Title - Health Human Resources in Hospitals: A review of recent evidence

Name – Prof. Mandakini Rajendra Bhosale

Address for Correspondence

Sindhunagar, LIG,

Block 46/6, Sector 25,

Pradhikaran, Nigdi, Pune - 411044

Lecturers

P.E. Society’s Institute of Management and Career Development,

Nigdi, Pune – 411044

Mobile – 9822789288.

Abstract

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Health Human Resources (HHR) — also known as “human resources for health” (HRH) or

“health workforce” — refers to the study and development of strategies to address human

resources issues for the healthcare sector. In its World Health Report 2006 the World Health

Organization defines human resources in health as “all people engaged in actions whose primary

intent is to enhance health. Health human resources are identified as one of the core building

blocks of a health system. India stands compared unfavourably with world levels, even with low

income countries, in the capacities of human resources. The number of physicians per 10000

populations for the world is 1.5, for India it is 7 which is at par with low income countries. The

number of nurses per 10000 populations in India is 8, while it is 33 for the world and 16 for low

income countries. At time when WHO is aiming to achieve a Doctor-Population ratio of

1:1000, India will not be able to do so before 2031. It is estimated that there will be still a

shortage of 9.54 lakh doctors. It is very pertinent that we have a proper framework of the public

health workforce, their classifications and standards, their career pathways and progression to

maintain a good quality of public health workforce. This is central to effective delivery of public

health services. However, it is a very complex exercise to bring the entire public health

workforce under a singular responsibility and under one banner.

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Health Human Resources (HHR) — also known as “human resources for health” (HRH) or

“health workforce” — refers to the study and development of strategies to address human

resources issues for the healthcare sector. In its World Health Report 2006 the World Health

Organization defines human resources in health as “all people engaged in actions whose primary

intent is to enhance health. Health human resources are identified as one of the core building

blocks of a health system. They include physicians, nurses, dentists, allied health professions,

community health workers and other health care providers, as well as health management and

support personnel – those who may not deliver services directly but are essential to effective

health system functioning, including health services managers, medical records and health

information technicians, health economists, medical secretaries, and others.

Health workers in adequate numbers, in the proper places, properly trained, motivated and

supported are the backbone of an effective, equitable, and efficient public health care system.

To deliver public health a large work force is necessary to cover diverse areas of public health
activities like

• Disease outbreaks;

• Public health emergencies;

• Health establishments and all the facilities providing health services;

• Health nuisances and bio-medical waste;

• Availability and accessibility of safe drinking water;

• Sanitation and environmental hygiene, including waste management for every kind of
waste;

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• Hygiene and safety in places and situations of public health importance including fairs,

festivals, cinema, theatres, circuses, markets, shopping places, malls, lodging houses,

burial and burning grounds, slaughter houses;

• Environmental disasters, environmental safety,

• Occupational safety and industrial hygiene;

• Health Impact Assessment (HIA) of all new development projects;

• Protection from and abatement of hazardous and injurious substances and activities or

any other health hazards;

• Lifestyle related diseases; mental illnesses, widely prevalent diseases; public health

related factors like use of tobacco, alcoholism and other substance abuse, and

consumption of unhealthy foods; and promotion of healthy lifestyles like breast feeding,

health seeking behavior, balanced diet, regular exercising, food and water safety,

including with regard to their packaging, labeling, advertising and sale and consumer

protection, including regulating advertising and taxation and excise polices that have

impact on these;

• Road and transport safety, accident injuries/ trauma care;

• Special public health measures for vulnerable or marginalized individuals and groups of

population; and

• Any other public health measures towards ensuring health and well being of all, including

physical, emotional and mental health.

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Public health in its present form is thus a combination of several disciplines viz. epidemiology,

bio-statistics, laboratory sciences, social sciences, demography etc and requires diverse skills like

epidemiological investigations, surveillance and response, evaluation etc and several categories

of professionals are involved in the delivery of public health.

Therefore it is very pertinent that we have a proper framework of the public health workforce,

their classifications and standards, their career pathways and progression to maintain a good

quality of public health workforce. This is central to effective delivery of public health services.

However, it is a very complex exercise to bring the entire public health workforce under a

singular responsibility and under one banner.

Methods -

Explored the published literature and collected data through secondary sources.

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 Processes of Retention in public health workforce

INFORMATION BASED
POLICY AND

DECISION MAKING

HR MANAGEMENT
PROGRAMMING
ORGANIZATIONAL FACTORS INDIDUAL EMPLOYEE
External FACTORS
Environment
Informational Life/job
issues on HRM PROGRAMME satisfaction
Vacancies
IMPLEMENTATION
Recruitment
Process Ambition/care
Poor, Working er aspiration
Conditions
Unfair or Lack Qualification /
of Promotion PROGRAMME experience
Poor. Living
EVALUATION
Conditions Parental/famil
Frequent/ y mobility
Unsatisfactory
transfer Personality
factors
Low Salaries
Lack of
External
Environment Poor excitement/In
novation
Retention

Large
Recruitment Number of
bottle neck Vacancies
6

Few medical
colleges and
PH schools
 councils
Poor retention
Inadequate supply

Recruitment bottle
necks

Few medical
colleges and
PH schools
Regulation from
India has a councils
severe shortage of human resources for health. It has a shortage of qualified health
Poor retention
workers Inadequate
and the supply
workforce is concentrated in urban areas. Bringing qualified health workers to
Recruitment bottle
rural, remote, and underserved areas is very challenging. Many Indians, especially those living in
necks

Few medical
rural areas, receive care from unqualified providers. The migration of qualified allopathic doctors
colleges and
PH schools
Regulation from
and nurses iscouncils
substantial and further strains the system. Nurses do not have much authority or say
Poor retention
Inadequate supply
within the health system, and the resources to train them are still inadequate. Little attention is
Recruitment bottle
paid during necks
medical education to the medical and public health needs of the population, and the
Few medical
rapid privatization
colleges andof medical and nursing education has implications for its quality and
PH schools
Regulation from
governance.councils
Such issues are a result of under investment in and poor governance of the health
Poor retention
sector—two issues that the government urgently needs to address. A comprehensive national
Recruitment bottle
necks
policy for human resources is needed to achieve universal health care in India.
Few medical
colleges and
The public PH
sector will
schools need to redesign appropriate packages of monetary and non-monetary
Regulation from
councils
incentives toretention
Poor encourage qualified health workers to work in rural and remote areas. Such a policy

might also encourage

Recruitment bottle task-shifting and mainstreaming doctors and practitioners who practice
necks

traditional Indian medicine (ayurveda, yoga and naturopathy, unani, and siddha) and
Few medical
colleges and
PH schools
homoeopathy to from
Regulation work in these areas while adopting other innovative ways of augmenting human
councils
Poor retentionv
resources for health. At the same time, additional investments will be needed to improve the
Recruitment bottle
necks
relevance, quantity, and quality of nursing, medical, and public health education in the country.

Health workers inbottle

Recruitment India
necks
 Doctors (allopathic): medical graduates with a bachelor‘s or postgraduate specialist

diploma orbottle
Recruitment degree registered with the Indian Medical Council.
necks
 Practitioners of ayurveda, yoga and naturopathy, unani, siddha, and homoeopathy:

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 Medical graduates with a bachelor’s or postgraduate degree in ayurveda, unani, siddha, or

homoeopathy registered with the Central Council for Indian Medicine or the Central

Council for Homoeopathy.

 Nurses: have a diploma in General Nursing and Midwifery (3·5 year course) or a 4-year

bachelors degree or a 2–3-year postgraduate degree registered with the Indian Nursing

Council.
 Dentists: graduates with a bachelor’s or postgraduate degree in dentistry registered with

the Dental Council of India.

 Auxiliary nurse midwives: have a diploma in auxiliary nurse midwifery (2-year course).
 Pharmacists: have a diploma or bachelor’s degree course in pharmacy.
 Technicians and allied health professionals: professionals who have undertaken

specialized studies, including laboratory technicians, radiology technicians, dental

assistants, and other technical staff. Allied health professionals include dieticians,
 nutritionists, opticians, physiotherapists, and administrators.
 Community health workers: professionals who have completed 10 years of formal

education and have undergone a 23-day training course. Other community health workers

include health educators and health assistants.

 Accredited social health activists: trained community health volunteers who reside in a

village, have completed 8 years of formal education, and are preferably aged 25–45

years.
 Registered medical practitioner: unlicensed health practitioners who give allopathic

treatment and work in rural areas with little or no formal medical training.
 Traditional medicine practitioners and faith healers: treat physical and mental illnesses

with the help of selling talismans and charms, and by performing special rites.

Initiatives to attract qualified health workers to underserved areas

Monetary incentives

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Most states in India offer a higher salary for public sector medical officers serving in rural or

remote areas than for those serving in urban areas, though the amount of the incentive varies

between states.

Educational incentives

Compulsory rural service bonds have been introduced by some states (e.g., Tamil Nadu and

Kerala for specialist doctors and Meghalaya for general doctors) in exchange for subsidized,

government-provided medical education. Other states have introduced mandatory rural service

for a doctor to be considered for admission to postgraduate specialisation programmes. Other

states, such as Tamil Nadu, Gujarat, and Andhra Pradesh, reserve postgraduate seats for or give

preference to those who have completed a specific c number of years of rural service.

Workforce policies

Haryana has adopted a simplified, decentralized recruitment process with incentive packages as a

way of filling medical officer and specialist vacancies. West Bengal has introduced location-

specific recruitment of candidates from underserviced areas. These candidates have to undergo

an 18-month training course for nurse midwives after which they are posted in their respective

local facilities.

New cadres

In Chhattisgarh, Assam, and West Bengal, a 3-year course for the provision of a rural medical

practitioner with adequate skills for primary health care has been introduced and it has helped fi

ll most vacancies in the public sector. In most Indian states, physicians trained in ayurveda, yoga

and naturopathy, unani, siddha, and homoeopathy are being recruited to primary health centre,

where they often serve as medical officers. In Rajasthan, nurse practitioners are being used for

primary health care in select areas.

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Public–private partnerships

These take several forms; the most common is the temporary employment (from private

hospitals) of physicians (and other staff) to fill vacancies. In Karnataka and Arunachal Pradesh,

select primary health centre have been contracted out to non-governmental organisations. In

Gujarat, the government has purchased services from private gynecologists to increase deliveries

in institutions among individuals who are poor.

Way forward

India urgently needs to develop a national human resource policy. Such a policy should also

examine the creation and establishment of cadres of trained health professionals (medical and

non-medical) who can provide leadership (technical and administrative) and direction to the

health sector in the states and nationally. Such cadres could correct the imbalance in

competencies and improve channels of communication between technical and administrative

personnel in addition to providing necessary incentives and opportunities for career progression

in the health sector.

India has to move away from the idea that only allopathic doctors should deliver primary health

services.

Other cadres of health workers, such as allopathic clinicians with less than 3 years of training,

nurse practitioners, and physicians trained in ayurveda, yoga and naturopathy, unani, siddha, and

homoeopathy, can take this responsibility with appropriate training. These cadres, as experience

suggests, are more likely to undertake rural service within the public sector than are allopathic

physicians. We are not suggesting that allopathic doctors have no role in rural health, but rather,

their presence and expertise are perhaps better used at sub district and district hospitals, where

they can supervise and receive support from peripheral health facilities staffed by these other

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cadres. Special efforts should be made to address the shortage of specialist allopathic doctors at

district and sub district hospitals.

To provide for the constitution of the National Council for Human Resources in Health for
prescribing standards with a view to the proper planning and co-ordinate development of medical
and allied health education throughout the country, the promotion of qualitative improvement of
such education in relation to planned quantitative growth, the maintenance of a national live
electronic register of medical and allied health professionals and to provide for an overarching
framework for the regulation of human resources in health in the country and proper
maintenance of norms and matters connected therewith or incidental thereto.
The National Council for Human Resources in Health Draft Bill, 2009 is passed. The

Sort Title and Commencement of the act is as – (1) This Act may be called the National
Council for Human Resources for Health Act, 2009.

(2) It extends to the whole of India.

(3) It shall come into force on such date as the Central Government may, by notification
in the Official Gazette, appoint and different dates may be appointed for different
provisions of this Act.

2. Interpretations – (1) In this Act, unless the context otherwise requires:-

“Act” means the The National Council for Human Resources in Health Act, 2009.
“Approved course” means a course recognised and approved by the Council under
section 13 of this Act.
As per section 19 of this act, the council shall cause to maintain a national live electronic register
of health professionals the subsections of the act are as follows.

Section 19 - National Register of Human Resources in Health –

1. The Council shall cause to be maintained in the prescribed manner a national live
electronic register of health professionals to be known as the “National Register of
Human Resources in Health”, which shall contain the names of all persons who are for

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 the time being enrolled by any of Board and who possess any of the recognised
qualifications.
2. It shall be the duty of the Secretary-General of the Council to keep the National Register
of Human Resources in Health in accordance with the provisions of this Act and of any
orders made by the Council, and from time to time to revise the register and publish it in
the Gazette of India and in such other manner as may be prescribed.
3. Such register shall be deemed to be public document within the meaning of the Indian
Evidence Act, 1872 and may be proved by a copy published in the Gazette of India.
4. The Council shall cause to be made such register available for public by electronic or
such other publication as may be prescribed.
5. The Secretary-General of the Council, may, on receipt of the report of registration of a
person by a Board or on application made in the prescribed manner by any such person,
enter his name in the National Register of Human Resources in Health
Provided that the Registrar is satisfied that the person concerned possesses a recognised
qualification.

Conclusion
Some experts have speculated that physician will assume more specialized roles as
medical care becomes increasingly dependent on technology, and that patients will only
see physician for high-take speciality care.
There will be a need for increased training in the use of information technology for all
healthcare professionals.
There will be an elimination of a number of clerical and other “Low-Tech” Professions.
There will be dramatically increased need for Health informatics specialist.
As healthcare finally embraces information technology in its full scope, we can expect to
see the significant changes in human resources brought on by efficiencies at local level.

Bibliography
1. Healthcare Quarterly Journal
2. Human Resource for Health – Volume 4 and Volume 9
3. HRM Managing the people at work – Mrs. Y. L. Giri

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4. The National Council for Human Resources in Health Draft Bill, 2009.
5. DNA News paper Dated – 5th October 2011
6. Conference proceeding on PP in health sector : issue and prospectus : Ahmadabad :
IIM
7. www.humancapitalonline.com
8. www.ihsummit.com
9. www.google.com
10. www.humanresource-health.com

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