since 2018, NITI Aayog, the apex governamental think tank has been tracking India’s and its states’ performance for achieving this target. As of 2020-21, the most recent year for data reporting, numbers from NITI Aayog tell us that India lags the target by about 8 doctors, nurses, and midwives per 10,000 people translating to a shortage of over 50 lakhs of these health workers. While this by itself might be disappointing, there has been improvement in the longer run. The census data from 1981 to 2011, shows over a 220% increase in the density of allopathic doctors, nurses and midwives per 10,000. However, this is mostly driven by the increase in nurses and midwives and not doctors (Graphic 1).
A more interesting and important picture emerges when we look at states. Some states/union territories (UTs), such as Andhra Pradesh and Delhi, have already achieved the SDG target and are well above it while others like Jharkhand and Nagaland are arguably not going to achieve it even by 2030 if the current trends follow. The NITI Aayog report points to a more complex problem. Achieving the SDG target for India is not the same as achieving that target for all Indians. This problem has been well known to those working in health research and related fields. For example, other health researchers have brought out the issue of how countries fail their poor people when they attempt to achieve such targets by making things increasingly better for their middle and upper-middle classes since that’s easier to do financially. However, such an approach would be unjust in a country as large and as diverse as India. India needs to aim for health equity to achieve the SDG target for all Indians.
It becomes crucial to identify the areas of disparity with regards to health worker availability that need to be addressed. There are several disparities that we as people need to be aware of. First is the rural-urban gap. India is still largely rural with about 65% of its population living in rural areas in most parts of the country. Yet, rural India is largely underserved. For instance, according to research using Periodic Labour Force Survey data, as of 2018, about 27% of doctors and 36% of nurses provided care in rural areas. More daunting is the fact that the rural-urban gap has remained somewhat consistent over forty years from 1981 to 2011 (Graphic 2). Immediate policy attention, targeted investments, and some innovative multi-stakeholder approaches engaging young health workers are needed to solve the chronic problem of rural health workforce shortage. The second disparity is that between public and private health care sectors. Better pays and professional opportunities promote health workers, especially doctors, to go for employment in the private sector – from small independent clinics to large corporate-run hospitals. Past research using National Sample Survey data of 2011-12 has shown that over 80% of allopathic doctors and 55% of nurses and midwives in India are employed in the private sector. This creates massive problems for a large section of the Indian population that has to rely on the public health system due to financial and other reasons. India’s equitable journey towards health SDG achievement relies on scaling up recruitment and retention of health workers in the public sector.
The intersection of health sectors (public vs. private) and regionality (rural vs. urban) reveals that high policy attention is needed towards the health workforce in rural public health centres. For instance, data from Rural Health Statistics reveals that in 2020-21, rural primary and community health care centres (PHCs and CHCs) had comparably less doctors, nurses and midwives per centre than their urban counterparts (Graphic 3). The rural-urban gap was particularly pronounced for auxiliary nurse midwives (ANMs) at PHCs, and nurses and specialist doctors (surgeons, internists, gynaecologists, etc.) at CHCs. Only exception was general duty medical officers (GDMOs – MBBS-level allopathic doctors) in CHCs, where rural regions did marginally better than urban regions.
Finally, we need to be mindful of the geographical differences. Going beyond the NITI Aayog’s state-level data, the previous 2011 census data informs that there is a large heterogeneity across over 640 districts for availability of allopathic doctors, nurses and midwives (Graphic 4). This heterogeneity translates to differential target achievement with only 42 districts (6.56%) crossing India’s SDG target threshold of 45 doctors, nurses, and midwives per 10,000 people. Hence, local policy making and planning is the key to solving the shortage problem for all Indians.
While we should be positive about the progress in the last several years, specific efforts focusing on health equity that engage stakeholders at all levels from local to national are needed to achieve the health workforce SDG target for citizens of the largest democracy in the world.
The article has been authored by Siddhesh Zadey, Commission Fellow, Lancet Citizens’ Commission for Reimagining India’s Health System.