Human resources for health

Human resources for health

Ramachandran, Prema

Human resources for health (HRH) are at the heart of India’s health system providing preventive, promotive, curative and rehabilitative services to the population. They make the health system functional, deliver services, generate resources and monitor performance. Their contribution to the unprecedented improvement in health status of the population in India during the last five decades is well recognized.

However, over the last two decades a HRH crisis is emerging because of the apparent inability of the growing HRH to (i) build up an integrated health system with appropriate screening and efficient referral linkages to provide access to needed care at appropriate level; (ii) translate increasing investments in health care into commensurate improvement in access to health care and health indices of the population; and (iii) bridge the ever widening gap between what is technologically possible and what is affordable in health care.

The crisis in HRH is not unique to India ; all countries – both developed and developing- have been witnessing this problem. HRH have a critical role in resolving the crisis by realigning the health policies, strategies and programmes in an increasingly pluralistic health system, so that equitable, good quality essential health care is made available to all al an affordable cost. In order to address this crisis, WHO is launching the Health Work Force Decade (2006-2015) during which HRH related WHO activities will cover countries, institutions and individuals, enable them to improve their health systems, and get the right number of service providers, with the right skills, to the right place at the right time, so that there is sustained improvement in health status of the population.

The curtain raiser will he the release of World Health Report 2006 devoted to the HRH on the World Health Day 2006.

Golden era of HRH in India: 1950-1990

In 1950 India had 50,000 medical graduates and similar number of nurses mostly working in urban hospitals and providing care to those who came to them. Access to health care and health indices of the population was poor in rural areas. The country then embarked on a massive expansion of medical and para-professional training, so that there are adequate number of health professionals to provide the health care needs of the growing population in urban and rural areas’. Medical education was not expensive. Talented students were attracted because there were excellent employment opportunities after graduation. During the period 1950-1990 the number of persons trained in health related educational institutions was sufficient to man the growing health care infrastructure in government, voluntary and private sectors. Improved access to health care and technological advances, which were relatively inexpensive and easy to implement, enabled India to achieve substantial improvement in health indices of the population and a steep decline in mortality1. Right from the sixties educational institutions in India have been training students from neighbouring countries and these students have played an important role in building up the health care services in their own countries. Inspite of several constraints, Indian health professionals and para-professionals have migrated to developed and developing countries and have gained global recognition for their knowledge, skills and commitment. 11 the objective of medical education is to train adequate number of professionals and para-professionals to man the health services, it would appear that by nineties India had achieved the objective.

HRH during health transition

The nineties witnessed a sea change in health sector. The demand for professional and paraprofessional education in health sector continued unabated because it was seen as passport for better life:4. Earlier government funded most medical, nursing and para-professional education; over the last two decades, private sector investment to meet the demand for professional and para-professional education in health sector has increased. As of July 2004, there are 229 medical colleges in India (104 in private sector) with admission capacity of 25,500 students per year5. About 20,000 Indian Systems of Medicine & Homeopathy (ISM&H) practitioners graduate every year. There is a continuing parallel growth in dental, nursing and para-professional training institutions and persons graduating from these. Professional and para-professional education has become expensive, more so in the institutions funded by private sector. This inevitably has some impact both in type of students enrolling for the courses and their career plans. The growing trend for focus on commercially viable tertiary/ superspeciality care and lack of interest in public health might partly be due to this phenomenon.

Review of current situation of pre-service training of HRH shows that medical colleges, nursing schools and para-professional training institutions are unevenly distributed; some States with poor infrastructure and inadequate medical manpower have very few training institutions. Medical educationists feel that over the years there has been a decline in quality of medical education. About one fourth of the teaching posts in medical colleges are vacant; persons with no teaching experience occupy many teaching posts. Lack of qualified faculty will have adverse impact on quality of medical education and inevitably lead to poor quality of health care. The current system of medical education does not appear to enable the students to develop clinical and analytical skills required for functioning effectively in the primary health care settings. Both teachers and students have problems in coping with the explosive expansion in medical knowledge and technology during the last two decades.

In spite of the fact that there is no dearth of HRH, and there is underemployment among them, there are very few hospitals or doctors in urban slum, remote rural and tribal areas where morbidity and mortality rates are high and health care is desperately needed. Even in urban areas where there are large number of trained doctors, untrained quacks provide health care. The family doctor who provided essential primary health care to the family is no longer there – too few to take up ‘family medicine’.

During the 1990s the mortality rates have plateaued. Prevalence of morbidity due to communicable diseases has not declined and infections have become more difficult to combat because of development of antibiotics resistant strains of bacteria and emergence of HIV infection. Longevity and changing life style have resulted in the increasing prevalence of obesity, diabetes and non communicable diseases, which require life long treatment. Health system was unable to ensure access to essential primary health care for these health problems. Most public health programmes suffer because of inadequate number of personnel, many of whom do not have the necessary skills to ensure that the programmes are implemented correctly and efficiently. The conclusion that medical education has not succeeded in creating a workforce that can cope with rapidly changing health scenario, keep people healthy and meet their health care needs when they fall ill, appears inescapable; this shows that country’s medical education programme requires modification.

Why did this crisis develop?

Two major factors are responsible for the emerging HRH crisis. The first is that planning for development of HRH has not received the attention it deserves1,2. Consequently there had been persistent problems in ensuring that the health systems have the right mix of workforce with appropriate attitude, capacity, knowledge and skills needed to deliver equitable good quality health care and ensure continued improvement in health status of the population1,2. Current HRH get very little exposure to the concepts of effectiveness, efficiency and equity in health care; consequently most of them have difficulty in prioritizing interventions based on these criteria. Health management which deals with systematic planning, organization, use of human, technical and financial resources of the health system to achieve stated health goals in the most efficient and cost-effective manner gets very little emphasis in undergraduate, postgraduate curriculum or even m inservice training programmes. Poor knowledge and understanding of health management by medical personnel is one of the major factors responsible for suboptimal performance of health system.

There has been underinvestment in all aspects of development of HRH including training to cope with the rapid demographic/health transition and tremendous improvement in health care related technologies. Health manpower requirements vary depending upon stage of epidemiological transition, the availability of institutions, income elasticity and public and private expenditure on health’. The requirement of HRH belonging to different categories is not being periodically reviewed and revised in keeping with changing health care needs. As a result there is underemployment among doctors and unemployment among para-professionals. Career aspirations of the HRH have not been factored into human resource development plans for health sector and hence there is a mismatch between need for health manpower and its availability at the right place and time.

Modification of medical curriculum

Medical Council of India (MCI) revised the undergraduate curriculum in 1997” and has set the following objectives: (i) Recognize ‘health for all’ as a national goal and right of all citizens for health; fulfil his/her obligations towards realization of this goal. (ii) Learn national health policies and programmes; devote to their effective implementation. (iii) Achieve competence in practice of holistic medicine, encompassing promotive, preventive health, curative and rehabilitative aspects of diseases. (iv) Develop scientific temper and proficiency in profession, (v) Become exemplary citizen by observing medical ethics, responding to national aspirations, fulfilling social and professional obligations.

However, the MCI curriculum does not seem to have got translated into action in medical colleges. The National Health Policy-20024 has stated that “the curriculum being followed in the graduate/ postgraduate courses is outdated and unrelated to contemporary community needs because, it does not reflect the needed response to ongoing socioeconomic, demographic, nutrition and health transition; does not provide the needed problem based learning for assessment of risk/benefit, cost benefit and cost-efficiency in health care and provide appropriate affordable intervention; and does not have public health orientation needed to achieve national health goals”.

Outcome-based education

There is a growing recognition that educational outcomes rather than the educational process should be the yardstick for assessment of medical education. Currently student training and examination system assesses whether the student has the knowledge in basic and clinical sciences and underlying principles but tails to assess whether (i) he has appropriate attitudes, ethical understanding and appropriate decision-making skills based on clinical reasoning and judgment; (ii) he as a professional, understands his role within the health system and the society; and (iii) he will be able to fulfil his responsibilities and obligations.

If the focus shifts to performance of the product of medical education – the kind of doctors produced, their professional knowledge, skills, abilities, values and attitudes, it may pay rich dividends.

A similar approach at service level would ensure that the questions as to why are HRH performing suboptimally. and how to enable them to perform optimally by modifying their training and working environment, are answered. The poor performance under service conditions might call for changes in salary structure, working environment, monitory and non monitory incentives to retain the workforce in the areas where they are needed. Continuous professional development (CPD) courses are required so that they learn to cope with changing requirements for effective functioning. These reforms can bring about dramatic improvement in performance of HRH under service conditions.

Learning and skill upgradation are life long processes for HRH; CPD plays a key role of health workforce strengthening. Currently, continuing medical education (CME)/CPD are highly fragmented, focusing on and often financed by disease control and reproductive health programmes. A major overhaul of CPD is required to ensure that HRH at all levels, undergo life long periodic upgradation of their knowledge and skills so that they strive to improve the quality of care in all settings.

Way forward

It is well recognized that the HRH are the most powerful resources for ensuring good health in any population. Strategies for HRH development in India should focus on (i) supporting the development of health workforce policies within a country’s overall development policies; (ii) assessing the number and nature of health service providers needed to address national health priorities and ensuring their production; (iii) investing in improving quality of teachers involved in pre-service education and inservice training; (iv) developing benchmarks and guidelines for accreditation of educational institutions to ensure standards of competence and ethical professional practice; (v) exploring policy options for recruitment, placement, management and retention of health workforce to ensure efficient and effective health system; (vi) enhancing the performance of public and private health systems, harmonizing the work of health workers in vertical disease control programmes with health systems activities; (vii) promoting equity by correcting skillmix imbalances, geographical (urban- rural interstate) maldistributions and enabling the country to attain the national health goals; and (viii) effective use of Information Technology (IT) and Information Technology Enabled Services (ITES) to ensure competent faculty with adequate communication skills to provide excellent educational material to HRH even in remote areas.

As an incidental byproduct of HRH developing and sustaining an effective and efficient health system for the country, is the possibility that India can become medical education destination with excellent teachers and wealth of clinical material and successful public health programmes; medical tourism destination providing good quality health care at affordable cost to developed and developing country people; and R&D destination especially for clinical trials.

The Indian health sector can become the major service sector that can contribute to the GDP growth. The development and accreditation procedures followed by health system in their attempt to become a stakeholder in the global health, will have a major impact on improving the quality of care in the country. The apprehension that these developments can have adverse effect on the health care for Indians, can be allayed through the demonstration that progress begins with health care for Indians. India’s major strength has been its ability to thrive by coping successfully with vast and varied problems. It is hoped that Indian HRH will demonstrate how the current HRH crisis can be turned into an opportunity to provide simultaneously excellent preventive/public health and clinical care at affordable cost not only for Indians but also for other nationals who seek care.

References

1. Planning Commission, New Delhi: Tenth Five Year Plan (2002-07). Available at www.planning commission.nic.in/ planrel/fiveyr/10th/default.htm, accessed on 28.03.2006.

2. World Health Organisation, Geneva. Draft World Health Report 2006. Available from www.who.hrh.whr06_consultation/cn/ index8.html, accessed on 28.03.2006.

3. WHO – WFME Task force: WHO-WFME Joint Policy on improvement in medical education action plan 2004-06. Available from www.sund.kudk/wfme/activities/WHOWFME JOINT POLICY_20140105KARLE.pdf, accessed on 28.03.2006.

4. Ministry of Health and Family Welfare, New Delhi. National Health Policy – 2002. Available from www.mohfw.nic.in/ np2002.htm, accessed on 28.03.2006.

5. Ministry of Health and Family Welfare: Report of the Macroeconomic Commission on Health, New Delhi. 2005.

6. Medical Council of India: Regulation of graduate medical examination; MCI – New Delhi; 1997.

Prema Ramachandran

Nutrition Foundation of India

C-13, Qutab Institutional Area

New Delhi I 10016, India

e-mail: premaramachandran@gmail.com

Copyright Indian Council of Medical Research Apr 2006

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