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array_files[25]=new Array(0,1,"./contact_us.html","2008-10-31","9K","Contact Us ","",""," Contact Us Contact Us Public Health Foundation of India (PHFI) The World Bank PHD House, II Floor 70 lodi Estate 4/2, Siri Fort Institutional Area New Delhi – 110003, India August Kranti Marg Website: www.worldbank.org New Delhi – 110016, India Ph: 46046000 Fax: 41648513 Website: www.phfi.org Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[26]=new Array(0,1,"./printAll.html","2008-10-31","815K","Print Version - Human Resources for Health in India ","",""," Print Version - Human Resources for Health in India Paper-1 Indias Health Workforce Size, Composition and Distribution Introduction The extent to which health systems provide quality health services in an equitable and efficient manner influences the level of health achieved in a population. Individuals, families, and health workers are all important providers of health care. However, the responsibility of delivering health services falls primarily on the health worker making them central to the health systems capacity to delivery health services. Issues concerning the health workforce such as its capability to cover different socioeconomic groups and geographic regions, the technical competence and skills of individual health workers and motivation with which they perform their jobs – all contribute in important ways to improving health system performance and population health. Having an adequate health workforce in terms of numbers and skill mix is critical for countries like India which hope to make significant progress towards achieving the Millennium Development Goals for health. Recent studies show that greater availability of health workers is associated with better service utilization and health outcomes such as immunization coverage, outreach of primary care and infant, child and maternal survival (WHO 2006, JLI 2004, Anand and Barnighausen 2007). In addition to numerical strength, the effectiveness of the health workforce is influenced by the skill mix, quality and geographical distribution of health workers, a work environment and infrastructure which enables them to effectively use their skills, adequate remuneration and opportunities for upgrading and refreshing skills. Information on these factors is a basic requirement for policy makers and planners to better manage the health workforce and make it more effective. Information on India’s diverse health work force is surprisingly fragmented and unreliable, despite recent efforts at quantifying it (WHO 2007, GOI 2005). The World Health Organisation "); array_files[27]=new Array(0,1,"./Paper1/Distribution_of_India’s_Health_Workforce_across_States_Census_Estimates_page3.html","2008-10-31","14K","Distribution of India’s Health Workforce across States Census EstimatesPage3 ","",""," Distribution of India’s Health Workforce across States Census EstimatesPage3 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Distribution of Indias Health Workforce across States: Census Estimates (Contd...) Nurse and Midwives Figure 5 shows the distribution of nurses & midwives across different states. Most of northern and central states fall in the bottom two density quartiles (less than 10 workers per 10,000 population. These include the states of Gujarat, Rajasthan, Haryana, Punjab, Jammu & Kashmir, Himachal Pradesh, Uttaranchal, Uttar Pradesh, Madhya Pradesh, Bihar, Jharkhand, Chhattisgarh, West Bengal and Assam. Many of these states, with the exception of Gujarat, Haryana and Punjab are also amongst the poorest in the country. Other low nurse & midwife density states include Karnataka, Andhra Pradesh and Tamil Nadu. States with higher nurse and midwife densities i.e. those in the top two quartiles, are present in the southern and eastern part of India. This includes the states of Maharashtra, Goa, Kerala, Orissa, Manipur, Mizoram, Arunachal Pradesh, Nagaland and Tripura. Differences between states in the bottom and top quartiles is considerable; some of the high nurse & midwife density states like Goa (20) and Kerala (19) have densities up to six times as much as the low density states like Bihar (3) and Uttar Pradesh (3). Female Health Workers Female doctors and health workers are a critical part of the health workforce. The presence of female doctors and health workers in health facilities and in communities is important for women’s access to health services. While female doctors and hea "); array_files[28]=new Array(0,1,"./Paper1/Data_Sources_page2.html","2008-10-31","14K","Data Sources-Page2 ","",""," Data Sources-Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Data Sources (Contd...) Based on majority of time spent during the 365 days before the survey, the usual principal activity of the sampled individuals was classified as: ‘Employed’, ‘Unemployed’ (job seekers, domestic duties, etc.) and ‘Not in Labor Force’ (students, pensioners, etc.). Information on the self-reported economic activity of employed individuals was recorded. Subsidiary economic activities of individuals were also recorded, if at least 30 days in the past year were spent on economic activity. This study presents the results of the usual principal activity of employed individuals. Government of India The Ministry of Health and Family Welfare (MOHFW), Government of India reports on certain aspects of human resources in the health sector through the Central Bureau of Health Intelligence and various official periodicals such as Health Information of India and the Bulletin of Rural Health Statistics. These sources include estimates of health workers employed by the public sector such as the number of doctors, specialists, multipurpose workers, other allied health workers and registered AYUSH practitioners. Government publications also report on the total number of doctors, dentists and nurses in the country, which is sourced from the Medical Council of India (MCI), the Dental Council of India and the Indian Nursing Council (INC), respectively. These councils compile the reported number of registered practitioners from their state counterparts. While the respective professional councils are autonomous institutions, the he "); array_files[29]=new Array(0,1,"./Paper1/Data_Sources.html","2008-10-31","13K","Data Sources ","",""," Data Sources Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Data Sources Census of India The 2001 Census collected information on the self-reported occupation of all individuals in the country. A sample drawn from this population was used by the Census to generate estimates of the health workforce in the country. From each district of the country, 20% of the rural and 50% of the urban enumeration blocks (EB) were selected using systematic sampling. An EB consisted of 600 and 750 individuals in the urban and rural areas, respectively. In the 11 smaller states and union territories (< 2 million population) all EBs were selected, making the total sample size roughly 300 million individuals. The sample estimates were then inflated by a factor of 5 for rural and 2 for urban to get population totals. Each individual in a selected EB was classified as a “Main Worker” if he/she worked for 6 months or more in the past year, “Marginal Worker” for less than 6 months and “Non-Worker” if he did not work at all in the past year. This study presents results for main workers. National Sample Survey Organisation (NSSO) Data was from the 61st round (July 2004-June 2005) of the National Sample Survey (NSS) on ‘Employment and Unemployment’, a multi-stage stratified cluster sample survey covering the entire country was used to estimate health workforce totals. The survey was spread over 7,999 villages and 4,602 urban blocks covering 1, 24,680 households and 602,833 persons: 398,025 in rural areas and 204,808 in urban areas. Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[30]=new Array(0,1,"./Paper1/Distribution_of_India%27s_Health_Workforce_across_States_Census_Estimates_page2.html","2008-10-31","14K","Distribution of India’s Health Workforce across States Census Estimates-Page2 ","",""," Distribution of India’s Health Workforce across States Census Estimates-Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Distribution of Indias Health Workforce across States: Census Estimates (Contd...) Allopathic Doctors and Surgeons The distribution of allopathic physicians across different states is shown in Figure 4. States with low doctor density, which are present in the bottom two density quartile (3 to 6 doctors per 10,000 population), tend to cluster in the belt running across north-central India. This spans the states of Gujarat, Rajasthan, Uttar Pradesh, Madhya Pradesh, Bihar, Jharkhand, Chhattisgarh, Orissa, Assam and the rest of the north-eastern states of India; which are also amongst the poorest in the country. Other low doctor density states include Himachal Pradesh and, surprisingly, Kerala and Tamil Nadu. States with higher doctor densities i.e. those in the top two quartiles, tend to cluster in northern and southern India. These include the states of Jammu & Kashmir, Punjab, Haryana, Uttaranchal, Maharashtra, Goa, Karnataka and Andhra Pradesh. There is considerable disparity between physician densities between states in the top and bottom quartiles; states like Goa (11) and Kerala (6) have doctor densities up to three times as high as the low density states like Orissa (3) and Chhattisgarh (4). Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[31]=new Array(0,1,"./site_map.html","2008-10-31","11K","Partner_new ","",""," Partner_new Site Map Back Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[32]=new Array(0,1,"./Paper3/Conclusion_page2.html","2008-10-31","15K","Conclusion-Page2 ","",""," Conclusion-Page2 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Conclusion (Contd...) The persistent dearth of nurses in the government health system can be explained through factors such as bottlenecks in the recruitment process, low number of overall sanctioned nursing posts with respect to needs, poor quality in the supply of nurses etc. Incentive Packages: Even though nursing students prefer an urban over a rural location for a job, they have a greater preference for the package of a public sector job over one in the private sector. As a result of this, nurses find the option of a rural posting in a government job more attractive than working in a private sector urban job. A government policy that reserves PG seats for in-service MBBS doctors posted in rural areas for a set period (enhanced with a supportive work environment and good living conditions) is likely to attract students even if other conditions are still unchanged. Should the government decide to pursue this policy, it would need to consider the ramifications of providing PG education to an increased number of in-service doctors serving in rural areas. It would also need to focus on PG colleges and upgrade their resources to increase numbers and intake. Consequently, there is a link between the need to bring more MBBS doctors to rural areas to provide basic care and a policy focus on specialized tertiary-level medical education. For Future Research: Significant differences existed between students in a medical college and those in a nursing school with respect to their expectations and aspirations. Medical students appeared to be far more urbanized in their tastes and lifestyles as compared to nursing students, irrespective of their background. Limited evidence from this study suggests that even the few medical students who are from a rural background tend to be far less inclined to return to a r "); array_files[33]=new Array(0,1,"./assets/css/_notes/dwsync.xml","2008-10-31","0K","./assets/css/_notes/dwsync.xml ","",""," dwsync file name=styles.css local=128697424165781250 remote=128698650000000000 testing=0 / "); array_files[34]=new Array(0,1,"./assets/images/Graphs/_notes/dwsync.xml","2008-10-31","1K","./assets/images/Graphs/_notes/dwsync.xml ","",""," dwsync file name=Fig_1.jpg local=128673345430000000 remote=128698650000000000 testing=0 / file name=Fig_11.jpg local=128659281970000000 remote=128698650000000000 testing=0 / file name=Fig_12.jpg local=128659280640000000 remote=128698650000000000 testing=0 / file name=Fig_2.jpg local=128659289270000000 remote=128698650000000000 testing=0 / file name=Fig_3.jpg local=128667314510000000 remote=128698650000000000 testing=0 / file name=Fig_4.jpg local=128659288300000000 remote=128698650000000000 testing=0 / file name=Fig_5.jpg local=128659287300000000 remote=128698649400000000 testing=0 / file name=Fig_6.jpg local=128673319697968750 remote=128698650000000000 testing=0 / file name=Fig_7.jpg local=128659286320000000 remote=128698649400000000 testing=0 / file name=Fig_8.jpg local=128673351507343750 remote=128698649400000000 testing=0 / file name=Fig_9.jpg local=128673353626562500 remote=128698649400000000 testing=0 / "); array_files[35]=new Array(0,1,"./assets/images/Large%20Figures/_notes/dwsync.xml","2008-10-31","1K","./assets/images/Large Figures/_notes/dwsync.xml ","",""," dwsync file name=fg_1.png local=128673345682968750 remote=128698633800000000 testing=0 / file name=fg_10.png local=128671670605625000 remote=128698633800000000 testing=0 / file name=fg_11.png local=128671646365468750 remote=128698633800000000 testing=0 / file name=fg_12.png local=128671647460468750 remote=128698633800000000 testing=0 / file name=fg_2.png local=128671654042812500 remote=128698633800000000 testing=0 / file name=fg_3.png local=128671652559531250 remote=128698634400000000 testing=0 / file name=fg_4.png local=128671651949843750 remote=128698634400000000 testing=0 / file name=fg_5.png local=128671651329843750 remote=128698634400000000 testing=0 / file name=fg_6.png local=128673321538593750 remote=128698634400000000 testing=0 / file name=fg_7.png local=128671649552968750 remote=128698634400000000 testing=0 / file name=fg_8.png local=128673351060156250 remote=128698634400000000 testing=0 / file name=fg_9.png local=128673353983281250 remote=128698634400000000 testing=0 / "); array_files[36]=new Array(0,1,"./assets/images/images/_notes/dwsync.xml","2008-10-31","0K","./assets/images/images/_notes/dwsync.xml ","",""," dwsync file name=top_banner_01.gif local=128667245080000000 remote=128698633800000000 testing=0 / file name=top_banner_02.gif local=128667245080000000 remote=128698633800000000 testing=0 / file name=top_banner_03.gif local=128667245080000000 remote=128698633800000000 testing=0 / "); array_files[37]=new Array(0,1,"./Paper3/introduction_page3.html","2008-10-31","15K","Introduction-Page3 ","",""," Introduction-Page3 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Introduction (Contd...) The public sector infrastructure in rural UP, as in that of India, is a three-tiered system. A sub-center is the most peripheral unit and is staffed by an Auxiliary Nurse Midwife (ANM) and a male multi-purpose worker (MPW). The first point of contact between a patient and a doctor is the Primary Health Center (PHC), a basic clinic which is supposed to serve a population of 30,000, but may, in reality, serve a much larger population. A community health center (CHC) was planned as a referral unit for four PHCs and is meant to serve a population of approximately 1,00,000. CHCs are 30-bedded hospitals staffed by five different types of specialist doctors as well as two general physicians. Though not officially part of the rural health infrastructure, district hospitals, usually located at the district headquarters, also serve the rural population. A general doctor entering the public sector is posted as a medical officer to a rural PHC while a specialist doctor’s entry point into the system is the CHC. Similarly, an entry-level position for a nurse in the public health sector is as a staff nurse in a rural PHC. Vacancies in the public health sector are acute. Figures from 2001 suggest that 40percent of the medical officer posts in PHCs and 50percent of the specialist posts in CHCs are lying vacant (Government of India). The Union Government has proposed to tackle this shortage of rural health workers in India by introducing a compulsory additional year of education for undergraduate medical students that has to be spent working in a rural setting. The license to practice medicine or pursue further education would be contingent on completion of this rural service (Times of India, 2006). Given that compulsory rural service has a weak record of success historically, and also given "); array_files[38]=new Array(0,1,"./Paper3/introduction_page2.html","2008-10-31","15K","Introduction-Page2 ","",""," Introduction-Page2 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Introduction (Contd...) The concentration of health workers in urban areas is not a problem that is unique to India. Indeed, both industrialized and developing countries around the world face disparities in the distribution of health personnel (Dussault and Franceschini 2006). There are many reasons why health workers typically choose not to work in rural areas. Salary emerges as an important component of a job and strongly affects the willingness to work in rural areas (Chomitz 1997; Serneels, Lindelow et al. 2007). However factors other than salary also play an important role in the preference of urban positions. For example access to training, health care and education for children, promotion opportunities, the availability of electricity, water and housing are all reasons that urban jobs are usually favored(Dussault and Franceschini 2006; Lindelow and Serneels 2006; Serneels, Lindelow et al. 2007).In Pakistan, the absence of equipment and supplies was a major deterrent for accepting a rural post (Zaidi 1986). A study on rural health worker motivation in Vietnam highlighted the importance of appreciation and support from managers and colleagues as well as from the community (Dieleman, Cuong et al. 2003). Individual characteristics can also affect the decision to serve in rural areas. It is generally accepted that a person from a rural background is more likely to pursue a career in rural areas (Laven and Wilkinson 2003; Matsumoto, Okayama et al. 2005; Dussault and Franceschini 2006; Lehmann, Dieleman et al. 2008). Schooling in rural areas also appears to have a similar effect although rural medical training alone is unlikely to have a major impact on increasing the rural workforce (Eley and Baker 2006). In addition, women are less likely to accept a post in a rural area than are men, though the "); array_files[39]=new Array(0,1,"./Paper2/Part_IV/Part_IV_Discussion.html","2008-10-31","16K","Part IV-Discussion ","",""," Part IV-Discussion Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part IV Discussion Summary This concluding discussion highlights the disconnect between the grand strategies of the policy planners at the national level and the more immediate and routine problems of bureaucrats at the implementing institutional level, which itself needs to become a priority concern but has so far been largely overlooked. The commitment of significantly greater financial resources that the central government intends to channel into the health sector, the renewed focus of NRHM on the HRH aspects of health policy and the greater role of the states expected in planning a state-specific health policy potentially provides an opportunity to productively take further a research agenda with a focus on institutions and the implementation process. Health is constitutionally a State subject, but in practice, the Centre has taken on the responsibility of health policy planning for the entire country. States, in most cases, have meanwhile largely been tasked with the responsibility of implementing these grand strategies to improve health outcomes and to manage the health personnel that these health policy plans and national programs deem necessary. Part I of this paper carries out a historical review of policy priorities across Five-Year Plans and of reports influencing the policy agenda concerning HRH, which reveals that the principal items on this policy agenda are not that numerous, and moreover, are recurrent. The fact that these policy priorities concerning human resources for health are largely recurrent necessitates a shift in the analytical approach – away from a focus simply on the concept of power and how it is distrib "); array_files[40]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_15.html","2008-10-31","18K","Part I-Page15 ","",""," Part I-Page15 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) One significant debate has revolved around whether or not to use private practitioners in government health care provision, what type of private practitioners, and to what extent. In the 1960s, the Mudaliar and Mukherjee Committees, as well as the 3rd (1961-66) Plan, recommended part-time use of private practitioners in the government health system. Partnership of the government sector with the private sector was then relatively ignored between the Third and Sixth Plan initiated in 1980, when incentives were proposed for doctors to set up private practice in rural areas and provide part-time service in government hospitals. The principal priority of policy was efficiency and quality and a focus on implementation with a cost-effective approach, which then called for more competition in the system. The 9th (1997-2002) Plan, and all following policy documents through to NRHM, promote collaborations with the private sector as a means to enhance access to quality health care. The 9th Plan suggests creating part-time ‘contract’ positions, which can be offered to local, qualified private practitioners and/or offer the PHC and CHC premises for after office hours private practice against a rent. The NHP-2002 is even in favor of states ‘expanding the pool of medical practitioners to include a cadre of licentiates of medical practice’ (GOI, 2002). As noted earlier, the proposal for a short term course for the training of medical assistants or practitioners less than full fledged doctors was given serious consideration in the 3rd (1960-65) Plan as a realistic solution to the problem of insufficient doctors for the rural areas. Beca "); array_files[41]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_10.html","2008-10-31","15K","Part I-Page10 ","",""," Part I-Page10 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) 1.3 HRH Problems at the National Policy Level: A Historical Perspective7 Summary This section historically reviews previous recommendations for reform in human resources for health. It thereby provides the context for the current approach articulated under NRHM which aims to “architecturally correct the health system” through: 1. better use of funds 2. improved service delivery through decentralization, community participation, improvement of infrastructure, horizontal integration of vertical Health and Family Welfare Programs and 3. transparent policies for Human Resources in Health. NRHM adopts a more comprehensive approach to health, incorporating ideas from throughout history, addressing almost every aspect of the public health system. It attempts to improve implementation by setting performance targets for states for institutional reform and focusing on outcomes and outputs. As this paper noted at the very beginning, there has been no dearth of grand strategizing through Plans and government-sponsored committee reports on which issues pertaining to human resources for health need to be prioritized in order to deliver better health care services to the people, especially the rural poor. The most recent such policy document, or grand strategy plan, is the National Rural Health Mission (NRHM), launched in 2005. Its overarching goal is to “improve the availability of, and access to, quality health care by people, especially for those residing in rural areas, the poor, women and children” (NRHM Mission Document). Its more specific objectives include reducing the Maternal Mortality Ratio (MMR) in the country from 407 to "); array_files[42]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_11.html","2008-10-31","16K","Part I-Page11 ","",""," Part I-Page11 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) Indeed, there are certain NRHM policy recommendations that have been expressed repeatedly over time by a majority of the committee reports and five-year plan documents. There is equally the case of a policy recommendation that features prominently at one time in a committee report and a five-year plan but which is shelved or reversed in a subsequent plan/report only to return later once again as a notable policy decision of a different government health plan. Understanding the reason for such a cyclical past to a particular policy can contextualize the policy in an existing debate and indicate which perspective was more dominant in government and internationally at the time. This section reviews both of these types of recurrent policy recommendations relating to human resources for health separately. That these policies are recurrent draws attention to why implementation has been inadequate and the significance of institutions as implementation agents (Part II and III of this paper). Policies recurrent continuously over time: The absence of adequate number of doctors in rural areas has plagued the government health system and policy makers at the Centre have grappled with different options on how to address the problem for at least over three decades now.8 Currently, NRHM recommends adapting the medical education curriculum and making it more pertinent towards rural health. Beginning with the Bhore Committee in 1943, this focus on public health has been constantly underlined in the form of proposals to increase and strengthen Departments of Preventive and Social Medicine (PSM) in medical colleges. Furthermore, in 1975, "); array_files[43]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_5.html","2008-10-31","16K","Part I-Page5 ","",""," Part I-Page5 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) AYUSH practitioners The dominant medical discourse projects practitioners of Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH) as the ‘unscientific other’ and assigns all of them a peripheral, residual role in the overall health care system (Abraham, 2005). The state-financed institutional development of ISM and Homeopathy in independent India really took off only in the 1970s and 1980s when institutions structured similar to those in allopathy were established in ayurveda and homeopathy. A separate department in the ministry was only created in 1995, in response to a long pending demand and an entire separate Ministry of AYUSH formed in 2003. The only other significant institutions are all involved with research or the regulation of research: In 1959, the Central Council of Ayurvedic Research was set up to advise the central government on the formulation of a coordinated policy for research in Ayurveda. Two advisory committees, one on Homoeopathy and the other on Unani, were also set up. In 1960, a Panel set up by the Planning Commission recommended establishing a Central Council of Indian Medicine for regulating the standards of medicines. Over a decade later, in 1973, the CCIM finally came into existence. Of the professional associations of AYUSH, the most prominent is the Ayurvedic Congress. However, despite being in its centenary year of existence, its role, like that of the other AYUSH associations has been marginal to health policy planning. Although the government discourse now emphasises a need to ‘mainstream AYUSH’ with allopathic medicine, evidence of the past fault line continues. It is most evident in the "); array_files[44]=new Array(0,1,"./Paper3/Sample_methods_page5.html","2008-10-30","13K","Sample Method-Page5 ","",""," Sample Method-Page5 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Sample & Methods (Contd...) This may have also been an issue with nursing students in public schools. In UP there are currently no final-year students and therefore FGDs were held with first-year nursing students. However, as these students had just entered the program, like medical undergraduates, they were less likely to have fully explored the options that were available to them upon graduation. At certain times, discussions and interviews with nurses were limited because of poor understanding or reluctance to talk. While most medical students were quite outspoken, many nursing students had to be encouraged to speak and had to be guided more thoroughly through the questions. For example instead of listing attributes of jobs on their own, sometimes various job attributes were offered to them and then students were asked about their relative importance. However, the most important job attributes and choices were always quite consistent, lending confidence in the validity of the data. It should also be noted that despite an attempt to get a variety of students, there were few medical students from rural backgrounds in this study. This is likely due to the fact that, in UP in general, few medical students come from rural backgrounds. Therefore, rural students may actually be over-represented in the study. Nonetheless, the small number of rural students makes it difficult to make definitive conclusions about how a rural upbringing influences the career decisions of a medical student. A final point is that among the career choices offered, medical education was not presented as an option. A few students brought it up themselves, and seemed somewhat attracted by this career choice. However, the focus of this study was the immediate career plans of medical students. As such, medical education was not "); array_files[45]=new Array(0,1,"./Paper3/Sample_methods_page4.html","2008-10-30","14K","Sample Method-Page4 ","",""," Sample Method-Page4 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Sample & Methods (Contd...) Both FGDs and in-depth interviews were held in order to get a range of opinions and also to cross-check views given by students while amongst their peers with those professed when on their own. A semi-structured questionnaire was used for in-depth interviews and a similar set of discussion topics was used for the FGDs. Students were asked about their plans upon graduation and their perspectives on working in the public and private sector and in urban and rural areas. Both English and Hindi were used to communicate during the FGDs and in-depth interviews. While most medical students were comfortable with English, nursing students preferred to converse in Hindi. To encourage students to express their views freely during the FGDs, they were segregated by sex and by the type of degree that they were pursuing. Two exceptions were made to this; FGDs for postgraduate and nursing students were in mixed groups. In these cases segregation was not feasible because there were very few postgraduate students which made it necessary to include both male and female students in the same FGD. Similarly, since most nursing students were female, they were also not segregated by gender. In a further effort to promote frank discussion, the students remained anonymous and no faculty was present in the room during the FGDs or interviews. The focus group discussions were taped, translated into English when necessary, and then transcribed. The quotes presented in this study are only from the focus-group discussions. Where data is presented numerically, these are based upon responses from individuals during in-depth interviews. In general, few differences in opinions were observed between males and females, or between students in different schools (see Appendix, Table 2). Therefore, unless noted "); array_files[46]=new Array(0,1,"./Paper3/Sample_methods_page3.html","2008-10-30","30K","Sample Method-Page3 ","",""," Sample Method-Page3 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Sample & Methods (Contd...) Selection of medical and nursing students Within each school, medical students were purposively selected based on the location of their hometown and their rank in a common entrance exam. This, once again, ensured that students participating in the study were from diverse backgrounds. Nursing students were selected on the basis of an institutional merit list. The total number, and the demographic characteristics, of the students who participated in the FGDs and interviews are shown in Table 2. This study was limited to medical undergraduates who were in their final year of study, and to postgraduate students. As these students are closest to the job-market they are most likely to have given serious thought to the future career options available to them. Final-year nursing students were also used in the study; however they were all from private colleges. In public nursing schools in Uttar Pradesh there are currently no final-year nursing students and hence first-year nursing students were asked to participate from these institutions. The undergraduate medical students were pursuing a five and a half year MBBS (Bachelor of Medicine, Bachelor of Surgery) degree while the postgraduate students had completed their MBBS and were studying for a postgraduate degree in a medical specialty. The nursing students were training for a basic nursing qualification called a GNM (General Nursing and Midwifery), a 3-year diploma program entered into after high school. Table 2: Background Characteristics of Sampled Medical and Nursing Students Sample Undergraduate Postgraduate Nurses Characteristics (UG) (PG) FGD Interview FGD Interview FGD Interview Public Private Private Mean age (years) 24 24 28 30 24 24 24 Female (percent) 51 51 33 39 96 92 89 Current Family Residence (percent) Village "); array_files[47]=new Array(0,1,"./Paper3/Sample_methods_page2.html","2008-10-30","22K","Sample Method-Page2 ","",""," Sample Method-Page2 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Sample & Methods (Contd...) This study uses a qualitative approach to understand the career preferences of final-year undergraduate (UG) and postgraduate (PG) medical and undergraduate nursing students. Both focus-group discussions (FGD) and in-depth interviews were carried out with these students. Selection of medical and nursing schools The medical and nursing schools were purposively chosen to fulfill two criteria: they should represent a diversity of both academic reputation and geographic locations. Lucknow is the capital of UP and the public medical college there is one of India’s and UP’s elite medical colleges. Allahabad is a large provincial town and, while the medical college selected there is not a top-tier institution, it is highly regarded. Finally, Gorakhpur is a provincial town, located in the economically poorer, eastern part of UP, in proximity to the rural areas of the state. The medical college there has a lesser academic reputation compared to the other medical colleges in the study. Medical students gain admission to a particular institution based on their rank in a common entrance examination. The study, therefore, draws on perceptions of medical students from those medical colleges which are high (Lucknow), medium (Allahabad) and low (Gorakhpur) on the admission preferences of medical students. Most of the medical colleges selected were public institutions, although in Lucknow, a private medical college was also included in the study. Nursing schools were selected from the same city/town where the sampled medical schools were located. This ensured that nursing schools from a range of geographic locations were included in the study. Both private and public nursing institutions were visited: discussions were held with first-year students at public nursing schools and final-ye "); array_files[48]=new Array(0,1,"./Paper3/Sample_methods.html","2008-10-30","13K","Sample Method ","",""," Sample Method Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Sample & Methods Summary This study uses a qualitative approach to understand the career preferences of: (1) final-year undergraduate (UG) and postgraduate (PG) medical students from public and private medical colleges and (2) undergraduate nursing students from public colleges. As these students are closest to the job-market, they are most likely to have given serious thought to future career options available. Both focus-group discussions (FGD) and in-depth interviews were carried out to get a range of opinions and to cross-check views given by students while amongst their peers with those professed when on their own. A semi-structured questionnaire was used for in-depth interviews and a similar set of discussion topics was used for the FGDs. Medical colleges and nursing schools were selected from Lucknow, Allahabad and Gorakhpur to represent a diversity of both academic reputation and geographic locations. Within each school, medical students were selected based on the location of their hometown and their rank in a common entrance exam, thus ensuring that participants came from diverse backgrounds. Nursing students were selected on the basis of an institutional merit list. In general, few differences in opinions were observed between males and females, or between students from different schools (see Appendix, Table 2). Therefore, unless noted, the results are not separated out by gender, by location or by type of medical school or nursing school. Despite an attempt to get a variety of students, few medical students from rural backgrounds participated in the study. This makes it difficult to make definitive conclusions about how a rural upbringing influences the career decisions of a medical student. Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[49]=new Array(0,1,"./Paper3/References.html","2008-10-30","17K","References ","",""," References Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download References Anderson, M. and M. W. Rosenberg (1990). Ontarios underserviced area program revisited: an indirect analysis. Soc Sci Med 30(1): 35-44. Chomitz, K. M. (1997). What do doctors want? Developing Incentives for Doctors to Serve in Indonesias Rural and Remote Areas. Connell, J., P. Zurn, et al. (2007). Sub-Saharan Africa: beyond the health worker migration crisis? Soc Sci Med 64(9): 1876-1891. Dieleman, M., P. Cuong, et al. (2003). Identifying factors for job motivation of rural health workers in North Viet Nam. Hum Resour Health 1(1): 10-10. Doescher, M. P., K. E. Ellsbury, et al. (2000). The distribution of rural female generalist physicians in the United States. J Rural Health 16(2): 111-118. Dussault, G. and M. C. Franceschini (2006). Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 4: 12-12. Eley, D. and P. Baker (2006). Does recruitment lead to retention?- Rural Clinical School training experiences and subsequent intern choices. Rural and Remote Health 6(511). Government of India.Task Force on Medical Education for the National Rural Health Mision. Ministry of Health and Family Welfare Government of India (2006). Bulletin on Rural Health Statistics in India 2006 Ministry of Health and Family Welfare. Laven, G. and D. Wilkinson (2003). Rural doctors and rural backgrounds: how strong is the evidence? A systematic review. Aust J Rural Health 11(6): 277-284. Lehmann, U., M. Dieleman, et al. (2008). Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res 8: 19-19. Lindelow, M. and P. Serneels (2006). The performance of health workers in Ethiopia: results from qualitative research. Soc Sci Med 62(9): 2225-2235. Matsumoto, M., M. Okayama, e "); array_files[50]=new Array(0,1,"./Paper3/introduction.html","2008-10-30","14K","Introduction ","",""," Introduction Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Introduction Summary The health sector, both in India and in Uttar Pradesh (UP), faces multiple challenges in the geographic distribution of human resources. Though the majority of the population lives in rural areas, doctors in both the public and private sectors are concentrated in urban areas. The WHO estimates that over 80 per cent of qualified private providers are concentrated in urban areas. This has resulted in the majority of rural households receiving care from private providers, many of whom are less than fully qualified, thus hampering access to quality health services. Financial incentives alone do not attract health workers to rural areas. Other than salary, factors such as access to training, health care, education for children, promotion, improved working and living conditions play an important part in their choice. Thus, incentive packages that address several aspects of employment choice are likely to be most successful in recruiting health workers to rural areas. Vacancies in the public health sector are acute. Figures from 2001 suggest that 40percent of the medical officer posts in PHCs and 50percent of the specialist posts in CHCs are lying vacant (Government of India). This study aims to understand the determinants of employment choice among graduating medical and nursing students in UP. It has three main objectives: (1) To examine job attributes that graduating medical and nursing students consider important when seeking their first job. (2) To explore medical and nursing students’ perspectives on jobs in the public and private sector, and on the urban and rural working environments. (3) To understand the influence of monetary and non-monetary incentives on medical and nursing students decision on whether to serve in a rural, public sector job upon graduation. Background The healt "); array_files[51]=new Array(0,1,"./Paper3/Conclusion_page5.html","2008-10-30","18K","Conclusion-Page5 ","",""," Conclusion-Page5 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Conclusion (Contd...) A better understanding of students’ preferences to attract doctors to rural service can also have policy implications of significance by drawing attention to innovative linkages, which may otherwise go unnoticed. For instance, should the government decide to pursue a policy of reservations of PG seats, it would then have to consider the ramifications of providing PG education to an increased number of in-service government doctors serving in rural areas. Policy would, therefore, need to, focus on PG colleges and possibly the resources required to increase their number or their intake. Consequently, there is a link between the need to bring more MBBS doctors to rural areas to provide basic care and a policy focus on specialized tertiary-level medical education. As the government considers the enormous shortage of medical and nursing personnel in rural areas, this study and its results make an important case to look beyond the policy measure of compulsory service in rural areas that the Union Government is inclined to promote as the remedial measure. The evidence from this paper suggests that the labor market and incentives as packages in step with the career preferences of medical and nursing students have significant influence on the choice they make for the job that they take on completion of their course of studies. For Future Research: Health care providers are driven by multiple factors in developing the preferences that contribute to making an employment choice, which include the following: extrinsic characteristics directly relating to the individual (rural/urban or socio-economic background); certain qualities intrinsic to the individual (such as age or gender); and finally the influence of current context (location, peer group, or societal) in which the individual is embedded. In engaging with three d "); array_files[52]=new Array(0,1,"./Paper3/Conclusion_page4.html","2008-10-30","16K","Conclusion-Page4 ","",""," Conclusion-Page4 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Conclusion (Contd...) In contrast, evidence in this study shows that nursing students, whether in public or private nursing institutes, are overwhelmingly in favor of a public sector job over one in the private sector. The study also finds the average nursing student is more inclined to working in rural areas than the average medical student. Any reported shortage of nurses in the government health system, therefore, cannot be attributed to low motivation of nurses to work in the public sector since reality in fact points to quite the opposite. With a significant growth of nursing schools across the country, including in UP, graduating nursing students are not in short supply but instead on the rise. Consequently, any persistent vacancies to sanctioned nursing posts or continued shortfall in inducting adequate numbers of nurses into the government health system is not a result of short supply or low motivation of nurses to join. Explanations for such persistent dearth of nurses in the government health system must instead be explained through other factors, whether they be bottlenecks in the recruitment process, low number of overall sanctioned nursing posts with respect to needs, poor quality in the supply of nurses or other reasons entirely. Incentive Packages: The evidence in this study makes clear that when both medical and nursing students are asked to identify a set of ideal job attributes, the resulting list of attributes is not surprising but somewhat a “known list” expected of any job in any sector (see, for example, the ideal job attributes identified by undergraduate medical students in Appendix, Table 5). For instance, in the case of both medical and nursing students, there is a preference for working in an urban location over a rural area for reasons that include prospects for better ed "); array_files[53]=new Array(0,1,"./Paper3/Conclusion_page3.html","2008-10-30","16K","Conclusion-Page3 ","",""," Conclusion-Page3 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Conclusion (Contd...) The acute imbalance in the geographic distribution of health workers has important implications for access to health care for the rural population. The government has invested in a vast rural health infrastructure in order to provide affordable and quality healthcare. However, recruiting personnel to staff these facilities is a major difficulty. For example, in UP, more than half the posts for various types of specialists are currently lying vacant (Government of India, 2006). There are several factors that could explain the shortage of doctors in the public system. For example, the State may not be producing sufficient medical personnel to fulfill its requirements. Or, even if there is an adequate supply of health workers, there may be bottlenecks in the recruitment process that make it difficult for qualified workers to enter the government system. Finally, it is possible that candidates that are eligible for these posts choose not to enter the system for various reasons. While it is likely that all these contribute to the large vacancy rates, it is this last issue that this study explores in further detail. In drawing on the evidence reported in this paper and observations from fieldwork for this study, the paper in conclusion forwards two arguments: first, with the majority of undergraduate medical students attracted to postgraduate study, under the current incentive environment, there is little likelihood in UP of increasing the supply of MBBS doctors for government jobs. In contrast, even under the current incentive environment, increasing the number of nurses in the public sector is very feasible, given their preference for government jobs. Secondly, in attracting students to take a job in the public sector health system, an incentive package approach with innovative lin "); array_files[54]=new Array(0,1,"./Paper3/Conclusion.html","2008-10-30","14K","Conclusion ","",""," Conclusion Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Conclusion Summary In UP, more than half the posts for various types of specialists in the public health system are currently lying vacant (Government of India, 2006). Several factors could explain this shortage: (1) the state may not be producing sufficient medical personnel to fulfill its requirements (2) bottlenecks in the recruitment process make it difficult for qualified workers to enter the government system (3) eligible candidates choose not to enter the system for various reasons. The paper forwards two arguments: (1) Firstly, with the majority of undergraduate medical students currently attracted to postgraduate study, there is little likelihood of increasing the supply of MBBS doctors for government jobs. (In contrast, nurses prefer government jobs). (2) Secondly, in attracting students to take a job in the public sector, an incentive package approach with innovative linkages tuned to the career-related preferences of students would be more effective. These arguments are important in understanding and addressing the shortage of doctors and nurses in the government health system, especially in rural areas. Labor Market: Within 2 to 3 years of completing the MBBS, the vast majority of undergraduate students wished to pursue a postgraduate course of study. After completing of their PG course, students’ job expectations were higher with respect to: (1) salary expectation (2) prioritization of skills utilization. This translated into a demand for better facilities and a patient-load of complex cases. PG students were therefore far less likely to join jobs advertised in the government health sector. This causes a shortage of non-specialist doctors in the government sector. Currently, PG doctors did not find government service (incentives and environment) attractive. The shortage was likely to get mor "); array_files[55]=new Array(0,1,"./Paper3/Appendices_page4.html","2008-10-30","60K","Appendices-Page4 ","",""," Appendices-Page4 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Appendices (Contd...) Table 7: Disadvantages of the working in the Public Sector, in a Private Corporate Hospital or in a Private Clinic that were mentioned by medical and nursing students during focus-group discussions and in-depth interviews Public sector Private corporate hospital Private clinic UG PG Nurses UG PG Nurses UG PG Nurses Low Salary Rural posting Poor living conditions Safety Adjustment problem Unable to utilize skills Red Tape/Corruption/Bribery No learning opportunities Frequent Trasnfers Lack of infrastructure Bad work environment No monitoring and evaluation system Long procedures/paperwork Lack of technology available Late Promotions Limited freedom to take decisions Non-availability of drugs Less self-satisfaction Promotions based on seniority Non-committed co-workers Job insecurity High workload Always on call Less exchange of knowledge Fewer patient types Pressure to deliver Limited outreach within community Limited annual leave Inflexible work timings Commercialization of medicine Less respect from patient Less respect from society High capital investment Long time for settlement Inconsistent income/ job insecurity Greater accountability Highly competitive No legal immunity Lack of guidance Fewer training opportunities No opportunity for research Multiple work roles Previous Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[56]=new Array(0,1,"./Paper3/Appendices_page3.html","2008-10-30","57K","Appendices-Page3 ","",""," Appendices-Page3 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Appendices (Contd...) Table 6: Advantages of working in the Public Sector, in a Private Corporate Hospital or in a Private Clinic that were mentioned by medical and nursing students during focus-group discussions and in-depth interviews Public sector Private corporate hospital Private clinic UG PG Nurses UG PG Nurses UG PG Nurses Job Security Annual Leave Pension Limited work-load Exposure to variety of patients Knowledge sharing Participate in National Programmes Respect from society Freedom to work independently Provides contacts/clients Opportunity to do research Good salary Promotion Opportunity to serve the needy Latest methods/procedures Good housing facilities Better work environment Opportunity to utilize skills Urban location Performance-based promotion Hospital managements system Growth opportunities Advanced learning opportunities Time-bound promotions Skill upgradation Better quality of life Flexibility in work hours Safety Better facilities at work In-service education/training Consistent income Freedom to take decisions Performance-based pay Flexibility in work location Long-term sustainable settlement Self-accountability for work Easily available option Self-satisfaction Easy to switch jobs Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[57]=new Array(0,1,"./Paper3/Appendices_page2.html","2008-10-30","25K","Appendices-Page2 ","",""," Appendices-Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Appendices (Contd...) Table 4: Mean Scores for incentives for rural service Category All Medical Students UG Medical Students (Male) UG Medical Students (Female) PG Medical Students Nursing Students (Private) Private Practice 2.44 2.83 2.00 2.71 NA Housing 1.98 1.83 2.32 1.67 2.28 Fast Promotion 2.35 2.08 2.47 2.40 2.56 Training 2.80 3.17 2.84 2.47 3.06 PG Reservation 3.02 3.50 2.79 2.93 3.11 Transfer 2.50 2.00 2.47 2.88 2.92 Home Posting 3.04 2.60 2.92 3.44 3.42 Note: Students were presented with each incentive on its own and asked to rate its attractiveness to them saying whether it was “Very Important”, “Important” “Somewhat Important” or “Not Important”. Each choice was then given a score ranging from 1 to 4, 1 being “Not Important” and 4 being “Very Important”. The mean scores for each incentive were calculated and are presented in the table above. A higher score indicates that that incentive was found more attractive. Table 5: Ideal job attributes listed by undergraduate medical students during in-depth interviews Extrinsic Factors Intrinsic Factors 1. Salary 1. Prestige 2. Better utilization of acquired skills 2. Social Respect and recognition 3. Better health infrastructure 3. Serving the community 4. Availability and Functioning of equipment 4. Better growth and learning opportunities 5. Availability of adequate trained staff 6. Amiable work environment 7. Good living conditions such as: a) Accommodation b) Water c) Electricity d) Roads e) Education for children f) Personal Safety 8. Job Security 9. Fixed work hours 10. Workload 11. Permission for private practice 12. Location Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[58]=new Array(0,1,"./Paper3/Appendices.html","2008-10-30","38K","Appendices ","",""," Appendices Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Appendices Table 1: Medical students’ preferences for postgraduate specialties Post Graduate Specialty Male (UG) Female (UG) Post Graduates Paediatrics 1 2 1 Obstetrics& Gynaecology 11 1 5 Pathology 10 9 9 Community Medicine (SPM) 9 10 11 Anaesthesiology 8 7 10 Radio-diagnosis 5 6 1 Medicine 3 4 3 Surgery 2 3 4 Orthopedics 3 11 7 Opthalmics 7 5 8 Dermatology & Venerology 6 8 6 Table 2: Preference for urban position or public sector job by location of medical/ nursing school and type of student Location Student Sector (percent) Location (percent) Public Private No pref Urban Rural No pref UG, Male 35 30 35 45 10 45 Lucknow UG, Female 39 39 22 83 4 13 PG 25 44 31 100 0 0 Nurses 59 0 41 68 0 32 UG, Male 27 53 20 53 20 27 Allahabad UG, Female 42 42 17 67 17 17 PG 17 50 33 85 0 15 Nurses 77 0 23 45 27 27 UG, Male 43 36 21 79 7 14 Gorakhpur UG, Female 40 27 33 100 0 0 PG 15 77 8 69 15 15 Nurses 65 8 27 88 8 4 Table 3: Students’ preferences for various combinations of location (urban/rural) and sector (public/private) Urban public Urban private Rural public Rural private UG male 2.11 1.61 1.50 0.78 UG female 2.61 2.11 0.94 0.67 PG 2.39 2.06 1.00 0.56 Nurses, pvt 2.72 1.11 1.78 0.39 Total 2.42 1.70 1.29 0.59 Note: Students were asked their preference based on binary choices with combinations of location (urban/rural) and sector (public/private); for example they were asked which they preferred between an urban public job and an urban private job. There were six such binary choices given with each combination appearing three times. Each time a certain combination was picked it was given a score of 1 and this was added up and then divided by the number of students in that category to obtain the mean score. The mean score gives an indication of the popularity of that choice relative to the other choices. Next Page C "); array_files[59]=new Array(0,1,"./Paper3/Analytical_section_page9.html","2008-10-30","15K","Analytical Section-Page9 ","",""," Analytical Section-Page9 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Good living conditions, which includes things like accommodation and education for children, was also cited as an important factor when selecting a job. “I am from a village but I would like to bring up my children where there are maximum facilities. I want to give our children the best education” Male UG student, Public Medical Institute, Allahabad “Accommodation should be good....accommodation should be within the posting campus” Female UG student, Public Medical Institute Allahabad Related to good living conditions was the concept of personal security, mentioned as an important characteristic of a job by all types of students. “Our protection is important. We cannot save each and every patient. Often the relatives of the patients in very critical emergency situations get very aggressive with us. They speak very badly to us, often use foul language” Male UG student, Public Medical Institute, Allahabad “Security is very important. The ‘pradhans’ and local leaders don’t let the doctor work or take his own decisions. Personal security is an issue that is important and needs attention not only in rural but also in urban areas” Male PG student, Public Medical Institute Gorakhpur A significant difference in the career perspectives of medical and nursing students relates to the importance attached to job security. During in-depth interviews, only 25 percent of medical students brought up job security as an important attribute of an ideal job. On the other hand, nursing students rated job security as the second most important characteristic of a good job, following salary. Therefore, for an average nursing student, job security was considered a crucial component of a good job and was associated with a stable life. “The reason why we go to the government sector is beca "); array_files[60]=new Array(0,1,"./Paper3/Analytical_section_page8.html","2008-10-30","15K","Analytical Section-Page8 ","",""," Analytical Section-Page8 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) For medical students, both undergraduates and postgraduates, as well as nursing students, salary was the most important component of a first job. “First of all money is important” Male UG student, Public medical institute, Lucknow “Financial security is the basic thing. And there is no limit to its need. A person can manage to live even on Rs. 15000 a month or more than that- but at least a person should get an amount justifying his qualification.” Male UG student, Public Medical Institute, Lucknow “The first thing is salary. Until and unless salary is good, we cannot work” Female Nursing Student, Private Nursing Institute, Allahabad Medical students often compared their future earnings with those who had commensurate education in other fields. “All my brothers and sisters are from engineering backgrounds. So they all are earning a lot-by just spending 4-4.5 years in an average engineering college they are all earning very good. In comparison we are studying for 10-12 years, and then we get only 20,000-22,000 rupees, initially when we get appointed in a government position we only get 20-25,000 rupees. The amount is so stagnant in this medical line; probably it is not so stagnant in any other non medical areas” Male UG student, Public Medical Institute Lucknow Along with a good salary, many students also highlighted the importance of being able to utilize the skills they have learned. “I want to practice general surgery once I complete my under-graduation and post- graduation and any sector, whether government or private, provides me the opportunity to practice general surgery I will take up that” Female UG student, Public Medical Institute, Lucknow “The work should be good, facilities should be good and salary should be good. All the things necessary for workin "); array_files[61]=new Array(0,1,"./Paper3/Analytical_section_page7.html","2008-10-30","14K","Analytical Section-Page7 ","",""," Analytical Section-Page7 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) “Since the number of institutes is very less in UP many students will require moving out of the state. For the females getting permission from the family for migrating is difficult. So not many go for BSc. Nursing” Male Nursing Student, Public Nursing Institute, Allahabad “We all are interested in doing BSc. Nursing but the number of institutes offering such course is very less and the fees is [sic] very high.” Female Nursing Student, Public Nursing Institute, Allahabad “Out of 54 students only 2-3 will be able to qualify for BSc Nursing.” Female Nursing Student, Public Nursing Institute, Allahabad The low likelihood of gaining a seat in a BSc. Nursing course meant that nursing students were prepared to seek a job once they had graduated from their course of study. “In case we get a right opportunity, we will immediately go in for a job.” Female Nursing Student, Private Nursing Institute, Allahabad Moreover, unlike medical students, seeking a job abroad was much more popular among nurses as they believed that there were good opportunities for them in countries such as America, Australia and Canada. “I have thought for a job in a foreign country for 5-6 years. There is a system of working in a foreign country. Besides you get a good salary. There is good scope in Canada America etc. There is more punctuality and you get respect too. Growth opportunities are there” Female Nursing Student, Private Nursing Institute, Gorakhpur Overall, the primary focus of undergraduate medical students is gaining admission to a postgraduate course and therefore they are less concerned about the options available to them in the job-market. In contrast, both postgraduate students and nursing students are prepared to enter the job-market upon completion of their course of study. Furth "); array_files[62]=new Array(0,1,"./Paper3/Analytical_section_page6.html","2008-10-30","15K","Analytical Section-Page6 ","",""," Analytical Section-Page6 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) What types of specialties do Medical Students prefer? The overwhelming desire to pursue a postgraduate degree raises the issue of the types of specialties that students tend to prefer. Despite the fact that students are keen on specialization, there are widespread vacancies in posts for specialist doctors in the public sector. Community Health Centres (CHCs) are now required to have five different types of specialist doctors, but many of these posts remain unfilled. Moreover, there are also acute shortages of medical faculty in UP, especially in certain fields such as anatomy, anesthesiology and obstetrics& gynecology. A possible explanation for this distribution of shortages across different medical fields could be that few medical students take up these specialties and, therefore, there is a shortfall in the number of specialists produced in these areas. Students were asked to rank eleven postgraduate specialties available to them according to their personal preferences (see Appendix, Table 1). Clinical specialties were generally more popular as evidenced by this quote from a male medical student in Lucknow: “PG has to be clinical. We do not want to go non-clinical.” Pediatrics and Surgery were two specialties that were rated highly by both undergraduate students as well as postgraduate students. Gender differences were clearly apparent as only women ranked obstetrics and gynecology high, while men leaned towards orthopedics. Interestingly, postgraduate students seemed to be strongly attracted to Radio-diagnosis as a specialty while this was lower down on the list for undergraduates. These results suggest that vacancies in certain fields, such as obstetrics and gynecology, are not a result of lack of popularity for these subjects amongst medical students. In t "); array_files[63]=new Array(0,1,"./Paper3/Analytical_section_page5.html","2008-10-30","15K","Analytical Section-Page5 ","",""," Analytical Section-Page5 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) “80-90percent of us will qualify for PG within next 2-3 years. Those who could not qualify go in for a house job and get Rs. 20,000-25,000 or can even take Diploma of the National Board (DNB) route.” Male UG student, Public Medical Institute, Lucknow “90percent of girls from KGMC get into PG, in fact within 2-3 years more than 50-60percent can get into it. The remaining go for Diplomas” Female UG student, Public Medical Institute, Lucknow The desire for specialization among undergraduates was strong enough for some to forsake careers abroad. “Only 4-5 out of total batch of 180 students among us have plans of going abroad - only gold medalists go there. Going there depends on how strong they are clinically and with family background.” Male UG Student, Public Medical Institute, Lucknow “Post Graduation is a must. I had an opportunity to settle in Germany after my MBBS from KGMC. But I left this opportunity just to do my PG. Everything else comes later, doing PG is a must.” Male PG Student, Public Medical Institute, Gorakhpur With this emphasis on pursuing a postgraduate degree, few final-year MBBS students have given serious thought to entering into the job market. On the other hand, postgraduate students are much keener to get a job once they obtain their degree, although there are also a few who would like to pursue super-specialty courses. “In cardiology field we do not have super specialization here in this institution so I will opt for a super specialization course in some other institute and after completing it I will seek job in the private sector” Male PG student, Public Medical Institute, Lucknow “After this, I would take experience for 1-2 years in private sector and then start private practice” Female PG student, Public Medical Institute, Allahabad Thus "); array_files[64]=new Array(0,1,"./Paper3/Analytical_section_page4.html","2008-10-30","15K","Analytical Section-Page4 ","",""," Analytical Section-Page4 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content u Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) The Importance of Specialization among Medical Students On graduation from their MBBS degree, ninety percent of the undergraduates who participated in this study intended to pursue a postgraduate course of study and use their internship year (i.e. the final year of their MBBS) to prepare for the postgraduate entrance examination. Of the remaining 10 percent, a minority were keen on taking up a job on completion of the MBBS, while a majority intended to diversify their career to non-medical fields like Hospital Administration, Business Management (MBA), Mass Communication or Civil Services. Therefore, upon graduation from their course of study, almost all undergraduate medical students wanted further specialization. This was true of both male and female students although the types of specialties that they were keen on pursuing varied somewhat by gender (See box). Students considered a postgraduate degree necessary for a successful and rewarding career in medicine. “If we do not do our PG we will have to live in small places (town/villages) while if we do our PG then we will have better opportunities” Male UG student, Private Medical Institute, Lucknow “I think MBBS doctor has no status in society…the patients do not go to MBBS doctors. They will go to a MD cardiology if they are having a heart problem, they will prefer to go to a specialist for every disease. Even if the MBBS is sitting in that area and has much more experience than a freshly qualified MD, still nobody will go to him” Female PG Student, Public Medical Institute, Lucknow Students also felt that an undergraduate degree (MBBS) did not adequately qualify them to practice medicine. The MBBS degree includes a one-year period of internship during which students are expected to gain much of thei "); array_files[65]=new Array(0,1,"./Paper3/Analytical_section_page3.html","2008-10-30","14K","Analytical Section-Page3 ","",""," Analytical Section-Page3 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Nursing Students The majority of nurses were keen to work in an urban area for many of the same reasons as medical students: better working and living conditions. However, in contrast with medical students, many nursing students seemed more open to the idea of working in rural areas, especially if they could return to their home villages. Combined Location (urban/rural) and Sector (public/private) Preferences Medical students preferred a government job in an urban area to a private job. This was somewhat surprising given that the private sector clearly seemed the preferred choice during discussions and interviews. For medical students, location is the dominant factor in selecting an ideal first job. On the other hand, for nurses the determining factor was not the location but the type of enterprise - the public sector being the most appealing choice. Like medical students, nurses also preferred an urban public job to an urban private job, though by a much larger margin than did medical students. Similarly in a rural area, a government job is again the preferred choice. Moreover, for nurses, rural private is also the least preferred option. The difference is that nursing students actually preferred a rural public job to an urban private job, whereas for medical students it was the other way around. Incentives for Rural Service Medical Students The most appealing non-financial incentive for both undergraduate and postgraduate medical students was a 50 percent reservation in PG courses for students who had completed a stint in a rural area following their MBBS degree. Over 80 percent of undergraduates interviewed were very attracted to rural service for 2-3 years with 50 percent PG reservation. Further trainings or continuing education was also an attractive incent "); array_files[66]=new Array(0,1,"./Paper3/Analytical_section_page2.html","2008-10-30","14K","Analytical Section-Page2 ","",""," Analytical Section-Page2 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Medical Students’ Preferences for the Private Sector Over 80 percent of undergraduates and about 60 percent of postgraduates cited high salaries as the major draw of the private sector. Low salaries were the single most important factor that discouraged students from opting for the public sector both for undergraduates (62percent) and for postgraduates (67percent). Job security was not significance enough in attracting students to join the public sector. For students planning to open up their own private practice, the social recognition provided by the public sector is especially important – it offers the opportunity to gain experience and build a network of clients, both of which are crucial for a successful private practice. Contrary to popular perception, this study showed that even medical students who grew up in rural areas were not especially keen on a job in a rural area, as they aspired to a better life for themselves and their children. Nursing Students’ Preference for the Public Sector In contrast to medical students, for nurses, the public sector was generally an attractive job option. A job in a private nursing home was the least preferred career option and was to be considered only when they had no job alternatives in the public sector or in a private hospital. Location Preferences Medical Students All categories of students favored working in urban areas. When all undergraduates participating in this study were questioned on their work location choices, the majority (70percent) expressed a preference for an urban job over a rural area (9percent), with the remainder stating no preference. This preference was even more prominent among postgraduate students - less than 5percent of PG students had plans of serving in a rural area at any point during th "); array_files[67]=new Array(0,1,"./Paper3/Analytical_section_page19.html","2008-10-30","15K","Analytical Section-Page19 ","",""," Analytical Section-Page19 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) “Only promotion cannot do anything. The main thing is money. Unless money will not be pouring in what difference will it make? Even after promotion if you become a CMO [Chief Medical Officer], you will still earn Rs. 30000-40000 as compared to a private doctor who ears Rs. 70000-80000” Male UG student, Private Medical Institute, Lucknow “Only promotion will not benefit much. Instead of promotions, qualifications should increase” Male UG student, Public Medical Institute, Allahabad Medical students were much more inclined to favor government policy that attempted to post students near their hometown. They were, in general, willing to tolerate only a certain distance from their hometown even if posted in the same district. As one student explained: “If posted in the hometown [sic] many of us can go but the CHC needs to be only 30 min to 1 hour distance from our house. If the time between home and CHC is more than that then what is the use of choosing hometown?” Male PG, Public Medical College, Gorakhpur Incentives for rural service: Nursing Students The most important incentives for nursing students were similar to those of medical students. As nurses are also keen to pursue further education, reservation in BSc courses for nurses who work in rural areas was considered an appealing prospect. “This is a good option if it helps you to get into BSc. Nursing. If we do it in private by our own means we might not be able to qualify it” Female Nursing student, Private Nursing Institute, Gorakhpur However, for nurses, the most attractive option was in fact a posting in a rural area near their hometown or village. “If we can get a job in our home village it is the best thing that can happen otherwise we can adjust to other options as well.” Female Nursing Student, Public "); array_files[68]=new Array(0,1,"./Paper3/Analytical_section_page18.html","2008-10-30","16K","Analytical Section-Page18 ","",""," Analytical Section-Page18 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Incentives for rural service: Medical Students In order to gain a sense of what would motivate them to work in rural areas, both medical and nursing students were presented with various incentives – addressed separately each time – for doing temporary service in the public sector in rural areas. These included a 50percent reservation in postgraduate courses, legalized private practice, increased training opportunities, good housing, faster promotions, a guaranteed urban transfer and a rural posting near the student’s hometown. Each of these incentives was presented by itself, in the absence of any other inducements. Students were then asked to rate the attractiveness of each incentive by saying that it was “Very Important”, “Important”, “Somewhat Important” and “Not important”. The incentives that were offered were all non-financial incentives. Students were also asked about the salaries they would like to receive if they were to work in a rural area. However, the results covered a wide range of amounts, and it was not clear whether students had a sense of what they would like to earn, or even what they would currently earn, in the public sector. The salary expectations of medical and nursing students require further study and are, therefore, not discussed in this paper. The most appealing non-financial incentive for both undergraduate and postgraduate medical students was a 50percent reservation in PG courses for students who had completed a stint in a rural area following their MBBS degree (see Appendix, Table 4). Over 80 per cent of undergraduates interviewed were very attracted to rural service for 2-3 years with 50percent PG reservation (saying that it was “very important”. This is perhaps not surprising, given the extreme competitiveness of admissions to "); array_files[69]=new Array(0,1,"./Paper3/Analytical_section_page17.html","2008-10-30","16K","Analytical Section-Page17 ","",""," Analytical Section-Page17 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) “If salary is there and facilities are there we will all go to rural” Female Nursing Student, Private Nursing Institute, Allahabad “If the facilities for education are increased in rural we will stay there for lifetime and not ask for urban transfer ever.” Female Nursing Student, Public Nursing Institute, Lucknow For many medical students, working in rural areas is not a very attractive option. Significantly, this was the case even for medical students with rural backgrounds. On the other hand, nursing students are much more receptive to the idea of working in a rural area. While nursing students also desire to work in an urban area, they appear not to be averse to serving in a rural area, perhaps a reflection of the stronger ties they have to their rural roots. Combined location (urban/rural) and sector (public/private) preferences The perceptions and results presented in the previous sections are based on students’ opinions when considering location, or the type of establishment (public/private), separately. Students were also asked to choose between combinations of location and sector: urban-private, urban-public, rural-private, rural-public. The results (Appendix, Table 3) lead to a few conclusions. For medical students, the choice between the public and private sector was a little ambiguous; while students seemed much more attracted to the private sector, they acknowledged that the public sector offered several advantages. Indeed when directly asked to choose between a government job in an urban area and a private job in an urban area, students actually preferred the former (Appendix, Table 3). This result was somewhat surprising given that the private sector clearly seemed the preferred choice during discussions and interviews. There are a couple of reaso "); array_files[70]=new Array(0,1,"./Paper3/Analytical_section_page16.html","2008-10-30","15K","Analytical Section-Page16 ","",""," Analytical Section-Page16 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) “The government has given me education at such a low cost. I would like to pay back to the government by working in private practice in rural.” Female PG student, Public Medical Institute, Allahabad These views, however, were extremely rare and very few students were willing to commit to being interested in taking a rural posting. Location Preferences: Nursing Students Nursing students also preferred working in urban areas although they were, in general, more amenable than medical students to working in rural areas. The majority of nurses were keen to work in an urban area for many of the same reasons as medical students: better working and living conditions. “In urban areas safety is more as compared to rural areas…there is a problem of electricity and water in the rural area. So we cannot give our 100percent to the patients” Female Nursing Student, Private Nursing Institute, Lucknow “There are no facilities over there [rural]- no proper living facility, no electricity. We cannot do night duty over there- it is unsafe and there is no proper living place…also there are no conveyance facilities- we cannot move to the city easily” Female Nursing Student, Public Nursing Institute, Lucknow However, many nursing students seemed more open to the idea of working in rural areas, especially if they could return to their home villages. Therefore, in contrast with medical students, a rural background apparently made nursing students more favorable towards a rural job. “Most of the respondents over here are from rural background so if we are offered a job in the same area we can work there as well. We can understand the local people’s problems better. In order to know the sufferings of the villagers better, I suggest that our training should be done in rural "); array_files[71]=new Array(0,1,"./Paper3/Analytical_section_page15.html","2008-10-30","15K","Analytical Section-Page15 ","",""," Analytical Section-Page15 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) “There is no source of entertainment- no friends, no society, no colleagues etc. We will have our family too in future. We don’t want our family to be isolated. We can stay in rural till we are not married but would like to stay on our own terms and conditions” Female UG student, Public Medical Institute, Allahabad “Even if the working conditions can be improved…what will we do for the roads? Where will we get enough drinking water? The connectivity is also not there. You cannot do anything for your children, for your wife” Male PG student, Public Medical Institute, Lucknow It is often argued that students from rural backgrounds are more likely to work in rural areas (Laven and Wilkinson 2003; Matsumoto, Okayama et al. 2005; Dussault and Franceschini 2006). In this study, however, even medical students who grew up in rural areas were not especially keen on a job in a rural area, as they aspired to a better life for themselves and their children. “I am from a village but I would like to bring up my children where there are maximum facilities. I want to give our children the best education. I cannot speak English very well but I would like my children to study in an English Medium School...I would choose such a location for upbringing [sic] my children so that they get best possible education opportunities” Male UG student, Public Medical Institute, Allahabad Many female medical students worried particularly about the opportunities available for their family, and the low likelihood that their family would be able to live with them in a rural area. “We will choose to work in urban areas. With time, we will have a family as well and everybody with you will not be willing to go in rural areas with you and when you have children, their education suffers in the "); array_files[72]=new Array(0,1,"./Paper3/Analytical_section_page14.html","2008-10-30","15K","Analytical Section-Page14 ","",""," Analytical Section-Page14 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Location Preferences: Medical Students While there was a difference between medical and nursing students in their preference for working in the private or public sector, all categories of students overwhelmingly favored working in an urban area. When all undergraduates participating in this study were questioned on their work location choices, the majority (70percent) expressed a preference for an urban job over a rural area (9percent) with the remainder stating no preference. The preference for an urban job was even more prominent among postgraduate students; less than 5percent of PG students had plans of serving in a rural area at any point during their lives. Most medical students equated working in a rural area with working in the public sector and, therefore, cited many of the disadvantages of the public sector as also being those of working in rural areas. For example, the lack of facilities in rural areas for carrying out medical procedures featured as a prominent concern. Students felt that without proper equipment available, they would not be able to use their skills and this would affect their job satisfaction. “The doctor alone cannot make a difference. Even if you want to do something the infrastructure is not there. If there is a super-specialty hospital in a rural area I would be willing to go there daily and work there” Female UG student, Public Medical Institute, Lucknow “The government wants us to go to rural areas. This is wastage [sic] of our studies. Neither they have the facilities over there nor do the people over there have the money. If suppose we have to do bypass surgery in rural areas how are we going to do it” Male UG Student, Private Medical Institute, Lucknow “Whatever we want to do there, we will not be able to do. There are no in "); array_files[73]=new Array(0,1,"./Paper3/Analytical_section_page13.html","2008-10-30","15K","Analytical Section-Page13 ","",""," Analytical Section-Page13 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Many nursing students also mentioned job security as being important towards their career decision. The students unanimously felt that a position in the public sector offers greater job security than the private sector. “We have safety in this [public sector] job as once you are into government job you do not have to change job every now and then.” Female Nursing Student, Public Nursing Institute, Lucknow “If we have some kind of personal problem and we don’t appear for maybe one month then the private people will not pay you but this is not the case in the government” Female Nursing Student, Private Nursing Institute, Lucknow “Most of the people go in for a government job for pension. You get secured for life. Pension will be your security for old age. Job is still there when something happens to us” Female Nursing Student, Public Nursing Institute, Lucknow An additional advantage of a government job was that the public sector offered fixed work timings. This was particularly important for female nursing students since their obligations to the family could be better planned around such a work schedule. As one such student elaborated: “We can finish our work within a fixed time. It is a 9 to 5 job. Rest of the time we can dedicate it with our family. As compared to private sector the job timings are fixed and workload is less. We have safety in this job, as once you are into a government job, you do not have to change job every now and then” Female nursing Student, Public Nursing Institute, Lucknow It is important to also note that, in their preference for the public sector over the private sector, students in private nursing schools think no differently from their colleagues attending a public nursing school. “In private job there is more work and less money. "); array_files[74]=new Array(0,1,"./Paper3/Analytical_section_page12.html","2008-10-30","15K","Analytical Section-Page12 ","",""," Analytical Section-Page12 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) “[A government job] gives us recognition from the society” Female UG student, Public Medical Institute, Allahabad A person in a government job works for 6-8 hours in a fixed time and patients keep on running after him just to meet him–because he is the only medical doctor in the area. Even if there is a very experienced private medical practitioner in that area the people might not know him to the extent people know this government doctor. “ Male PG student, Public Medical Institute, Gorakhpur For students planning to open up their own private practice in future, the social recognition provided by the public sector is especially important. A government job offers the opportunity to gain experience and build a network of clients, both of which are crucial for a successful private practice. As one student explains: “If somebody knows that I am belonging to a medical college, I get special respect. It gives you name and fame. Many of the professors over here have joined this medical college although they are very competent and can earn much more in the private sector; they still have joined this just to get a platform.” Male PG student, Public Medical Institute, Allahabad A student sums up the benefits of a government job in the following way: “It [a government job] gives us recognition from the society. We can establish our private practice after recognition. Workload is less and no one can pull us out. Our job is also fixed-whether you work or not work nobody can terminate you. Female Undergraduate student, Public medical institute, Allahabad The fact that students were able to recognize some advantages of working in the public sector suggests that it may be possible to attract students into government jobs with some additional incentives. However, currently the "); array_files[75]=new Array(0,1,"./Paper3/Analytical_section_page11.html","2008-10-30","15K","Analytical Section-Page11 ","",""," Analytical Section-Page11 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Personal security, which was mentioned as an important concern by many medical students was also believed to be more of a problem in the government sector. “First of all there is a pressure of local politician. They ask a doctor to give forged certificate and do paperwork. Due to these false documents, hassles are created” Male UG Student, Public Medical Institute, Lucknow One student summarizes the various disadvantages of a public sector job as follows: “There are more disadvantages than advantages in a government job- safety, financial and political pressure. Pressure is more in rural areas. Anybody can kill us and get away with it.” Male UG student, Public Medical Institute, Lucknow Medical students did, however, acknowledge that there were some advantages that working in the public sector had over working in the private sector. Foremost among these was job security and a limited workload. Over 80 percent of undergraduates and 70 percent of postgraduate medical students stated, during interviews, that job security was the greatest advantage of a public sector job. However, since job security, as an attribute of a first job, was not prioritized as being of great significance, it is not especially effective in attracting students to join the public sector. “In a government job you cannot be pulled out of a job. In private, if you do not work well you will be warned for 2-3 times and then terminated from your job. Also, if they are getting another employee on a lesser pay scale than you- with the same efficiency level as you, the private sector replaces you as quickly” Male PG student, Public Medical Institute, Gorakhpur “The only advantage that I think is there in a government job or a job in a public sector is that you have time to live even in times of emer "); array_files[76]=new Array(0,1,"./Paper3/Analytical_section_page10.html","2008-10-30","15K","Analytical Section-Page10 ","",""," Analytical Section-Page10 Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section (Contd...) Medical Students’ Preferences for the Private Sector Medical students preferred to work in the private rather than in the public sector, as the former offered many of the job characteristics that students valued. For example, one of the primary reasons medical students were attracted to the private sector is that the salaries offered there are generally much higher than those in the public sector. In fact, low salaries were the single most important factor that discouraged medical students from opting for the public sector both for undergraduates (62percent) and for postgraduates (67percent). Similarly, over 80 percent of the undergraduates and about 60 percent of postgraduates cited high salaries as the major draw of the private sector. “Private people give performance-based incentives…also salary is good” Female UG Student, Public Medical Institute, Allahabad “Entrant level salary [in private job] is Rs. 60,000 which I believe is good” Female PG student, Public Medical Institute, Allahabad “The salary in government job is less. I think that a government job should follow the corporate culture- pay in accordance to your work. People are thus leaving government jobs because of low pay.” Male UG student, Public Medical Institute, Allahabad Students also felt that they had better opportunities to utilize their skills in a private hospital than in government clinics as the latter often lack basic equipment and facilities. Especially once the student undertakes a postgraduate course of study, the learning opportunities in a job is felt to exist largely if posted in a tertiary level healthcare facility that both brings complex patient-cases as well as the possibility of more complete utilization of the doctor’s specialist skills. “…If we want to make d "); array_files[77]=new Array(0,1,"./Paper3/Analytical_section.html","2008-10-30","14K","Analytical Section ","",""," Analytical Section Search Career Preferences of Medical and Nursing Students in Uttar Pradesh: A Qualitative Analysis Content Introduction Sample & Methods Analytical Section Conclusion References Appendices Download Analytical Section Summary The Importance of Specialization among Medical Students Medical undergraduates Upon graduation, almost all undergraduate medical students (male and female) wanted further specialization for a successful and rewarding career due to the following reasons: (1) better career opportunities (2) the perception that MBBS doctors have less status in society and (3) the belief that an MBBS degree does not sufficiently qualify them to practice medicine. They were prepared to spend 2-3 years preparing for the entrance examination to a postgraduate course (a very competitive process due to limited seats), and only if still unsuccessful, would they consider entering the job market. This desire was strong enough for some to forsake careers abroad. The types of specializations that they were keen on pursuing varied somewhat by gender. With the emphasis on pursuing a postgraduate degree, few final-year MBBS students gave serious thought to entering the job market. Medical postgraduates Postgraduate students are much keener to get a job once they obtain their degree, although there are also a few who would like to pursue super-specialty courses. Nursing Students’ plans upon graduation About 65 percent of the nursing students expressed an inclination towards a postgraduate course. However, since they felt that the chance of getting a seat in a BSc course was extremely low, nursing students were much more amenable to entering the job market on completion of the GNM diploma than were medical students graduating with an MBBS. Unlike medical students, seeking a job abroad was much more popular among nurses as they believed that there were good opportunities for them in countries such as America, Australia and Canada. Job Preferences of Students: Ideal Attributes For most medical students, a re "); array_files[78]=new Array(0,1,"./Paper2/Structure_of_the_Paper/Structure_of_the_Paper.html","2008-10-30","16K","Structure of the Paper ","",""," Structure of the Paper Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Structure of the Paper Summary Despite significant improvements having been achieved in public health since independence, this area continues to be “one of the most neglected aspects” of government policy. (Dreze and Sen, 2002). This paradox is examined and addressed by: - the concept of power in the health system and how it is used to influence policy. - focusing on the implementation level of institutions. - analyses on the existing disconnect between the grand strategies at national level policy planning and the more immediate problems that the bureaucrat officials (tasked with the implementation of policies) are preoccupied with at the institutional level. India is one of the pioneers in health service planning and in recognizing human resources as key to a well-functioning system. The first independent government of India had no less than three significant reports on health policy planning even before it initiated the first of its Five-Year Plans.1 Ever since, each subsequent Plan until the current eleventh one, has strived with all good-intention to strategize on elements of human resource development for better health care provision. There is no doubt that significant improvements in health have been achieved since independence, particularly in the lowering of infant mortality and a steady increase in life expectancy. Nevertheless, public health has been “one of the most neglected aspects” of government policies for furthering development in the country (Dreze and Sen, 2002). An overall objective of this paper is to attempt an understanding and explanation of this paradox, but it is principally driven by two broad aims: F "); array_files[79]=new Array(0,1,"./Paper2/Select_Bibliography/Select_Bibliography_page2.html","2008-10-30","20K","Select Bibliography-Page2 ","",""," Select Bibliography-Page2 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Select Bibliography Haggard, S., and S. Webb. 1993. What do we know about the political economy of economic reform? The World Bank Research Observer 8 (2):143-68. Hariharan, S. 2004 unpublished. Central Health Service - A Review for Government. Herbst, J. 1990. The structural adjustment of politics in Africa. World Development 18 (7):949-958. Hirschman, A.O. 1970. Exit, Voice and Loyalty. Cambridge, Massachusetts: Harvard. ICSSR/ICMR. 1981. Health for All: An Alternative Strategy. Second Edition, 2002 ed: ICSSR. Illich, I. 1975. Medical Nemesis: the expropriation of health. London: Calder & Boyars. Jeffrey, R. 1986. Health Planning in India 1951-84: the role of the Planning Commission. Health Policy and Planning 1 (2):127-137. ———. 1988. The Politics of Health in India. Berkeley: University of California Press. JLI. 2004. Human Resources for Health: Overcoming the crisis: Joint Learning Initiative (Global Equity Initiative, Harvard University). Leslie, C. 1985. What Caused Indias Massive Community Health Worker Scheme. Social Science and Medicine 21 (8):923-930. Mahal, A., and M. Mohanan. 2006 unpublished. Medical Education in India and its implications for access to care and quality. Martinez, J., and T. Martineau. 1998. Rethinking human resources: an agenda for the millenium. Health Policy and Planning 13 (4):345-358. Mavlankar, D. Undated mimeo. Auxiliary Nurse Midwifes changing role in India. Misra, R., R. Chatterjee, and K. Sujatha Rao. 2003. India Health Report. Delhi: OUP. NCMH, GOI. 2005. Background Papers:Financing and Delivery of Health Care Services in India. New Delhi: Government of India. ———. 2005. Report of the "); array_files[80]=new Array(0,1,"./Paper2/Select_Bibliography/Select_Bibliography.html","2008-10-30","18K","Select Bibliography ","",""," Select Bibliography Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Select Bibliography Abraham, L. 2005. Indian Systems of Medicine (ISM) and Public Health Care in India. In Review of Health Care in India, edited by CEHAT. Mumbai. Amrith, S. 2007. The Political Culture of Public Health in India: A Historical Perspective. Economic and Political Weekly (13 January). Ananthakrishnan, N. 2007. Acute shortage of teachers in medical colleges. The National Medical Journal of India 20 (1):25-29. Bajaj Committee, GOI. 1987. Report of Expert Committee on Health Manpower Planning, Production and Management: Government of India. Berman, P. 1987. Community-Based Health Workers: Head Start or False Start towards Health for All? Social Science and Medicine 25 (5):443-459. ———.1998. Rethinking Health Care Systems: Private Health Care Provision in India. World Development 26 (8):1463-1479. Berman, P., and R. Ahuja. 2008 unpublished. Government Health Spending in India: Getting to 2percent of GDP. Bhore Report, GOI. 1946. Report of the Health Survey and Development Committee. New Delhi: Government of India. Bossert, T., et. al. 1998. Transformations of ministries of health in the era of health reform: the case of Columbia. Health Policy and Planning 13 (1): 59-77. CEHAT. 2005. Review of Health Care in India. Mumbai. Central Bureau of Health Intelligence, GOI. 2005. Health Information of India 2005. Delhi: Government of India Press. Chaudhury, N., et al. Missing in Action: Teacher and Health Worker Absence in Developing Countries. Journal of Economic Perspectives 20 (1): 91-116. CPR. 1999. Report on the Restructuring the Ministry of Health & Family Welfare. New Delhi: Centre for Policy Research. DFID. 2003. Promoting "); array_files[81]=new Array(0,1,"./Paper2/Part_IV/Part_IV_Discussion_page4.html","2008-10-30","14K","Part IV-Discussion-Page4 ","",""," Part IV-Discussion-Page4 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part IV (Contd...) First: With such a focus on challenges faced at the implementation level of institutions, it is significant to understand how similar ‘mini-battles’ (if not even the same) between government and providers of health care have been dealt with in other state health systems with better health indicators. In state health systems known to better manage health service delivery, it is important to ascertain whether these more routine HR-related problems that affect health system efficiency were resolved, circumnavigated, or were of little relevance to how policy measures were more successfully implemented. Second: NRHM framework is designed to provide states with a greater role in policy planning through the instrument of detailed State PIPs for the health sector. There is now new opportunity to review the HRH plans of these State PIPs in select states and to assess to what extent they reflect the particular problems of implementation and institutional inadequacies separately diagnosed for those states. The importance of the linkage of institutional analysis in the states for a realistic assessment of State PIPs may be a task relevant specifically to the new National Health Systems Resource Centre (NHSRC). Third: It is argued that a clear distinction drawn between the payor and the provider, or even complete separation between the two through innovative use of private providers will bring more transparency and accountability to the health system to improve service delivery (WDR, 2004). Further work along institutional lines, as in this paper, may probe whether or not such separation between payor and provider better "); array_files[82]=new Array(0,1,"./Paper2/Part_IV/Part_IV_Discussion_page3.html","2008-10-30","16K","Part IV-Discussion-Page3 ","",""," Part IV-Discussion-Page3 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part IV (Contd...) The policies in Plans therefore can sit uncomfortably at the implementation level where institutions are faced in reality with related, but more mundane, pressing concerns. In other words, policy planning at the national level and the level where the implementation of these policies are expected function in entirely different contexts, with different pressures from the Courts and interest groups. A few examples from this paper may suffice to make the point. The Plans, for instance, focus on strategies to increase the numbers of doctors joining the government medical service. At the implementation level in UP, however, the immediate problems due to cadre reorganization (and possibly political motives), made the government implement a policy that in fact restricts entry into the PMS to only medical graduates from the ‘reserved category’. Similarly, with regard to medical education, the recent Plans and NRHM call only for increased numbers of medical colleges. Any implementation of such policy in UP is, however, superseded by a more severe immediate problem of faculty shortage in even the few existing medical colleges and more numbers of colleges in this context only weaken further these institutions. Recent Plans as well as NRHM recognize the acute shortage of nurses in the country and consequently, at the national level, priority is wholly on more nursing schools. In UP, the current Service Rules for nurses allows for nurses not qualified or trained for teaching posts to occupy these, which has brought a host of other problems that prevent the government from building more nursing schools since these will not "); array_files[83]=new Array(0,1,"./Paper2/Part_IV/Part_IV_Discussion_page2.html","2008-10-30","16K","Part IV-Discussion-Page2 ","",""," Part IV-Discussion-Page2 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part IV (Contd...) This concluding discussion highlights the disconnect between the grand strategies of the policy planners at the national level and the more immediate and routine problems of bureaucrats at the implementing institutional level, which itself needs to become a priority concern but has so far been largely overlooked. For instance, the routine battles with doctors’ interests and the grievances of other health staff define a different set of problems from those diagnosed in the Plans. Officials in state-level institutions tasked with implementation of the Centre’s strategies are often preoccupied with these ordinary problems as immediate concerns. As evident in the case studies on the medical and nursing services in UP, the solutions to these ordinary problems can create unexpected new bureaucratic difficulties that preoccupy officials or have unintended implications for institutions (such as for nursing education in UP) that are at variance with the aims of the grand policy Plans. The mini-battles and conflicts at the state-level exist between the government administrative-officials as ‘payors’ and the individual/group interests of the ‘providers’. The fact that in most government health systems in the country, the payor and the provider are both within the government system hides from public view the ways in which the majority of these internal conflicts occur at different levels; an indication of the scale of these conflicts is perhaps best provided by the fact that the government officials at national and state-level have to engage with legal cases numbering in several thousands filed by current or former provi "); array_files[84]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page9.html","2008-10-30","16K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page9 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page9 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) The promotion of nurses to teaching posts in nursing schools, without possessing the minimum prescribed educational training, has further jeopardised the quality of government nursing education institutions. The incentive for the nurses who successfully completed the 2-year course of Post-Basic B.Sc.(N) was that it made them eligible to become tutors in nursing schools and colleges as nursing tutors. Staff nurses who pursued a 10-month ‘tutor course’ in nursing, were eligible to become PHN tutors in nursing schools. With the change in Service Rules and subsequent promotions only on a seniority criterion, teaching staff in government nursing schools in UP no longer all have the educational training that the INC deems mandatory (see Appendix: Tables 5&6). Consequently, the INC has withheld recognition from all nursing schools under the state government. This has created another dimension to the conflict between some nurses trained from these institutes and the government and friction between the State government and the central regulatory authority on the standards of the nursing institutes. The government has ensured that the State Nursing Council, separate and autonomous from the INC, recognises these nursing schools and registers nurses graduating from these schools. Since it is the INC, and not the State Nursing Council that is tasked with the inspection of nursing schools, the latter recognises these government schools without undertaking inspection. There is consequently an overlapping regulatory role that both the INC and the State Nursing Coun "); array_files[85]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page8.html","2008-10-30","16K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page8 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page8 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) Case Study 3 UP Nursing Service Rules: impact on educational incentives and institutions After over a decade of neglect, the nursing profession features prominently in the strategy that current policy planning is engaged in to make better health care reach the poorest and most vulnerable. The specific strategy with regard to nursing is largely centred on the need and ways to produce more nurses. The state government in UP and officials overseeing nursing have a different problem to address first: there are few qualified and adequately trained nurse staff for teaching at the existing GNM schools which place these institutions precariously close to being, if not already, deemed unsuitable for producing nurses. If the government built new schools, they would face the same situation, since the problem is deeper and affects the entire government-nursing cadre of the state. The core problem is the government’s own creation since it is the consequence of a change in nursing Service Rules in the state in 1996 to placate the agitation of nurses seeking a solution to facilitate promotions that were almost non-existent in the cadre. The 1980 Service Rules for nurses give significance to educational qualification as an eligibility requirement for different nursing posts, as prescribed by INC norms. However, the State has never separately registered nurses with the following additional educational training: Public Health Nurse and B.Sc. (Nursing)/Post Basic B.Sc. (N). There is provision to only register nurses with ANM, GNM and LHV training. The absence of insti "); array_files[86]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page7.html","2008-10-30","20K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page7 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page7 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) Box 4: UP Medical Education: Scale of the Faculty Shortage problem At the national level the Plans have been concerned with more medical colleges or not, with current policy of NRHM in favor of increased numbers. Especially in a populous state such as UP, while there are currently 16 medical colleges, population-based norms for the number of medical colleges (one college per lakh population) demand, at the very least, doubling (to 35) of the existing number. At the institutional level, the severe problem faced even in the few medical colleges existing in the state is the enormous scale of faculty shortage. According to 2006 data, of the 738 officially sanctioned faculty positions in UP government medical colleges (and this is already lower than the numbers actually required), over 40 per cent of the teaching posts remained vacant (see Appendix: Table 3). This is a significantly higher proportion than the 20-25 per cent shortage suggested to exist in most departments of the country, with highs of 33 per cent. (Ananthakrishnan, 2007) De-recognized PG courses The implications of MCI Rules on faculty-student ratio for medical education has significantly contributed to the de-recognition of certain numbers of PG seats in UP medical colleges, even though the state government continues to admit students to fill these seats. MCI norms require a 1:1 ratio to be maintained between students and postgraduate teachers. This norm was created at a time and context far removed from the reality facing UP, but still must be adhered to in order for a medical college t "); array_files[87]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page6.html","2008-10-30","17K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page6 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page6 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) New Recruitment problems: The promotions of many doctors to the newly formed higher intermediate levels created ‘space’ for a round of new recruitment of Male General doctors at the entry-level in 2005. By the time the requisitioned posts in 2005 were filled in 2007, it was found that in relation to the officially sanctioned posts in the Service Rules, there appeared to be a ‘surplus’ number of some seven hundred doctors at the entry-level (Level 1) of the Male General sub-cadre (See Appendix: Table 1). The Directorate in Lucknow acknowledges that many of the 2278 doctors at the entry-level are not currently in the system. The process for determining a ‘vacancy’ when a doctor still remains on the registers is nevertheless lengthy, since the UP Public Services Commission needs to confirm that a doctor recruited by the Commission is no longer in active service. This need to formally declare a vacancy created additional work for the Directorate, with no link at all to its principal institutional function of providing technical assistance to health service delivery. At the institutional level of the directorate, there was consequently a problem that may be summed up in the following way: there was an undisputable need to recruit more doctors, but since the doctors who remained on the rolls exceeded the numbers sanctioned, no recruitment was possible. The solution finally found for a second round of doctor recruitment was determined considering the social background of doctors. The Law requires that fixed percentage of the current workforce must be drawn "); array_files[88]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page5.html","2008-10-30","17K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page5 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page5 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) Case Study 2 UP Medical Service: Cadre Review and resulting problems A rarity of promotions had also been a feature of the UP Provincial Medical Service for decades and the constant lobbying of in-service doctors led to formulating new Service Rules in 2005, which brought about change in the structure of the cadre and several promotions to new positions with it. There had been few promotions previously due to institutional reasons of contested seniority lists, the absence of ACRs and also a general apathy towards convening of the Departmental Promotion Committees that selected from among eligible candidates. The Provincial Medical Service Association had been outspoken about the doctors’ grievances and involved with the government in the Cadre Review resulting in changes that most benefited in-service doctors. The new Service Rules and the formation of new sub-cadres, however, have created fresh problems: the recruitment of new doctors and the way current in-service doctors have been repositioned has had consequences that have in fact been the very opposite of the goals that the national policy plans pursue. Therefore, while beneficial for significant numbers of doctors who had been in the Service, cadre reorganisation retains the focus of officials on dealing with bureaucratic problems internal to the system concerning doctors, rather than a health outcomes focus concerning patients. The implementation of the new Service Rules created the following four sub-cadres on lines of generalist/specialist and gender: 1) Male General; 2) Male Specialist; 3) "); array_files[89]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page4.html","2008-10-30","15K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page4 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page4 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) Prior to the subdivision of the CHS cadre in 1982, MBBS and PG degree/diploma holders entered a unified cadre with a single seniority list. Entrants were regarded as ‘Specialist’ or ‘General’ depending on their educational qualifications and were posted to wherever vacancies appeared that best used their educational training and experience. The creation of sub-cadres forced recruitment to be rigidly to vacancies advertised within a particular sub-cadre and any future movement from the GDMO sub-cadre to the specialist sub-cadres was not permissible. Unlike before the subdivision of the cadre, doctors with postgraduate degrees, who join the CHS as a GDMO for reasons noted above, can no longer be recognized as specialists by the system. These post-graduate GDMOs are nevertheless undertaking functions of a specialist nature in various hospitals and teaching institutions. However, this institutional disregard of their specialist status means that they are unable to avail the advantages of career avenues and seniority lists open to the Specialist sub-cadre to which these PG-GDMOs cannot directly transfer to, even after valid experience within CHS. Participating institutions of the CHS currently have posts deemed strictly as ‘specialist sub-cadre’ posts. The CHS is unable to recruit eligible candidates to fill vacancies in all the three specialist sub-cadres, and yet neither is it able to utilise the PG-GDMOs, already in its rolls with appropriate educational qualifications, to fill these vacant posts. A PG-GDMO with the requisite experience gained in CHS "); array_files[90]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page3.html","2008-10-30","16K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page3 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page3 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) Implications of the current organization of CHS a) On Attrition The division of the CHS in 1982 into four sub-cadres introduced, over time, a structural problem affecting promotions and selection of in-service doctors to higher grade posts. Promotions have been within each of the four sub-cadres from entry-level up to and including the Senior Administrative Grade level (see diagram in Appendix: Figure 4). Thereafter, the sub-cadres are merged into a common hierarchy for promotions to the Higher Administrative Grade posts of Additional Directors General of Health Service and equivalent and Director General Health Services. In the two Teaching Specialists and Non-Teaching Specialists sub-cadres, promotions up to the Senior Administrative Grade level are not only confined to within the particular sub-cadre, but also confined to within the respective Specialities and Super-Specialities. Consequently, in the CHS itself there are over 70 separate seniority lists. Multiple seniority lists create their own share of problems, such as those of accountability and transparency in selections and postings to higher levels. The process of selection for promotion is however made further complicated since the sub-cadres and seniority lists need to be merged at the highest two levels of the CHS cadre. Consequently, there is stagnancy of large numbers of doctors at a single grade for many years, which is a central cause of complaint for CHS doctors over the last 15 years and more. Moreover, it is a focal ground of conflict between CHS doctors and bureaucrats of the Ca "); array_files[91]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page2.html","2008-10-30","16K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page2 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page2 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) Case Study 1 CHS: Problem of cadre organization on doctor incentives The cadre management of the CHS is housed in the central Ministry of Health and Family Welfare, with the central Directorate – the principal technical/managerial support to health policy and national programs – almost entirely staffed by CHS doctors. Considering this proximity of the CHS to central health policy planning for better efficiency in the system and considering that the Centre has always had complete control (unlike in the states, where it is only able to promote adopting best practices to state governments), it might well have been expected that the CHS cadre would have served as a model vastly superior in the implementation of its core HRH administrative management functions as compared to states such as UP. In fact, Departmental Promotion Committees (DPCs) that decide on promotions have been convened rarely for decades. The related agitation of CHS doctors and the doctors’ lobby-group (JACSDO) for several years in the late-1980s resulted in the Tikku Committee Report (1990), and the central government accepted the doctors’ call for time-bound promotions for the initial years of a CHS doctor’s career (first 13 years for a GDMO; first 6 years for the specialist cadres). Even so, the absence of adequate promotions thereafter remains a severe grievance for the doctors. Moreover, in spite of the CHS providing medical graduates employment with a Class ‘A’ central government service, very low numbers finally join as GDMO or in specialist posts after being successfully select "); array_files[92]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_page10.html","2008-10-30","17K","Part III-HRH Problems at the implementation level of Institutions Case Studies-Page10 ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies-Page10 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III (Contd...) Therefore, looking simply at annual numbers of nursing schools and numbers of graduating ‘qualified’ staff nurses, the trend appears to be very positive and is being further encouraged by policy planners and NRHM. From the perspective at the institutional level where this policy of new schools is implemented and teaching is imparted to growing number of students, there is a whole different concern of problems and inadequacies that never get reported. Moreover, this latter perspective questions the very soundness of a policy extensively promoting more production of nurses in more nursing schools while present institutional inadequacies continue to allow for poor teaching staff and a weak regulatory system. Box 5: De-institutionalization of Public Health Nursing Education in UP NRHM plans for 2 ANMs in every sub-centre and has allocated funds also for an increase in the number of sub-centres. UP currently has 20,251 sub-centres, and official documents state that each is manned by a single ANM. Under NRHM, the state envisages 7,000 additional sub-centres. The NRHM plan of 2 ANMs in the existing and new sub-centres, therefore, calls for the additional training of broadly 34,000 new ANMs in the span of five years remaining of the Mission. This ambitious aim depends on institutions with teaching staff for the production of ANMs, but the condition in public health nursing has become even worse than the deterioration in educational institutions for clinical nursing; they simply ceased to exist. Through a policy decision, all the 40 ANM Training Centres and "); array_files[93]=new Array(0,1,"./Paper2/Part_III/Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies.html","2008-10-30","15K","Part III-HRH Problems at the implementation level of Institutions Case Studies ","",""," Part III-HRH Problems at the implementation level of Institutions Case Studies Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Part III 3. HRH Problems at the implementation level of Institutions: Case Studies Summary The three case studies in this section address key problems relating to HRH that bureaucrats face with regard to (i) the CHS cadre, (ii) the UP Provincial Medical Service cadre, and (iii) nursing in UP. In each case, how the central problem is defined and influenced by interest groups in the particular context determines the subsequent policy to address the immediate HR-related problem. The grand strategies of the policy Planners (section 1.3 above) identify problems and priorities relating to human resources in health that are very different from the ‘more real’ and immediate problems of bureaucrats at institutions tasked with their implementation. Using three case studies, Part III of this paper addresses the more specific problems relating to HRH that bureaucrats face. In each case, how the central problem is defined and influenced by interest groups in the particular context determines the subsequent policy to address the immediate HR-related problem. As shown in the diagram below, the policy can then influence any of the core HRH functions of our conceptual framework and its implementation can have unintended or unforeseen implications for institutions. This results in institutional inefficiencies in the health system and, in some cases, such as in public health nursing in UP (Box 5), render institutions close to complete breakdown. The three case studies address the key problem bureaucrats face, respectively, with regard to (i) the CHS cadre, (ii) the UP Provincial Medical Servic "); array_files[94]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page9.html","2008-10-30","15K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page9 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page9 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) 2.4 Organizations at work: Recruitment process of doctors in UP and CHS Summary In this section, the recruitment process of doctors into the UP Government Medical Service and into the Central Health Service (CHS) is taken as illustrative examples of how organizations are involved in the implementation of a significant HR function. In this section, the recruitment process of doctors into the UP Government Medical Service and into the Central Health Service (CHS) is taken as illustrative examples of how organizations are involved in the implementation of a significant HR function. The number of doctors to be recruited into the government health system depends on the number of existing vacancies in relation to the officially sanctioned posts.17 Recruitment, therefore, relies on the extent of Public Sector Doctor Vacancy. Since we use the recruitment process as only an illustrative example, Figures 1 & 2 shows how we conceptually approach the matter. In Figure 1, Public Sector Doctor Vacancy is located in the context of broader HRH concerns in the government system. In Figure 2, the recruitment process is located as one among various other contributing factors to the Public Sector Doctor Vacancy problem. Figure 1: Doctor Vacancy in context of broader Government HRH concerns Adapted from T. Sundararaman, “NRHM and Human Resources for Health”, presentation in IIM Ahmedabad, January 2008 17The government’s norms for health manpower requirement are supposed to be computed on the basis of the population. The 9th (1997-2002) Plan suggested that the require "); array_files[95]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page8.html","2008-10-30","22K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page8 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page8 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) Table 4: Organization Mapping of the Nursing cadre in UP Government Health System Core function Function components Central Level State Level Policy Allocation of funds Secretariat, State Finance Ministry Employment regulations Secretariat (Current Service Rule in function made in 1996 for gazetted and 1999 for non-gazetted nursing staff) New Nursing Schools INC (inspection) No new government nursing school in decades Setting staff Nurses INC (in Education) HRH Production Staff Supply Recruitment of PMS Doctors Directorate (Medical Care cell), Secretariat role only to give final authorisation Allocation of Nurses Director (Medical Care); Secretariat involved in only top two nursing positions at the Directorate Education & Training Admission to NursingSchools Directorate (Medical Care) Setting curriculum INC Continued training for upgradation of Nursingskills & further new training No refresher-training avenue in existence. For Further training, no organization currently tasked (Earlier, Directorate sent nurses for further training) Organisation/ Management Personnel administration Promotions Directorate, (Medical Care) - for gazetted grades For non-gazetted grades - District level (CMO) Transfers Directorate (Medical Care) Staff grievances Grievance cell, Directorate Disciplinary action Directorate (all grades) Maintaining informational records on staff Directorate (section 17), but record keeping is poor Performance Management Job descriptions No organization currently tasked Regular supervision No organization currently tasked Performance-based "); array_files[96]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page7.html","2008-10-30","24K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page7 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page7 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) Table 3: Organization Mapping of the Medical Doctor Cadre in UP Government Health System Core function Function components Central Level State Level Policy Allocation of funds Secretariat (H&FW), State Finance Ministry Employment regulations Governed by Service Rules. To amend Rules, Secretary (H&FW), State Finance Ministry and PMS doctors Association involved New Medical Colleges Health Ministry, DGHS (only for Centre-managed institutions), MCI (for inspection) Cabinet with approval from Chief Minister Setting staff norms MCI (in Medical Education), Ministry/DGHS (for enforcing IPHS) Secretariat (H&FW), State Finance Ministry (to determine sanctioned posts) HRH Production Staff Supply Recruitment of PMS Doctors Secretariat, For Health Service: Directorate (Administration and Women cells), For Teaching: Administration cell, UPPSC Allocation of PMS Doctors Secretariat Education & Training Admission to Medical Colleges Medical Education wing, DGHS for All-India quotas of seats Directorate (Medical Education) – for State quotas of seats Setting curriculum MCI Continued training for upgradation of skills NAMS, NIHFW (possible, but rare) Professional Associations No organization currently tasked Further New Training In service training for PG-diploma: Director (Plan, Budget & Training) Organisation/ Management Personnel administration Promotions Secretariat (For higher 2 grades) Directorate, Admn. and Women cells (for lower grades) Transfers Secretariat for most decisions. In recent years, Directorate (only for Class 2 doctors, Level 1 & 2; with appro "); array_files[97]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page6.html","2008-10-30","19K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page6 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page6 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) 6. For both doctors and nurses in the government system, there is no organization clearly charged with maintaining or evaluating the job descriptions relating to the different posts existing. In the case of the CGHS within the CHS, a compendium on what each rank in the Service should do exists, but not monitored or updated. 7. There is much more central level involvement in the HR-functions concerning state-level doctors relative to such central involvement in the cases of the nursing cadre, at least as evident from UP. Table 2: Organization Mapping of the CHS Core function Function components Mapped Organization Policy Allocation of funds Principal Secretary, Financial Advisor, Cadre Controlling Authority - CCA (Ministry) Employment regulations Principal organization: CCA, (Ministry). For change in CHS Rules, permission needed from Dept of Personnel & Training (DOPT), Ministry of Finance Setting staff norms DOPT, CCA (Ministry) and changes with permission of UPSC HRH Production Staff Supply Recruitment of CHS Doctors CCA (Ministry) and UPSC Allocation of CHS Doctors CCA (Ministry) Education & Training Continued Education & Further Training for CHS Doctors DGHS (Medical Education wing) Organisation/ Management Personnel administration Promotions For 2 senior-most grades, UPSC; MOHFW informs UPSC of vacancies For all other promotions, DPCs formed in MOHFW guidelines by DOPT Transfers Principal organization: CCA, (Ministry). Committee constituted under DGHS for transfers up to CMO grade Staff grievances Vigilance Officer for CHS (DGHS) CCA, (Minist "); array_files[98]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page5.html","2008-10-30","16K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page4 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page4 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) Analysis of Tables (3, 4 & 5) 1. For CHS doctors, the Cadre Controlling Authority (CCA) in the Ministry is the organization tasked with most of the functions. In the case of doctors in the UP government medical service, there are multiple sections of the Directorate (Health) and the Directorate (Medical Education) as well as the Secretariat involved, sometimes for the same function. This reduces accountability of any single organisation involved in the implementation of the task. In the case of nursing in UP, most functions are undertaken at the Directorate and the Secretariat is much less involved than it is with the medical doctor cadre. There is also less organizational development for undertaking key HR functions relating to the nursing cadre. 2. The Cadre Controlling Authority is charged with the administrative function relating to both teaching and non-teaching doctors in the Service. This is not so in UP, where organizations responsible for HRH functions concerned with medical health service are entirely distinct from those concerned with medical education. The administrative functions relating to doctors in the Provincial Medical Service (PMS) come under the purview of the Secretariat (H & FW) and the Directorate (Health). The administrative functions relating to teaching-doctors in medical colleges is managed entirely separately and come under the purview of Secretariat (Medical Education) and Directorate (Medical Education). The organization map in Table 3 considers only complex allocation of responsibilities in the Provincial Medical H "); array_files[99]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page4.html","2008-10-30","15K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page4 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page4 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) These core human resources related functions are utilised here in a framework that allows us to map a single or a cluster of organizations tasked with the implementation of each of these functions. This provides a static mapping of the institutional context. With regard to the coverage (density and distribution), motivation and the competence of any cadre of health personnel in the system, it is the characteristics and performance of the concerned institutions that then largely determine how far these cross-cutting HRH objectives are achieved. The link between this framework of key HRH functions and the institutional context to health system goals (efficiency, equitable access) and to health outcomes is diagrammatically presented in the Appendix. In the next section of this paper, this framework is used to map organizations that carry out the key HR-related functions, separately, for Central Health Service (CHS) doctors, UP government medical doctors and UP nurses in the government system. While a mapping of organizations to functions is a useful overview of the institutional context, it is principally a snapshot of the organizations involved and does not inform on how they interact with each other to carry out a function. In the final section of Part II, we take the ‘recruitment process’ of doctors into the CHS and into the UP government medical service as an illustrative example of how the implementation process of an important HRH function occurs in two different contexts involving different sets of organizations.16 2.3 Organizational Mapping "); array_files[100]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page3.html","2008-10-30","19K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page3 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page3 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) Health systems diagnostic framework: The narrative approach, however, lends itself better to analysis of more focused subject areas than to human resources across health systems in India, the aim of the broader situational analysis here. Bringing a systematic approach to bear upon analysing each of a country’s disparate health systems poses a greater challenge to a purely narrative approach than if the focus of study is a single specific case study, such as a particular government drug policy or reform measure. A separate literature develops a parsimonious framework providing a conceptual template, which both informs the range of information that may be collected and also organizes a ‘thick’ description of a particular case in a systematic manner allowing for comparative analysis with other cases that adopt the same framework for heuristic purposes. One such recent diagnostic framework in Roberts et al (2004) provides a powerful tool to assess overall health-system performance – a component of which is organization. Recent work by the WHO (2006) and the Joint Learning Initiative (JLI, 2004) have developed separate conceptual frameworks for specifically addressing human resource actions in the health system and how they relate to health system goals and to health outcomes. These frameworks, however, have a broader scope than an institutional focus, which is the aim of this paper. On the other hand, analytical toolkits published by DfID (2003) and the World Bank (2007) provide general useful guidelines for institutional analysis that can be applied "); array_files[101]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page2.html","2008-10-30","17K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page2 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page2 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) 2.2 Methodology Summary In this study, an approach to institutional analysis and to policy process is juxtaposed with a diagnostic approach to health systems that is focused on HR-related functions. With regard to the coverage (density and distribution), motivation and the competence of any cadre of health personnel in the system, it is the performance of the concerned institutions that largely determine how far these cross-cutting HRH objectives are achieved. This research draws on conceptual tools used separately in political economy and health systems studies to analyze institutions as implementation agents of essential human resource (HR) functions in Health.13 In this study, an approach to institutional analysis and to policy process is juxtaposed with a diagnostic approach to health systems that is focused on HR-related functions. Policy Analysis approach: The recent literature on the political economy of health brings to light the significance of the concepts of ‘power’ and ‘process’ to health policy implementation (Walt, 1994). It highlights the important role that powerful domestic interest groups can play to the success, failure, or partial implementation of health policy or reform measures, even to the extent of legitimizing or destabilizing the political regime (Reich, 1994, 2002; Bossert et al, 1998; Glassman et al, 1999). The emphasis is on individual or collective actors and their power to influence, on the institutional role in undertaking the implementation process, and finally, on the broader context in which the actors and inst "); array_files[102]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page14.html","2008-10-30","18K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page14 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page14 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) Table 9: Recruitment of Specialist sub-cadres in CHS (since recruitment resumed in 2005) Specialist Sub-Cadre Number of requisitions sent to UPSC Number of successful candidates from UPSC Approval by Minister Offers Sent Candidates Joined 1. Teaching 255 125 123 111 77 2. Public Health 25 10 10 9 4 3. Non-Teaching 123 76 73 69 45 Source: Cadre Controlling Authority, MOHFW, New Delhi In Table 9 above, for the Teaching sub-cadre, 62.6percent of those who received offer letters joined, but this still translates into only 30.1percent of the requisitioned posts being filled. For the small Public Health sub-cadre, 40percent of successful candidates joined, but only 16percent of the requisitioned posts were filled through the recruitment rounds. Finally, for the Non-Teaching Specialist sub-cadre, 61.6percent of the candidates sent offer letters indicated they would join, which would fill 36.5percent of the requisitioned posts. Note on Contracting of Doctors: The lengthy recruitment process is considered by NRHM as a significant bottleneck to the immediate requirement of filling existing doctor vacancies. NRHM therefore promotes the option of contractual doctors who can be recruited instantly in a walk-in interview that is held weekly. There is no arrangement of contractual doctors in the CHS. In UP, the state government decided in favor of contractual doctors filling the present needs in the health system. Recruitment is undertaken at the district-level through a committee that includes the District Magistrate (DM) and the Chief Medical Officer (CMO). "); array_files[103]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page13.html","2008-10-30","19K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page13 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page13 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) CHS: Doctor Recruitment Process The recruitment procedure for doctors in the CHS is identical to the procedure in UP. It principally concerns the Cadre Controlling Authority (CCA) in the central ministry of health that sends the requisition of doctors to be recruited to the Union Public Services Commission (UPSC). Between 2000 and 2004, there was no recruitment due to a central ban on all UPSC recruitment that was lifted exceptionally for central medical services, such as for Railways, Defence, MCD and the CHS. Table 8: Recruitment of General Duty Medical Officers (GDMO) – recent years CMSE Batch Requisition sent to UPSC for MOs Total Number of candidates received from UPSC* Candidature cancelled (before issue of offer letter) Number of offers issued Offers Cancelled Candidates Joined Candidates yet to join I II III IV V VI VII VIII 2004 200 168 32 136 80 53 3 2005 300 275 80 195 118 59 18 2006 300 238 9 119 0 25 94 2007 200 Dossier of Successful Candidates not received by Cadre Controlling Authority, MOHFW from UPSC. Allocation of cadres will be made thereafter. *All successful candidates received the approval of the Minister of Health & FW Source: Cadre Controlling Authority, MOHFW, New Delhi In Table 8 above, after successful candidates from UPSC are approved by the Minister for offer letters, there is a still a notable cancellation of candidatures prior to the offer letter being issued. There are three main reasons provided by the Cadre Controlling Authority for cancellations at this stage in the recruitment process: 1) the candidate is foun "); array_files[104]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page12.html","2008-10-30","25K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page12 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page12 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) Table 7: Government Appointment letters sent on Requisition of Posts made in 2005-06 Sl. No Name of Post Requisition of Posts recd from Govt. Number Selected by UPPSC Number recommended by UPPSC to Govt. Shortfall in number recommended by UPPSC Number of Govt. appointment letters sent Number of Responses recd by UPPSC I II III IV V VI VII VIII 1 Medical Officer (General - Male) 1489 1467 1448 41 1411 2 Medical Officer (Specialist - Male) 592 Anesthetist 139 38 31 108 31 Radiologist 167 10 7 160 7 Pathologist 105 13 13 92 13 Cardiologist 68 - - 68 - Physician 54 - - 54 - Surgeon 42 - - 42 - Chest Physician 17 21 19 0 (+2) 19 3 Medical Officer (Specialist - Female) 369 Anesthetist 61 13 11 56 11 1* Radiologist 64 5 5 54 4 0* Pathologist 40 23 20 20 19 2* Obs & Gyn 204 145 92 112 90 26* Totals 2450 1735 1645 805 1608 * Denotes currently available data from the periphery on number of doctors who have joined. Source: U.P. Ministry of Health, corroborated with data from Directorate, Administrative Unit and Women Cell In Table 7 above, the number of Government appointment letters is marginally lower than the number recommended by the UPPSC in the case of General Medical Officers, as the Directorate finds incomplete records existing for some. However, in the case of Male Specialists (where the numbers are already significantly lower than requirement), the number of appointment letters sent match the numbers that the UPPSC recommended and no issues are raised at the Directorate or Secretariat. Data on numbers who finally join the government medical servi "); array_files[105]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page11.html","2008-10-30","26K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page11 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page11 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) The data collected from UP show that in the case of specialists, there is a significant decline in numbers between the stages of those who respond and those who are selected by the Public Services Commission. For instance, in Table 6, of the 100 anaesthetists who responded to the advertisement, 38 were initially selected and finally 31 recommended to the Government. The principal reasons for such few numbers chosen by the Commission over those who initially responded are as follows: 1) the scrutiny of the responses reveal that the candidates did not all meet the minimum eligibility requirements of educational qualification and other experience required by the Service Rules; 2) the candidates claim to have the required educational qualification, but the degree is not recognized by the MCI and consequently deemed invalid by the Public Services Commission. For instance, a postgraduate, say, from Gorakhpur Medical College in 2005 when none of the PG seats there were MCI-recognized, would be eliminated from joining government service at this stage (see table in Box 4). There is no one single procedural timeline set out for each of the stages in the entire recruitment process. On average, from the point of advertisement to a person joining the service, one-year-and-a-half is taken. Table 6: Requisition of Posts received in 2005 and Selection data by the UPPSC Sl. No Name of Post Requisition of Posts recd from Govt. Category of Posts to be filled Number of Responses recd by UPPSC Number Selected by UPPSC Number recommended by UPPSC to Govt. I II III IV "); array_files[106]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_page10.html","2008-10-30","15K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page10 ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page10 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II (Contd...) Figure 2: Recruitment Process in the larger Doctor Vacancy problem-tree Uttar Pradesh: Doctor Recruitment Process The UP Government sends the UP Public Services Commission (UPPSC) a requisition order for posts that require to be filled by eligible candidates. The requisition from the UP Government is scrutinized by the UPPSC on two principal grounds. First, the Commission checks whether the terms and conditions of the posts that are being requisitioned are on the basis of the existing Service Rules of the particular cadre. If the scrutiny finds small aberrations, such as a difference in only the nomenclature used by the Government requisition and the Service Rules, these minor differences are cleared without causing much delay. However, if major discrepancies are found between Service Rules and the requisition, the latter is returned to the Government and cause of certain delay. A second significant ground on which requisitions come to be scrutinized by the Commission relate to whether the Government requisition is in compliance with the current reservation policy of not more than 50percent posts in favor of reserved categories (Scheduled Castes, Scheduled Tribes, Other Backward Classes). The Government is prone to overrepresentation of the numbers requisitioned for reserved groups, which is then deemed illegal by the Commission. After the requisition passes the scrutiny of the Commission, the latter places an advertisement with fixed time-frame as a deadline. The length of time till the deadline changes with the size of the requisition and all "); array_files[107]=new Array(0,1,"./Paper2/Part_II/Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health.html","2008-10-30","17K","Part II-Institutions as Implementation Agents of Essential HR Functions in Health ","",""," Part II-Institutions as Implementation Agents of Essential HR Functions in Health Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part II 2. Institutions as implementation agents of essential HR functions in Health Summary Two institutional case studies examine the following: i)The Central Health Service (CHS) has a very significant managerial and technical role in relation to health policy formation and oversight of the vertical national health programmes implemented in states. ii)Why the Uttar Pradesh (UP) State Health System that has made weak progress in health outcomes. 2.1 Overview of Case Studies (a) Central Health Service The Central Health Service (CHS) was conceived of as a single organised cadre of doctors that would serve in the medical, public health, medical research and teaching posts in central government hospitals, dispensaries, scientific research institutions and institutions of higher medical education. The members of the CHS were also required to serve health-related posts in the Union Territories (under central administrative control) and some autonomous institutions. There are 127 participating units in the CHS. An important component of CHS is the Central Government Health Scheme (CGHS), which serves as an insurance scheme essentially for central government employees. The CGHS was started in 1954 and at present 24 cities are covered with a total of 9.12 lakh card holders and 33.01 lakh beneficiaries (as on 31.3.2006). 72.5percent card holders are serving employees, 25.4percent are pensioners and rest belong to categories such as freedom fighters, M.Ps, ex M.Ps, journalists and others.The NCMH Report (2005) notes that 6 per cent of the combined budget of health and family wel "); array_files[108]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_9.html","2008-10-30","17K","Part I-Page9 ","",""," Part I-Page9 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) Human resources in health are therefore not only largely under the jurisdiction of state governments, but salaries are also a significant share of the states’ health expenditure in many cases. This is with the exception of ANMs whose salaries are paid for by the central government under the almost-wholly (98.4percent) centrally funded Family Welfare program, and staff for specific disease control programs whose salaries are funded from grants for the particular program. However, it is for state governments to manage implementation and, for instance, to ensure that the ANM resides at her place of work. In many states there are enormous shortages of health personnel. In Uttar Pradesh, for example, a number of sanctioned posts for doctors in the public sector lie vacant. Surprisingly, however, even the number of doctors sanctioned by the State government falls short of the total required according to nationwide norms. This is essentially a financial issue as many states are unable to afford the number of doctors needed in the state. The central government has very little control over this aspect of the health system although, under the NRHM, the Centre is contributing funds towards the hiring of doctors on contract. However, the resources for this contractual staff are only guaranteed for the duration of the program, which is currently due to end in the year 2012. The 1990s witnessed a reduction in health spending due to fiscal stress, especially for poorer states, to which the implementation of the Fifth Pay Commission in 1997 contributed in later years. Public expenditures on health (through the central and state governme "); array_files[109]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_8.html","2008-10-30","17K","Part I-Page8 ","",""," Part I-Page8 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) Both at the Centre and states the budget is divided into Plan and Non-Plan expenditures. Plan expenditures generally include spending on new schemes and up-gradation or expansion of existing schemes as well as outlays on new or replacement infrastructure. In contrast, Non-Plan expenditures cover recurrent expenditures (such as on salaries) as well as expenditures on the operation and maintenance of completed schemes (previously once in ‘Plan’) and already existing institutions. The distinction appears to be somewhat artificial and is also quite flexible; even though guidelines exist, it is up to individual state governments to divide their spending into Plan and Non-Plan (Finance Commission, 2004). The main focus of expenditures of the central government has been on various Centrally-sponsored Disease Control Programs. These are funded primarily by the central government as part of the Plan-budget but implemented by the states. Consequently, at the Centre, Plan expenditures on Health greatly exceed Non-Plan expenditure with a ratio most recently of approximately 10:1. Since 2005, the more prominent of these programs, except for the National AIDS Control Program, have been subsumed under the NRHM. The increased outlays by the Central government under NRHM have meant that the historically already high ratio of Plan to Non-Plan spending on Health at the Centre has further increased within the last few years. Health Budget in the states is also divided into Plan and Non-Plan expenditures, with the Plan component requiring approval by the Planning Commission. This has been essentially to allow a state to demonstrate that it i "); array_files[110]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_7.html","2008-10-30","16K","Part I-Page7 ","",""," Part I-Page7 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) 1.2 Influence of Central financing process on state health expenditures Summary This section addresses four concerns: i) the main focus of expenditures for the Centre and the states; ii) the flexibility for adopting strategic context-driven policy in the states; iii) locating where and how HRH fits into this financial arrangement; and, iv) how the National Rural Health Mission (NRHM) envisages changes in this existing arrangement. NRHM is a partnership between the central government and the states, with increased ownership of planned expenditures by the latter, in an effort to raise public health spending and improve the quality and access to care for the most vulnerable groups of the population. State Project Implementation Plans (PIPs) will have performance indicators (such as vacancy rates in various staff posts, institutional reforms and targets for each of the disease control programmes) for release of grants-in-aid subject to satisfactory progress on these indicators. One lasting legacy of the Bhore Report and endorsement of governments to it from early on has been a continued vision of a national health system funded and delivered by the public sector to all. Yet, post-independence allocation patterns have not always matched with the discourse of the central governments. The contradiction is apparent in the fact that in spite of the policy declarations of ‘comprehensive healthcare provision’ by the state, health spending is mostly out-of-pocket (80percent of ambulatory care and 65percent of hospitalisations5) because public resources committed have, historically, remained low. The very poor also undertake the maxi "); array_files[111]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_6.html","2008-10-30","15K","Part I-Page6 ","",""," Part I-Page6 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) Nurses The 8th (1992-1997) Plan observed that ‘while the States have been more than anxious to start new medical colleges, their efforts to develop institutions for training of paramedical staff have been entirely suboptimal’. It further noted that while, ideally, the doctor- nurse ratio should be 1:3, in 1992 there were less than 3,00,000 registered nurses against 4,00,000 registered medical graduates. It is remarkable that after a 1954 Committee that addressed the employment conditions of the nursing profession, there was no subsequent review of all aspects of the nursing component of health services until 1989, when a so-called High Power Committee of the government on nursing reported on its findings. Unlike in other countries, nursing personnel are not actively involved in policy formulation in India, even on matters that affect nursing practice. In a recent note on nursing for the National Commission on the Macroeconomics of Health, the nursing advisor at the central government and the senior-most representative of the profession in policy for over a decade laments: “There are an inadequate number of nurse and midwife leaders at the national and State levels for nursing practice, research, education, management, planning and policy development. Although the nurse is a member of the health team, she/he is never asked to represent the profession in planning and policy formulation for nursing services, education, etc.” As the 1989 Report succinctly observes, following its extensive field visits and interviews, ‘the nurses are given the role of simply following the instructions’ and ‘are hardly involved in any decision "); array_files[112]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_4.html","2008-10-30","16K","Part I-Page4 ","",""," Part I-Page4 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) The ‘Out-Groups’:Private Practitioners At present, there is no uniform nationwide system of registering either practitioners or institutions providing health care in the private/voluntary sectors; nor is there a mechanism for obtaining and analyzing information on health care infrastructure and manpower in these sectors at the district level. This is a notable omission since it is likely that even in the 1950s and 1960s government was not the principal provider of ambulatory care services. The omission is more significant today when 68 per cent of the 15,393 hospitals (cited by Ministry of Health & Family Welfare), 37 per cent of the hospital/clinic based beds are contributed by the private sector3 and over 80 per cent of the provisioning of ambulatory health care is attributed to the private sector. The private sector already occupies centre-stage. Whether this situation has developed by design is debatable, even though the National Health Policy, 1983 encouraged government to enter into contractual arrangements with the private sector to augment providers and improve quality of care. The National Health Policy, 2002 further endorsed and promoted the need to institutionalize partnerships with diverse providers to rapidly increase the supply of health services, expand coverage, improve technical quality of care at all levels, and control costs for users. Governments have subsidized important inputs for private hospitals such as prime land, exemptions on import of drugs and equipment as well as officially recognized the enormous growth of educational institutions of medicine and nursing in the private sector. However, a c "); array_files[113]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_3.html","2008-10-30","18K","Part I- Page3 ","",""," Part I- Page3 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) (b) ‘Voice’ of different types of health providers in influencing policy The extent of ‘voice’ (Hirschman, 1970) that members of a group have in any system conveys the extent to which these members can express their dissatisfaction and interests to the prevailing authority – here, the government – to influence policy. In the health system, as in many such large systems, members of a group can most effectively articulate their position through collective action lobbying (Olson, 1982). In the Indian health system, both at the Centre and states, the interests of doctors employed in the government service, called as the ‘In-Group’, have, in the past, been the most influential. In relation to past health policy, other significant numbers of the health workforce such as private practitioners, practitioners of traditional Indian medicine and Homeopathy, as well as nurses have, in contrast, been the ‘Out-Groups’. This section reviews the engagement of the policy process with these different groups of health personnel. The ‘In-Group’: Doctors in the Government System Public health policy in the early decades of India must be contextualised in the modernist enterprise of state – the aim of the state to transform society and economy drawing on the most advanced models and scientific approach available. As one historical analysis of health policy at the central level notes, the doctor syndrome loomed large in the minds of the planners, with actual policy revolving around conditions and prospects of doctors over and above all other health personnel (Duggal, 2005). Another review of government health policy observes that although maj "); array_files[114]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_2.html","2008-10-30","21K","Part I- Page2 ","",""," Part I- Page2 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) In the first two Plans, the Centre’s principal expenditure towards health was on the communicable diseases programs. In the 1950s and 1960s, the entire focus of the health sector in India was to manage epidemics. The remarkable initial achievement of the malaria program and use of extensive trained personnel is a case in point. This single program employed as many as 1,50,000 people by 1961. The expenditure of the state governments was largely on the urban health infrastructure and on tertiary medical care. Consequently, a separation of functional responsibilities in the health system came about with the Centre (through the Planning Commission) investing in preventive and promotive programs, while the states largely focused their attention on curative care. Moreover, there was little focus of the state governments on strengthening the infrastructure for a primary healthcare system, even though reports at the Centre (from Bhore to Mudaliar) kept this at the centre of health policy discourse. The weakness of the primary health care system ironically undermined what the Centre set out to achieve through the central disease programs. The ‘targets’ of these programs aimed at coverage, but this was an unsustainable enterprise when not supported by a primary health system that provided promotive and curative services to these ‘targets’ as patients. The Centre approached rural infrastructure , therefore, from the perspective of communicable disease programs and stressed the need for functional PHCs to consolidate the maintenance phase of these programs.2 A clear demarcation of central and state roles has never been attempted, b "); array_files[115]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_17.html","2008-10-30","16K","Part I-Page17 ","",""," Part I-Page17 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) Box 3: The ROME Experience: why institutions matter Under the scheme of Re-orientation of Medical Education (ROME) that is proposed to be revisited again in NRHM, each medical college in the country was to adopt 3 primary health centres in the first phase with the twin objectives of providing a rural bias to medical education and also curative health care and referral facilities to the rural population covered. In the 7th (1985-89) Plan, the Planning Commission outlines the innovative idea of the ROME programme and the reasons for its failure: The scheme for re-orientation of medical education (ROME) was introduced with the objectives of (i) introducting community bias in the training of undergraduate medical students with emphasis on preventive and promotive services, (ii) reorientation of the role of medical colleges, so that they became an integral part of the health-care system and did not continue to function in isolation, (iii) reorientation of all faculty members so that hospital-based and disease-oriented training was progressively complemented by community-based and health-oriented training for providing comprehensive primary health care, and (iv) the development of effective referral linkages between PHCs, District Hospitals and Medical Colleges. The scheme has been implemented in its first phase, in about 106 medical colleges. In spite of a one-time grant-in-aid to each of the participating institutions, the objectives of the scheme could not be achieved to the desired extent. This was largely due to (i) lack of commitment to the programme at all levels, (ii) slow progress in the utilization of Central funds, "); array_files[116]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_16.html","2008-10-30","17K","Part I-Page16 ","",""," Part I-Page16 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) The shift in policy thinking towards a community-based health care system in the 1970s brought with it the debate on whether policy calling for further expansion of medical colleges is justified or not. The 1979 Alma Ata declaration of ‘Health for All by 2000AD’, the 1981 ICSSR-ICMR report and the 1983 National Health Policy were part of a similar paradigm of thought as the Shrivastava Report. It is not wholly coincidental that the a questioning of the early promise of western medical science to provide miracles in the 1970s occurred alongside a search for other alternatives to health care provision – whether increasing engagement with Indian Systems of Medicine and Homeopathy or a more community-based health system approach. No longer was there complete faith in drugs which had once appeared to be ‘magic bullets’, but had, by the 1970s, shown to have many unintended consequences (Illich, 1975). The 6th (1980-85) Plan in this context noted ‘serious dissatisfaction with the existing model of medical and health services with its emphasis on hospitals, specialization and super specialization and highly trained doctors which is availed of mostly by the well to do classes.’ The Plan diagnosed outright that ‘this model’ was responsible for ‘depriving the rural areas and the poor people of the benefits of good health and medical services’. In stressing the priority to be a community-based health system, the 6th Plan also stated that there would be no further linear expansion of curative facilities in urban areas and medical colleges. Medical colleges have, however, significantly expanded over the last decade, especially in the "); array_files[117]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_14.html","2008-10-30","16K","Part I-Page14 ","",""," Part I-Page14 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) Some ideas of NRHM such as the concept of horizontal linkages between the various national disease-control programs have their roots in policy proposals that can be traced back even earlier to the 3rd (1961-65) Five Year Plan.9 After a gap of a decade, it returns on the policy reform agenda in the Kartar Singh Committee Report proposal of 1973 that there should be integrated training for all workers engaged in the field of health, family planning and nutrition. Similarly, the 6th (1980-85) plan places emphasis on collaboration between programs in water supply, environment, sanitation, nutrition, education, family planning and maternal and child health. By the 9th (1997-2002) Plan and the National Health Policy of 2002, the concept of linkages had progressed to the vision outlined in NRHM that, in addition to inter-sectoral integration, there should also be integration within the health sector between the vertical health and family welfare programs. Decentralization is another central theme of NRHM that has been prioritized increasingly in recent years. The 7th (1985-89) Plan advocated community participation in health10, while the 8th (1992-1997) Plan recommended involvement of the Panchayati Raj Institutions (PRI) in health planning. Since then the 9th (1997-2002) and 10th Plans (2002-2007), as well as the National Health Policy in 2002, all make reference towards more decentralized planning and services. The NHP-1983 recommended a decentralized system of health care but it however also stressed that this decentralization be accompanied with a low cost, de-professionalization of the public sector system based more on v "); array_files[118]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_13.html","2008-10-30","17K","Part I-Page13 ","",""," Part I-Page13 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) Box 2: Increase in Primary Health Infrastructure relative to increase in numbers of government doctors Sources: Infrastructure Division, MOHFW, GOI, Rural Health Bulletin, March 2007 Source: Indiastat, MOHFW, GOI As the first graph above shows, in the decade between 1980 and 1990 the number of PHCs and CHCs increased dramatically. Before 1980, there were between one and two thousand additional PHCs and CHCs every decade. In the eighties, however, over 16,000 new buildings were added to the rural health infrastructure. The number of doctors, however, grew much more steadily over the last six decades. While the number of doctors did increase in the 1980s as well, the growth did not match that of the infrastructure. The vast expansion in the rural health infrastructure would have required a concomitant increase in the number of doctors to fulfil the staffing requirements of these new facilities. As this did not occur, it likely resulted in an acute shortage of doctors in the public sector and an increase in the number of vacancies. The shortage was probably even more severe than is apparent, for a few reasons. The first is that the Medical Council of India, which registers doctors, does not account for deaths or for those who leave the service. As a result it tends to overestimate the number of doctors, and increasingly so, as the years go by. Moreover, it is possible that much of the growth in doctors was in the private sector which suggests that the gap between the required number of doctors in the public sector and the number available could be even larger than would be predicted from these numbers. This has important i "); array_files[119]=new Array(0,1,"./Paper2/Part_I/Part_I_Page_12.html","2008-10-30","15K","Part I-Page12 ","",""," Part I-Page12 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I (Contd...) The Medical Education Review Committee (1983) recommended the establishment of a central coordinating agency for planning, organizing and monitoring continuing education programmes all over the country. This has remained on the agenda of every Plan since. For instance, the 9th (1997-2002) Plan set out to ‘ensure continuing knowledge and skill upgradation of all health care providers through Continuing Education Programmes with emphasis on multi-professional problem solving learning strategies’, even though the previously proposed central coordinating agency had never been established in the interim. The training of paramedical human resources has also been a frequent objective in policy documents over the past six decades. Training of nurses, midwives, ANMs and health visitors was particularly emphasized although pharmacists, sanitary inspectors, medical assistants, hospital workers and public health engineers were also mentioned. NRHM also promotes increased training of paramedical staff and takes it one step further by also emphasizing skill upgradation and multi-skilling of existing medical and paramedical workers. Primary health care infrastructure finds mention in all Plans. However, the Mudaliar Committee (1961) acknowledged that, in reality, primary health care infrastructure was not given the importance it was ascribed in the Bhore Report right from the start. Gains from the central government’s focus on the communicable disease programmes, it was argued, was less sustainable in light of the absence of support from non-existing or non-functional primary health centres. The government’s priority, however, has sub "); array_files[120]=new Array(0,1,"./Paper2/Part_I/Part_I.html","2008-10-30","18K","Part I ","",""," Part I Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions: Case Studies Part IV - Discussion Appendix Select Bibliography Download Part I Summary This section examines the distribution of power within the government health system with respect to: 1. Present roles of the centre and states where clear demarcation is still nonexistent 2. Existing gaps in spite of recent policy to mainstream AYUSH, due to: 2.1 Government neglect of nurses and allied health professionals. 2.2 Absence of a clear policy or vision for inclusion of the private sector. 1.1 Distribution of Power to influence the Government Health System (a) Political/Constitutional: Centre-State dimension According to the Indian constitution, Health is considered a State subject and therefore, in theory, states are responsible for developing and maintaining their own health services. The Centre is allocated responsibility only for institutions deemed of national importance in medical education and research. On the Concurrent List are the following health-related functions: preventing the spread of infectious diseases, medical education, regulation of the medical profession and drugs, population control, mental health and vital statistics. There is no rationale for the distribution of specific subjects concerning health between the Centre and the states. The existing constitutional division of responsibilities in the health sector are the remnants of reforms introduced under British Rule through Government Acts in 1935 and earlier still in 1919. The reforms initially introduced the concept of ‘dyarchy’ to India which devolved specified functional responsibilities to the states that were not considered a core priority concern to the central government in Delhi and to imperial interests; the subjects of public health an "); array_files[121]=new Array(0,1,"./Paper2/Appendix/Appendix_page6.html","2008-10-30","12K","Appendix-Page6 ","",""," Appendix-Page6 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Appendix (Contd...) Figure 4: Career Paths of the CHS sub-cadres source: MOHFW Previous Page Next Topic Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[122]=new Array(0,1,"./Paper2/Appendix/Appendix_page5.html","2008-10-30","17K","Appendix-Page5 ","",""," Appendix-Page5 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Appendix (Contd...) Table 5: Norms for Schools of Nursing (GNM) with 60 students (i.e. annual intake of 20 students) Teaching Faculty Previous Norm Current Norm till 2012 (after relaxation) Principal 1 1 Vice Principal 1 1 Senior Tutor 1 0 Tutor 5 4 Additional Tutor for Interns 1 1 Source: Indian Nursing Council, New Delhi Table 6: Norms for Schools of Nursing (GNM) with 60 students (i.e. annual intake of 20 students) S.No. Post Educational Qualification Norm (Previous) Current Educational Qualificationl Norm till 2012 (after relaxation) 1. Principal M.Sc. Nursing with 6 years of teaching experience or B.Sc. Nursing (Basic)/Post-Basic with 8 years of teaching experience. M.Sc. Nursing with 3 years of teaching experience or B.Sc. Nursing (Basic)/Post-Basic with 5 years of teaching experience 2. Vice Principal M.Sc. Nursing with 4 years of teaching experience or B.Sc. Nursing (Basic)/Post-Basic with 6 years of teaching experience. M.Sc. Nursing or B.Sc. Nursing (Basic)/Post-Basic with 3 years of teaching experience. 3. Senior Tutor M.Sc. Nursing with 2 years of teaching experience or B.Sc. with 4 years of teaching experience 4. Tutor Minimum requirement of Diploma in Nursing Education and Administration with 2 years of professional experience Minimum requirement of Diploma in Nursing Education and Administration with 2 years of professional experience Source: Indian Nursing Council, New Delhi Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[123]=new Array(0,1,"./Paper2/Appendix/Appendix_page4.html","2008-10-30","18K","Appendix-Page3 ","",""," Appendix-Page3 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Appendix (Contd...) Table 4: Changes in Service Rules (Gazetted) 1980 Name of Post 1980 (Source of Recruitment) 1996 (Source of Recruitment) Current Post Tutor (Education) Promotion from amongst permanent Sisters and ward Masters with at least 3 years’ service as such and who possess diploma in nursing administration or Nursing Tutor’s Diploma or B.Sc. Nursing (Post Basic) Promotion from amongst substantively appointed Sisters and ward Masters who have completed 7 years’ service, as such on the first day of recruitment Tutor Assistant Matron (Service) Promotion from amongst permanent Sisters who have put in at least 3 years’ service as such and who possess diploma in nursing administration or Nursing Tutor’s Diploma or B.Sc. Nursing (Post Basic) (Existed in 1996 Rules, but no longer applicable, as position currently merged with that of Matron) (position merged with that of Matron) Principal Tutor (Education) Promotion from amongst permanent Tutors and assistant Matrons who have put in at least 3 years’ service as such and who possess diploma in nursing administration or Nursing Tutor’s Diploma or B.Sc. Nursing (Post Basic) Promotion from amongst substantively appointed Tutors and PHN Tutors who have completed 5 years’ service, as such on the first day of recruitment Principal Tutor Matron Promotion from amongst permanent Assistant Matrons, Female Tutors, Female Thetre Supervisors and PHN Tutors who have put in at least 3 years’ service as such and who possess diploma in nursing administration or Nursing Tutor’s Diploma or B.Sc. Nursing (Post Basic) Matron (including previous positions of Assistant matron and Deputy Superitendent, Nursing "); array_files[124]=new Array(0,1,"./Paper2/Appendix/Appendix_page3.html","2008-10-30","25K","Appendix-Page3 ","",""," Appendix-Page3 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Appendix (Contd...) Table 3: Current Situation of Medical Faculty in UP State (2006) S.No. Name of Discipline Sanctioned Currently-filled Vacant 1. Anatomy 36 14 22 2. Anesthesia 49 37 12 3. Biochemistry 17 09 08 4. Cardiology 17 08 09 5. Dentistry 13 09 04 6. E.N.T. 18 10 08 7. Forensic Medicine 15 06 09 8. General Medicine 51 24 27 9. Neurology 08 06 02 10. Nephrology 07 04 03 11. Human Metabolism 03 01 02 12. Nuclear Medicine 01 - 01 13. Gastroenterology 04 02 02 14. Microbiology 11 05 06 15. O & G 44 33 11 16. Health Education 06 01 05 17. Ophthalmology 29 22 07 18. Orthopedics 26 13 13 19. Pediatrics 31 25 06 20. Pathology 40 28 12 21. Pharmacology 34 17 17 22. Pharmacy 19 12 07 23. Physiology 37 18 19 24. Psychiatry 08 05 03 25. Radio-diagnosis 17 09 08 26. Radio-therapy 15 09 06 27. S.P.M. 47 31 16 28. Statistician 06 03 03 29. Assistant Public Health Engineer-cum-Lecturer 01 - 01 30. Skin and BD 14 08 06 31. General Surgery 50 34 16 32. Urology 02 02 - 33. Thoracic Surgery 05 02 03 34. Neuro-surgery 12 06 06 35. Plastic Surgery 06 04 02 36. T.B. 18 07 11 37. Demography 06 05 01 38. Cardiac Anesthesia 04 - 04 39. Physicist 08 05 03 40. Cardiac Surgery 03 02 01 738 436 302 Source: Directorate of Medical Education, U.P. Government, Lucknow Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[125]=new Array(0,1,"./Paper2/Appendix/Appendix_page2.html","2008-10-30","24K","Appendix-Page2 ","",""," Appendix-Page2 Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Appendix (Contd...) Table 1: PMHS Male Cadre Strength in Oct-Nov 2007 (and as on 1 May 2007) Male Specialist General I II III IV V VI VII VIII IX Sanctioned Working Vacant Change (Working Status) Sanctioned Working Vacant Change (Working Status) L-1 1372* (1080) 802 (792) 570 (288) 10 1590* (1547) 2278 (2278) - 688 (-731) 0 L-2 978* (938) 730 (739) 248 (199) -9 1518 (1518) 1007 (1007) 511 (511) 0 L-3 900 (900) 847 (864) 53 (36) -17 1432 (1432) 834 (834) 598 (598) 0 L-4 884* (883) 610 (670) 274 (213) -60 1293 (1293) 741 (741) 552 (552) 0 L-5 40 (40) 23 (24) 17 (16) -1 50 (50) 12 (14) 38 (36) -2 Total 4174 (3841) 3012 (3089) 1162 (752) -77 5883 (5840) 4872 (4874) 1011 (966) -2 Source: Directorate of Medical Health, Lucknow, U.P. Table 2: PMHS Female Cadre Strength in Oct-Nov 2007 (and as on 1 May 2007) Female Specialist General I II III IV V VI VII VIII IX Sanctioned Working Vacant Change (Working Status) Sanctioned Working Vacant Change (Working Status) L-1 393* (320) 90 (157) 303 (163) 24 150 (150) 453 (453) -303 (-303) 0 L-2 301* (300) 132 (41) 169 (259) (91) 138 (138) 28 (28) 110 (110) 0 L-3 270 (270) 226 (232) 44 (38) -6 127 (127) 71 (71) 56 (56) 0 L-4 250 (250) 186 (190) 64 (60) -4 119 (119) 122 (122) -3 (-3) 0 L-5 9 (9) 5 (7) 4 (2) -2 5 (5) 2 (2) 3 (3) 0 Total 1223 (1149) 639 (627) 584 (522) 12 539 (539) 676 (676) -137 (-137) 0 Source: Directorate of Medical Health, Lucknow, U.P. Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[126]=new Array(0,1,"./Paper2/Appendix/Appendix.html","2008-10-30","14K","Appendix ","",""," Appendix Search Human Resources for Health: A Political Economy and Institutional Analysis of the Indian Context Content Structure of the Paper Part I Part II - Institutions as Implementation Agents of Essential HR Functions in Health Part III - HRH Problems at the Implemetation level of Institutions Case Studies Part IV - Discussion Appendix Select Bibliography Download Appendix Figure 1: Essential HRH Functions framework and Health Outcomes NB: The grey area above denotes where institutions fit and why institutional analysis is consequently relevant. Adapted from JLI Framework (2004) Figure 2: Growth of Medical Colleges in recent years (Public and Private) Source: MCI Figure 3: Growth in Recognized Nursing Institutions (2000-2007) Source: MCI Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[127]=new Array(0,1,"./Paper1/Size_and_Composition_of_the_Health_Workforce_in_India_Triangulating_Results_from_different_data_sources_page7.html","2008-10-30","14K","Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page7 ","",""," Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page7 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Size and Composition of the Health Workforce in India: Triangulating Results from different data sources (Contd...) The Census and NSSO estimates of the health workforce have several attractive features which overcome the problems in Government reported data. As they are based on population counts in each state, they avoid the problem of double counting, cover a large variety of health workers, are available for all states in India, provide geographic estimates and have fewer comparability issues because they are based on standard occupational codes like the NCO and NIC. However, they have their own set of problems too. For one, both the Census and NSSO estimates are based on self-reported occupations and it is quite likely that some unqualified health workers are also counted among the qualified ones, resulting in an overestimation of qualified medical workers (see Box 1). Secondly, and this pertains only to the NSSO, the small sample size prevents robust disaggregated estimates at the state level and by health worker type. A third issue concerns the frequency of data collection. The NSSO survey on Employment and Unemployment repeats itself every five years while the Census is carried out once in ten years. Therefore these data sources cannot provide health workforce estimates on an ongoing basis, which might be important to planners and policy makers. Overall, the Census appears to be the preferred source on which to base estimates of the "); array_files[128]=new Array(0,1,"./Paper1/Size_and_Composition_of_the_Health_Workforce_in_India_Triangulating_Results_from_different_data_sources_page6.html","2008-10-30","15K","Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page6 ","",""," Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page6 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Size and Composition of the Health Workforce in India: Triangulating Results from different data sources (Contd...) Government estimates of the health workforce are important because they can potentially provide the exact number of different types of health workers available in the country or state at a given point in time and on an ongoing basis. These estimates are based on a variety of sources including internal information systems for health workers employed by the public sector and from the various professional councils such as the medical, dental, nursing and AYUSH councils for the total number of registered doctors, dentists, nurses and AYUSH practitioners. One set of issues concerning Government data is its comprehensiveness in terms of the health worker categories, geographic distribution and states covered. For example, there is no information on certain health worker categories in the private sector like medical technicians, pharmacists and practitioners of traditional medicine. This prevents estimating the size of the entire health workforce in India. Further, it is only possible to estimate the urban-rural distribution of certain health worker categories and not for the entire health workforce. All states are also not included in the Government reported data. For instance, doctors working in the north-east are registered in the Assam Medical Council, which prevents estimating the number of doctors in each of the seven north eas "); array_files[129]=new Array(0,1,"./Paper1/Size_and_Composition_of_the_Health_Workforce_in_India_Triangulating_Results_from_different_data_sources_page5.html","2008-10-30","14K","Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page5 ","",""," Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page5 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Size and Composition of the Health Workforce in India: Triangulating Results from different data sources (Contd...) State level comparisons have been limited to the Census and NSSO and excluded the Government densityestimates for the following reasons. Government estimates of health worker densities at the state level are available for certain types of health workers like doctors and nurses. Therefore state level estimates are possible only for certain health worker categories which prevents estimating total health workforce densities. Second, estimates of the full range of states are not possible given that information on some states is missing or states have been grouped together. For example, doctors seeking registration in any of the north eastern states register themselves with the State Medical Council of Assam. Furthermore, Government estimates may not always be accurate as doctors registered with a particular state council may be working in other states. Triangulation and Selection of the Preferred Estimate The previous sections provided a comparative analysis of the health workforce estimates from the Census, the NSSO and the Government. In general, there is a higher degree of correspondence between the Census and NSSO estimates compared to those of the Government. In selecting a preferred data source for health workforce estimates, several criteria need to be kept in mind. These include, the reliability and validity of the estimat "); array_files[130]=new Array(0,1,"./Paper1/Size_and_Composition_of_the_Health_Workforce_in_India_Triangulating_Results_from_different_data_sources_page4.html","2008-10-30","15K","Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page4 ","",""," Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page4 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Size and Composition of the Health Workforce in India: Triangulating Results from different data sources (Contd...) The density of AYUSH practitioners differs among the three data sources (Census 1.76, NSSO 2.58; Govt. 6.52) but the difference is the largest for the Government estimates. For dentists, the density estimates of the Government (0.50) are twice that of the Census (0.21) and NSSO (0.24), the latter being close. Density estimates of pharmacists are similar in the Census (2.15) and the NSSO (1.68). In the ‘Others’ category, which mainly includes technicians, assistants and allied health workers, the NSSO estimates are almost twice that of the Census. Density estimates for Other Traditional workers, which mainly includes traditional healers, for both the Census (0.46) and the NSSO (0.73) are very similar. Overall, the health workforce estimates from the Census and NSSO tend to correspond well with each other at the aggregate level. This is seen both in the total health worker density and, barring few exceptions, in the densities of individual health worker categories. Government estimates tend to be substantially higher than the Census and NSSO estimates. Size of the Health Workforce Across States State level health workforce density estimates from the Census and NSSO are shown in Figure 2. There is considerable variation in the density of health workforce across the states in India (Figure 2 and Annex 7). These range from a low of "); array_files[131]=new Array(0,1,"./Paper1/Size_and_Composition_of_the_Health_Workforce_in_India_Triangulating_Results_from_different_data_sources_page3.html","2008-10-30","20K","Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page3 ","",""," Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page3 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Size and Composition of the Health Workforce in India: Triangulating Results from different data sources (Contd...) Box 1: What Is A Doctor? The Census and the NSSO classify worker occupations based on self-reported occupation descriptions. This procedure of identifying and classifying health workers can over estimate the number of qualified health professionals. For example, individuals with a range of qualifications practice as allopathic doctors in India. These include specialists, general practitioners, rural medical practitioners, and others with no formal training or certification in medicine. A study conducted in Udaipur district of Rajasthan in 2003 found that 41% of private practitioners who called themselves doctors had no medical degree, 18% had no medial training at all and 17% had not even graduated from high school (Banerjee, Deaton and Duflo 2003). The 61st round (July 2004-June 2005) of the National Sample Survey (NSSO) on ‘Employment and Unemployment’ collected information on the self-reported occupation, educational and technical qualifications of respondents. This makes it possible to cross-check the technical qualification of individuals classified as allopathic doctors (Table B1). A total of 75% of the individuals classified as doctors had some medical training, which means that 25% of those identified as doctors had no technical training in medicine at all. However, individuals with an undergraduate diploma or certific "); array_files[132]=new Array(0,1,"./Paper1/Size_and_Composition_of_the_Health_Workforce_in_India_Triangulating_Results_from_different_data_sources_page2.html","2008-10-30","15K","Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page2 ","",""," Size and Composition of the Health Workforce in India Triangulating Results from different data sources-Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Size and Composition of the Health Workforce in India: Triangulating Results from different data sources (Contd...) Amongst different health worker types estimates from the Census, NSSO and the Government differ, and in some cases, these differences are quite substantial. In general, however, except for Allopathic Physicians and Others, estimates from the NSSO and Census are quite similar. The density of allopathic physicians according to the Census (6.07 per 10,000 population) is similar to that of the Government (5.93), but substantially higher than that of the NSSO (4.28). In 1961, the Mudaliar Committee recommended a doctor-population ratio of 1:3000, which translates into around 3 physicians per 10,000 population (GOI 2005). Despite the current doctor density being higher than this recommended level, it is low in comparison to more developed countries in North America, Western Europe, Australia and others such as China and Cuba (GOI 2005). The difference between the Government estimates and those of the Census and NSSO are more dramatic for the Nurses and Midwife category. Nurse and midwife density according to the Census (7.39) and NSSO (7.09) are very similar, but are about half as much as that reported by the government (12.77). The nurse density in India is low in comparison with more developed countries in North America, Western Europe, Australia and others such as China, Thailand and Cuba (GOI 2005). The relative share of allopat "); array_files[133]=new Array(0,1,"./Paper1/Size_and_Composition_of_the_Health_Workforce_in_India_Triangulating_Results_from_different_data_sources.html","2008-10-30","13K","Size and Composition of the Health Workforce in India Triangulating Results from different data sources ","",""," Size and Composition of the Health Workforce in India Triangulating Results from different data sources Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Size and Composition of the Health Workforce in India: Triangulating Results from different data sources Size and Composition of the Health Workforce Estimates of the number health workers by category in India according to the NSSO and Census are shownin Figure 1. All estimates are for the year 2005. The NSSO and the Census estimates of total health workers are remarkably similar (Figure 1). Both these sources estimate that India has around 2.2 million health workers, which translates into a density of approximately 20 health workers per 10,000 population. The Government estimate of the total number of health workers was not available. Health workers were classified into the following broad categories - allopathic physicians (including surgeons), nurses and midwifes, AYUSH physicians, dentists, pharmacists, Others (includes dieticians, nutritionists, opticians, dental assistants, physiotherapists, medical assistants, medical technicians and other hospital staff) and Other traditional health care practitioners (includes traditional medical practitioners and faith healers). Size and density estimates of health worker types within the Others and Other Traditional category is shown in Annex 3 and 4. Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[134]=new Array(0,1,"./terms_of_use.html","2008-10-30","7K","Partner_new ","",""," Partner_new Terms of Use Back Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[135]=new Array(0,1,"./privacy_policy.html","2008-10-30","7K","Partner_new ","",""," Partner_new Privacy Policy Back Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[136]=new Array(0,1,"./Partnerships.html","2008-10-30","10K","Partnerships ","",""," Partnerships PHFI The Public Health Foundation of India (PHFI) was launched by the Honourable Prime Minister of India, Dr. Manmohan Singh in March 2006 in New Delhi. PHFI is a large scale, uniquely designed, sustainable response to the severe shortfall of public health professionals (needed in government, NGOs and private sector) thereby addressing one of the root causes of India’s public health challenge. PHFI is an autonomously governed public private partnership. PHFI was conceptualized as a response to growing concern over the emerging public health challenges in India. Thus, it works towards redressing the limited institutional capacity of India for strengthening training, research and policy development in the area of Public Health. It aims to set quality standards for public health education, and establish public health institutes of excellence based on these standards to undertake meaningful public health research, and to advocate for public policy linked to broader public health goals. The World Bank is a vital source of financial and technical assistance to developing countries around the world. It is not a bank in the common sense. It is made up of two unique development institutions owned by 185 member countries—the International Bank for Reconstruction and Development (IBRD)and the International Development Association (IDA).The World Bank isone of the world’s largest sources of funding and knowledge to support governments of member countries in their efforts to invest in schools and health centers,provide water and electricity,fight disease,and protect the environment. World Bank The World Bank is a vital source of financial and technical assistance to developing countries around the world. It is not a bank in the common sense. It is made up of two unique development institutions owned by 185 member countries – the International Bank for Reconstruction and Development (IBRD)and the International Development Association (IDA).The World Bank isone of the world’s largest sources of funding and knowl "); array_files[137]=new Array(0,1,"./Paper1/Methodology_page2.html","2008-10-30","15K","Methodology-Page2 ","",""," Methodology-Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Methodology (Contd...) The NSSO and the Census used different NCO code series to classify health workers. While the Census used the NCO-2004 codes, the NSSO used the NCO-1968 codes. The NCO-68 classification codes were converted to the NCO-2004 codes with little loss of information. To further improve comparability between the two data sources, certain health worker categories were merged together. The final set of health worker categories for which estimates were produced include - allopathic physicians & surgeons, dentists, AYUSH practitioners, nurses & midwives, dentists, pharmacists, others (dieticians, opticians, dental assistants, physiotherapists, medial assistants and technicians and other hospital staff) and other traditional practitioners. The type of health worker included in each category is shown in Annex 1. The method of identifying individuals in the workforce differs between the Census and the NSSO and in some cases this could lead to the NSSO overestimating the number of health workers. The Census classified each individual as a “Main Worker” if he/she worked for 6 months or more in the past year, “Marginal Worker” for less than 6 months and “Non-Worker” if he/she did not work at all in the past year. The NSSO used a different approach - based on majority of time spent by an individual during the 365 days before the survey, the individual’s usual principal activity was classified as: ‘Employed’, ‘Unemployed’ (job seekers, domestic duties, etc.) and ‘Not in Labor Force’ (students, pensioners, etc.). The analysis of "); array_files[138]=new Array(0,1,"./Paper1/Methodology.html","2008-10-30","13K","Methodology ","",""," Methodology Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Methodology Classification of Health Workers The NSSO and the Census use the National Industrial Classification (NIC) and National Occupational Classification (NCO) codes to classify worker occupations. For example, in the NIC classification, health workers are grouped as those involved in hospital activities, medical and dental practices and other human health activities. On the other hand, the NCO classifies health workers according to their specific occupation such as doctors, nurses, homeopaths, ayurvedic practitioners, medical assistants etc. Therefore the NCO classification provides a finer differentiation between occupations compared to the NIC. As a result, this study uses the NCO classification to identify categories of health workers. Comparability of the Census and NSSO Health Workforce Estimates Several adjustments were made to make the NSSO and Census estimates comparable. These relate to the period of data collection and the different NCO classification codes used. The Census estimates of the population and health workers reflect the situation as on March 2001. The NSSO survey was conducted between July 04-June 05 and the health workforce estimates reflect the situation in this period. To make health workforce totals from these two data sources and time periods comparable, the Census estimates of the total number of health workers was inflated by 8% to reflect the growth in the general population between 2000 and 2005. This upward adjustment assumes that the growth in the health workforce follows that of the general populat "); array_files[139]=new Array(0,1,"./Paper1/Introduction_page2.html","2008-10-30","14K","Introduction_paqge2 ","",""," Introduction_paqge2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Introduction (Contd...) The Government collects information on the number of health workers employed in the public sector and reports on doctors, dentists and nurses registered with their respective state professional councils. In principal, this information covers the main health workers working in the public and private sectors. However, information on registered doctors, dentists and nurses from their respective state councils is likely to be inaccurate. There are several reasons for this including double counting of workers due to their being registered in more than one state, non-adjustment for health workers leaving the workforce due to death, migration and/or retirement. Further, various categories of health workers like physiotherapists, registered medical practitioners, health administrators, medical technicians and faith healers are not recorded in official statistics. In sum, the size and composition of the health workforce in the private sector, which employs the majority of health workers, is not reliably known. This has important consequences on the reliability of the information on India’s health workforce as a whole. Recent data sources on India’s population offer an important opportunity to estimate the size of India’s health workforce and evaluate the reliability of these estimates. The overall aim of this study is to estimate various dimensions of India’s health workforce, in particular, the number, composition and geographic distribution of health workers. Three different data sources are used to derive workf "); array_files[140]=new Array(0,1,"./Paper1/Introduction.html","2008-10-30","14K","Introduction ","",""," Introduction Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Introduction The extent to which health systems provide quality health services in an equitable and efficient manner influences the level of health achieved in a population. Individuals, families, and health workers are all important providers of health care. However, the responsibility of delivering health services falls primarily on the health worker making them central to the health systems capacity to delivery health services. Issues concerning the health workforce such as its capability to cover different socioeconomic groups and geographic regions, the technical competence and skills of individual health workers and motivation with which they perform their jobs – all contribute in important ways to improving health system performance and population health. Having an adequate health workforce in terms of numbers and skill mix is critical for countries like India which hope to make significant progress towards achieving the Millennium Development Goals for health. Recent studies show that greater availability of health workers is associated with better service utilization and health outcomes such as immunization coverage, outreach of primary care and infant, child and maternal survival (WHO 2006, JLI 2004, Anand and Barnighausen 2007). In addition to numerical strength, the effectiveness of the health workforce is influenced by the skill mix, quality and geographical distribution of health workers, a work environment and infrastructure which enables them to effectively use their skills, adequate remuneration and opportunities for u "); array_files[141]=new Array(0,1,"./Paper1/Health_Workers_in_the_Government_and_Non-Government_Sector.html","2008-10-30","14K","Health Workers in the Government and Non-Government Sector ","",""," Health Workers in the Government and Non-Government Sector Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Health Workers in the Government and Non-Government Sector Data on health workers in the public and private sector were available only from the NSSO. Figure 9 shows the distribution of health worker categories by sector (public or private). Overall, the majority (70%) of health workers work in the private sector in both urban and rural areas. This pattern generally holds across health worker categories though there are some important exceptions. The majority of allopathic physicians in rural (90%) and in urban (80%) are employed by the private sector, indicating that the public sector plays a small role in providing physician services in both rural and urban areas of India. This finding confirms findings from other studies which show that the majority of curative care services are provided by the private sector in India (GOI 2005). In contrast, around 50% of the nurses & midwifes in both urban and rural areas are employed by the public sector. While this indicates that the public sector contains a large capacity to providing nursing and midwifery services in both rural and urban areas, this finding is at variance with findings from national surveys which indicate that the majority of attended births take place in the private sector (IIPS 2005). AYUSH physicians and dentists are also mostly present in the private sector in both urban and rural areas. Pharmacists and health workers in the Others category tend to be equally distributed between the public and private sector in rural areas, but a "); array_files[142]=new Array(0,1,"./Paper1/Health_service_utilization_and_the_health_workforce_page2.html","2008-10-30","14K","Health service utilization and the health workforce-Page2 ","",""," Health service utilization and the health workforce-Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Health, service utilization and the health workforce (Cond...) In all three Figures the effect of health workforce density on the outcomes of interest appears to peakand plateau between 20 to 30 health workers (doctors, nurses and midwifes) per 10,000 population. This simple association suggests the importance of health worker adequacy for improving service use and better health. Further, in general, states with higher per capita health spending tend to have higher workforce density and better health outcomes. State health spending and workforce density is closely linked since the majority of state health spending is on workforce salaries. Among states, Bihar and UP tend to have low health worker density and poor health outcomes, while Goa and Kerala are at the opposite extreme. While Figures 10 to 12 indicate that there is a strong association between health workforce density and health and service utilization outcomes, interestingly there is considerable variation in these outcomes for given density levels, particularly at lower workforce densities. For example, Tamil Nadu has better or comparable performance relative to Goa and Kerala in terms of measles immunization and attended deliveries, though it has a considerably lower health workforce density. Such large variation in health and service utilization outcomes for given health workforce density indicates that there are several factors other than the workforce density which are influencing health and service utilization. This includes, "); array_files[143]=new Array(0,1,"./Paper1/Health_service_utilization_and_the_health_workforce.html","2008-10-30","14K","Health service utilization and the health workforce ","",""," Health service utilization and the health workforce Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Health, service utilization and the health workforce A series of recent studies showed that the availability of health workers is an important determinant of service utilization and key health outcomes including immunization coverage, outreach of primary care and infant, child and maternal survival (WHO 2006, JLI 2004, Anand and Barnighausen 2007). Since health services are delivered by health workers, having an adequate health workforce in terms of size, composition, quality and geographical distribution is important for ensuring uptake of health services and population health. This section of the report examines the association between health workforce availability (i.e. density) and key health and service utilization outcomes at the state level in India. Health worker density here includes the combined density of allopathic physicians, nurses and midwifes. These health workers were chosen because they are involved in providing a range of health services to the population. Figures 10, 11 and 12 show the association between health worker density and coverage of measles immunization (Figure 10), infant mortality (Figure 11) and assisted deliveries (Figure 12). Each circle in the graph represents a state and the size of the circle indicates the relative size of per capita government health spending in the state. The trend lines in each graph are from fitting median splines to the data. All three figures show a strong association between health workforce density and health outcomes and service use. H "); array_files[144]=new Array(0,1,"./Paper1/Fig_3.html","2008-10-30","12K","Fig_3 ","",""," Fig_3 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Back Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[145]=new Array(0,1,"./Paper1/Distribution_of_India’s_Health_Workforce_across_States_Census_Estimates_page6.html","2008-10-30","15K","Distribution of India’s Health Workforce across States Census Estimates-Page6 ","",""," Distribution of India’s Health Workforce across States Census Estimates-Page6 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Distribution of Indias Health Workforce across States: Census Estimates (Contd...) Rural-Urban Distribution of the Health Workforce The rural-urban distribution of health workers is an important issue for India and it is well known that the distribution of health workers is heavily skewed towards urban areas. Figure 8 describes the urban-rural distribution of India’s health workforce according to the Census. These estimates indicate that overall and across most health worker categories, typically 60 percent of the health workers are present in urban areas. In contrast, only 28% of the country’s population is urban (Census of India 2001). Health worker density in urban and rural areas is dramatically different, with the density of health workers in former being 4 times that of latter. This is particularly alarming because the rural population is a little more than two and a half times the urban population, indicating that a relatively small fraction of the country’s health workforce is available in areas where the majority of the population resides. Government estimates of the number of health workers in rural and urban areas are only available for those in the public sector. Allopathic physicians are highly concentrated in urban (13.34) compared to rural (3.28) areas. In general, there are a little more than four times as many allopathic physicians in urban compared to rural areas. Nurses and Midwifes density is similarly skewed between urban (15.88) and rural (4.13). In "); array_files[146]=new Array(0,1,"./Paper1/Distribution_of_India’s_Health_Workforce_across_States_Census_Estimates_page5.html","2008-10-30","14K","Distribution of India’s Health Workforce across States Census Estimates-Page5 ","",""," Distribution of India’s Health Workforce across States Census Estimates-Page5 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Distribution of Indias Health Workforce across States: Census Estimates (Contd...) The density of female doctors is around 3 (6) in urban and 0.2 (0.4) in rural areas per 10,000 population (females), making the density of female doctors in urban areas 15 times that of rural areas. Compared to the rural density of 3 doctors per 10,000 population, female doctors comprise only 6% of the rural doctors in the country. Urban-rural differences in the availability of female nurse & midwifes is also quite large. The density of female nurses & midwifes in urban (11) is around four times that or rural (3) areas. The geographic distribution of female health workers, particularly doctors, indicates substantial variability (Figure 7). States with low female doctor density, which are present in the bottom two density quartiles (less than 2 female doctors per 10,000 females), tend to cluster in the belt running across north-central India. This spans the states of Gujarat, Rajasthan, Haryana, Himachal Pradesh, Uttaranchal, Uttar Pradesh, Madhya Pradesh, Bihar, Jharkhand, Chhattisgarh, West Bengal, Orissa, Assam, Arunachal Pradesh and Nagaland. The bulk of these states, with the exception of Gujarat and Haryana, are also amongst the poorest in the country. States with higher female doctor densities i.e. those in the top two quartiles, tend to cluster in the north and southern and north-eastern fringes of India. This includes the states of Jammu& Kashmir, Punjab, Maharashtra, Goa, Karnataka "); array_files[147]=new Array(0,1,"./Paper1/Distribution_of_India’s_Health_Workforce_across_States_Census_Estimates_page4.html","2008-10-30","14K","Distribution of India’s Health Workforce across States Census Estimates-Page4 ","",""," Distribution of India’s Health Workforce across States Census Estimates-Page4 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Distribution of Indias Health Workforce across States: Census Estimates (Contd...) In India, there are approximately 7 (15) female health workers per 10,000 population (females). This is remarkably low, when compared to the total health workforce density of 20 per 10,000 population, indicating that women comprise only around a third of all health workers in the country (Figure 6). The share of female doctors is also surprisingly low. There are around 1(2) female doctors per 10,000 population (females). Compared to the density of 6 doctors per 10,000 population, female doctors comprise only 17% of the doctors in the country. Female nurse and midwife density is around 5 (10) per 10,000 population (females). Not surprisingly, female nurses and midwifes constitute the majority of the 7 per 10,000 nurses and midwives in India. As expected, there are substantial differences in the presence of female health workers between urban and rural areas in the country. The density of female health workers in rural and urban India is around 3 and 16 per 10,000 population, respectively, making the density of the urban female health workforce more than five times that of rural areas. This difference is even more remarkable in terms of the female population. The density of female health workers per 10,000 females in urban (35) is around five times that of rural (7) areas. Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[148]=new Array(0,1,"./Paper1/Distribution_of_India%27s_Health_Workforce_across_States_Census_Estimates.html","2008-10-30","14K","Distribution of India’s Health Workforce across States Census Estimates ","",""," Distribution of India’s Health Workforce across States Census Estimates Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Distribution of Indias Health Workforce across States: Census Estimates The previous section of this report described the size and composition of India’s health workforce using different sources of data. In this section, the distribution of all health workers, doctors, nurses & midwives and female health workers across states and between urban and rural areas is examined using the “preferred” estimate, i.e. the Census. The distribution of the health workforce across states of India is illustrated in Figures 8 to 11. In these figures, states were ranked from lowest to highest according to the relevant health workforce density and then divided into quartiles, each quartile containing approximately 25% of the states. States were then colour coded according to the quartile which they belonged. All Health Workers Figure 3 shows the distribution of Indias total health workforce across different states. States with low health workforce density, which are present in the bottom density quartile (10 -16 workers per 10,000 population), tend to cluster in the belt running across north-central India. This spans the states of Rajasthan, Uttar Pradesh, Madhya Pradesh, Bihar, Jharkhand, Chhattisgarh, Assam and Meghalaya. These states are also amongst the poorest in the country. States which are in the second quartile (16 – 22 workers per 10,000 population) include Jammu & Kashmir, Haryana, Uttaranchal, Orissa, Andhra Pradesh, Karnataka, Manipur and Tripura. States with higher workforce densitie "); array_files[149]=new Array(0,1,"./Paper1/Discussion_and_Policy_Implications_Page2.html","2008-10-30","15K","Discussion and Policy Implications-Page2 ","",""," Discussion and Policy Implications-Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Discussion and Policy Implications (Contd...) The findings from the study provide many suggestions for policy makers and planners as well as the Census and other health information systems for collection and classification of health workforce information. The upcoming Census in 2011 could consider modifying its questionnaire in a manner which would separate out the professionally trained medical practitioners from those who are not. Similarly, the use of new classification codes can segregate a nurse from a midwife. Estimates from both Census and NSSO indicate that the density of health workers is less than the WHO norm of 2.5 workers/ 1000 population (WHO 2006, JLI 2004). These findings suggest the need for policy measures to increase density of health workers, especially doctors, nurses and female health workers. However, when community workers like ASHAs are added to the aggregate health workforce, India appears to meet the WHO norm. The large geographic differences in the health workforce, both in terms of rural-urban and between states, are important challenges in reforming India’s health workforce policies. The disparity between urban and rural areas is particularly significant as the urban population accounts for less than a third of India’s total population. Similarly, the distribution of health workers between public and private sector is also a cause of concern, mainly due to higher cost of treatment involved in the private sector. Another important issue, especially from a health systems point of "); array_files[150]=new Array(0,1,"./Paper1/Discussion_and_Policy_Implications.html","2008-10-30","14K","Discussion and Policy Implications ","",""," Discussion and Policy Implications Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Discussion and Policy Implications This study shows that a variety of data sources can be used to provide useful information on the health workforce in India. The results from this study suggest that the Census appears to be the preferred source for health workforce estimates. An important reason behind this is its large sample size which covered every district in the country and, within each district, both urban and rural areas. This allows for robust estimates of the health workforce across health worker categories, states and geographical areas. Further, the Census estimates have been shown to have good correspondence with the NSSO estimates at the aggregate level, indicating good reliability. The health workforce estimates reported by the Government and allied agencies need strengthening in terms of comprehensiveness, reliability and ability to report current information on the health workforce. In regard to this, an important recommendation to the state professional councils would be to maintain a live register of health workers. The quality of health workforce data in the Census and NSSO can be strengthened in several ways. These include greater clarity in the NCO codes, redefining some health worker categories and grouping them under more appropriate headings. Certain categories of health workers like community health workers deserve separate classification codes. Community health workers have been an important part of rural health workforce in India. Yet, the current classification either merges them with n "); array_files[151]=new Array(0,1,"./Paper1/Bibliography.html","2008-10-30","15K","bibliography ","",""," bibliography Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Bibliography 1. Anand S and Bärnighausen T. 2004. “Human resources and health outcomes: cross-country econometric study”. Lancet, 364: 1603–09. 2. Anand S and Bärnighausen T. 2007. “Health Workers and Vaccination Coverage in Developing Countries: An Econometric Analysis”. Lancet, 369: 1277-1285. 3.Banerjee A, Deaton A and Duflo E. 2004. Wealth, Health and Health Services in Rural Rajasthan. Paper No. 8, Poverty Action Lab, Massachusetts Institute of Technology. 4.Census of India. 2001. http://www.censusindia.gov.in 5.Government of India. 1961. Report of Health Survey and Planning Committee (Chairman: Mudaliar), Ministry of Health and Family Welfare, Government of India. 6.Government of India. 2005. Human Resources for Health. In Financing and Delivery of Health Services in India. National Commission on Macroeconomics and Health Background Papers, Ministry of Health and Family Welfare, Government of India. 7.Government of India. 2005. Central Bureau of Health Intelligence. http://www.cbhidghs.nic.in 8.Government of India. 2006. Bulletin on Rural Health Statistics in India. Infrastructure Division, Department of Family Welfare, Ministry of Health and Family Welfare, Government of India. 9.International Institute of Population Sciences.2005. National Family Health Survey (NFHS-3), 2005-06, India. International Institute of Population Sciences and ORC Macro: Mumbai. 10.Joint Learning Initiative. 2004. Human Resources for Health – Overcoming the Crisis. Joint Learning Initiative, Harvard University and World Health Organization. 11.Medical C "); array_files[152]=new Array(0,1,"./Paper1/Annexure_9.html","2008-10-30","56K","Annexure-9 ","",""," Annexure-9 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 9 Annex 9: Female health worker density by State State Density (Per 10,000 Population) Density (Per 10,000 Females) Allopathic Physician Nurse & Midwives All Health Workers Allopathic Physician Nurse & Midwives All Health Workers INDIA 1.03 5.31 7.24 2.14 11.06 15.08 Andhra Pradesh 1.14 5.00 6.82 2.28 9.99 13.65 Arunachal 0.84 9.18 10.66 1.79 19.54 22.68 Assam 0.45 4.86 5.65 0.93 10.13 11.77 Bihar 0.26 1.77 2.12 0.54 3.69 4.41 Chhattisgarh 0.48 3.99 5.15 0.97 7.98 10.30 Delhi 4.43 11.35 18.12 9.84 25.23 40.28 Goa 3.59 16.68 24.53 7.33 34.04 50.07 Gujarat 0.84 4.44 6.32 1.75 9.25 13.16 Haryana 1.09 3.34 5.21 2.36 7.27 11.33 Himachal Pradesh 1.02 7.69 9.84 2.09 15.69 20.08 Jammu & Kashmir 1.60 3.46 5.86 3.33 7.21 12.20 Jharkhand 0.44 4.46 5.09 0.89 9.09 10.40 Karnataka 1.69 6.09 8.78 3.46 12.43 17.91 Kerala 2.13 16.72 24.33 4.18 32.79 47.71 Madhya Pradesh 0.67 3.74 4.75 1.39 7.79 9.89 Maharashtra 2.03 8.17 12.52 4.23 17.01 26.07 Manipur 1.29 9.10 11.66 2.62 18.58 23.79 Meghalaya 1.06 7.83 9.76 2.17 15.97 19.93 Mizoram 1.83 10.97 23.38 3.82 22.85 48.70 Nagaland 0.63 13.42 15.30 1.31 27.96 31.87 Orissa 0.43 10.10 10.81 0.87 20.62 22.06 Punjab 1.72 5.91 8.87 3.65 12.57 18.86 Rajasthan 0.56 3.23 4.00 1.16 6.74 8.33 Sikkim 2.74 12.68 21.04 5.82 26.98 44.77 Tamil Nadu 1.97 7.52 10.84 3.94 15.05 21.69 Tripura 0.28 5.78 6.39 0.57 11.80 13.04 UP 0.47 1.73 2.42 0.98 3.61 5.04 Uttaranchal 0.85 4.07 5.39 1.74 8.31 10.99 West Bengal 0.63 6.98 8.19 1.32 14.55 17.07 A&N Islands 2.47 14.86 22.97 5.36 32.30 49.94 Chandigarh 7.49 19.11 31.95 17.03 "); array_files[153]=new Array(0,1,"./Paper1/Annexure_8.html","2008-10-30","54K","Annexure-8 ","",""," Annexure-8 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 8 Annex 8: Nurse density (per 10,000 population) by state and area State/UT Total Rural Urban NSSO Census INC NSSO Census NSSO Census INDIA 7.09 7.39 12.77 4.27 4.13 14.42 15.88 Andhra Pradesh 11.48 7.54 22.53 8.42 4.41 19.71 15.98 Arunachal 6.10 17.92 - 5.79 12.72 7.33 38.46 Assam 3.93 6.18 7.90 0.80 4.20 25.51 19.84 Bihar 2.73 2.80 1.86 2.46 1.71 5.05 12.15 Chhattisgarh 9.01 5.74 0.12 7.57 3.33 14.72 15.35 Delhi 8.34 15.80 1.84 0.00 8.40 8.96 16.36 Goa 34.64 19.72 - 61.29 16.73 7.99 22.71 Gujarat 2.83 5.95 22.44 1.08 2.78 5.78 11.26 Haryana 9.58 4.52 12.86 10.72 2.34 6.78 9.88 Himachal Pradesh 8.21 9.76 27.11 7.16 6.83 18.01 36.97 Jammu & Kashmir 2.22 6.29 2.42 4.71 1.62 11.06 Jharkhand 0.44 6.23 0.01 0.41 2.87 0.51 17.96 Karnataka 1.98 8.29 19.42 2.69 3.46 0.60 17.67 Kerala 18.08 19.16 31.87 15.65 18.10 25.02 22.19 Madhya Pradesh 7.64 5.79 17.77 2.31 2.88 22.29 13.82 Maharashtra 9.73 11.06 10.40 4.74 4.58 16.52 19.87 Manipur 3.87 12.32 - 2.46 8.86 8.40 23.38 Meghalaya 11.68 9.19 - 2.27 4.53 50.57 28.47 Mizoram 10.20 11.84 28.71 5.16 5.19 15.33 18.64 Nagaland 12.45 17.30 3.96 13.93 52.27 33.09 Orissa 6.72 12.84 19.57 4.41 11.81 19.85 18.72 Punjab 9.93 7.79 24.42 11.13 4.96 7.59 13.32 Rajasthan 17.61 4.95 9.38 4.74 2.68 59.76 12.37 Sikkim 12.21 14.11 - 13.40 11.37 2.79 36.03 Tamil Nadu 3.27 10.43 34.24 0.77 5.38 6.47 16.91 Tripura 9.85 9.15 4.94 10.44 5.91 7.02 24.68 UP 4.02 2.76 2.57 2.66 1.47 9.20 7.70 Uttaranchal 12.10 6.27 - 5.67 4.31 30.77 11.96 West Bengal 7.79 10.44 13.03 4.46 5.10 16.34 24.15 A&N Islands 28.81 17.43 - "); array_files[154]=new Array(0,1,"./Paper1/Annexure_7.html","2008-10-30","54K","Annexure-7 ","",""," Annexure-7 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 7 Annex 7: Doctor density (per 10,000 population) by state and area State/UT Total Rural Urban NSSO Census MCI NSSO Census NSSO Census INDIA 4.28 6.07 5.78 2.42 3.28 9.12 13.34 Andhra Pradesh 4.52 7.84 4.32 3.87 5.41 6.30 14.36 Arunachal 1.97 3.17 - 0.62 1.53 7.33 9.65 Assam* 0.16 2.83 - 0.17 1.37 0.11 12.89 Bihar 2.06 3.96 3.91 2.02 2.86 2.38 13.31 Chhattisgarh 2.59 4.09 0.21 1.56 2.69 6.67 9.67 Delhi 1.53 15.03 17.02 0.00 8.32 1.64 15.53 Goa 6.35 10.99 16.07 0.00 4.43 12.71 17.55 Gujarat 3.89 4.40 7.05 1.59 1.35 7.74 9.52 Haryana 4.02 8.21 0.60 3.68 5.31 4.86 15.32 Himachal Pradesh 5.97 5.96 0.19 4.54 3.91 19.33 24.96 Jammu & Kashmir 1.81 6.77 7.37 1.70 2.07 2.14 21.03 Jharkhand 4.23 3.94 0.19 0.91 2.45 15.85 9.12 Karnataka 7.58 7.32 12.28 3.65 3.02 15.19 15.68 Kerala 4.45 6.28 10.30 2.05 3.29 11.29 14.80 Madhya Pradesh 2.68 4.89 4.44 2.85 2.47 2.20 11.54 Maharashtra 7.09 7.88 9.28 2.61 3.42 13.19 13.95 Manipur 1.91 4.54 - 0.92 2.03 5.09 12.55 Meghalaya 1.12 2.51 - 0.38 0.58 4.21 10.49 Mizoram 0.47 5.32 - 0.00 1.92 0.95 8.78 Nagaland 2.05 3.37 - 1.16 2.10 6.27 9.33 Orissa 0.48 2.69 3.90 0.56 1.29 0.00 10.68 Punjab 6.57 11.14 13.46 5.57 6.55 8.51 20.08 Rajasthan 5.03 3.97 3.76 2.22 1.81 14.26 11.03 Sikkim 1.66 7.49 - 1.49 5.07 2.95 26.65 Tamil Nadu 9.07 6.09 11.22 3.16 1.73 16.63 11.66 Tripura 1.05 3.21 - 0.47 1.35 3.81 12.16 UP 3.76 6.04 2.60 2.63 3.94 8.06 14.05 Uttaranchal 4.19 7.40 - 1.29 4.86 12.64 14.78 West Bengal 3.16 7.07 6.24 1.90 5.01 6.38 12.37 A&N Islands 0.00 7.59 - 0.00 5.14 0.00 12.50 Chandigarh 14.03 23.17 - 9 "); array_files[155]=new Array(0,1,"./Paper1/Annexure_6.html","2008-10-30","103K","Annexure-6 ","",""," Annexure-6 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 6 Annex 6: Health Worker Density (Per 10,000 Population) by State State All Health Workers Allopathic Physician Nurse & Midwife Ayush Dentist Pharmacist Others Other Traditional NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census INDIA 19.72 19.46 4.28 6.07 7.09 7.39 2.58 1.76 0.24 0.21 1.68 2.15 3.12 1.42 0.73 0.46 Andhra Pradesh 23.54 21.31 4.52 7.84 11.48 7.54 1.60 0.90 0.18 0.12 1.43 2.37 1.97 1.66 2.35 0.88 Arunachal Pradesh 15.08 26.83 1.97 3.17 6.10 17.92 0.00 0.29 0.00 0.19 4.70 2.50 2.30 1.98 0.00 0.78 Assam 7.93 14.37 0.16 2.83 3.93 6.18 0.66 1.15 1.23 0.06 0.50 2.24 0.55 1.28 0.89 0.63 Bihar 9.55 10.19 2.06 3.96 2.73 2.80 1.21 1.02 0.06 0.04 0.27 1.88 2.89 0.43 0.33 0.06 Chhattisgarh 14.89 15.81 2.59 4.09 9.01 5.74 0.43 1.20 0.00 0.07 0.55 1.19 1.19 2.77 1.13 0.75 Delhi 10.20 44.56 1.53 15.03 8.34 15.80 0.00 3.22 0.00 1.02 0.12 4.44 0.21 4.43 0.00 0.63 Goa 59.27 41.55 6.35 10.99 34.64 19.72 0.00 1.32 2.66 1.26 15.62 3.71 0.00 3.95 0.00 0.60 Gujarat 19.69 17.27 3.89 4.40 2.83 5.95 0.79 1.94 0.08 0.21 4.51 2.97 4.84 1.24 2.75 0.57 Haryana 24.36 19.68 4.02 8.21 9.58 4.52 2.49 2.27 0.39 0.45 2.52 2.80 4.78 1.24 0.58 0.18 Himachal Pradesh 19.53 26.37 5.97 5.96 8.21 9.76 0.27 2.89 0.00 0.49 4.84 5.33 0.00 1.63 0.24 0.31 Jammu & Kashmir 8.10 20.66 1.81 6.77 2.22 6.29 0.23 0.61 0.18 0.28 0.21 4.66 3.45 1.90 0.00 0.15 Jharkhand 9.66 14.09 4.23 3.94 0.44 6.23 1.89 0.84 0.00 0.08 0.00 1.77 3.10 1.06 0.00 0.17 Karnataka 25.43 20.59 7.58 7.32 1.98 8.29 3.58 1.17 0.00 0.32 0.00 1.25 12.3 "); array_files[156]=new Array(0,1,"./Paper1/Annexure_5.html","2008-10-30","43K","Annexure-5 ","",""," Annexure-5 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 5 Annex 5: Density of Female Health Workers by Area Category NCO Classification Density (Per 10,000 Population) Density (Per 10,000 Females) Rural Urban Total Rural Urban Total Allopathic Physicians & Surgeons Allopathic Physician/Surgeon 0.22 3.12 1.03 0.47 6.45 2.14 Dentists Dentist 0.01 0.16 0.05 0.02 0.32 0.10 AYUSH Ayur 0.05 0.42 0.15 0.11 0.86 0.32 Unani 0.00 0.03 0.01 0.00 0.05 0.02 Homeopathy 0.03 0.27 0.10 0.07 0.56 0.21 Total 0.08 0.71 0.26 0.18 1.47 0.54 Nurses, Midwives & Related Professionals Nursing Professional 0.06 0.22 0.11 0.13 0.46 0.22 Nursing Associate Prof.=3231 1.92 9.01 3.89 4.01 18.63 8.11 Midwives 0.62 1.30 0.81 1.29 2.69 1.68 Sanitarian 0.32 0.98 0.50 0.66 2.02 1.04 Total 2.92 11.51 5.31 6.10 23.80 11.06 Pharmacists & Related Pharmaceutical Asst. 0.10 0.49 0.21 0.20 1.02 0.43 Dieticians & Nutritionists Dietician & Nutritionist 0.01 0.03 0.01 0.01 0.07 0.03 Opticians & Optometrists Optometrist 0.00 0.02 0.01 0.01 0.05 0.02 Medical Asst. & Tech. Medical Equipment Operator 0.01 0.04 0.02 0.02 0.09 0.04 Medical Assistant 0.10 0.47 0.20 0.20 0.97 0.42 Total 0.11 0.51 0.22 0.22 1.06 0.46 Dental Assistants Dental Asst. 0.00 0.01 0.01 0.00 0.03 0.01 Physiotherapists Physiotherapist 0.00 0.06 0.02 0.01 0.13 0.04 Modern Health Associate Prof. 0.02 0.07 0.04 0.05 0.14 0.07 Total 0.03 0.13 0.06 0.06 0.27 0.11 Other Traditional Health Workers Traditional Medicine Practioners 0.01 0.02 0.01 0.01 0.03 0.02 Faith Healer 0.00 0.00 0.00 0.00 0.00 0.00 Health Professional except Nursing 0.04 0.19 0.08 0.08 0.40 0.17 Tot "); array_files[157]=new Array(0,1,"./Paper1/Annexure_4.html","2008-10-30","42K","Annexure-4 ","",""," Annexure-4 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 4 Annex 4: Health Worker Density by Area (Per 10,000 Population) Estimate NSSO Census Category NCO Classification Rural Urban NCO Classification Rural Urban Allopathic Physician/Surgeons Allopathic Doctor 2.23 8.87 Allopathic Physician/Surgeon 3.28 13.34 Public Health Physician 0.18 0.25 0.00 0.00 Total 2.42 9.12 Total 3.28 13.34 Dentists Dentist 0.15 0.47 Dentist 0.06 0.59 AYUSH Ayur 0.81 2.22 Ayur 0.60 2.17 Unani 0.13 0.57 Unani 0.04 0.24 Homeopathy 0.56 2.60 Homeopathy 0.39 1.23 Total 1.51 5.38 Total 1.04 3.64 Nurses, Midwives & Related Professionals Nurse 1.04 6.92 Nursing Professional 0.08 0.28 Nursing, Sanitary Assistant 2.29 6.32 Nursing Associate Professional 2.33 11.07 Midwives 0.94 1.18 Midwives 0.68 1.44 0.00 0.00 Sanitarian 1.03 3.08 Total 4.27 14.42 Total 4.13 15.88 Pharmacists & Related Pharmacist 0.72 1.83 Pharmaceutical Asst. 0.28 1.61 Pharmaceutical Asst. 1.33 4.28 Total 1.00 3.44 Total 1.33 4.28 Dieticians & Nutritionists Dietician & Nutritionist 0.00 0.01 Dietician & Nutritionist 0.02 0.06 Opticians & Optometrists Optician & Optometrist 0.03 0.03 Optometrist 0.04 0.34 Medical Assistants & Technicians Medical Asst. & Technician 1.14 2.46 Medical Equipment Operator 0.05 0.40 0.00 0.00 Medical Assistant 0.43 2.08 Total 1.14 2.46 Total 0.48 2.48 Dental Assistants Dental Asst. 0.04 0.21 Dental Asst. 0.01 0.06 Physiotherapists Physiotherapist 0.00 0.00 Physiotherapist 0.02 0.18 0.00 0.00 Modern Health Associate Prof. 0.10 0.24 Total 0.00 0.00 Total 0.12 0.43 Other Traditional Health Workers Other Traditional Health "); array_files[158]=new Array(0,1,"./Paper1/Annexure_3.html","2008-10-30","52K","Annexure-3 ","",""," Annexure-3 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 3 Annex 3: Size and density (per 10,000 population) of the Health Workforce in India Estimate NSSO Census Government Estimates Category NCO Classification Number Density NCO Classification Number Density Number Density Allopathic Physicians & Surgeons Allopathic Doctor 454,233 4.08 Allopathic Physician/Surgeon 676,756 6.07 660,856 5.93 Public Health Physician 22,461 0.20 Total 476,694 4.28 Total 676,756 6.07 660,856 5.93 Dentists Dentist 26,336 0.24 Dentist 22,962 0.21 55,344 0.50 AYUSH Ayur 134,015 1.20 Ayur 115,934 1.04 Unani 28,361 0.25 Unani 10,822 0.10 Homeopathy 125,391 1.13 Homeopathy 69,732 0.63 Total 287,767 2.58 Total 196,488 1.76 726,370 6.52 Nurses, Midwives & Related Professionals Nurse 298,230 2.68 Nursing Professional 15,490 0.14 Nursing, Sanitary Asst. 379,602 3.41 Nursing Associate Professional 530,443 4.76 Midwives 111,841 1.00 Midwives 99,504 0.89 0.00 Sanitarian 178,151 1.60 Total 789,673 7.09 Total 823,589 7.39 1,422,452 12.77 Pharmacists & Related Pharmacist 114,926 1.03 Pharmaceutical Asst. 72,349 0.65 Pharmaceutical Asst. 239,276 2.15 Total 187,275 1.68 Total 239,276 2.15 Dieticians & Nutritionists Dietician & Nutritionist 260 0.00 Dietician & Nutritionist 3,587 0.03 Opticians & Optometrists Optician & Optometrist 3,539 0.03 Optometrist 13,678 0.12 Medical Asst. & Tech. Medical Asst. & Tech. 168,159 1.51 Medical Equipment Operator 16,240 0.15 Medical Assistant 99,010 0.89 Total 168,159 1.51 Total 115,250 1.03 Dental Assistants Dental Assistant 10,002 0.09 Dental Assistant 2,658 0.02 Physiotherapist Physi "); array_files[159]=new Array(0,1,"./Paper1/Annexure_2_page2.html","2008-10-30","16K","Annexure-2 Page2 ","",""," Annexure-2 Page2 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 2 (Contd...) NSSO-NCO (1968) Census-NCO (2004) 078 Public Health Physicians 078.10 Health Officer 2229.10 2229 Health Professionals (except Nursing) 2229.10 Health Officer 2229.15 Administrator, Hospital 2229.30 Physician, Osteopathic 2229.20 Naturopath 2229.40 Physician, Sidha 2229.90 Physician & Surgeons, Other 078.10 079.10 071.20 079.90 079 Other Physicians 079.10 Naturopath 079.20 Chiropodist 079.90 Physician & Surgeons, Other 2229.20 3226.30 2229.90 Thus, code 2229 in the Census is a combination of 078 and 079 in the NSSO. Thus, to split 2229 into public health physicians and other physicians, a formula of 078/ (078+079) was applied to derive the proportion of 1:4. This proportion was used to split all relevant Census estimates Previous Page Next Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[160]=new Array(0,1,"./Paper1/Annexure_2_Page1.html","2008-10-30","14K","Annexure-2 Page1 ","",""," Annexure-2 Page1 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 2 Annex 2: Adjustments and Imputations made to NSSO and census data Using the NSSO and Census data the number, composition and distribution of health workers were estimated using NCO codes. The NSSO used the NCO-68 codes to classify occupations and 19 categories in the NCO-68 codes were pertinent to the health workforce. These were grouped according to the comparable categories listed in Appendix 1. The 2001 Census used the NCO (2004) codes to categorise workers, with 20 codes characterising the health workforce. These were grouped according to the categories listed in Appendix 1. A. Missing Values and Imputation Some of the individuals classified as employed in the NSSO data had missing NCO codes. On cross-tabulating the missing NCO codes with the NIC codes, the missing values pertaining to health workers were identified. These individuals (health workers) were assigned to health worker groups (see Appendix 1) based on the information collected on their educational degrees and their NIC codes. There was a group of non-physician health workers who, based on their NIC codes, were identified as working in the hospital but could not be further classified and were placed in the category called “Other Hospital Staff”. B. Combining and Splitting Health Worker Categories To makes NSSO and Census estimates comparable, one NCO-2004 code in the Census, “Health Professionals except Nursing”(NCO code 2229) had to be split into two. This was required as the category consisted of two very different kinds of health workers: health offic "); array_files[161]=new Array(0,1,"./Paper1/Annexure_11.html","2008-10-30","31K","Annexure-11 ","",""," Annexure-11 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 11 Annex 11: Health worker density (per 10,000 population) by sector Estimate NSSO Official Estimates Category Non-Government Government Non-Government Government Total Rural Urban Total Rural Urban Total Allopathic Physician 2.23 6.91 3.53 0.18 2.20 0.74 7.26 2.48 5.93 Dentist 0.14 0.44 0.23 0.00 0.03 0.01 - - - AYUSH 1.46 5.09 2.47 0.04 0.29 0.11 - - - Nurse & Midwife 2.16 7.70 3.70 2.11 6.72 3.39 - - - Pharmacist 0.53 2.77 1.15 0.48 0.67 0.53 - - - Dieticians & Nutritionists 0.00 0.01 0.00 0.00 0.00 0.00 - - - Opticians & Optometrists 0.02 0.03 0.02 0.01 0.00 0.01 - - - Medical Asst. & Technicians 0.59 1.64 0.88 0.56 0.82 0.63 - - - Dental Asst. 0.04 0.10 0.06 0.00 0.11 0.03 - - - Other Traditional Health Workers 0.62 1.01 0.73 0.00 0.02 0.00 - - - Other Hospital Staff 0.31 2.80 1.00 0.24 1.10 0.48 - - - All Health Workers 8.11 28.49 13.77 3.63 11.97 5.94 - - - Source: National Sample Survey Organisation 2004-05; Medical Council of India (MCI) 2005 Previous Page Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[162]=new Array(0,1,"./Paper1/Annexure_10.html","2008-10-30","53K","Annexure-10 ","",""," Annexure-10 Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of India’s Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures 10 Annex 10: Female health worker density by State and area State Density (Per 10,000 Females) Allopathic Physician Nurse & Midwives All Health Workers Rural Urban Rural Urban Rural Urban INDIA 0.47 6.45 6.10 23.80 7.34 34.96 Andhra Pradesh 0.69 6.58 5.82 21.26 7.12 31.30 Arunachal 0.86 5.50 12.15 49.10 13.50 59.41 Assam 0.26 5.41 6.95 31.38 7.59 39.76 Bihar 0.20 3.68 2.06 18.31 2.32 23.16 Chhattisgarh 0.23 3.91 4.18 23.18 5.27 30.42 NCT of Delhi 3.22 10.34 9.92 26.38 15.58 42.14 Goa 2.15 12.48 28.30 39.78 35.67 64.46 Gujarat 0.19 4.40 4.32 17.64 4.96 27.14 Haryana 0.57 6.75 3.21 17.20 4.18 28.83 Himachal Pradesh 0.95 12.35 10.54 62.09 12.96 84.18 Jammu & Kashmir 0.57 11.60 4.76 14.57 6.32 29.83 Jharkhand 0.19 3.38 3.83 27.77 4.18 32.42 Karnataka 0.73 8.76 5.03 26.80 6.39 40.28 Kerala 2.01 10.37 31.15 37.47 41.87 64.35 Madhya Pradesh 0.20 4.62 3.34 19.84 3.75 26.50 Maharashtra 0.81 8.95 6.91 30.96 9.22 49.34 Manipur 0.77 8.50 13.31 35.29 15.40 50.35 Meghalaya 0.34 9.94 8.25 48.88 9.13 65.95 Mizoram 1.39 6.35 9.56 36.69 21.90 76.59 Nagaland 0.84 3.40 21.94 55.35 24.54 65.26 Orissa 0.19 4.73 19.79 25.31 20.27 32.20 Punjab 0.75 9.28 7.80 21.82 9.61 36.83 Rajasthan 0.17 4.45 3.29 18.27 3.61 24.16 Sikkim 3.65 23.41 21.32 72.75 34.10 131.10 Tamil Nadu 0.89 7.82 7.72 24.38 9.65 37.01 Tripura 0.06 3.07 6.91 35.70 7.37 40.70 UP 0.27 3.64 1.86 10.20 2.29 15.37 Uttaranchal 0.57 5.09 5.17 17.24 6.04 25.08 West Bengal 0.29 3.98 6.36 35.59 7.12 42.63 A&N Islands 3.56 9.03 28.19 40.63 39.13 71.87 Chandigarh 0.73 18.85 8.72 47.28 10.42 79.53 "); array_files[163]=new Array(0,1,"./Paper1/Annexures.html","2008-10-30","41K","Annexures ","",""," Annexures Search Indias Health Workforce: Size, Composition and Distribution Content Introduction Data Sources Methodology Size and Composition of the Health Workforce in India: Triangulating Results From different data sources Distribution of Indias Health Workforce across States : Census Estimates Health Workers in the Government and Non-Government Sector Discussion and Policy Implications Health, service utilization and the health workforce Bibliography Annexures Download Annexures Annex 1: Concordance Table for NCO-1968 and NCO-2004 Categories NCO 1968 used for classification by NSSO NCO 2004 used for classification by Census Allopathic physicians/surgeons/ specialists Allopathic physicians/surgeons/specialists = 070 070.10 Physician, General 070.15 Surgeon, General 070.20 Anatomist, Medical 070.25 Anaesthetist 070.30 Psychiatrist 070.35 Neurologist 070.40 Dermatologist 070.45 Ear, Nose and Throat Specialist 070.50 Cardiologist 070.55 Radiologist 070.60 Tuberculosis Specialist 070.65 Opthalmologist 070.70 Venereologist 070.75 Obstetrician 070.78 Gynaecologist 070.80 Paediatrician 070.85 Orthopaedist 070.90 Surgeons and Medical Specialists, Allopathic, Other 2221.10 2221.15 2221.20 2221.25 2221.30 2221.35 2221.40 2221.45 2221.50 2221.55 2221.60 2221.65 2221.70 2221.75 2221.78 2221.80 2221.85 2221.90 Allopathic physicians/surgeons = 2221 2221.10 Physician, General 2221.15 Surgeon, General 2221.20 Anatomist, Medical 2221.25 Anaesthetist 2221.30 Psychiatrist 2221.35 Neurologist 2221.40 Dermatologist 2221.42 Allergy Specialist 2221.45 Ear, Nose and Throat Specialist 2221.50 Cardiologist 2221.55 Radiologist 2221.60 Tuberculosis Specialist 2221.65 Ophthalmologist 2221.68 Urologist 2221.70 Venereologist 2221.75 Obstetrician 2221.78 Gynaecologist 2221.80 Paediatrician 2221.85 Orthopaedist 2221.90 Surgeons and Medical Specialists, Allopathic, Other 070.10 070.15 070.20 070.25 070.30 070.35 070.40 070.45 070.50 070.55 070.60 070.65 070.70 070.75 070.78 070.80 070.85 070.90 Public Health Physicians = 078 078.10 Health "); array_files[164]=new Array(0,1,"./index.html","2008-10-30","11K","Home ","",""," Home COLLABORATIVE INSTITUTIONS Search The role of health workers in the performance of health systems has attracted much recent attention. The quality, availability and efficiency with which health services are delivered are closely linked with the skills, presence, composition and distribution of health workers. Paying attention to issues concerning human resources for health (HRH) is important for countries like India which hope to make significant progress towards achieving the MDGs and greater equity in health. Information on HRH issues is surprisingly fragmented in India. At the very basic level, there is little reliable information about the volume, composition, distribution of the health workforce. The health sector in India faces multiple challenges in the geographic distribution of human resources for health. Though the majority of the population lives in rural areas, doctors in both the public and private sectors are concentrated in urban areas. Understanding the determinants of employment choice among graduating medical and nursing students becomes an essential step in positioning health workers in rural areas. Hence, the Public Health Foundation of India (PHFI), in partnership with the World Bank conducted a systematic and detailed analysis of human resources for health in India. The overall objective of this situation analysis was to provide a deeper understanding of issues concerning HRH in India. PUBLICATIONS Indias Health Workforce Size, Composition and Distribution Human Resources for Health: A Political, Economy and Institutional Analysis of the Indian Context Career Preferences of Medical and Nursing students in Uttar Pradesh: A Qualitative Analysis Copyright - PHFI, World Bank Privacy Policy Terms of Use Site Map "); array_files[165]=new Array(0,1,"./About_the_project.html","2008-10-30","14K","About_the_project ","",""," About_the_project The role of health workers in the performance of health systems has attracted much recent attention. While their importance in the delivery of health services is well recognized, little attention has been paid to the systematic study of health workforce issues and how it influences health system performance and health outcomes. The quality, availability and efficiency with which health services are delivered are closely linked with the skills, presence, composition and distribution of health workers. Further, recent studies have shown that the availability of health workers is associated with the utilization of health services and key health outcomes (WHO 2006, JLI 2004, Anand and Barnighausen 2007). Paying attention to issues concerning human resources for health (HRH) is important for countries like India which hope to make significant progress towards achieving the MDGs and greater equity in health. Information on HRH issues is surprisingly fragmented in India. At the very basic level, there is little reliable information about the volume, composition, distribution of the health workforce. While the Government collects information on the health workforce it employs, the majority of health workers in India are in the private sector and little is known about their numbers, composition, distribution and quality. The private health workforce includes providers of allopathic and traditional health care. Despite recent efforts at quantifying the health workforce in India (WHO 2007), detailed information on their availability, skill levels, distribution and private sector participation is lacking. Further, no studies till date in India have been attempted to systematically study the association between health workforce indicators and health outcomes/health service utilization in the country. Another area of limited understanding concerns stakeholders in HRH, their behavior, the causes behind the way they act and how it influences the human resource situation in India. A variety of issues such as "); array_files[166]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page10.html","2008-10-29","6K","Print Version-Analytical Section-Page10 ","",""," Print Version-Analytical Section-Page10 Analytical Section (contd...) Medical Students’ Preferences for the Private Sector Medical students preferred to work in the private rather than in the public sector, as the former offered many of the job characteristics that students valued. For example, one of the primary reasons medical students were attracted to the private sector is that the salaries offered there are generally much higher than those in the public sector. In fact, low salaries were the single most important factor that discouraged medical students from opting for the public sector both for undergraduates (62percent) and for postgraduates (67percent). Similarly, over 80 percent of the undergraduates and about 60 percent of postgraduates cited high salaries as the major draw of the private sector. “Private people give performance-based incentives…also salary is good” Female UG Student, Public Medical Institute, Allahabad “Entrant level salary [in private job] is Rs. 60,000 which I believe is good” Female PG student, Public Medical Institute, Allahabad “The salary in government job is less. I think that a government job should follow the corporate culture- pay in accordance to your work. People are thus leaving government jobs because of low pay.” Male UG student, Public Medical Institute, Allahabad Students also felt that they had better opportunities to utilize their skills in a private hospital than in government clinics as the latter often lack basic equipment and facilities. Especially once the student undertakes a postgraduate course of study, the learning opportunities in a job is felt to exist largely if posted in a tertiary level healthcare facility that both brings complex patient-cases as well as the possibility of more complete utilization of the doctor’s specialist skills. “…If we want to make diagnosis on basis of MRI, CT Scan etc.- such diagnostic facilities are not necessarily present in government setup. We will not be able to use our skills” Male UG Student, Public Medic "); array_files[167]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page11.html","2008-10-29","6K","Print Version-Analytical Section-Page11 ","",""," Print Version-Analytical Section-Page11 Analytical Section (contd...) Personal security, which was mentioned as an important concern by many medical students was also believed to be more of a problem in the government sector. “First of all there is a pressure of local politician. They ask a doctor to give forged certificate and do paperwork. Due to these false documents, hassles are created” Male UG Student, Public Medical Institute, Lucknow One student summarizes the various disadvantages of a public sector job as follows: “There are more disadvantages than advantages in a government job- safety, financial and political pressure. Pressure is more in rural areas. Anybody can kill us and get away with it.” Male UG student, Public Medical Institute, Lucknow Medical students did, however, acknowledge that there were some advantages that working in the public sector had over working in the private sector. Foremost among these was job security and a limited workload. Over 80 percent of undergraduates and 70 percent of postgraduate medical students stated, during interviews, that job security was the greatest advantage of a public sector job. However, since job security, as an attribute of a first job, was not prioritized as being of great significance, it is not especially effective in attracting students to join the public sector. “In a government job you cannot be pulled out of a job. In private, if you do not work well you will be warned for 2-3 times and then terminated from your job. Also, if they are getting another employee on a lesser pay scale than you- with the same efficiency level as you, the private sector replaces you as quickly” Male PG student, Public Medical Institute, Gorakhpur “The only advantage that I think is there in a government job or a job in a public sector is that you have time to live even in times of emergencies it is a 8-2 job with fixed timings. We are not busy with work all the time” Female UG student, Public Medical Institute, Lucknow “It [a private sector job] takes a toll on your "); array_files[168]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page12.html","2008-10-29","6K","Print Version-Analytical Section-Page12 ","",""," Print Version-Analytical Section-Page12 Analytical Section (contd...) “[A government job] gives us recognition from the society” Female UG student, Public Medical Institute, Allahabad A person in a government job works for 6-8 hours in a fixed time and patients keep on running after him just to meet him–because he is the only medical doctor in the area. Even if there is a very experienced private medical practitioner in that area the people might not know him to the extent people know this government doctor. “ Male PG student, Public Medical Institute, Gorakhpur For students planning to open up their own private practice in future, the social recognition provided by the public sector is especially important. A government job offers the opportunity to gain experience and build a network of clients, both of which are crucial for a successful private practice. As one student explains: “If somebody knows that I am belonging to a medical college, I get special respect. It gives you name and fame. Many of the professors over here have joined this medical college although they are very competent and can earn much more in the private sector; they still have joined this just to get a platform.” Male PG student, Public Medical Institute, Allahabad A student sums up the benefits of a government job in the following way: “It [a government job] gives us recognition from the society. We can establish our private practice after recognition. Workload is less and no one can pull us out. Our job is also fixed-whether you work or not work nobody can terminate you. Female Undergraduate student, Public medical institute, Allahabad The fact that students were able to recognize some advantages of working in the public sector suggests that it may be possible to attract students into government jobs with some additional incentives. However, currently the draws of the private sector- higher salaries, better facilities at the workplace and greater personal security- are of greater importance to medical students and outweigh the benefits "); array_files[169]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page13.html","2008-10-29","6K","Print Version-Analytical Section-Page13 ","",""," Print Version-Analytical Section-Page13 Analytical Section (contd...) Many nursing students also mentioned job security as being important towards their career decision. The students unanimously felt that a position in the public sector offers greater job security than the private sector. “We have safety in this [public sector] job as once you are into government job you do not have to change job every now and then.” Female Nursing Student, Public Nursing Institute, Lucknow “If we have some kind of personal problem and we don’t appear for maybe one month then the private people will not pay you but this is not the case in the government” Female Nursing Student, Private Nursing Institute, Lucknow “Most of the people go in for a government job for pension. You get secured for life. Pension will be your security for old age. Job is still there when something happens to us” Female Nursing Student, Public Nursing Institute, Lucknow An additional advantage of a government job was that the public sector offered fixed work timings. This was particularly important for female nursing students since their obligations to the family could be better planned around such a work schedule. As one such student elaborated: “We can finish our work within a fixed time. It is a 9 to 5 job. Rest of the time we can dedicate it with our family. As compared to private sector the job timings are fixed and workload is less. We have safety in this job, as once you are into a government job, you do not have to change job every now and then” Female nursing Student, Public Nursing Institute, Lucknow It is important to also note that, in their preference for the public sector over the private sector, students in private nursing schools think no differently from their colleagues attending a public nursing school. “In private job there is more work and less money. In a government job you have a fixed 8-hour job and after that job you are free. Even if you want to earn more money by working in private once you are finished with a government job, "); array_files[170]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page14.html","2008-10-29","5K","Print Version-Analytical Section-Page14 ","",""," Print Version-Analytical Section-Page14 Analytical Section (contd...) Location Preferences: Medical Students While there was a difference between medical and nursing students in their preference for working in the private or public sector, all categories of students overwhelmingly favored working in an urban area. When all undergraduates participating in this study were questioned on their work location choices, the majority (70percent) expressed a preference for an urban job over a rural area (9percent) with the remainder stating no preference. The preference for an urban job was even more prominent among postgraduate students; less than 5percent of PG students had plans of serving in a rural area at any point during their lives. Most medical students equated working in a rural area with working in the public sector and, therefore, cited many of the disadvantages of the public sector as also being those of working in rural areas. For example, the lack of facilities in rural areas for carrying out medical procedures featured as a prominent concern. Students felt that without proper equipment available, they would not be able to use their skills and this would affect their job satisfaction. “The doctor alone cannot make a difference. Even if you want to do something the infrastructure is not there. If there is a super-specialty hospital in a rural area I would be willing to go there daily and work there” Female UG student, Public Medical Institute, Lucknow “The government wants us to go to rural areas. This is wastage [sic] of our studies. Neither they have the facilities over there nor do the people over there have the money. If suppose we have to do bypass surgery in rural areas how are we going to do it” Male UG Student, Private Medical Institute, Lucknow “Whatever we want to do there, we will not be able to do. There are no instruments over there. We have spent 10 years of our life in studying to be a good doctor- what is the use of that if we are not able to do that” Male PG Student, Public Medical Institu "); array_files[171]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page15.html","2008-10-29","6K","Print Version-Analytical Section-Page15 ","",""," Print Version-Analytical Section-Page15 Analytical Section (contd...) “There is no source of entertainment- no friends, no society, no colleagues etc. We will have our family too in future. We don’t want our family to be isolated. We can stay in rural till we are not married but would like to stay on our own terms and conditions” Female UG student, Public Medical Institute, Allahabad “Even if the working conditions can be improved…what will we do for the roads? Where will we get enough drinking water? The connectivity is also not there. You cannot do anything for your children, for your wife” Male PG student, Public Medical Institute, Lucknow It is often argued that students from rural backgrounds are more likely to work in rural areas (Laven and Wilkinson 2003; Matsumoto, Okayama et al. 2005; Dussault and Franceschini 2006). In this study, however, even medical students who grew up in rural areas were not especially keen on a job in a rural area, as they aspired to a better life for themselves and their children. “I am from a village but I would like to bring up my children where there are maximum facilities. I want to give our children the best education. I cannot speak English very well but I would like my children to study in an English Medium School...I would choose such a location for upbringing [sic] my children so that they get best possible education opportunities” Male UG student, Public Medical Institute, Allahabad Many female medical students worried particularly about the opportunities available for their family, and the low likelihood that their family would be able to live with them in a rural area. “We will choose to work in urban areas. With time, we will have a family as well and everybody with you will not be willing to go in rural areas with you and when you have children, their education suffers in the rural and also their future. If you take all these things into considerations then you just cannot go out serving in the rural area; serving of course is a part of this job and will a "); array_files[172]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page16.html","2008-10-29","6K","Print Version-Analytical Section-Page16 ","",""," Print Version-Analytical Section-Page16 Analytical Section (contd...) “The government has given me education at such a low cost. I would like to pay back to the government by working in private practice in rural.” Female PG student, Public Medical Institute, Allahabad These views, however, were extremely rare and very few students were willing to commit to being interested in taking a rural posting. Location Preferences: Nursing Students Nursing students also preferred working in urban areas although they were, in general, more amenable than medical students to working in rural areas. The majority of nurses were keen to work in an urban area for many of the same reasons as medical students: better working and living conditions. “In urban areas safety is more as compared to rural areas…there is a problem of electricity and water in the rural area. So we cannot give our 100percent to the patients” Female Nursing Student, Private Nursing Institute, Lucknow “There are no facilities over there [rural]- no proper living facility, no electricity. We cannot do night duty over there- it is unsafe and there is no proper living place…also there are no conveyance facilities- we cannot move to the city easily” Female Nursing Student, Public Nursing Institute, Lucknow However, many nursing students seemed more open to the idea of working in rural areas, especially if they could return to their home villages. Therefore, in contrast with medical students, a rural background apparently made nursing students more favorable towards a rural job. “Most of the respondents over here are from rural background so if we are offered a job in the same area we can work there as well. We can understand the local people’s problems better. In order to know the sufferings of the villagers better, I suggest that our training should be done in rural as well” Female Nursing Student, Public Nursing Institute, Lucknow “If I were offered a job in rural, I will take it because it will give me a better chance to serve the society. In th "); array_files[173]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page17.html","2008-10-29","6K","Print Version-Analytical Section-Page17 ","",""," Print Version-Analytical Section-Page17 Analytical Section (contd...) “If salary is there and facilities are there we will all go to rural” Female Nursing Student, Private Nursing Institute, Allahabad “If the facilities for education are increased in rural we will stay there for lifetime and not ask for urban transfer ever.” Female Nursing Student, Public Nursing Institute, Lucknow For many medical students, working in rural areas is not a very attractive option. Significantly, this was the case even for medical students with rural backgrounds. On the other hand, nursing students are much more receptive to the idea of working in a rural area. While nursing students also desire to work in an urban area, they appear not to be averse to serving in a rural area, perhaps a reflection of the stronger ties they have to their rural roots. Combined location (urban/rural) and sector (public/private) preferences The perceptions and results presented in the previous sections are based on students’ opinions when considering location, or the type of establishment (public/private), separately. Students were also asked to choose between combinations of location and sector: urban-private, urban-public, rural-private, rural-public. The results (Appendix, Table 3) lead to a few conclusions. For medical students, the choice between the public and private sector was a little ambiguous; while students seemed much more attracted to the private sector, they acknowledged that the public sector offered several advantages. Indeed when directly asked to choose between a government job in an urban area and a private job in an urban area, students actually preferred the former (Appendix, Table 3). This result was somewhat surprising given that the private sector clearly seemed the preferred choice during discussions and interviews. There are a couple of reasons that could explain this anomaly: firstly it is possible that while the private sector is more attractive in the long-term, a government job is preferable as a first job, and is used "); array_files[174]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page18.html","2008-10-29","7K","Print Version-Analytical Section-Page18 ","",""," Print Version-Analytical Section-Page18 Analytical Section (contd...) Incentives for rural service: Medical Students In order to gain a sense of what would motivate them to work in rural areas, both medical and nursing students were presented with various incentives – addressed separately each time – for doing temporary service in the public sector in rural areas. These included a 50percent reservation in postgraduate courses, legalized private practice, increased training opportunities, good housing, faster promotions, a guaranteed urban transfer and a rural posting near the student’s hometown. Each of these incentives was presented by itself, in the absence of any other inducements. Students were then asked to rate the attractiveness of each incentive by saying that it was “Very Important”, “Important”, “Somewhat Important” and “Not important”. The incentives that were offered were all non-financial incentives. Students were also asked about the salaries they would like to receive if they were to work in a rural area. However, the results covered a wide range of amounts, and it was not clear whether students had a sense of what they would like to earn, or even what they would currently earn, in the public sector. The salary expectations of medical and nursing students require further study and are, therefore, not discussed in this paper. The most appealing non-financial incentive for both undergraduate and postgraduate medical students was a 50percent reservation in PG courses for students who had completed a stint in a rural area following their MBBS degree (see Appendix, Table 4). Over 80 per cent of undergraduates interviewed were very attracted to rural service for 2-3 years with 50percent PG reservation (saying that it was “very important”. This is perhaps not surprising, given the extreme competitiveness of admissions to postgraduate programs of study. “Two years compulsory [rural] posting for quota [50percent reservation] is very attractive” Male PG student, Public Medical Institute, Allahabad “Those "); array_files[175]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page19.html","2008-10-29","6K","Print Version-Analytical Section-Page19 ","",""," Print Version-Analytical Section-Page19 Analytical Section (contd...) “Only promotion cannot do anything. The main thing is money. Unless money will not be pouring in what difference will it make? Even after promotion if you become a CMO [Chief Medical Officer], you will still earn Rs. 30000-40000 as compared to a private doctor who ears Rs. 70000-80000” Male UG student, Private Medical Institute, Lucknow “Only promotion will not benefit much. Instead of promotions, qualifications should increase” Male UG student, Public Medical Institute, Allahabad Medical students were much more inclined to favor government policy that attempted to post students near their hometown. They were, in general, willing to tolerate only a certain distance from their hometown even if posted in the same district. As one student explained: “If posted in the hometown [sic] many of us can go but the CHC needs to be only 30 min to 1 hour distance from our house. If the time between home and CHC is more than that then what is the use of choosing hometown?” Male PG, Public Medical College, Gorakhpur Incentives for rural service: Nursing Students The most important incentives for nursing students were similar to those of medical students. As nurses are also keen to pursue further education, reservation in BSc courses for nurses who work in rural areas was considered an appealing prospect. “This is a good option if it helps you to get into BSc. Nursing. If we do it in private by our own means we might not be able to qualify it” Female Nursing student, Private Nursing Institute, Gorakhpur However, for nurses, the most attractive option was in fact a posting in a rural area near their hometown or village. “If we can get a job in our home village it is the best thing that can happen otherwise we can adjust to other options as well.” Female Nursing Student, Public Nursing Institute, Lucknow Once again the least appealing incentive was the promise of solely good housing in rural areas. “Only for the house we will not go. Maybe our house in the ur "); array_files[176]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page2.html","2008-10-29","4K","Print Version-Analytical Section-Page2 ","",""," Print Version-Analytical Section-Page2 Analytical Section (contd...) Medical Students’ Preferences for the Private Sector Over 80 percent of undergraduates and about 60 percent of postgraduates cited high salaries as the major draw of the private sector. Low salaries were the single most important factor that discouraged students from opting for the public sector both for undergraduates (62percent) and for postgraduates (67percent). Job security was not significance enough in attracting students to join the public sector. For students planning to open up their own private practice, the social recognition provided by the public sector is especially important – it offers the opportunity to gain experience and build a network of clients, both of which are crucial for a successful private practice. Contrary to popular perception, this study showed that even medical students who grew up in rural areas were not especially keen on a job in a rural area, as they aspired to a better life for themselves and their children. Nursing Students’ Preference for the Public Sector In contrast to medical students, for nurses, the public sector was generally an attractive job option. A job in a private nursing home was the least preferred career option and was to be considered only when they had no job alternatives in the public sector or in a private hospital. Location Preferences Medical Students All categories of students favored working in urban areas. When all undergraduates participating in this study were questioned on their work location choices, the majority (70percent) expressed a preference for an urban job over a rural area (9percent), with the remainder stating no preference. This preference was even more prominent among postgraduate students - less than 5percent of PG students had plans of serving in a rural area at any point during their lives. Most medical students equated working in a rural area with working in the public sector and, therefore, cited many of the disadvantages of the public sector as also being th "); array_files[177]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page3.html","2008-10-29","5K","Print Version-Analytical Section-Page3 ","",""," Print Version-Analytical Section-Page3 Analytical Section (contd...) Nursing Students The majority of nurses were keen to work in an urban area for many of the same reasons as medical students: better working and living conditions. However, in contrast with medical students, many nursing students seemed more open to the idea of working in rural areas, especially if they could return to their home villages. Combined Location (urban/rural) and Sector (public/private) Preferences Medical students preferred a government job in an urban area to a private job. This was somewhat surprising given that the private sector clearly seemed the preferred choice during discussions and interviews. For medical students, location is the dominant factor in selecting an ideal first job. On the other hand, for nurses the determining factor was not the location but the type of enterprise - the public sector being the most appealing choice. Like medical students, nurses also preferred an urban public job to an urban private job, though by a much larger margin than did medical students. Similarly in a rural area, a government job is again the preferred choice. Moreover, for nurses, rural private is also the least preferred option. The difference is that nursing students actually preferred a rural public job to an urban private job, whereas for medical students it was the other way around. Incentives for Rural Service Medical Students The most appealing non-financial incentive for both undergraduate and postgraduate medical students was a 50 percent reservation in PG courses for students who had completed a stint in a rural area following their MBBS degree. Over 80 percent of undergraduates interviewed were very attracted to rural service for 2-3 years with 50 percent PG reservation. Further trainings or continuing education was also an attractive incentive for medical students. Nursing Students Reservations in PG courses (for medical students) and BSc. courses (for nursing students) emerged as one of the most successful methods of en "); array_files[178]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page4.html","2008-10-29","6K","Print Version-Analytical Section-Page4 ","",""," Print Version-Analytical Section-Page4 Analytical Section (contd...) The Importance of Specialization among Medical Students On graduation from their MBBS degree, ninety percent of the undergraduates who participated in this study intended to pursue a postgraduate course of study and use their internship year (i.e. the final year of their MBBS) to prepare for the postgraduate entrance examination. Of the remaining 10 percent, a minority were keen on taking up a job on completion of the MBBS, while a majority intended to diversify their career to non-medical fields like Hospital Administration, Business Management (MBA), Mass Communication or Civil Services. Therefore, upon graduation from their course of study, almost all undergraduate medical students wanted further specialization. This was true of both male and female students although the types of specialties that they were keen on pursuing varied somewhat by gender (See box). Students considered a postgraduate degree necessary for a successful and rewarding career in medicine. “If we do not do our PG we will have to live in small places (town/villages) while if we do our PG then we will have better opportunities” Male UG student, Private Medical Institute, Lucknow “I think MBBS doctor has no status in society…the patients do not go to MBBS doctors. They will go to a MD cardiology if they are having a heart problem, they will prefer to go to a specialist for every disease. Even if the MBBS is sitting in that area and has much more experience than a freshly qualified MD, still nobody will go to him” Female PG Student, Public Medical Institute, Lucknow Students also felt that an undergraduate degree (MBBS) did not adequately qualify them to practice medicine. The MBBS degree includes a one-year period of internship during which students are expected to gain much of their practical clinical experience. However, as many students spend this year studying for the postgraduate entrance examination, they feel unprepared to practice medicine with only an MBBS "); array_files[179]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page5.html","2008-10-29","6K","Print Version-Analytical Section-Page5 ","",""," Print Version-Analytical Section-Page5 Analytical Section (contd...) “80-90percent of us will qualify for PG within next 2-3 years. Those who could not qualify go in for a house job and get Rs. 20,000-25,000 or can even take Diploma of the National Board (DNB) route.” Male UG student, Public Medical Institute, Lucknow “90percent of girls from KGMC get into PG, in fact within 2-3 years more than 50-60percent can get into it. The remaining go for Diplomas” Female UG student, Public Medical Institute, Lucknow The desire for specialization among undergraduates was strong enough for some to forsake careers abroad. “Only 4-5 out of total batch of 180 students among us have plans of going abroad - only gold medalists go there. Going there depends on how strong they are clinically and with family background.” Male UG Student, Public Medical Institute, Lucknow “Post Graduation is a must. I had an opportunity to settle in Germany after my MBBS from KGMC. But I left this opportunity just to do my PG. Everything else comes later, doing PG is a must.” Male PG Student, Public Medical Institute, Gorakhpur With this emphasis on pursuing a postgraduate degree, few final-year MBBS students have given serious thought to entering into the job market. On the other hand, postgraduate students are much keener to get a job once they obtain their degree, although there are also a few who would like to pursue super-specialty courses. “In cardiology field we do not have super specialization here in this institution so I will opt for a super specialization course in some other institute and after completing it I will seek job in the private sector” Male PG student, Public Medical Institute, Lucknow “After this, I would take experience for 1-2 years in private sector and then start private practice” Female PG student, Public Medical Institute, Allahabad Thus, medical students, especially undergraduates, placed great emphasis on specialization for several reasons including better career opportunities, the perception that MBBS doctors have "); array_files[180]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page6.html","2008-10-29","5K","Print Version-Analytical Section-Page6 ","",""," Print Version-Analytical Section-Page6 Analytical Section (contd...) What types of specialties do Medical Students prefer? The overwhelming desire to pursue a postgraduate degree raises the issue of the types of specialties that students tend to prefer. Despite the fact that students are keen on specialization, there are widespread vacancies in posts for specialist doctors in the public sector. Community Health Centres (CHCs) are now required to have five different types of specialist doctors, but many of these posts remain unfilled. Moreover, there are also acute shortages of medical faculty in UP, especially in certain fields such as anatomy, anesthesiology and obstetrics& gynecology. A possible explanation for this distribution of shortages across different medical fields could be that few medical students take up these specialties and, therefore, there is a shortfall in the number of specialists produced in these areas. Students were asked to rank eleven postgraduate specialties available to them according to their personal preferences (see Appendix, Table 1). Clinical specialties were generally more popular as evidenced by this quote from a male medical student in Lucknow: “PG has to be clinical. We do not want to go non-clinical.” Pediatrics and Surgery were two specialties that were rated highly by both undergraduate students as well as postgraduate students. Gender differences were clearly apparent as only women ranked obstetrics and gynecology high, while men leaned towards orthopedics. Interestingly, postgraduate students seemed to be strongly attracted to Radio-diagnosis as a specialty while this was lower down on the list for undergraduates. These results suggest that vacancies in certain fields, such as obstetrics and gynecology, are not a result of lack of popularity for these subjects amongst medical students. In this case, however, obstetrics and gynecology is favored mostly by women who are less likely to join public service under current conditions, as the first posting would be in a rural ar "); array_files[181]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page7.html","2008-10-29","5K","Print Version-Analytical Section-Page7 ","",""," Print Version-Analytical Section-Page7 Analytical Section (contd...) “Since the number of institutes is very less in UP many students will require moving out of the state. For the females getting permission from the family for migrating is difficult. So not many go for BSc. Nursing” Male Nursing Student, Public Nursing Institute, Allahabad “We all are interested in doing BSc. Nursing but the number of institutes offering such course is very less and the fees is [sic] very high.” Female Nursing Student, Public Nursing Institute, Allahabad “Out of 54 students only 2-3 will be able to qualify for BSc Nursing.” Female Nursing Student, Public Nursing Institute, Allahabad The low likelihood of gaining a seat in a BSc. Nursing course meant that nursing students were prepared to seek a job once they had graduated from their course of study. “In case we get a right opportunity, we will immediately go in for a job.” Female Nursing Student, Private Nursing Institute, Allahabad Moreover, unlike medical students, seeking a job abroad was much more popular among nurses as they believed that there were good opportunities for them in countries such as America, Australia and Canada. “I have thought for a job in a foreign country for 5-6 years. There is a system of working in a foreign country. Besides you get a good salary. There is good scope in Canada America etc. There is more punctuality and you get respect too. Growth opportunities are there” Female Nursing Student, Private Nursing Institute, Gorakhpur Overall, the primary focus of undergraduate medical students is gaining admission to a postgraduate course and therefore they are less concerned about the options available to them in the job-market. In contrast, both postgraduate students and nursing students are prepared to enter the job-market upon completion of their course of study. Furthermore, while medical students are not keen on seeking a job or further education abroad, nurses are much more attracted to the overseas market. Job Preferences of Students: Ideal Attr "); array_files[182]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page8.html","2008-10-29","6K","Print Version-Analytical Section-Page8 ","",""," Print Version-Analytical Section-Page8 Analytical Section (contd...) For medical students, both undergraduates and postgraduates, as well as nursing students, salary was the most important component of a first job. “First of all money is important” Male UG student, Public medical institute, Lucknow “Financial security is the basic thing. And there is no limit to its need. A person can manage to live even on Rs. 15000 a month or more than that- but at least a person should get an amount justifying his qualification.” Male UG student, Public Medical Institute, Lucknow “The first thing is salary. Until and unless salary is good, we cannot work” Female Nursing Student, Private Nursing Institute, Allahabad Medical students often compared their future earnings with those who had commensurate education in other fields. “All my brothers and sisters are from engineering backgrounds. So they all are earning a lot-by just spending 4-4.5 years in an average engineering college they are all earning very good. In comparison we are studying for 10-12 years, and then we get only 20,000-22,000 rupees, initially when we get appointed in a government position we only get 20-25,000 rupees. The amount is so stagnant in this medical line; probably it is not so stagnant in any other non medical areas” Male UG student, Public Medical Institute Lucknow Along with a good salary, many students also highlighted the importance of being able to utilize the skills they have learned. “I want to practice general surgery once I complete my under-graduation and post- graduation and any sector, whether government or private, provides me the opportunity to practice general surgery I will take up that” Female UG student, Public Medical Institute, Lucknow “The work should be good, facilities should be good and salary should be good. All the things necessary for working should be there (at the workplace). If there is a lack of facilities that are required for working, how are we going to work over there? It will gradually waste our talent and will b "); array_files[183]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section_page9.html","2008-10-29","5K","Print Version-Analytical Section-Page9 ","",""," Print Version-Analytical Section-Page9 Analytical Section (contd...) Good living conditions, which includes things like accommodation and education for children, was also cited as an important factor when selecting a job. “I am from a village but I would like to bring up my children where there are maximum facilities. I want to give our children the best education” Male UG student, Public Medical Institute, Allahabad “Accommodation should be good....accommodation should be within the posting campus” Female UG student, Public Medical Institute Allahabad Related to good living conditions was the concept of personal security, mentioned as an important characteristic of a job by all types of students. “Our protection is important. We cannot save each and every patient. Often the relatives of the patients in very critical emergency situations get very aggressive with us. They speak very badly to us, often use foul language” Male UG student, Public Medical Institute, Allahabad “Security is very important. The ‘pradhans’ and local leaders don’t let the doctor work or take his own decisions. Personal security is an issue that is important and needs attention not only in rural but also in urban areas” Male PG student, Public Medical Institute Gorakhpur A significant difference in the career perspectives of medical and nursing students relates to the importance attached to job security. During in-depth interviews, only 25 percent of medical students brought up job security as an important attribute of an ideal job. On the other hand, nursing students rated job security as the second most important characteristic of a good job, following salary. Therefore, for an average nursing student, job security was considered a crucial component of a good job and was associated with a stable life. “The reason why we go to the government sector is because it secures our lives. Whether we work or not but our jobs are secured.” Female Nursing Student, Private Nursing Institute, Lucknow For most students, therefore, a respectable salar "); array_files[184]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Analytical_section.html","2008-10-29","5K","Print Version-Analytical Section ","",""," Print Version-Analytical Section Analytical Section Summary The Importance of Specialization among Medical Students Medical undergraduates Upon graduation, almost all undergraduate medical students (male and female) wanted further specialization for a successful and rewarding career due to the following reasons: (1) better career opportunities (2) the perception that MBBS doctors have less status in society and (3) the belief that an MBBS degree does not sufficiently qualify them to practice medicine. They were prepared to spend 2-3 years preparing for the entrance examination to a postgraduate course (a very competitive process due to limited seats), and only if still unsuccessful, would they consider entering the job market. This desire was strong enough for some to forsake careers abroad. The types of specializations that they were keen on pursuing varied somewhat by gender. With the emphasis on pursuing a postgraduate degree, few final-year MBBS students gave serious thought to entering the job market. Medical postgraduates Postgraduate students are much keener to get a job once they obtain their degree, although there are also a few who would like to pursue super-specialty courses. Nursing Students’ plans upon graduation About 65 percent of the nursing students expressed an inclination towards a postgraduate course. However, since they felt that the chance of getting a seat in a BSc course was extremely low, nursing students were much more amenable to entering the job market on completion of the GNM diploma than were medical students graduating with an MBBS. Unlike medical students, seeking a job abroad was much more popular among nurses as they believed that there were good opportunities for them in countries such as America, Australia and Canada. Job Preferences of Students: Ideal Attributes For most medical students, a respectable salary, the opportunity to utilize their skills, good living conditions and a safe working environment figured prominently as essential criteria for a first job.Nurses also p "); array_files[185]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Appendices_page2.html","2008-10-29","15K","Print Version-Appendices-Page2 ","",""," Print Version-Appendices-Page2 Appendices (Contd...) Table 4: Mean Scores for incentives for rural service Category All Medical Students UG Medical Students (Male) UG Medical Students (Female) PG Medical Students Nursing Students (Private) Private Practice 2.44 2.83 2.00 2.71 NA Housing 1.98 1.83 2.32 1.67 2.28 Fast Promotion 2.35 2.08 2.47 2.40 2.56 Training 2.80 3.17 2.84 2.47 3.06 PG Reservation 3.02 3.50 2.79 2.93 3.11 Transfer 2.50 2.00 2.47 2.88 2.92 Home Posting 3.04 2.60 2.92 3.44 3.42 Note: Students were presented with each incentive on its own and asked to rate its attractiveness to them saying whether it was “Very Important”, “Important” “Somewhat Important” or “Not Important”. Each choice was then given a score ranging from 1 to 4, 1 being “Not Important” and 4 being “Very Important”. The mean scores for each incentive were calculated and are presented in the table above. A higher score indicates that that incentive was found more attractive. Table 5: Ideal job attributes listed by undergraduate medical students during in-depth interviews Extrinsic Factors Intrinsic Factors 1. Salary 1. Prestige 2. Better utilization of acquired skills 2. Social Respect and recognition 3. Better health infrastructure 3. Serving the community 4. Availability and Functioning of equipment 4. Better growth and learning opportunities 5. Availability of adequate trained staff 6. Amiable work environment 7. Good living conditions such as: a) Accommodation b) Water c) Electricity d) Roads e) Education for children f) Personal Safety 8. Job Security 9. Fixed work hours 10. Workload 11. Permission for private practice 12. Location Copyright - PHFI, World Bank "); array_files[186]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Appendices_page3.html","2008-10-29","48K","Print Version-Appendices-Page3 ","",""," Print Version-Appendices-Page3 Appendices (Contd...) Table 6: Advantages of working in the Public Sector, in a Private Corporate Hospital or in a Private Clinic that were mentioned by medical and nursing students during focus-group discussions and in-depth interviews Public sector Private corporate hospital Private clinic UG PG Nurses UG PG Nurses UG PG Nurses Job Security Annual Leave Pension Limited work-load Exposure to variety of patients Knowledge sharing Participate in National Programmes Respect from society Freedom to work independently Provides contacts/clients Opportunity to do research Good salary Promotion Opportunity to serve the needy Latest methods/procedures Good housing facilities Better work environment Opportunity to utilize skills Urban location Performance-based promotion Hospital managements system Growth opportunities Advanced learning opportunities Time-bound promotions Skill upgradation Better quality of life Flexibility in work hours Safety Better facilities at work In-service education/training Consistent income Freedom to take decisions Performance-based pay Flexibility in work location Long-term sustainable settlement Self-accountability for work Easily available option Self-satisfaction Easy to switch jobs Copyright - PHFI, World Bank "); array_files[187]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Appendices_page4.html","2008-10-29","51K","Print Version-Appendices-Page4 ","",""," Print Version-Appendices-Page4 Appendices (Contd...) Table 7: Disadvantages of the working in the Public Sector, in a Private Corporate Hospital or in a Private Clinic that were mentioned by medical and nursing students during focus-group discussions and in-depth interviews Public sector Private corporate hospital Private clinic UG PG Nurses UG PG Nurses UG PG Nurses Low Salary Rural posting Poor living conditions Safety Adjustment problem Unable to utilize skills Red Tape/Corruption/Bribery No learning opportunities Frequent Trasnfers Lack of infrastructure Bad work environment No monitoring and evaluation system Long procedures/paperwork Lack of technology available Late Promotions Limited freedom to take decisions Non-availability of drugs Less self-satisfaction Promotions based on seniority Non-committed co-workers Job insecurity High workload Always on call Less exchange of knowledge Fewer patient types Pressure to deliver Limited outreach within community Limited annual leave Inflexible work timings Commercialization of medicine Less respect from patient Less respect from society High capital investment Long time for settlement Inconsistent income/ job insecurity Greater accountability Highly competitive No legal immunity Lack of guidance Fewer training opportunities No opportunity for research Multiple work roles Copyright - PHFI, World Bank "); array_files[188]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Appendices.html","2008-10-29","29K","Print Version-Appendices ","",""," Print Version-Appendices Appendices Table 1: Medical students’ preferences for postgraduate specialties Post Graduate Specialty Male (UG) Female (UG) Post Graduates Paediatrics 1 2 1 Obstetrics& Gynaecology 11 1 5 Pathology 10 9 9 Community Medicine (SPM) 9 10 11 Anaesthesiology 8 7 10 Radio-diagnosis 5 6 1 Medicine 3 4 3 Surgery 2 3 4 Orthopedics 3 11 7 Opthalmics 7 5 8 Dermatology & Venerology 6 8 6 Table 2: Preference for urban position or public sector job by location of medical/ nursing school and type of student Location Student Sector (percent) Location (percent) Public Private No pref Urban Rural No pref UG, Male 35 30 35 45 10 45 Lucknow UG, Female 39 39 22 83 4 13 PG 25 44 31 100 0 0 Nurses 59 0 41 68 0 32 UG, Male 27 53 20 53 20 27 Allahabad UG, Female 42 42 17 67 17 17 PG 17 50 33 85 0 15 Nurses 77 0 23 45 27 27 UG, Male 43 36 21 79 7 14 Gorakhpur UG, Female 40 27 33 100 0 0 PG 15 77 8 69 15 15 Nurses 65 8 27 88 8 4 Table 3: Students’ preferences for various combinations of location (urban/rural) and sector (public/private) Urban public Urban private Rural public Rural private UG male 2.11 1.61 1.50 0.78 UG female 2.61 2.11 0.94 0.67 PG 2.39 2.06 1.00 0.56 Nurses, pvt 2.72 1.11 1.78 0.39 Total 2.42 1.70 1.29 0.59 Note: Students were asked their preference based on binary choices with combinations of location (urban/rural) and sector (public/private); for example they were asked which they preferred between an urban public job and an urban private job. There were six such binary choices given with each combination appearing three times. Each time a certain combination was picked it was given a score of 1 and this was added up and then divided by the number of students in that category to obtain the mean score. The mean score gives an indication of the popularity of that choice relative to the other choices. Copyright - PHFI, World Bank "); array_files[189]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Conclusion_page2.html","2008-10-29","6K","Print Version-Conclusion-Page2 ","",""," Print Version-Conclusion-Page2 Conclusion (Contd...) The persistent dearth of nurses in the government health system can be explained through factors such as bottlenecks in the recruitment process, low number of overall sanctioned nursing posts with respect to needs, poor quality in the supply of nurses etc. Incentive Packages: Even though nursing students prefer an urban over a rural location for a job, they have a greater preference for the package of a public sector job over one in the private sector. As a result of this, nurses find the option of a rural posting in a government job more attractive than working in a private sector urban job. A government policy that reserves PG seats for in-service MBBS doctors posted in rural areas for a set period (enhanced with a supportive work environment and good living conditions) is likely to attract students even if other conditions are still unchanged. Should the government decide to pursue this policy, it would need to consider the ramifications of providing PG education to an increased number of in-service doctors serving in rural areas. It would also need to focus on PG colleges and upgrade their resources to increase numbers and intake. Consequently, there is a link between the need to bring more MBBS doctors to rural areas to provide basic care and a policy focus on specialized tertiary-level medical education. For Future Research: Significant differences existed between students in a medical college and those in a nursing school with respect to their expectations and aspirations. Medical students appeared to be far more urbanized in their tastes and lifestyles as compared to nursing students, irrespective of their background. Limited evidence from this study suggests that even the few medical students who are from a rural background tend to be far less inclined to return to a rural area to work, but instead are motivated to give their children a very different upbringing from their own. Nursing students from rural areas, however, indicated in this study that "); array_files[190]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Conclusion_page3.html","2008-10-29","6K","Print Version-Conclusion-Page3 ","",""," Print Version-Conclusion-Page3 Conclusion (Contd...) The acute imbalance in the geographic distribution of health workers has important implications for access to health care for the rural population. The government has invested in a vast rural health infrastructure in order to provide affordable and quality healthcare. However, recruiting personnel to staff these facilities is a major difficulty. For example, in UP, more than half the posts for various types of specialists are currently lying vacant (Government of India, 2006). There are several factors that could explain the shortage of doctors in the public system. For example, the State may not be producing sufficient medical personnel to fulfill its requirements. Or, even if there is an adequate supply of health workers, there may be bottlenecks in the recruitment process that make it difficult for qualified workers to enter the government system. Finally, it is possible that candidates that are eligible for these posts choose not to enter the system for various reasons. While it is likely that all these contribute to the large vacancy rates, it is this last issue that this study explores in further detail. In drawing on the evidence reported in this paper and observations from fieldwork for this study, the paper in conclusion forwards two arguments: first, with the majority of undergraduate medical students attracted to postgraduate study, under the current incentive environment, there is little likelihood in UP of increasing the supply of MBBS doctors for government jobs. In contrast, even under the current incentive environment, increasing the number of nurses in the public sector is very feasible, given their preference for government jobs. Secondly, in attracting students to take a job in the public sector health system, an incentive package approach with innovative linkages tuned to the career-related preferences of students is probably more effective than an exclusive focus on bettering any key job attribute to satisfactory levels. These arguments "); array_files[191]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Conclusion_page4.html","2008-10-29","7K","Print Version-Conclusion-Page4 ","",""," Print Version-Conclusion-Page4 Conclusion (Contd...) In contrast, evidence in this study shows that nursing students, whether in public or private nursing institutes, are overwhelmingly in favor of a public sector job over one in the private sector. The study also finds the average nursing student is more inclined to working in rural areas than the average medical student. Any reported shortage of nurses in the government health system, therefore, cannot be attributed to low motivation of nurses to work in the public sector since reality in fact points to quite the opposite. With a significant growth of nursing schools across the country, including in UP, graduating nursing students are not in short supply but instead on the rise. Consequently, any persistent vacancies to sanctioned nursing posts or continued shortfall in inducting adequate numbers of nurses into the government health system is not a result of short supply or low motivation of nurses to join. Explanations for such persistent dearth of nurses in the government health system must instead be explained through other factors, whether they be bottlenecks in the recruitment process, low number of overall sanctioned nursing posts with respect to needs, poor quality in the supply of nurses or other reasons entirely. Incentive Packages: The evidence in this study makes clear that when both medical and nursing students are asked to identify a set of ideal job attributes, the resulting list of attributes is not surprising but somewhat a “known list” expected of any job in any sector (see, for example, the ideal job attributes identified by undergraduate medical students in Appendix, Table 5). For instance, in the case of both medical and nursing students, there is a preference for working in an urban location over a rural area for reasons that include prospects for better education of children in a town or city. However, when jobs are considered as packages rather than addressed through the lens of a single attribute, the evidence in this study points to "); array_files[192]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Conclusion_page5.html","2008-10-29","8K","Print Version-Conclusion-Page5 ","",""," Print Version-Conclusion-Page5 Conclusion (Contd...) A better understanding of students’ preferences to attract doctors to rural service can also have policy implications of significance by drawing attention to innovative linkages, which may otherwise go unnoticed. For instance, should the government decide to pursue a policy of reservations of PG seats, it would then have to consider the ramifications of providing PG education to an increased number of in-service government doctors serving in rural areas. Policy would, therefore, need to, focus on PG colleges and possibly the resources required to increase their number or their intake. Consequently, there is a link between the need to bring more MBBS doctors to rural areas to provide basic care and a policy focus on specialized tertiary-level medical education. As the government considers the enormous shortage of medical and nursing personnel in rural areas, this study and its results make an important case to look beyond the policy measure of compulsory service in rural areas that the Union Government is inclined to promote as the remedial measure. The evidence from this paper suggests that the labor market and incentives as packages in step with the career preferences of medical and nursing students have significant influence on the choice they make for the job that they take on completion of their course of studies. For Future Research: Health care providers are driven by multiple factors in developing the preferences that contribute to making an employment choice, which include the following: extrinsic characteristics directly relating to the individual (rural/urban or socio-economic background); certain qualities intrinsic to the individual (such as age or gender); and finally the influence of current context (location, peer group, or societal) in which the individual is embedded. In engaging with three different locations in UP, and with both medical and nursing students, this study also contributes in a limited way to ascertaining the relative influenc "); array_files[193]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Conclusion.html","2008-10-29","5K","Print Version-Conclusion ","",""," Print Version-Conclusion Conclusion Summary In UP, more than half the posts for various types of specialists in the public health system are currently lying vacant (Government of India, 2006). Several factors could explain this shortage: (1) the state may not be producing sufficient medical personnel to fulfill its requirements (2) bottlenecks in the recruitment process make it difficult for qualified workers to enter the government system (3) eligible candidates choose not to enter the system for various reasons. The paper forwards two arguments: (1) Firstly, with the majority of undergraduate medical students currently attracted to postgraduate study, there is little likelihood of increasing the supply of MBBS doctors for government jobs. (In contrast, nurses prefer government jobs). (2) Secondly, in attracting students to take a job in the public sector, an incentive package approach with innovative linkages tuned to the career-related preferences of students would be more effective. These arguments are important in understanding and addressing the shortage of doctors and nurses in the government health system, especially in rural areas. Labor Market: Within 2 to 3 years of completing the MBBS, the vast majority of undergraduate students wished to pursue a postgraduate course of study. After completing of their PG course, students’ job expectations were higher with respect to: (1) salary expectation (2) prioritization of skills utilization. This translated into a demand for better facilities and a patient-load of complex cases. PG students were therefore far less likely to join jobs advertised in the government health sector. This causes a shortage of non-specialist doctors in the government sector. Currently, PG doctors did not find government service (incentives and environment) attractive. The shortage was likely to get more severe in the state as UP has very few medical colleges. In contrast, nursing students, whether in public or private nursing institutes, were overwhelmingly in favor of a public sect "); array_files[194]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Introduction_page2.html","2008-10-29","6K","Print Version-Introduction-Page2 ","",""," Print Version-Introduction-Page2 Introduction(Contd...) The concentration of health workers in urban areas is not a problem that is unique to India. Indeed, both industrialized and developing countries around the world face disparities in the distribution of health personnel (Dussault and Franceschini 2006). There are many reasons why health workers typically choose not to work in rural areas. Salary emerges as an important component of a job and strongly affects the willingness to work in rural areas (Chomitz 1997; Serneels, Lindelow et al. 2007). However factors other than salary also play an important role in the preference of urban positions. For example access to training, health care and education for children, promotion opportunities, the availability of electricity, water and housing are all reasons that urban jobs are usually favored(Dussault and Franceschini 2006; Lindelow and Serneels 2006; Serneels, Lindelow et al. 2007). In Pakistan, the absence of equipment and supplies was a major deterrent for accepting a rural post (Zaidi 1986). A study on rural health worker motivation in Vietnam highlighted the importance of appreciation and support from managers and colleagues as well as from the community (Dieleman, Cuong et al. 2003). Individual characteristics can also affect the decision to serve in rural areas. It is generally accepted that a person from a rural background is more likely to pursue a career in rural areas (Laven and Wilkinson 2003; Matsumoto, Okayama et al. 2005; Dussault and Franceschini 2006; Lehmann, Dieleman et al. 2008). Schooling in rural areas also appears to have a similar effect although rural medical training alone is unlikely to have a major impact on increasing the rural workforce (Eley and Baker 2006). In addition, women are less likely to accept a post in a rural area than are men, though the presence of family members in rural areas may mitigate this effect (Doescher, Ellsbury et al. 2000; Dussault and Franceschini 2006). Several financial and non-financial incentives hav "); array_files[195]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Introduction_page3.html","2008-10-29","5K","Print Version-Introduction-Page3 ","",""," Print Version-Introduction-Page3 Introduction(Contd...) The public sector infrastructure in rural UP, as in that of India, is a three-tiered system. A sub-center is the most peripheral unit and is staffed by an Auxiliary Nurse Midwife (ANM) and a male multi-purpose worker (MPW). The first point of contact between a patient and a doctor is the Primary Health Center (PHC), a basic clinic which is supposed to serve a population of 30,000, but may, in reality, serve a much larger population. A community health center (CHC) was planned as a referral unit for four PHCs and is meant to serve a population of approximately 1,00,000. CHCs are 30-bedded hospitals staffed by five different types of specialist doctors as well as two general physicians. Though not officially part of the rural health infrastructure, district hospitals, usually located at the district headquarters, also serve the rural population. A general doctor entering the public sector is posted as a medical officer to a rural PHC while a specialist doctor’s entry point into the system is the CHC. Similarly, an entry-level position for a nurse in the public health sector is as a staff nurse in a rural PHC. Vacancies in the public health sector are acute. Figures from 2001 suggest that 40percent of the medical officer posts in PHCs and 50percent of the specialist posts in CHCs are lying vacant (Government of India). The Union Government has proposed to tackle this shortage of rural health workers in India by introducing a compulsory additional year of education for undergraduate medical students that has to be spent working in a rural setting. The license to practice medicine or pursue further education would be contingent on completion of this rural service (Times of India, 2006). Given that compulsory rural service has a weak record of success historically, and also given that it is not currently very popular among medical students in India, the government would likely be more successful in pursuing a policy that encourages health workers to voluntarily "); array_files[196]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Introduction.html","2008-10-29","5K","Print Version-Introduction ","",""," Print Version-Introduction Introduction Summary The health sector, both in India and in Uttar Pradesh (UP), faces multiple challenges in the geographic distribution of human resources. Though the majority of the population lives in rural areas, doctors in both the public and private sectors are concentrated in urban areas. The WHO estimates that over 80 per cent of qualified private providers are concentrated in urban areas. This has resulted in the majority of rural households receiving care from private providers, many of whom are less than fully qualified, thus hampering access to quality health services. Financial incentives alone do not attract health workers to rural areas. Other than salary, factors such as access to training, health care, education for children, promotion, improved working and living conditions play an important part in their choice. Thus, incentive packages that address several aspects of employment choice are likely to be most successful in recruiting health workers to rural areas. Vacancies in the public health sector are acute. Figures from 2001 suggest that 40percent of the medical officer posts in PHCs and 50percent of the specialist posts in CHCs are lying vacant (Government of India). This study aims to understand the determinants of employment choice among graduating medical and nursing students in UP. It has three main objectives: (1) To examine job attributes that graduating medical and nursing students consider important when seeking their first job. (2) To explore medical and nursing students’ perspectives on jobs in the public and private sector, and on the urban and rural working environments. (3) To understand the influence of monetary and non-monetary incentives on medical and nursing students decision on whether to serve in a rural, public sector job upon graduation. Background The health sector, both in India as a whole and in the state of Uttar Pradesh (UP), faces multiple challenges in the geographic distribution of human resources for health. Though the majority o "); array_files[197]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_References.html","2008-10-29","8K","Print Version-References ","",""," Print Version-References References Anderson, M. and M. W. Rosenberg (1990). Ontarios underserviced area program revisited: an indirect analysis. Soc Sci Med 30(1): 35-44. Chomitz, K. M. (1997). What do doctors want? Developing Incentives for Doctors to Serve in Indonesias Rural and Remote Areas. Connell, J., P. Zurn, et al. (2007). Sub-Saharan Africa: beyond the health worker migration crisis? Soc Sci Med 64(9): 1876-1891. Dieleman, M., P. Cuong, et al. (2003). Identifying factors for job motivation of rural health workers in North Viet Nam. Hum Resour Health 1(1): 10-10. Doescher, M. P., K. E. Ellsbury, et al. (2000). The distribution of rural female generalist physicians in the United States. J Rural Health 16(2): 111-118. Dussault, G. and M. C. Franceschini (2006). Not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. Hum Resour Health 4: 12-12. Eley, D. and P. Baker (2006). Does recruitment lead to retention?- Rural Clinical School training experiences and subsequent intern choices. Rural and Remote Health 6(511). Government of India.Task Force on Medical Education for the National Rural Health Mision. Ministry of Health and Family Welfare Government of India (2006). Bulletin on Rural Health Statistics in India 2006 Ministry of Health and Family Welfare. Laven, G. and D. Wilkinson (2003). Rural doctors and rural backgrounds: how strong is the evidence? A systematic review. Aust J Rural Health 11(6): 277-284. Lehmann, U., M. Dieleman, et al. (2008). Staffing remote rural areas in middle- and low-income countries: a literature review of attraction and retention. BMC Health Serv Res 8: 19-19. Lindelow, M. and P. Serneels (2006). The performance of health workers in Ethiopia: results from qualitative research. Soc Sci Med 62(9): 2225-2235. Matsumoto, M., M. Okayama, et al. (2005). Factors associated with rural doctors intention to continue a rural career: A survey of 3072 doctors in Japan. Australian Journal of Rural Health 13(4): 219-225. Sempowsk "); array_files[198]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Sample_methods_page2.html","2008-10-29","13K","Print Version-Sample Method-Page2 ","",""," Print Version-Sample Method-Page2 Sample & Methods (Contd...) This study uses a qualitative approach to understand the career preferences of final-year undergraduate (UG) and postgraduate (PG) medical and undergraduate nursing students. Both focus-group discussions (FGD) and in-depth interviews were carried out with these students. Selection of medical and nursing schools The medical and nursing schools were purposively chosen to fulfill two criteria: they should represent a diversity of both academic reputation and geographic locations. Lucknow is the capital of UP and the public medical college there is one of India’s and UP’s elite medical colleges. Allahabad is a large provincial town and, while the medical college selected there is not a top-tier institution, it is highly regarded. Finally, Gorakhpur is a provincial town, located in the economically poorer, eastern part of UP, in proximity to the rural areas of the state. The medical college there has a lesser academic reputation compared to the other medical colleges in the study. Medical students gain admission to a particular institution based on their rank in a common entrance examination. The study, therefore, draws on perceptions of medical students from those medical colleges which are high (Lucknow), medium (Allahabad) and low (Gorakhpur) on the admission preferences of medical students. Most of the medical colleges selected were public institutions, although in Lucknow, a private medical college was also included in the study. Nursing schools were selected from the same city/town where the sampled medical schools were located. This ensured that nursing schools from a range of geographic locations were included in the study. Both private and public nursing institutions were visited: discussions were held with first-year students at public nursing schools and final-year students at private institutions. A summary of the characteristics of the schools selected is shown in Table 1 below: Table 1: List of Sampled Medical and Nursing Schools. Location "); array_files[199]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Sample_methods_page3.html","2008-10-29","21K","Print Version-Sample Method-Page3 ","",""," Print Version-Sample Method-Page3 Sample & Methods (Contd...) Selection of medical and nursing students Within each school, medical students were purposively selected based on the location of their hometown and their rank in a common entrance exam. This, once again, ensured that students participating in the study were from diverse backgrounds. Nursing students were selected on the basis of an institutional merit list. The total number, and the demographic characteristics, of the students who participated in the FGDs and interviews are shown in Table 2. This study was limited to medical undergraduates who were in their final year of study, and to postgraduate students. As these students are closest to the job-market they are most likely to have given serious thought to the future career options available to them. Final-year nursing students were also used in the study; however they were all from private colleges. In public nursing schools in Uttar Pradesh there are currently no final-year nursing students and hence first-year nursing students were asked to participate from these institutions. The undergraduate medical students were pursuing a five and a half year MBBS (Bachelor of Medicine, Bachelor of Surgery) degree while the postgraduate students had completed their MBBS and were studying for a postgraduate degree in a medical specialty. The nursing students were training for a basic nursing qualification called a GNM (General Nursing and Midwifery), a 3-year diploma program entered into after high school. Table 2: Background Characteristics of Sampled Medical and Nursing Students Sample Undergraduate Postgraduate Nurses Characteristics (UG) (PG) FGD Interview FGD Interview FGD Interview Public Private Private Mean age (years) 24 24 28 30 24 24 24 Female (percent) 51 51 33 39 96 92 89 Current Family Residence (percent) Village 13 22 8 11 35 35 17 Small town 30 16 17 44 27 19 22 City 57 62 75 44 35 46 61 Residence during school years (percent) Village 8 19 17 17 12 12 17 Small town 32 8 21 33 46 27 22 City 5 "); array_files[200]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Sample_methods_page4.html","2008-10-29","5K","Print Version-Sample Method-Page4 ","",""," Print Version-Sample Method-Page4 Sample & Methods (Contd...) Both FGDs and in-depth interviews were held in order to get a range of opinions and also to cross-check views given by students while amongst their peers with those professed when on their own. A semi-structured questionnaire was used for in-depth interviews and a similar set of discussion topics was used for the FGDs. Students were asked about their plans upon graduation and their perspectives on working in the public and private sector and in urban and rural areas. Both English and Hindi were used to communicate during the FGDs and in-depth interviews. While most medical students were comfortable with English, nursing students preferred to converse in Hindi. To encourage students to express their views freely during the FGDs, they were segregated by sex and by the type of degree that they were pursuing. Two exceptions were made to this; FGDs for postgraduate and nursing students were in mixed groups. In these cases segregation was not feasible because there were very few postgraduate students which made it necessary to include both male and female students in the same FGD. Similarly, since most nursing students were female, they were also not segregated by gender. In a further effort to promote frank discussion, the students remained anonymous and no faculty was present in the room during the FGDs or interviews. The focus group discussions were taped, translated into English when necessary, and then transcribed. The quotes presented in this study are only from the focus-group discussions. Where data is presented numerically, these are based upon responses from individuals during in-depth interviews. In general, few differences in opinions were observed between males and females, or between students in different schools (see Appendix, Table 2). Therefore, unless noted, the results are not separated out by gender, by location or by type of medical school or nursing school. Moreover, while there was some diversity in the opinions presented, the story "); array_files[201]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Sample_methods_page5.html","2008-10-29","4K","Print Version-Sample Method-Page5 ","",""," Print Version-Sample Method-Page5 Sample & Methods (Contd...) This may have also been an issue with nursing students in public schools. In UP there are currently no final-year students and therefore FGDs were held with first-year nursing students. However, as these students had just entered the program, like medical undergraduates, they were less likely to have fully explored the options that were available to them upon graduation. At certain times, discussions and interviews with nurses were limited because of poor understanding or reluctance to talk. While most medical students were quite outspoken, many nursing students had to be encouraged to speak and had to be guided more thoroughly through the questions. For example instead of listing attributes of jobs on their own, sometimes various job attributes were offered to them and then students were asked about their relative importance. However, the most important job attributes and choices were always quite consistent, lending confidence in the validity of the data. It should also be noted that despite an attempt to get a variety of students, there were few medical students from rural backgrounds in this study. This is likely due to the fact that, in UP in general, few medical students come from rural backgrounds. Therefore, rural students may actually be over-represented in the study. Nonetheless, the small number of rural students makes it difficult to make definitive conclusions about how a rural upbringing influences the career decisions of a medical student. A final point is that among the career choices offered, medical education was not presented as an option. A few students brought it up themselves, and seemed somewhat attracted by this career choice. However, the focus of this study was the immediate career plans of medical students. As such, medical education was not particularly relevant as it is only available to postgraduate students after they have completed a few years of work experience. Copyright - PHFI, World Bank "); array_files[202]=new Array(0,1,"./Print_Version_Paper_3/Print_Version_Sample_methods.html","2008-10-29","4K","Print Version-Sample Method ","",""," Print Version-Sample Method Sample & Methods Summary This study uses a qualitative approach to understand the career preferences of: (1) final-year undergraduate (UG) and postgraduate (PG) medical students from public and private medical colleges and (2) undergraduate nursing students from public colleges. As these students are closest to the job-market, they are most likely to have given serious thought to future career options available. Both focus-group discussions (FGD) and in-depth interviews were carried out to get a range of opinions and to cross-check views given by students while amongst their peers with those professed when on their own. A semi-structured questionnaire was used for in-depth interviews and a similar set of discussion topics was used for the FGDs. Medical colleges and nursing schools were selected from Lucknow, Allahabad and Gorakhpur to represent a diversity of both academic reputation and geographic locations. Within each school, medical students were selected based on the location of their hometown and their rank in a common entrance exam, thus ensuring that participants came from diverse backgrounds. Nursing students were selected on the basis of an institutional merit list. In general, few differences in opinions were observed between males and females, or between students from different schools (see Appendix, Table 2). Therefore, unless noted, the results are not separated out by gender, by location or by type of medical school or nursing school. Despite an attempt to get a variety of students, few medical students from rural backgrounds participated in the study. This makes it difficult to make definitive conclusions about how a rural upbringing influences the career decisions of a medical student. Copyright - PHFI, World Bank "); array_files[203]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health.html","2008-10-29","7K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health Part II 2. Institutions as implementation agents of essential HR functions in Health Summary Two institutional case studies examine the following: i)The Central Health Service (CHS) has a very significant managerial and technical role in relation to health policy formation and oversight of the vertical national health programmes implemented in states. ii)Why the Uttar Pradesh (UP) State Health System that has made weak progress in health outcomes. 2.1 Overview of Case Studies (a) Central Health Service The Central Health Service (CHS) was conceived of as a single organised cadre of doctors that would serve in the medical, public health, medical research and teaching posts in central government hospitals, dispensaries, scientific research institutions and institutions of higher medical education. The members of the CHS were also required to serve health-related posts in the Union Territories (under central administrative control) and some autonomous institutions. There are 127 participating units in the CHS. An important component of CHS is the Central Government Health Scheme (CGHS), which serves as an insurance scheme essentially for central government employees. The CGHS was started in 1954 and at present 24 cities are covered with a total of 9.12 lakh card holders and 33.01 lakh beneficiaries (as on 31.3.2006). 72.5percent card holders are serving employees, 25.4percent are pensioners and rest belong to categories such as freedom fighters, M.Ps, ex M.Ps, journalists and others.The NCMH Report (2005) notes that 6 per cent of the combined budget of health and family welfare departments (in 2003-4) or18percent of the budget of the Department of Health was spent on 44 lakh beneficiaries or 0.5percent of the country’s population under the Central Government Health Scheme (CGHS). The CHS is divided into four sub-cadres: (i) Teaching Specialists; (ii) Non-Teaching Specialists; (iii) Public Health Specialists; and (iv) G "); array_files[204]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page10.html","2008-10-29","5K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page10 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page10 Part II (contd...) Figure 2: Recruitment Process in the larger Doctor Vacancy problem-tree Uttar Pradesh: Doctor Recruitment Process The UP Government sends the UP Public Services Commission (UPPSC) a requisition order for posts that require to be filled by eligible candidates. The requisition from the UP Government is scrutinized by the UPPSC on two principal grounds. First, the Commission checks whether the terms and conditions of the posts that are being requisitioned are on the basis of the existing Service Rules of the particular cadre. If the scrutiny finds small aberrations, such as a difference in only the nomenclature used by the Government requisition and the Service Rules, these minor differences are cleared without causing much delay. However, if major discrepancies are found between Service Rules and the requisition, the latter is returned to the Government and cause of certain delay. A second significant ground on which requisitions come to be scrutinized by the Commission relate to whether the Government requisition is in compliance with the current reservation policy of not more than 50percent posts in favor of reserved categories (Scheduled Castes, Scheduled Tribes, Other Backward Classes). The Government is prone to overrepresentation of the numbers requisitioned for reserved groups, which is then deemed illegal by the Commission. After the requisition passes the scrutiny of the Commission, the latter places an advertisement with fixed time-frame as a deadline. The length of time till the deadline changes with the size of the requisition and all responses must be received within that time. The responses are then scrutinized by the Commission. The Government and the Commission decide jointly on which advertised jobs and responses to these will be looked at first as a matter of priority. The selection process through interviews takes place and recommendations are made from the Commission to th "); array_files[205]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page11.html","2008-10-29","16K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page11 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page11 Part II (contd...) The data collected from UP show that in the case of specialists, there is a significant decline in numbers between the stages of those who respond and those who are selected by the Public Services Commission. For instance, in Table 6, of the 100 anaesthetists who responded to the advertisement, 38 were initially selected and finally 31 recommended to the Government. The principal reasons for such few numbers chosen by the Commission over those who initially responded are as follows: 1) the scrutiny of the responses reveal that the candidates did not all meet the minimum eligibility requirements of educational qualification and other experience required by the Service Rules; 2) the candidates claim to have the required educational qualification, but the degree is not recognized by the MCI and consequently deemed invalid by the Public Services Commission. For instance, a postgraduate, say, from Gorakhpur Medical College in 2005 when none of the PG seats there were MCI-recognized, would be eliminated from joining government service at this stage (see table in Box 4). There is no one single procedural timeline set out for each of the stages in the entire recruitment process. On average, from the point of advertisement to a person joining the service, one-year-and-a-half is taken. Table 6: Requisition of Posts received in 2005 and Selection data by the UPPSC Sl. No Name of Post Requisition of Posts recd from Govt. Category of Posts to be filled Number of Responses recd by UPPSC Number Selected by UPPSC Number recommended by UPPSC to Govt. I II III IV V VI VII VIII IX X 1 Medical Officer (General - Male) 1239 619 336 360 24 5326 1220 1220 2 Medical Officer (Specialist - Male) 420 Anesthetist 95 47 27 20 1 100 38 31 Radiologist 125 63 34 26 2 36 10 10 Pathologist 105 52 29 22 2 49 13 13 Cardiologist 68 34 19 14 1 92 - - Chest Physician 27 13 8 6 - 79 21 19 3 Medical Officer (Specialist - Female) 3 "); array_files[206]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page12.html","2008-10-29","15K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page12 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page12 Part II (contd...) Table 7: Government Appointment letters sent on Requisition of Posts made in 2005-06 Sl. No Name of Post Requisition of Posts recd from Govt. Number Selected by UPPSC Number recommended by UPPSC to Govt. Shortfall in number recommended by UPPSC Number of Govt. appointment letters sent Number of Responses recd by UPPSC I II III IV V VI VII VIII 1 Medical Officer (General - Male) 1489 1467 1448 41 1411 2 Medical Officer (Specialist - Male) 592 Anesthetist 139 38 31 108 31 Radiologist 167 10 7 160 7 Pathologist 105 13 13 92 13 Cardiologist 68 - - 68 - Physician 54 - - 54 - Surgeon 42 - - 42 - Chest Physician 17 21 19 0 (+2) 19 3 Medical Officer (Specialist - Female) 369 Anesthetist 61 13 11 56 11 1* Radiologist 64 5 5 54 4 0* Pathologist 40 23 20 20 19 2* Obs & Gyn 204 145 92 112 90 26* Totals 2450 1735 1645 805 1608 * Denotes currently available data from the periphery on number of doctors who have joined. Source: U.P. Ministry of Health, corroborated with data from Directorate, Administrative Unit and Women Cell In Table 7 above, the number of Government appointment letters is marginally lower than the number recommended by the UPPSC in the case of General Medical Officers, as the Directorate finds incomplete records existing for some. However, in the case of Male Specialists (where the numbers are already significantly lower than requirement), the number of appointment letters sent match the numbers that the UPPSC recommended and no issues are raised at the Directorate or Secretariat. Data on numbers who finally join the government medical service are not available at all for Male General or Specialist sub-cadres, since the information needs to be collected from the periphery, whether the Chief Medical Officer in the district or the Chief Medical Superintendent in the district hospital for specialists in that hospital. For the Female Specialist sub-cadre, incomplete data available so far re "); array_files[207]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page13.html","2008-10-29","9K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page13 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page13 Part II (contd...) CHS: Doctor Recruitment Process The recruitment procedure for doctors in the CHS is identical to the procedure in UP. It principally concerns the Cadre Controlling Authority (CCA) in the central ministry of health that sends the requisition of doctors to be recruited to the Union Public Services Commission (UPSC). Between 2000 and 2004, there was no recruitment due to a central ban on all UPSC recruitment that was lifted exceptionally for central medical services, such as for Railways, Defence, MCD and the CHS. Table 8: Recruitment of General Duty Medical Officers (GDMO) – recent years CMSE Batch Requisition sent to UPSC for MOs Total Number of candidates received from UPSC* Candidature cancelled (before issue of offer letter) Number of offers issued Offers Cancelled Candidates Joined Candidates yet to join I II III IV V VI VII VIII 2004 200 168 32 136 80 53 3 2005 300 275 80 195 118 59 18 2006 300 238 9 119 0 25 94 2007 200 Dossier of Successful Candidates not received by Cadre Controlling Authority, MOHFW from UPSC. Allocation of cadres will be made thereafter. *All successful candidates received the approval of the Minister of Health & FW Source: Cadre Controlling Authority, MOHFW, New Delhi In Table 8 above, after successful candidates from UPSC are approved by the Minister for offer letters, there is a still a notable cancellation of candidatures prior to the offer letter being issued. There are three main reasons provided by the Cadre Controlling Authority for cancellations at this stage in the recruitment process: 1) the candidate is found personally medically unfit in the second medical examination that follows the UPSC interviews; 2) the candidate’s file is marked as an “Offer Not to be Issued” – as a ONI Case - because the candidate fails to provide original or verified documentary proof of educational qualifications; and 3) the candidate does not appear before the Medical Board f "); array_files[208]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page14.html","2008-10-29","8K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page14 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page14 Part II (contd...) Table 9: Recruitment of Specialist sub-cadres in CHS (since recruitment resumed in 2005) Specialist Sub-Cadre Number of requisitions sent to UPSC Number of successful candidates from UPSC Approval by Minister Offers Sent Candidates Joined 1. Teaching 255 125 123 111 77 2. Public Health 25 10 10 9 4 3. Non-Teaching 123 76 73 69 45 Source: Cadre Controlling Authority, MOHFW, New Delhi In Table 9 above, for the Teaching sub-cadre, 62.6percent of those who received offer letters joined, but this still translates into only 30.1percent of the requisitioned posts being filled. For the small Public Health sub-cadre, 40percent of successful candidates joined, but only 16percent of the requisitioned posts were filled through the recruitment rounds. Finally, for the Non-Teaching Specialist sub-cadre, 61.6percent of the candidates sent offer letters indicated they would join, which would fill 36.5percent of the requisitioned posts. Note on Contracting of Doctors: The lengthy recruitment process is considered by NRHM as a significant bottleneck to the immediate requirement of filling existing doctor vacancies. NRHM therefore promotes the option of contractual doctors who can be recruited instantly in a walk-in interview that is held weekly. There is no arrangement of contractual doctors in the CHS. In UP, the state government decided in favor of contractual doctors filling the present needs in the health system. Recruitment is undertaken at the district-level through a committee that includes the District Magistrate (DM) and the Chief Medical Officer (CMO). The Directorate is informed about any new recruitment. The scheme has however been mostly unsuccessful. The contractual doctors could be trained in either allopathic medicine or in AYUSH. Initially, it required the doctor on contract to work eight hours in the public health centre and he was paid a third less than an entry-level doctor in regular gov "); array_files[209]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page2.html","2008-10-29","7K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page2 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page2 Part II (contd...) 2.2 Methodology Summary In this study, an approach to institutional analysis and to policy process is juxtaposed with a diagnostic approach to health systems that is focused on HR-related functions. With regard to the coverage (density and distribution), motivation and the competence of any cadre of health personnel in the system, it is the performance of the concerned institutions that largely determine how far these cross-cutting HRH objectives are achieved. This research draws on conceptual tools used separately in political economy and health systems studies to analyze institutions as implementation agents of essential human resource (HR) functions in Health.13 In this study, an approach to institutional analysis and to policy process is juxtaposed with a diagnostic approach to health systems that is focused on HR-related functions. Policy Analysis approach: The recent literature on the political economy of health brings to light the significance of the concepts of ‘power’ and ‘process’ to health policy implementation (Walt, 1994). It highlights the important role that powerful domestic interest groups can play to the success, failure, or partial implementation of health policy or reform measures, even to the extent of legitimizing or destabilizing the political regime (Reich, 1994, 2002; Bossert et al, 1998; Glassman et al, 1999). The emphasis is on individual or collective actors and their power to influence, on the institutional role in undertaking the implementation process, and finally, on the broader context in which the actors and institutions are embedded. Context is affected by many factors such as by the nature of political regime, by the legitimating ‘authority-claims’ of the particular ruling government and by historical experience and culture; none of these factors are directly health-related but of potential significance to policy agenda-setting14 and implementation that di "); array_files[210]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page3.html","2008-10-29","9K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page3 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page3 Part II (contd...) Health systems diagnostic framework: The narrative approach, however, lends itself better to analysis of more focused subject areas than to human resources across health systems in India, the aim of the broader situational analysis here. Bringing a systematic approach to bear upon analysing each of a country’s disparate health systems poses a greater challenge to a purely narrative approach than if the focus of study is a single specific case study, such as a particular government drug policy or reform measure. A separate literature develops a parsimonious framework providing a conceptual template, which both informs the range of information that may be collected and also organizes a ‘thick’ description of a particular case in a systematic manner allowing for comparative analysis with other cases that adopt the same framework for heuristic purposes. One such recent diagnostic framework in Roberts et al (2004) provides a powerful tool to assess overall health-system performance – a component of which is organization. Recent work by the WHO (2006) and the Joint Learning Initiative (JLI, 2004) have developed separate conceptual frameworks for specifically addressing human resource actions in the health system and how they relate to health system goals and to health outcomes. These frameworks, however, have a broader scope than an institutional focus, which is the aim of this paper. On the other hand, analytical toolkits published by DfID (2003) and the World Bank (2007) provide general useful guidelines for institutional analysis that can be applied to the health system. This paper draws from these different sources to adapt a framework suggested by Martinez and Martineau (1998), which defines five essential functions related to human resources for health (HRH). These are functions that are considered necessary for a health system to operate effectively and efficiently with regards to HRH issue "); array_files[211]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page4.html","2008-10-29","5K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page4 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page4 Part II (contd...) These core human resources related functions are utilised here in a framework that allows us to map a single or a cluster of organizations tasked with the implementation of each of these functions. This provides a static mapping of the institutional context. With regard to the coverage (density and distribution), motivation and the competence of any cadre of health personnel in the system, it is the characteristics and performance of the concerned institutions that then largely determine how far these cross-cutting HRH objectives are achieved. The link between this framework of key HRH functions and the institutional context to health system goals (efficiency, equitable access) and to health outcomes is diagrammatically presented in the Appendix. In the next section of this paper, this framework is used to map organizations that carry out the key HR-related functions, separately, for Central Health Service (CHS) doctors, UP government medical doctors and UP nurses in the government system. While a mapping of organizations to functions is a useful overview of the institutional context, it is principally a snapshot of the organizations involved and does not inform on how they interact with each other to carry out a function. In the final section of Part II, we take the ‘recruitment process’ of doctors into the CHS and into the UP government medical service as an illustrative example of how the implementation process of an important HRH function occurs in two different contexts involving different sets of organizations.16 2.3 Organizational Mapping Summary This section maps HRH functions that are principally shared in the health system across the country between the policymaking administrator-bureaucrats (located in the Central Ministry or state health Secretariats) and administrator-doctors who are also the technical support for the policymakers (located in the central DGHS or State Directorat "); array_files[212]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page5.html","2008-10-29","6K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page5 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page5 Part II (contd...) Analysis of Tables (3, 4 & 5) 1. For CHS doctors, the Cadre Controlling Authority (CCA) in the Ministry is the organization tasked with most of the functions. In the case of doctors in the UP government medical service, there are multiple sections of the Directorate (Health) and the Directorate (Medical Education) as well as the Secretariat involved, sometimes for the same function. This reduces accountability of any single organisation involved in the implementation of the task. In the case of nursing in UP, most functions are undertaken at the Directorate and the Secretariat is much less involved than it is with the medical doctor cadre. There is also less organizational development for undertaking key HR functions relating to the nursing cadre. 2. The Cadre Controlling Authority is charged with the administrative function relating to both teaching and non-teaching doctors in the Service. This is not so in UP, where organizations responsible for HRH functions concerned with medical health service are entirely distinct from those concerned with medical education. The administrative functions relating to doctors in the Provincial Medical Service (PMS) come under the purview of the Secretariat (H & FW) and the Directorate (Health). The administrative functions relating to teaching-doctors in medical colleges is managed entirely separately and come under the purview of Secretariat (Medical Education) and Directorate (Medical Education). The organization map in Table 3 considers only complex allocation of responsibilities in the Provincial Medical Health Service, and not medical education as well, to avoid confusion. 3. Institutional provision to oversee and conduct continued education and further training is either weak (CHS doctors, UP doctors) or non-existent (UP nurses). For CHS doctors, the medical-wing in the Directorate recommends doctors for further training. However, it neither has the "); array_files[213]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page6.html","2008-10-29","8K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page6 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page6 Part II (contd...) 6. For both doctors and nurses in the government system, there is no organization clearly charged with maintaining or evaluating the job descriptions relating to the different posts existing. In the case of the CGHS within the CHS, a compendium on what each rank in the Service should do exists, but not monitored or updated. 7. There is much more central level involvement in the HR-functions concerning state-level doctors relative to such central involvement in the cases of the nursing cadre, at least as evident from UP. Table 2: Organization Mapping of the CHS Core function Function components Mapped Organization Policy Allocation of funds Principal Secretary, Financial Advisor, Cadre Controlling Authority - CCA (Ministry) Employment regulations Principal organization: CCA, (Ministry). For change in CHS Rules, permission needed from Dept of Personnel & Training (DOPT), Ministry of Finance Setting staff norms DOPT, CCA (Ministry) and changes with permission of UPSC HRH Production Staff Supply Recruitment of CHS Doctors CCA (Ministry) and UPSC Allocation of CHS Doctors CCA (Ministry) Education & Training Continued Education & Further Training for CHS Doctors DGHS (Medical Education wing) Organisation/ Management Personnel administration Promotions For 2 senior-most grades, UPSC; MOHFW informs UPSC of vacancies For all other promotions, DPCs formed in MOHFW guidelines by DOPT Transfers Principal organization: CCA, (Ministry). Committee constituted under DGHS for transfers up to CMO grade Staff grievances Vigilance Officer for CHS (DGHS) CCA, (Ministry) Disciplinary action Approval from Minister Maintaining informational records on staff CHS-5 wing in CCA, Ministry Performance Management Job descriptions CCA. (Ministry) Health worker supervision Not well defined; a ‘compendium’ only for CGHS states what each rank should do Performance-based incentives for staff Only through the mechanism of ACR, "); array_files[214]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page7.html","2008-10-29","14K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page7 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page7 Part II (contd...) Table 3: Organization Mapping of the Medical Doctor Cadre in UP Government Health System Core function Function components Central Level State Level Policy Allocation of funds Secretariat (H&FW), State Finance Ministry Employment regulations Governed by Service Rules. To amend Rules, Secretary (H&FW), State Finance Ministry and PMS doctors Association involved New Medical Colleges Health Ministry, DGHS (only for Centre-managed institutions), MCI (for inspection) Cabinet with approval from Chief Minister Setting staff norms MCI (in Medical Education), Ministry/DGHS (for enforcing IPHS) Secretariat (H&FW), State Finance Ministry (to determine sanctioned posts) HRH Production Staff Supply Recruitment of PMS Doctors Secretariat, For Health Service: Directorate (Administration and Women cells), For Teaching: Administration cell, UPPSC Allocation of PMS Doctors Secretariat Education & Training Admission to Medical Colleges Medical Education wing, DGHS for All-India quotas of seats Directorate (Medical Education) – for State quotas of seats Setting curriculum MCI Continued training for upgradation of skills NAMS, NIHFW (possible, but rare) Professional Associations No organization currently tasked Further New Training In service training for PG-diploma: Director (Plan, Budget & Training) Organisation/ Management Personnel administration Promotions Secretariat (For higher 2 grades) Directorate, Admn. and Women cells (for lower grades) Transfers Secretariat for most decisions. In recent years, Directorate (only for Class 2 doctors, Level 1 & 2; with approval from Secretariat) Staff grievances Grievance cell, Directorate Disciplinary action Only Secretariat; either Secretary (health) or Principal Secretary Maintaining informational records on staff Secretariat: Section2, higher levels & Section 3 (lower levels) Section 11 (lady doctors). Directorate: Section 1 and Section 2 under Admn cell (male docto "); array_files[215]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page8.html","2008-10-29","12K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page8 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page8 Part II (contd...) Table 4: Organization Mapping of the Nursing cadre in UP Government Health System Core function Function components Central Level State Level Policy Allocation of funds Secretariat, State Finance Ministry Employment regulations Secretariat (Current Service Rule in function made in 1996 for gazetted and 1999 for non-gazetted nursing staff) New Nursing Schools INC (inspection) No new government nursing school in decades Setting staff Nurses INC (in Education) HRH Production Staff Supply Recruitment of PMS Doctors Directorate (Medical Care cell), Secretariat role only to give final authorisation Allocation of Nurses Director (Medical Care); Secretariat involved in only top two nursing positions at the Directorate Education & Training Admission to NursingSchools Directorate (Medical Care) Setting curriculum INC Continued training for upgradation of Nursingskills & further new training No refresher-training avenue in existence. For Further training, no organization currently tasked (Earlier, Directorate sent nurses for further training) Organisation/ Management Personnel administration Promotions Directorate, (Medical Care) - for gazetted grades For non-gazetted grades - District level (CMO) Transfers Directorate (Medical Care) Staff grievances Grievance cell, Directorate Disciplinary action Directorate (all grades) Maintaining informational records on staff Directorate (section 17), but record keeping is poor Performance Management Job descriptions No organization currently tasked Regular supervision No organization currently tasked Performance-based incentives for staff Only in the form of ACRs – Directorate (Medical Care) Contracting staff Committee comprising District CMO, DM is charged with contracting nurses Regulation Accreditation of NursingColleges INC Registration of Nurses State Medical Faculty Copyright - PHFI, World Bank "); array_files[216]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_II/Print_Version_Part_II_Institutions_as_Implementation_Agents_of_Essential_HR_Functions_in_Health_Page9.html","2008-10-29","5K","Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page9 ","",""," Print Version-Part II-Institutions as Implementation Agents of Essential HR Functions in Health-Page9 Part II (contd...) 2.4 Organizations at work: Recruitment process of doctors in UP and CHS Summary In this section, the recruitment process of doctors into the UP Government Medical Service and into the Central Health Service (CHS) is taken as illustrative examples of how organizations are involved in the implementation of a significant HR function. In this section, the recruitment process of doctors into the UP Government Medical Service and into the Central Health Service (CHS) is taken as illustrative examples of how organizations are involved in the implementation of a significant HR function. The number of doctors to be recruited into the government health system depends on the number of existing vacancies in relation to the officially sanctioned posts.17 Recruitment, therefore, relies on the extent of Public Sector Doctor Vacancy. Since we use the recruitment process as only an illustrative example, Figures 1 & 2 shows how we conceptually approach the matter. In Figure 1, Public Sector Doctor Vacancy is located in the context of broader HRH concerns in the government system. In Figure 2, the recruitment process is located as one among various other contributing factors to the Public Sector Doctor Vacancy problem. Figure 1: Doctor Vacancy in context of broader Government HRH concerns Adapted from T. Sundararaman, “NRHM and Human Resources for Health”, presentation in IIM Ahmedabad, January 2008 17The government’s norms for health manpower requirement are supposed to be computed on the basis of the population. The 9th (1997-2002) Plan suggested that the requirement of personnel be computed not only on the basis of population, but also on the basis of workload, distance to be covered and difficulties in delivery of Health Services. In practice, finances play an important role in determining the actual number of posts sanctioned. Copyright - PHFI, World Bank "); array_files[217]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page10.html","2008-10-29","7K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page10 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page10 Part III (Contd...) Therefore, looking simply at annual numbers of nursing schools and numbers of graduating ‘qualified’ staff nurses, the trend appears to be very positive and is being further encouraged by policy planners and NRHM. From the perspective at the institutional level where this policy of new schools is implemented and teaching is imparted to growing number of students, there is a whole different concern of problems and inadequacies that never get reported. Moreover, this latter perspective questions the very soundness of a policy extensively promoting more production of nurses in more nursing schools while present institutional inadequacies continue to allow for poor teaching staff and a weak regulatory system. Box 5: De-institutionalization of Public Health Nursing Education in UP NRHM plans for 2 ANMs in every sub-centre and has allocated funds also for an increase in the number of sub-centres. UP currently has 20,251 sub-centres, and official documents state that each is manned by a single ANM. Under NRHM, the state envisages 7,000 additional sub-centres. The NRHM plan of 2 ANMs in the existing and new sub-centres, therefore, calls for the additional training of broadly 34,000 new ANMs in the span of five years remaining of the Mission. This ambitious aim depends on institutions with teaching staff for the production of ANMs, but the condition in public health nursing has become even worse than the deterioration in educational institutions for clinical nursing; they simply ceased to exist. Through a policy decision, all the 40 ANM Training Centres and 4 health schools, which were producing ANMs, LHVs, PHNs and PHN Tutors were closed down in the early 1990s. The reason was that the number of ANMs required trained for each sub-centre had been achieved. At a time of financial difficulty, the step appeared justified, even though it affected the training of community-oriented nurses other than ANMs. T "); array_files[218]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page2.html","2008-10-29","6K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page2 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page2 Part III (Contd...) Case Study 1 CHS: Problem of cadre organization on doctor incentives The cadre management of the CHS is housed in the central Ministry of Health and Family Welfare, with the central Directorate – the principal technical/managerial support to health policy and national programs – almost entirely staffed by CHS doctors. Considering this proximity of the CHS to central health policy planning for better efficiency in the system and considering that the Centre has always had complete control (unlike in the states, where it is only able to promote adopting best practices to state governments), it might well have been expected that the CHS cadre would have served as a model vastly superior in the implementation of its core HRH administrative management functions as compared to states such as UP. In fact, Departmental Promotion Committees (DPCs) that decide on promotions have been convened rarely for decades. The related agitation of CHS doctors and the doctors’ lobby-group (JACSDO) for several years in the late-1980s resulted in the Tikku Committee Report (1990), and the central government accepted the doctors’ call for time-bound promotions for the initial years of a CHS doctor’s career (first 13 years for a GDMO; first 6 years for the specialist cadres). Even so, the absence of adequate promotions thereafter remains a severe grievance for the doctors. Moreover, in spite of the CHS providing medical graduates employment with a Class ‘A’ central government service, very low numbers finally join as GDMO or in specialist posts after being successfully selected through the recruitment process (Tables 3 and 4, above). In addition, the attrition of experienced doctors employed with the CHS for several years is another significant problem that plagues the Service. A committee in 2005 headed by former health secretary, Javed Chaudhury, investigated and reported on the causes of this attrition of senior docto "); array_files[219]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page3.html","2008-10-29","6K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page3 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page3 Part III (Contd...) Implications of the current organization of CHS a) On Attrition The division of the CHS in 1982 into four sub-cadres introduced, over time, a structural problem affecting promotions and selection of in-service doctors to higher grade posts. Promotions have been within each of the four sub-cadres from entry-level up to and including the Senior Administrative Grade level (see diagram in Appendix: Figure 4). Thereafter, the sub-cadres are merged into a common hierarchy for promotions to the Higher Administrative Grade posts of Additional Directors General of Health Service and equivalent and Director General Health Services. In the two Teaching Specialists and Non-Teaching Specialists sub-cadres, promotions up to the Senior Administrative Grade level are not only confined to within the particular sub-cadre, but also confined to within the respective Specialities and Super-Specialities. Consequently, in the CHS itself there are over 70 separate seniority lists. Multiple seniority lists create their own share of problems, such as those of accountability and transparency in selections and postings to higher levels. The process of selection for promotion is however made further complicated since the sub-cadres and seniority lists need to be merged at the highest two levels of the CHS cadre. Consequently, there is stagnancy of large numbers of doctors at a single grade for many years, which is a central cause of complaint for CHS doctors over the last 15 years and more. Moreover, it is a focal ground of conflict between CHS doctors and bureaucrats of the Cadre Controlling Authority at the Ministry that preoccupy both parties. b) On Recruitment and career prospect incentives Although the minimum qualification needed for joining the GDMO sub-cadre is a MBBS degree, there are a significant number of doctors with postgraduate (PG) degrees within the sub-cadre. Fresh postgraduates have in the past chosen to "); array_files[220]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page4.html","2008-10-29","5K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page4 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page4 Part III (Contd...) Prior to the subdivision of the CHS cadre in 1982, MBBS and PG degree/diploma holders entered a unified cadre with a single seniority list. Entrants were regarded as ‘Specialist’ or ‘General’ depending on their educational qualifications and were posted to wherever vacancies appeared that best used their educational training and experience. The creation of sub-cadres forced recruitment to be rigidly to vacancies advertised within a particular sub-cadre and any future movement from the GDMO sub-cadre to the specialist sub-cadres was not permissible. Unlike before the subdivision of the cadre, doctors with postgraduate degrees, who join the CHS as a GDMO for reasons noted above, can no longer be recognized as specialists by the system. These post-graduate GDMOs are nevertheless undertaking functions of a specialist nature in various hospitals and teaching institutions. However, this institutional disregard of their specialist status means that they are unable to avail the advantages of career avenues and seniority lists open to the Specialist sub-cadre to which these PG-GDMOs cannot directly transfer to, even after valid experience within CHS. Participating institutions of the CHS currently have posts deemed strictly as ‘specialist sub-cadre’ posts. The CHS is unable to recruit eligible candidates to fill vacancies in all the three specialist sub-cadres, and yet neither is it able to utilise the PG-GDMOs, already in its rolls with appropriate educational qualifications, to fill these vacant posts. A PG-GDMO with the requisite experience gained in CHS and eligible for a specialist post vacancy, only due to the strict sub-division of the cadre, must retake the Central Medical Services Examination and re-apply to the specialist sub-cadre post as a fresh applicant. The central problems of the CHS concerning low numbers joining the cadre and high rates of attrition of experienced doctors closely relat "); array_files[221]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page5.html","2008-10-29","6K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page5 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page5 Part III (Contd...) Case Study 2 UP Medical Service: Cadre Review and resulting problems A rarity of promotions had also been a feature of the UP Provincial Medical Service for decades and the constant lobbying of in-service doctors led to formulating new Service Rules in 2005, which brought about change in the structure of the cadre and several promotions to new positions with it. There had been few promotions previously due to institutional reasons of contested seniority lists, the absence of ACRs and also a general apathy towards convening of the Departmental Promotion Committees that selected from among eligible candidates. The Provincial Medical Service Association had been outspoken about the doctors’ grievances and involved with the government in the Cadre Review resulting in changes that most benefited in-service doctors. The new Service Rules and the formation of new sub-cadres, however, have created fresh problems: the recruitment of new doctors and the way current in-service doctors have been repositioned has had consequences that have in fact been the very opposite of the goals that the national policy plans pursue. Therefore, while beneficial for significant numbers of doctors who had been in the Service, cadre reorganisation retains the focus of officials on dealing with bureaucratic problems internal to the system concerning doctors, rather than a health outcomes focus concerning patients. The implementation of the new Service Rules created the following four sub-cadres on lines of generalist/specialist and gender: 1) Male General; 2) Male Specialist; 3) Female General; and 4) Female Specialist. New Organisation/Management problems: The promotional avenue for the Male Specialist sub-cadre has been made distinct from that of the Male General. The Male Specialist, in the revised rigid career paths, can become a Chief Medical Superintendent (CMS) at a hospital but not a Chief Medical Officer (CMO). The "); array_files[222]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page6.html","2008-10-29","7K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page6 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page6 Part III (Contd...) New Recruitment problems: The promotions of many doctors to the newly formed higher intermediate levels created ‘space’ for a round of new recruitment of Male General doctors at the entry-level in 2005. By the time the requisitioned posts in 2005 were filled in 2007, it was found that in relation to the officially sanctioned posts in the Service Rules, there appeared to be a ‘surplus’ number of some seven hundred doctors at the entry-level (Level 1) of the Male General sub-cadre (See Appendix: Table 1). The Directorate in Lucknow acknowledges that many of the 2278 doctors at the entry-level are not currently in the system. The process for determining a ‘vacancy’ when a doctor still remains on the registers is nevertheless lengthy, since the UP Public Services Commission needs to confirm that a doctor recruited by the Commission is no longer in active service. This need to formally declare a vacancy created additional work for the Directorate, with no link at all to its principal institutional function of providing technical assistance to health service delivery. At the institutional level of the directorate, there was consequently a problem that may be summed up in the following way: there was an undisputable need to recruit more doctors, but since the doctors who remained on the rolls exceeded the numbers sanctioned, no recruitment was possible. The solution finally found for a second round of doctor recruitment was determined considering the social background of doctors. The Law requires that fixed percentage of the current workforce must be drawn from the Scheduled Castes (SC), Scheduled Tribes (ST) and Other Backward Classes (OBC) – that comprise the ‘Reserved category’. The government refers to the gap between the numbers that are required to meet the percentages fixed for each of the ‘Reserved categories’ and the lower numbers actually present in the workforce as the ‘Backlog’. The offici "); array_files[223]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page7.html","2008-10-29","10K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page7 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page7 Part III (Contd...) Box 4: UP Medical Education: Scale of the Faculty Shortage problem At the national level the Plans have been concerned with more medical colleges or not, with current policy of NRHM in favor of increased numbers. Especially in a populous state such as UP, while there are currently 16 medical colleges, population-based norms for the number of medical colleges (one college per lakh population) demand, at the very least, doubling (to 35) of the existing number. At the institutional level, the severe problem faced even in the few medical colleges existing in the state is the enormous scale of faculty shortage. According to 2006 data, of the 738 officially sanctioned faculty positions in UP government medical colleges (and this is already lower than the numbers actually required), over 40 per cent of the teaching posts remained vacant (see Appendix: Table 3). This is a significantly higher proportion than the 20-25 per cent shortage suggested to exist in most departments of the country, with highs of 33 per cent. (Ananthakrishnan, 2007) De-recognized PG courses The implications of MCI Rules on faculty-student ratio for medical education has significantly contributed to the de-recognition of certain numbers of PG seats in UP medical colleges, even though the state government continues to admit students to fill these seats. MCI norms require a 1:1 ratio to be maintained between students and postgraduate teachers. This norm was created at a time and context far removed from the reality facing UP, but still must be adhered to in order for a medical college to retain MCI recognition. The annual numbers of additional faculty vacancies already increase each year due to the retirement or resignation of existing faculty – worsening an already acute problem. In this context, the MCI teacher-student norm only further exacerbates the problem of shortage. In UP, as elsewhere, this norm of 1:1 ratio between stude "); array_files[224]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page8.html","2008-10-29","6K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page8 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page8 Part III (Contd...) Case Study 3 UP Nursing Service Rules: impact on educational incentives and institutions After over a decade of neglect, the nursing profession features prominently in the strategy that current policy planning is engaged in to make better health care reach the poorest and most vulnerable. The specific strategy with regard to nursing is largely centred on the need and ways to produce more nurses. The state government in UP and officials overseeing nursing have a different problem to address first: there are few qualified and adequately trained nurse staff for teaching at the existing GNM schools which place these institutions precariously close to being, if not already, deemed unsuitable for producing nurses. If the government built new schools, they would face the same situation, since the problem is deeper and affects the entire government-nursing cadre of the state. The core problem is the government’s own creation since it is the consequence of a change in nursing Service Rules in the state in 1996 to placate the agitation of nurses seeking a solution to facilitate promotions that were almost non-existent in the cadre. The 1980 Service Rules for nurses give significance to educational qualification as an eligibility requirement for different nursing posts, as prescribed by INC norms. However, the State has never separately registered nurses with the following additional educational training: Public Health Nurse and B.Sc. (Nursing)/Post Basic B.Sc. (N). There is provision to only register nurses with ANM, GNM and LHV training. The absence of institutional records on qualified B.Sc and PHN nurses put them at a disadvantage, even as they should have been favored in promotions and with certain posts open only to them. In reality, like in the case of doctors, there were very few promotions of nurses in the 1980s and 1990s, which became a major source of grievance and conflict between nursing inte "); array_files[225]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_III/Print_Version_Part_III_HRH_Problems_at_the_Implemetation_level_of_Institutions_Case_Studies_Page9.html","2008-10-29","6K","Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page9 ","",""," Print Version-Part III HRH Problems at the Implemetation level of Institutions Case Studies-Page9 Part III (Contd...) The promotion of nurses to teaching posts in nursing schools, without possessing the minimum prescribed educational training, has further jeopardised the quality of government nursing education institutions. The incentive for the nurses who successfully completed the 2-year course of Post-Basic B.Sc.(N) was that it made them eligible to become tutors in nursing schools and colleges as nursing tutors. Staff nurses who pursued a 10-month ‘tutor course’ in nursing, were eligible to become PHN tutors in nursing schools. With the change in Service Rules and subsequent promotions only on a seniority criterion, teaching staff in government nursing schools in UP no longer all have the educational training that the INC deems mandatory (see Appendix: Tables 5&6). Consequently, the INC has withheld recognition from all nursing schools under the state government. This has created another dimension to the conflict between some nurses trained from these institutes and the government and friction between the State government and the central regulatory authority on the standards of the nursing institutes. The government has ensured that the State Nursing Council, separate and autonomous from the INC, recognises these nursing schools and registers nurses graduating from these schools. Since it is the INC, and not the State Nursing Council that is tasked with the inspection of nursing schools, the latter recognises these government schools without undertaking inspection. There is consequently an overlapping regulatory role that both the INC and the State Nursing Council play in this case. Until and unless the state government pays ‘re-inspection fees’ to the INC (and none have so far), no further inspection is undertaken. In data provided by the INC on request, none of the state government nursing schools has paid the re-inspection fees. In 2004, it was found that 61.2percent of all nursing schools/colleges in t "); array_files[226]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_IV/Print_Version_Part_IV_Discussion_page2.html","2008-10-29","6K","Print Version-Part IV Discussion-Page2 ","",""," Print Version-Part IV Discussion-Page2 Part IV (Contd...) This concluding discussion highlights the disconnect between the grand strategies of the policy planners at the national level and the more immediate and routine problems of bureaucrats at the implementing institutional level, which itself needs to become a priority concern but has so far been largely overlooked. For instance, the routine battles with doctors’ interests and the grievances of other health staff define a different set of problems from those diagnosed in the Plans. Officials in state-level institutions tasked with implementation of the Centre’s strategies are often preoccupied with these ordinary problems as immediate concerns. As evident in the case studies on the medical and nursing services in UP, the solutions to these ordinary problems can create unexpected new bureaucratic difficulties that preoccupy officials or have unintended implications for institutions (such as for nursing education in UP) that are at variance with the aims of the grand policy Plans. The mini-battles and conflicts at the state-level exist between the government administrative-officials as ‘payors’ and the individual/group interests of the ‘providers’. The fact that in most government health systems in the country, the payor and the provider are both within the government system hides from public view the ways in which the majority of these internal conflicts occur at different levels; an indication of the scale of these conflicts is perhaps best provided by the fact that the government officials at national and state-level have to engage with legal cases numbering in several thousands filed by current or former providers in the system. The seriousness of these conflicts is, however, clear when they do spill into publicized legal cases or, as in UP, currently result separately in Court orders that ban appointment of contractual doctors or halt the doctor recruitment process based on the latest government requisition. Moreover, when the battles between the govern "); array_files[227]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_IV/Print_Version_Part_IV_Discussion_page3.html","2008-10-29","6K","Print Version-Part IV Discussion-Page3 ","",""," Print Version-Part IV Discussion-Page3 Part IV (Contd...) The policies in Plans therefore can sit uncomfortably at the implementation level where institutions are faced in reality with related, but more mundane, pressing concerns. In other words, policy planning at the national level and the level where the implementation of these policies are expected function in entirely different contexts, with different pressures from the Courts and interest groups. A few examples from this paper may suffice to make the point. The Plans, for instance, focus on strategies to increase the numbers of doctors joining the government medical service. At the implementation level in UP, however, the immediate problems due to cadre reorganization (and possibly political motives), made the government implement a policy that in fact restricts entry into the PMS to only medical graduates from the ‘reserved category’. Similarly, with regard to medical education, the recent Plans and NRHM call only for increased numbers of medical colleges. Any implementation of such policy in UP is, however, superseded by a more severe immediate problem of faculty shortage in even the few existing medical colleges and more numbers of colleges in this context only weaken further these institutions. Recent Plans as well as NRHM recognize the acute shortage of nurses in the country and consequently, at the national level, priority is wholly on more nursing schools. In UP, the current Service Rules for nurses allows for nurses not qualified or trained for teaching posts to occupy these, which has brought a host of other problems that prevent the government from building more nursing schools since these will not be INC-recognized. NRHM, likewise, calls for two ANMs per sub-centre as part of a grand strategy of rural health infrastructure strengthening. But the de-institutionalization of public health nursing in UP has meant that for the bureaucrats at the implementation level, the immediate problem revolves around lack of ANM trainers, which, in turn, requi "); array_files[228]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_IV/Print_Version_Part_IV_Discussion_page4.html","2008-10-29","4K","Print Version-Part IV Discussion-Page4 ","",""," Print Version-Part IV Discussion-Page4 Part IV (Contd...) First: With such a focus on challenges faced at the implementation level of institutions, it is significant to understand how similar ‘mini-battles’ (if not even the same) between government and providers of health care have been dealt with in other state health systems with better health indicators. In state health systems known to better manage health service delivery, it is important to ascertain whether these more routine HR-related problems that affect health system efficiency were resolved, circumnavigated, or were of little relevance to how policy measures were more successfully implemented. Second: NRHM framework is designed to provide states with a greater role in policy planning through the instrument of detailed State PIPs for the health sector. There is now new opportunity to review the HRH plans of these State PIPs in select states and to assess to what extent they reflect the particular problems of implementation and institutional inadequacies separately diagnosed for those states. The importance of the linkage of institutional analysis in the states for a realistic assessment of State PIPs may be a task relevant specifically to the new National Health Systems Resource Centre (NHSRC). Third: It is argued that a clear distinction drawn between the payor and the provider, or even complete separation between the two through innovative use of private providers will bring more transparency and accountability to the health system to improve service delivery (WDR, 2004). Further work along institutional lines, as in this paper, may probe whether or not such separation between payor and provider better resolves or keeps in check the nature of these routine HR conflicts that plague the health system. Copyright - PHFI, World Bank "); array_files[229]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Select_Bibliography/Print_Version_Select_Bibliography_Page2.html","2008-10-29","10K","Print Version-Select Bibliography-Page2 ","",""," Print Version-Select Bibliography-Page2 Select Bibliography (Contd...) Haggard, S., and S. Webb. 1993. What do we know about the political economy of economic reform? The World Bank Research Observer 8 (2):143-68. Hariharan, S. 2004 unpublished. Central Health Service - A Review for Government. Herbst, J. 1990. The structural adjustment of politics in Africa. World Development 18 (7):949-958. Hirschman, A.O. 1970. Exit, Voice and Loyalty. Cambridge, Massachusetts: Harvard. ICSSR/ICMR. 1981. Health for All: An Alternative Strategy. Second Edition, 2002 ed: ICSSR. Illich, I. 1975. Medical Nemesis: the expropriation of health. London: Calder & Boyars. Jeffrey, R. 1986. Health Planning in India 1951-84: the role of the Planning Commission. Health Policy and Planning 1 (2):127-137. ———. 1988. The Politics of Health in India. Berkeley: University of California Press. JLI. 2004. Human Resources for Health: Overcoming the crisis: Joint Learning Initiative (Global Equity Initiative, Harvard University). Leslie, C. 1985. What Caused Indias Massive Community Health Worker Scheme. Social Science and Medicine 21 (8):923-930. Mahal, A., and M. Mohanan. 2006 unpublished. Medical Education in India and its implications for access to care and quality. Martinez, J., and T. Martineau. 1998. Rethinking human resources: an agenda for the millenium. Health Policy and Planning 13 (4):345-358. Mavlankar, D. Undated mimeo. Auxiliary Nurse Midwifes changing role in India. Misra, R., R. Chatterjee, and K. Sujatha Rao. 2003. India Health Report. Delhi: OUP. NCMH, GOI. 2005. Background Papers:Financing and Delivery of Health Care Services in India. New Delhi: Government of India. ———. 2005. Report of the Narional Commission on the Macroeconomics of Health. New Delhi: Government of India. NHSRC. 2008. State Public Health Budget: National Health Systems Resource Centre. Nursing, (Report). 2005. Situational Analysis of Public Health Nursing Personnel in India. Hyderabad: Academy for Nursing. Olson, M. 1982. The Rise and Decline of Nations. N "); array_files[230]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Structure_of_the_Paper/Print_Version_Structure_of_the_Paper.html","2008-10-29","7K","Print Version-Structure of the Paper ","",""," Print Version-Structure of the Paper Structure of the Paper Summary Despite significant improvements having been achieved in public health since independence, this area continues to be “one of the most neglected aspects” of government policy. (Dreze and Sen, 2002). This paradox is examined and addressed by: - the concept of power in the health system and how it is used to influence policy. - focusing on the implementation level of institutions. - analyses on the existing disconnect between the grand strategies at national level policy planning and the more immediate problems that the bureaucrat officials (tasked with the implementation of policies) are preoccupied with at the institutional level. India is one of the pioneers in health service planning and in recognizing human resources as key to a well-functioning system. The first independent government of India had no less than three significant reports on health policy planning even before it initiated the first of its Five-Year Plans.1 Ever since, each subsequent Plan until the current eleventh one, has strived with all good-intention to strategize on elements of human resource development for better health care provision. There is no doubt that significant improvements in health have been achieved since independence, particularly in the lowering of infant mortality and a steady increase in life expectancy. Nevertheless, public health has been “one of the most neglected aspects” of government policies for furthering development in the country (Dreze and Sen, 2002). An overall objective of this paper is to attempt an understanding and explanation of this paradox, but it is principally driven by two broad aims: First, it aims to analyze the political-economic context of health policy in India through clarity on the distribution of power in the health system and the influences that determine policy content on human resources for health. Second, it aims to bring focus especially to the institutional context in which policies pertaining to human resources for h "); array_files[231]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_11.html","2008-10-29","6K","Print Version-Part I-Page11 ","",""," Print Version-Part I-Page11 Part I (contd...) Indeed, there are certain NRHM policy recommendations that have been expressed repeatedly over time by a majority of the committee reports and five-year plan documents. There is equally the case of a policy recommendation that features prominently at one time in a committee report and a five-year plan but which is shelved or reversed in a subsequent plan/report only to return later once again as a notable policy decision of a different government health plan. Understanding the reason for such a cyclical past to a particular policy can contextualize the policy in an existing debate and indicate which perspective was more dominant in government and internationally at the time. This section reviews both of these types of recurrent policy recommendations relating to human resources for health separately. That these policies are recurrent draws attention to why implementation has been inadequate and the significance of institutions as implementation agents (Part II and III of this paper). Policies recurrent continuously over time: The absence of adequate number of doctors in rural areas has plagued the government health system and policy makers at the Centre have grappled with different options on how to address the problem for at least over three decades now.8 Currently, NRHM recommends adapting the medical education curriculum and making it more pertinent towards rural health. Beginning with the Bhore Committee in 1943, this focus on public health has been constantly underlined in the form of proposals to increase and strengthen Departments of Preventive and Social Medicine (PSM) in medical colleges. Furthermore, in 1975, on the recommendation of the Study Group on Medical Education and Support Manpower (Shrivastava Committee), the Reorienting of Medical Education (ROME) program was initiated. Since then, the 6th (1980-85), 7th (1985-89) and 8th (1992-1997) Plans, including the National Health Policy of 1983, have all recognized the need to orient medical education to "); array_files[232]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_12.html","2008-10-29","5K","Print Version-Part I-Page12 ","",""," Print Version-Part I-Page12 Part I (contd...) The Medical Education Review Committee (1983) recommended the establishment of a central coordinating agency for planning, organizing and monitoring continuing education programmes all over the country. This has remained on the agenda of every Plan since. For instance, the 9th (1997-2002) Plan set out to ‘ensure continuing knowledge and skill upgradation of all health care providers through Continuing Education Programmes with emphasis on multi-professional problem solving learning strategies’, even though the previously proposed central coordinating agency had never been established in the interim. The training of paramedical human resources has also been a frequent objective in policy documents over the past six decades. Training of nurses, midwives, ANMs and health visitors was particularly emphasized although pharmacists, sanitary inspectors, medical assistants, hospital workers and public health engineers were also mentioned. NRHM also promotes increased training of paramedical staff and takes it one step further by also emphasizing skill upgradation and multi-skilling of existing medical and paramedical workers. Primary health care infrastructure finds mention in all Plans. However, the Mudaliar Committee (1961) acknowledged that, in reality, primary health care infrastructure was not given the importance it was ascribed in the Bhore Report right from the start. Gains from the central government’s focus on the communicable disease programmes, it was argued, was less sustainable in light of the absence of support from non-existing or non-functional primary health centres. The government’s priority, however, has subsequently oscillated between a policy of consolidation and upgradation of existing infrastructure (as the Mudaliar Committee recommended) and a policy in favor of rapid expansion in numbers of primary healthcare infrastructure. In the 6th (1980-85) and 7th (1985-89) Five Year Plans, there was a massive program of expansion of primary health care faci "); array_files[233]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_13.html","2008-10-29","8K","Print Version-Part I-Page13 ","",""," Print Version-Part I-Page13 Part I (contd...) Box 2: Increase in Primary Health Infrastructure relative to increase in numbers of government doctors Sources: Infrastructure Division, MOHFW, GOI, Rural Health Bulletin, March 2007 Source: Indiastat, MOHFW, GOI As the first graph above shows, in the decade between 1980 and 1990 the number of PHCs and CHCs increased dramatically. Before 1980, there were between one and two thousand additional PHCs and CHCs every decade. In the eighties, however, over 16,000 new buildings were added to the rural health infrastructure. The number of doctors, however, grew much more steadily over the last six decades. While the number of doctors did increase in the 1980s as well, the growth did not match that of the infrastructure. The vast expansion in the rural health infrastructure would have required a concomitant increase in the number of doctors to fulfil the staffing requirements of these new facilities. As this did not occur, it likely resulted in an acute shortage of doctors in the public sector and an increase in the number of vacancies. The shortage was probably even more severe than is apparent, for a few reasons. The first is that the Medical Council of India, which registers doctors, does not account for deaths or for those who leave the service. As a result it tends to overestimate the number of doctors, and increasingly so, as the years go by. Moreover, it is possible that much of the growth in doctors was in the private sector which suggests that the gap between the required number of doctors in the public sector and the number available could be even larger than would be predicted from these numbers. This has important implications for the delivery of health care in rural areas in India.   The Shrivastava Committee (1975) recommended that immediate steps be taken to set up a Medical and Health Education Commission, comprising the MCI, INC, DCI, PCI, representatives of central and state governments, and leading persons in the field of health services and medical educ "); array_files[234]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_14.html","2008-10-29","6K","Print Version-Part I-Page14 ","",""," Print Version-Part I-Page14 Part I (contd...) Some ideas of NRHM such as the concept of horizontal linkages between the various national disease-control programs have their roots in policy proposals that can be traced back even earlier to the 3rd (1961-65) Five Year Plan.9 After a gap of a decade, it returns on the policy reform agenda in the Kartar Singh Committee Report proposal of 1973 that there should be integrated training for all workers engaged in the field of health, family planning and nutrition. Similarly, the 6th (1980-85) plan places emphasis on collaboration between programs in water supply, environment, sanitation, nutrition, education, family planning and maternal and child health. By the 9th (1997-2002) Plan and the National Health Policy of 2002, the concept of linkages had progressed to the vision outlined in NRHM that, in addition to inter-sectoral integration, there should also be integration within the health sector between the vertical health and family welfare programs. Decentralization is another central theme of NRHM that has been prioritized increasingly in recent years. The 7th (1985-89) Plan advocated community participation in health10, while the 8th (1992-1997) Plan recommended involvement of the Panchayati Raj Institutions (PRI) in health planning. Since then the 9th (1997-2002) and 10th Plans (2002-2007), as well as the National Health Policy in 2002, all make reference towards more decentralized planning and services. The NHP-1983 recommended a decentralized system of health care but it however also stressed that this decentralization be accompanied with a low cost, de-professionalization of the public sector system based more on village-based volunteers, paramedics and community participation. The NHP-1983 judged the exclusive dependence of the public sector health system on state-trained doctors providing service in rural areas to be unrealistic. Instead, the NHP-1983 called for an expansion of the private curative sector, which would help reduce the government’s burden. How "); array_files[235]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_15.html","2008-10-29","8K","Print Version-Part I-Page15 ","",""," Print Version-Part I-Page15 Part I (contd...) One significant debate has revolved around whether or not to use private practitioners in government health care provision, what type of private practitioners, and to what extent. In the 1960s, the Mudaliar and Mukherjee Committees, as well as the 3rd (1961-66) Plan, recommended part-time use of private practitioners in the government health system. Partnership of the government sector with the private sector was then relatively ignored between the Third and Sixth Plan initiated in 1980, when incentives were proposed for doctors to set up private practice in rural areas and provide part-time service in government hospitals. The principal priority of policy was efficiency and quality and a focus on implementation with a cost-effective approach, which then called for more competition in the system. The 9th (1997-2002) Plan, and all following policy documents through to NRHM, promote collaborations with the private sector as a means to enhance access to quality health care. The 9th Plan suggests creating part-time ‘contract’ positions, which can be offered to local, qualified private practitioners and/or offer the PHC and CHC premises for after office hours private practice against a rent. The NHP-2002 is even in favor of states ‘expanding the pool of medical practitioners to include a cadre of licentiates of medical practice’ (GOI, 2002). As noted earlier, the proposal for a short term course for the training of medical assistants or practitioners less than full fledged doctors was given serious consideration in the 3rd (1960-65) Plan as a realistic solution to the problem of insufficient doctors for the rural areas. Because of the opposition from the Medical Council and the doctors lobby, this policy has been shelved to resurface again in the NRHM Task Force Report on Medical Education (2006) and implemented piecemeal in at least one state, Chattisgarh. The idea of the multi-purpose health workers or assistants was proposed as a new category of health personnel and "); array_files[236]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_16.html","2008-10-29","7K","Print Version-Part I-Page16 ","",""," Print Version-Part I-Page16 Part I (contd...) The shift in policy thinking towards a community-based health care system in the 1970s brought with it the debate on whether policy calling for further expansion of medical colleges is justified or not. The 1979 Alma Ata declaration of ‘Health for All by 2000AD’, the 1981 ICSSR-ICMR report and the 1983 National Health Policy were part of a similar paradigm of thought as the Shrivastava Report. It is not wholly coincidental that the a questioning of the early promise of western medical science to provide miracles in the 1970s occurred alongside a search for other alternatives to health care provision – whether increasing engagement with Indian Systems of Medicine and Homeopathy or a more community-based health system approach. No longer was there complete faith in drugs which had once appeared to be ‘magic bullets’, but had, by the 1970s, shown to have many unintended consequences (Illich, 1975). The 6th (1980-85) Plan in this context noted ‘serious dissatisfaction with the existing model of medical and health services with its emphasis on hospitals, specialization and super specialization and highly trained doctors which is availed of mostly by the well to do classes.’ The Plan diagnosed outright that ‘this model’ was responsible for ‘depriving the rural areas and the poor people of the benefits of good health and medical services’. In stressing the priority to be a community-based health system, the 6th Plan also stated that there would be no further linear expansion of curative facilities in urban areas and medical colleges. Medical colleges have, however, significantly expanded over the last decade, especially in the private sector, but with approval from government (see Appendix: Figure 2). Currently NRHM expresses the need for further increase in numbers of medical colleges. A Policy promoting a University of Medical and Health Sciences in every state was first proposed by the 1983 Medical Education Review Committee. The 7th (1985-89) Plan initiated the need t "); array_files[237]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_17.html","2008-10-29","6K","Print Version-Part I-Page17 ","",""," Print Version-Part I-Page17 Part I (contd...) Box 3: The ROME Experience: why institutions matter Under the scheme of Re-orientation of Medical Education (ROME) that is proposed to be revisited again in NRHM, each medical college in the country was to adopt 3 primary health centres in the first phase with the twin objectives of providing a rural bias to medical education and also curative health care and referral facilities to the rural population covered. In the 7th (1985-89) Plan, the Planning Commission outlines the innovative idea of the ROME programme and the reasons for its failure: The scheme for re-orientation of medical education (ROME) was introduced with the objectives of (i) introducting community bias in the training of undergraduate medical students with emphasis on preventive and promotive services, (ii) reorientation of the role of medical colleges, so that they became an integral part of the health-care system and did not continue to function in isolation, (iii) reorientation of all faculty members so that hospital-based and disease-oriented training was progressively complemented by community-based and health-oriented training for providing comprehensive primary health care, and (iv) the development of effective referral linkages between PHCs, District Hospitals and Medical Colleges. The scheme has been implemented in its first phase, in about 106 medical colleges. In spite of a one-time grant-in-aid to each of the participating institutions, the objectives of the scheme could not be achieved to the desired extent. This was largely due to (i) lack of commitment to the programme at all levels, (ii) slow progress in the utilization of Central funds, and (iii) absence of efforts in the restructuring of teaching and training programmes at the college levels. The clarity with which the 7th Plan took stock on the content of the ROME programme explains where the primary focus of the policy planners had been. The diagnosis of reasons for the failed programme, however, emphasizes the importance of the "); array_files[238]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_2.html","2008-10-29","11K","Print Version-Part I-Page2 ","",""," Print Version-Part I-Page2 Part I (contd...) In the first two Plans, the Centre’s principal expenditure towards health was on the communicable diseases programs. In the 1950s and 1960s, the entire focus of the health sector in India was to manage epidemics. The remarkable initial achievement of the malaria program and use of extensive trained personnel is a case in point. This single program employed as many as 1,50,000 people by 1961. The expenditure of the state governments was largely on the urban health infrastructure and on tertiary medical care. Consequently, a separation of functional responsibilities in the health system came about with the Centre (through the Planning Commission) investing in preventive and promotive programs, while the states largely focused their attention on curative care. Moreover, there was little focus of the state governments on strengthening the infrastructure for a primary healthcare system, even though reports at the Centre (from Bhore to Mudaliar) kept this at the centre of health policy discourse. The weakness of the primary health care system ironically undermined what the Centre set out to achieve through the central disease programs. The ‘targets’ of these programs aimed at coverage, but this was an unsustainable enterprise when not supported by a primary health system that provided promotive and curative services to these ‘targets’ as patients. The Centre approached rural infrastructure , therefore, from the perspective of communicable disease programs and stressed the need for functional PHCs to consolidate the maintenance phase of these programs.2 A clear demarcation of central and state roles has never been attempted, being notably absent in the 1983 and 2002 National Health Policies as well. While this results in slight flexibility in interpretation of central and state roles that has benefited the former in having greater involvement in programme management in states in the past, it has also allowed for an overlap of functions. One such instance is in the regulato "); array_files[239]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_3.html","2008-10-29","8K","Print Version-Part I-Page3 ","",""," Print Version-Part I-Page3 Part I (contd...) (b) ‘Voice’ of different types of health providers in influencing policy The extent of ‘voice’ (Hirschman, 1970) that members of a group have in any system conveys the extent to which these members can express their dissatisfaction and interests to the prevailing authority – here, the government – to influence policy. In the health system, as in many such large systems, members of a group can most effectively articulate their position through collective action lobbying (Olson, 1982). In the Indian health system, both at the Centre and states, the interests of doctors employed in the government service, called as the ‘In-Group’, have, in the past, been the most influential. In relation to past health policy, other significant numbers of the health workforce such as private practitioners, practitioners of traditional Indian medicine and Homeopathy, as well as nurses have, in contrast, been the ‘Out-Groups’. This section reviews the engagement of the policy process with these different groups of health personnel. The ‘In-Group’: Doctors in the Government System Public health policy in the early decades of India must be contextualised in the modernist enterprise of state – the aim of the state to transform society and economy drawing on the most advanced models and scientific approach available. As one historical analysis of health policy at the central level notes, the doctor syndrome loomed large in the minds of the planners, with actual policy revolving around conditions and prospects of doctors over and above all other health personnel (Duggal, 2005). Another review of government health policy observes that although major health policy documents since 1947 have all stressed the need for more numbers of auxiliary personnel than doctors, the problems of training more doctors have always been discussed first (Jeffrey, 1988). The Bhore Report (1946) endorsed a policy where the government focused its limited resources in training only one kind of doctor – ‘the highly tra "); array_files[240]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_4.html","2008-10-29","6K","Print Version-Part I-Page4 ","",""," Print Version-Part I-Page4 Part I (contd...) The ‘Out-Groups’:Private Practitioners At present, there is no uniform nationwide system of registering either practitioners or institutions providing health care in the private/voluntary sectors; nor is there a mechanism for obtaining and analyzing information on health care infrastructure and manpower in these sectors at the district level. This is a notable omission since it is likely that even in the 1950s and 1960s government was not the principal provider of ambulatory care services. The omission is more significant today when 68 per cent of the 15,393 hospitals (cited by Ministry of Health & Family Welfare), 37 per cent of the hospital/clinic based beds are contributed by the private sector3 and over 80 per cent of the provisioning of ambulatory health care is attributed to the private sector. The private sector already occupies centre-stage. Whether this situation has developed by design is debatable, even though the National Health Policy, 1983 encouraged government to enter into contractual arrangements with the private sector to augment providers and improve quality of care. The National Health Policy, 2002 further endorsed and promoted the need to institutionalize partnerships with diverse providers to rapidly increase the supply of health services, expand coverage, improve technical quality of care at all levels, and control costs for users. Governments have subsidized important inputs for private hospitals such as prime land, exemptions on import of drugs and equipment as well as officially recognized the enormous growth of educational institutions of medicine and nursing in the private sector. However, a clear policy or vision on how the government system of healthcare accommodates the private sector remains amiss. By the time NHP-2002 was formulated, the document also acknowledged that less than 20 percent of the population, which seek OPD services, and less than 45 percent of that which seek indoor treatment, avail of such services in public hospita "); array_files[241]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_5.html","2008-10-29","7K","Print Version-Part I-Page5 ","",""," Print Version-Part I-Page5 Part I (contd...) AYUSH practitioners The dominant medical discourse projects practitioners of Ayurveda, Yoga, Unani, Siddha and Homeopathy (AYUSH) as the ‘unscientific other’ and assigns all of them a peripheral, residual role in the overall health care system (Abraham, 2005). The state-financed institutional development of ISM and Homeopathy in independent India really took off only in the 1970s and 1980s when institutions structured similar to those in allopathy were established in ayurveda and homeopathy. A separate department in the ministry was only created in 1995, in response to a long pending demand and an entire separate Ministry of AYUSH formed in 2003. The only other significant institutions are all involved with research or the regulation of research: In 1959, the Central Council of Ayurvedic Research was set up to advise the central government on the formulation of a coordinated policy for research in Ayurveda. Two advisory committees, one on Homoeopathy and the other on Unani, were also set up. In 1960, a Panel set up by the Planning Commission recommended establishing a Central Council of Indian Medicine for regulating the standards of medicines. Over a decade later, in 1973, the CCIM finally came into existence. Of the professional associations of AYUSH, the most prominent is the Ayurvedic Congress. However, despite being in its centenary year of existence, its role, like that of the other AYUSH associations has been marginal to health policy planning. Although the government discourse now emphasises a need to ‘mainstream AYUSH’ with allopathic medicine, evidence of the past fault line continues. It is most evident in the issue of regulating physicians trained in AYUSH and their practicing of modern medicine. The Indian Medical Association (IMA) and its state-level branches have been rallying, so far successfully, against this privilege. Supreme Court rulings in two separate cases in 1996 and 1998 favoured the IMA’s stand. In spite of current laws not favourable to t "); array_files[242]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_6.html","2008-10-29","5K","Print Version-Part I-Page6 ","",""," Print Version-Part I-Page6 Part I (contd...) Nurses The 8th (1992-1997) Plan observed that ‘while the States have been more than anxious to start new medical colleges, their efforts to develop institutions for training of paramedical staff have been entirely suboptimal’. It further noted that while, ideally, the doctor- nurse ratio should be 1:3, in 1992 there were less than 3,00,000 registered nurses against 4,00,000 registered medical graduates. It is remarkable that after a 1954 Committee that addressed the employment conditions of the nursing profession, there was no subsequent review of all aspects of the nursing component of health services until 1989, when a so-called High Power Committee of the government on nursing reported on its findings. Unlike in other countries, nursing personnel are not actively involved in policy formulation in India, even on matters that affect nursing practice. In a recent note on nursing for the National Commission on the Macroeconomics of Health, the nursing advisor at the central government and the senior-most representative of the profession in policy for over a decade laments: “There are an inadequate number of nurse and midwife leaders at the national and State levels for nursing practice, research, education, management, planning and policy development. Although the nurse is a member of the health team, she/he is never asked to represent the profession in planning and policy formulation for nursing services, education, etc.” As the 1989 Report succinctly observes, following its extensive field visits and interviews, ‘the nurses are given the role of simply following the instructions’ and ‘are hardly involved in any decision making process’. The Trained Nurses’ Association of India (TNAI), founded prior to even the Medical Council in 1922, has its own branches (unlike the Medical Council) in almost all states representing all forms of nursing, including ANMs. It has, however, had very limited success in its advocacy with state governments. For instance, the TNAI has bee "); array_files[243]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_7.html","2008-10-29","6K","Print Version-Part I-Page7 ","",""," Print Version-Part I-Page7 Part I (contd...) 1.2 Influence of Central financing process on state health expenditures Summary This section addresses four concerns: i) the main focus of expenditures for the Centre and the states; ii) the flexibility for adopting strategic context-driven policy in the states; iii) locating where and how HRH fits into this financial arrangement; and, iv) how the National Rural Health Mission (NRHM) envisages changes in this existing arrangement. NRHM is a partnership between the central government and the states, with increased ownership of planned expenditures by the latter, in an effort to raise public health spending and improve the quality and access to care for the most vulnerable groups of the population. State Project Implementation Plans (PIPs) will have performance indicators (such as vacancy rates in various staff posts, institutional reforms and targets for each of the disease control programmes) for release of grants-in-aid subject to satisfactory progress on these indicators. One lasting legacy of the Bhore Report and endorsement of governments to it from early on has been a continued vision of a national health system funded and delivered by the public sector to all. Yet, post-independence allocation patterns have not always matched with the discourse of the central governments. The contradiction is apparent in the fact that in spite of the policy declarations of ‘comprehensive healthcare provision’ by the state, health spending is mostly out-of-pocket (80percent of ambulatory care and 65percent of hospitalisations5) because public resources committed have, historically, remained low. The very poor also undertake the maximum burden of direct payments to access health care - national data (52nd Round NSS data, 1996) reveals that nearly 50 per cent of the lowest income quintile sold assets or took loans to access hospital care. The Constitution expects that the principal contribution for the funding of public health services will be from the resources of the states, wi "); array_files[244]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_8.html","2008-10-29","7K","Print Version-Part I-Page8 ","",""," Print Version-Part I-Page8 Part I (contd...) Both at the Centre and states the budget is divided into Plan and Non-Plan expenditures. Plan expenditures generally include spending on new schemes and up-gradation or expansion of existing schemes as well as outlays on new or replacement infrastructure. In contrast, Non-Plan expenditures cover recurrent expenditures (such as on salaries) as well as expenditures on the operation and maintenance of completed schemes (previously once in ‘Plan’) and already existing institutions. The distinction appears to be somewhat artificial and is also quite flexible; even though guidelines exist, it is up to individual state governments to divide their spending into Plan and Non-Plan (Finance Commission, 2004). The main focus of expenditures of the central government has been on various Centrally-sponsored Disease Control Programs. These are funded primarily by the central government as part of the Plan-budget but implemented by the states. Consequently, at the Centre, Plan expenditures on Health greatly exceed Non-Plan expenditure with a ratio most recently of approximately 10:1. Since 2005, the more prominent of these programs, except for the National AIDS Control Program, have been subsumed under the NRHM. The increased outlays by the Central government under NRHM have meant that the historically already high ratio of Plan to Non-Plan spending on Health at the Centre has further increased within the last few years. Health Budget in the states is also divided into Plan and Non-Plan expenditures, with the Plan component requiring approval by the Planning Commission. This has been essentially to allow a state to demonstrate that it is contributing its share towards the national programs and thus enable it to receive the corresponding share from the central government. For example, in the Malaria Program, a state had to demonstrate that it was contributing equally towards the cost of the program as was the central government. In the case of NRHM, beginning in 2008, many states ha "); array_files[245]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_9.html","2008-10-29","7K","Print Version-Part I-Page9 ","",""," Print Version-Part I-Page9 Part I (contd...) Human resources in health are therefore not only largely under the jurisdiction of state governments, but salaries are also a significant share of the states’ health expenditure in many cases. This is with the exception of ANMs whose salaries are paid for by the central government under the almost-wholly (98.4percent) centrally funded Family Welfare program, and staff for specific disease control programs whose salaries are funded from grants for the particular program. However, it is for state governments to manage implementation and, for instance, to ensure that the ANM resides at her place of work. In many states there are enormous shortages of health personnel. In Uttar Pradesh, for example, a number of sanctioned posts for doctors in the public sector lie vacant. Surprisingly, however, even the number of doctors sanctioned by the State government falls short of the total required according to nationwide norms. This is essentially a financial issue as many states are unable to afford the number of doctors needed in the state. The central government has very little control over this aspect of the health system although, under the NRHM, the Centre is contributing funds towards the hiring of doctors on contract. However, the resources for this contractual staff are only guaranteed for the duration of the program, which is currently due to end in the year 2012. The 1990s witnessed a reduction in health spending due to fiscal stress, especially for poorer states, to which the implementation of the Fifth Pay Commission in 1997 contributed in later years. Public expenditures on health (through the central and state governments), as a percentage of total government expenditure, have actually declined from 3.12 per cent in 1992-93 to 2.99 per cent in 2003-04. Similarly, the combined expenditure on health as a percentage of Gross Domestic Product (GDP) has also marginally declined from 1.01 per cent of GDP in 1992-93 to 0.99 per cent in 2003-04.The less than one percent o "); array_files[246]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I_Page_10.html","2008-10-29","6K","Print Version-Part I-Page10 ","",""," Print Version-Part I-Page10 Part I (contd...) 1.3 HRH Problems at the National Policy Level: A Historical Perspective7 Summary This section historically reviews previous recommendations for reform in human resources for health. It thereby provides the context for the current approach articulated under NRHM which aims to “architecturally correct the health system” through: better use of funds improved service delivery through decentralization, community participation, improvement of infrastructure, horizontal integration of vertical Health and Family Welfare Programs and transparent policies for Human Resources in Health. NRHM adopts a more comprehensive approach to health, incorporating ideas from throughout history, addressing almost every aspect of the public health system. It attempts to improve implementation by setting performance targets for states for institutional reform and focusing on outcomes and outputs. As this paper noted at the very beginning, there has been no dearth of grand strategizing through Plans and government-sponsored committee reports on which issues pertaining to human resources for health need to be prioritized in order to deliver better health care services to the people, especially the rural poor. The most recent such policy document, or grand strategy plan, is the National Rural Health Mission (NRHM), launched in 2005. Its overarching goal is to “improve the availability of, and access to, quality health care by people, especially for those residing in rural areas, the poor, women and children” (NRHM Mission Document). Its more specific objectives include reducing the Maternal Mortality Ratio (MMR) in the country from 407 to 100 per 1,00,000 live births, Infant Mortality Ratio (IMR) from 60 to 30 per 1000 live births and the Total Fertility Rate (TFR) from 3.0 to 2.1 by the projected conclusion of the mission in 2012. The NRHM Mission Document and the Framework for Implementation both outline in detail the strategies to be adopted to achieve these goals. These include what is ref "); array_files[247]=new Array(0,1,"./Print_Version_Paper_2/Print_Version_Part_I/Print_Version_Part_I.html","2008-10-29","8K","Print Version-Part I ","",""," Print Version-Part I Part I Summary This section examines the distribution of power within the government health system with respect to: Present roles of the centre and states where clear demarcation is still nonexistent Existing gaps in spite of recent policy to mainstream AYUSH, due to: 2.1 Government neglect of nurses and allied health professionals. 2.2 Absence of a clear policy or vision for inclusion of the private sector. 1.1 Distribution of Power to influence the Government Health System (a) Political/Constitutional: Centre-State dimension According to the Indian constitution, Health is considered a State subject and therefore, in theory, states are responsible for developing and maintaining their own health services. The Centre is allocated responsibility only for institutions deemed of national importance in medical education and research. On the Concurrent List are the following health-related functions: preventing the spread of infectious diseases, medical education, regulation of the medical profession and drugs, population control, mental health and vital statistics. There is no rationale for the distribution of specific subjects concerning health between the Centre and the states. The existing constitutional division of responsibilities in the health sector are the remnants of reforms introduced under British Rule through Government Acts in 1935 and earlier still in 1919. The reforms initially introduced the concept of ‘dyarchy’ to India which devolved specified functional responsibilities to the states that were not considered a core priority concern to the central government in Delhi and to imperial interests; the subjects of public health and sanitation, in this early prioritization of concerns, were deemed the responsibility of states. The health of the army, however, remained a core priority for British Rule and the Indian Medical Service (IMS), which existed to principally serve this very interest, remained an All-India service. The first independent Indian government at the centre abolish "); array_files[248]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures.html","2008-10-29","31K","Print Version-Annexures ","",""," Print Version-Annexures Annex 1: Concordance Table for NCO-1968 and NCO-2004 Categories NCO 1968 used for classification by NSSO NCO 2004 used for classification by Census Allopathic physicians/surgeons/ specialists Allopathic physicians/surgeons/specialists = 070 070.10 Physician, General 070.15 Surgeon, General 070.20 Anatomist, Medical 070.25 Anaesthetist 070.30 Psychiatrist 070.35 Neurologist 070.40 Dermatologist 070.45 Ear, Nose and Throat Specialist 070.50 Cardiologist 070.55 Radiologist 070.60 Tuberculosis Specialist 070.65 Opthalmologist 070.70 Venereologist 070.75 Obstetrician 070.78 Gynaecologist 070.80 Paediatrician 070.85 Orthopaedist 070.90 Surgeons and Medical Specialists, Allopathic, Other 2221.10 2221.15 2221.20 2221.25 2221.30 2221.35 2221.40 2221.45 2221.50 2221.55 2221.60 2221.65 2221.70 2221.75 2221.78 2221.80 2221.85 2221.90 Allopathic physicians/surgeons = 2221 2221.10 Physician, General 2221.15 Surgeon, General 2221.20 Anatomist, Medical 2221.25 Anaesthetist 2221.30 Psychiatrist 2221.35 Neurologist 2221.40 Dermatologist 2221.42 Allergy Specialist 2221.45 Ear, Nose and Throat Specialist 2221.50 Cardiologist 2221.55 Radiologist 2221.60 Tuberculosis Specialist 2221.65 Ophthalmologist 2221.68 Urologist 2221.70 Venereologist 2221.75 Obstetrician 2221.78 Gynaecologist 2221.80 Paediatrician 2221.85 Orthopaedist 2221.90 Surgeons and Medical Specialists, Allopathic, Other 070.10 070.15 070.20 070.25 070.30 070.35 070.40 070.45 070.50 070.55 070.60 070.65 070.70 070.75 070.78 070.80 070.85 070.90 Public Health Physicians = 078 078.10 Health Officer 2229.10 Health Professional (except nursing) = 2229 (20%) 2229.10 Health Officer 2229.15 Administrator, Hospital 2229.30 Physician, Osteopathic 078.10 Dentists Dentists = 074 074.10 Dentist 2225.10 Dental Specialists = 2225 2225.10 Dentist 2225.20 Oral and Maxillofacial Surgeon 2225.30 Orthodontist 2225.40 Periodontist 2225.50 Prosthodontist 2225.60 Paediatric Dentist 2225.90 Dental Specialists, Other 074.10 Ayush Ayurvedic physicians/surgeons = 071 071 "); array_files[249]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures10.html","2008-10-29","43K","Print Version-Annexures10 ","",""," Print Version-Annexures10 Annex 10: Female health worker density by State and area State Density (Per 10,000 Females) Allopathic Physician Nurse & Midwives All Health Workers Rural Urban Rural Urban Rural Urban INDIA 0.47 6.45 6.10 23.80 7.34 34.96 Andhra Pradesh 0.69 6.58 5.82 21.26 7.12 31.30 Arunachal 0.86 5.50 12.15 49.10 13.50 59.41 Assam 0.26 5.41 6.95 31.38 7.59 39.76 Bihar 0.20 3.68 2.06 18.31 2.32 23.16 Chhattisgarh 0.23 3.91 4.18 23.18 5.27 30.42 NCT of Delhi 3.22 10.34 9.92 26.38 15.58 42.14 Goa 2.15 12.48 28.30 39.78 35.67 64.46 Gujarat 0.19 4.40 4.32 17.64 4.96 27.14 Haryana 0.57 6.75 3.21 17.20 4.18 28.83 Himachal Pradesh 0.95 12.35 10.54 62.09 12.96 84.18 Jammu & Kashmir 0.57 11.60 4.76 14.57 6.32 29.83 Jharkhand 0.19 3.38 3.83 27.77 4.18 32.42 Karnataka 0.73 8.76 5.03 26.80 6.39 40.28 Kerala 2.01 10.37 31.15 37.47 41.87 64.35 Madhya Pradesh 0.20 4.62 3.34 19.84 3.75 26.50 Maharashtra 0.81 8.95 6.91 30.96 9.22 49.34 Manipur 0.77 8.50 13.31 35.29 15.40 50.35 Meghalaya 0.34 9.94 8.25 48.88 9.13 65.95 Mizoram 1.39 6.35 9.56 36.69 21.90 76.59 Nagaland 0.84 3.40 21.94 55.35 24.54 65.26 Orissa 0.19 4.73 19.79 25.31 20.27 32.20 Punjab 0.75 9.28 7.80 21.82 9.61 36.83 Rajasthan 0.17 4.45 3.29 18.27 3.61 24.16 Sikkim 3.65 23.41 21.32 72.75 34.10 131.10 Tamil Nadu 0.89 7.82 7.72 24.38 9.65 37.01 Tripura 0.06 3.07 6.91 35.70 7.37 40.70 UP 0.27 3.64 1.86 10.20 2.29 15.37 Uttaranchal 0.57 5.09 5.17 17.24 6.04 25.08 West Bengal 0.29 3.98 6.36 35.59 7.12 42.63 A&N Islands 3.56 9.03 28.19 40.63 39.13 71.87 Chandigarh 0.73 18.85 8.72 47.28 10.42 79.53 Dadra & Nagar Haveli 0.13 5.72 8.29 22.02 9.60 30.82 Daman & Diu 1.23 2.85 6.38 36.64 8.35 44.78 Lakshadweep 1.36 1.36 25.91 28.64 30.68 36.14 Pondicherry 0.94 8.36 15.91 57.73 18.36 73.99 Source: Census of India 2001 Copyright - PHFI, World Bank "); array_files[250]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures11.html","2008-10-29","21K","Print Version-Annexures11 ","",""," Print Version-Annexures11 Annex 11:Health worker density (per 10,000 population) by sector Estimate NSSO Official Estimates Category Non-Government Government Non-Government Government Total Rural Urban Total Rural Urban Total Allopathic Physician 2.23 6.91 3.53 0.18 2.20 0.74 7.26 2.48 5.93 Dentist 0.14 0.44 0.23 0.00 0.03 0.01 - - - AYUSH 1.46 5.09 2.47 0.04 0.29 0.11 - - - Nurse & Midwife 2.16 7.70 3.70 2.11 6.72 3.39 - - - Pharmacist 0.53 2.77 1.15 0.48 0.67 0.53 - - - Dieticians & Nutritionists 0.00 0.01 0.00 0.00 0.00 0.00 - - - Opticians & Optometrists 0.02 0.03 0.02 0.01 0.00 0.01 - - - Medical Asst. & Technicians 0.59 1.64 0.88 0.56 0.82 0.63 - - - Dental Asst. 0.04 0.10 0.06 0.00 0.11 0.03 - - - Other Traditional Health Workers 0.62 1.01 0.73 0.00 0.02 0.00 - - - Other Hospital Staff 0.31 2.80 1.00 0.24 1.10 0.48 - - - All Health Workers 8.11 28.49 13.77 3.63 11.97 5.94 - - - Source: National Sample Survey Organisation 2004-05; Medical Council of India (MCI) 2005 Copyright - PHFI, World Bank "); array_files[251]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures2_page1.html","2008-10-29","4K","Print Version-Annexures2 ","",""," Print Version-Annexures2 Annex 2:Adjustments and Imputations made to NSSO and census data Using the NSSO and Census data the number, composition and distribution of health workers were estimated using NCO codes. The NSSO used the NCO-68 codes to classify occupations and 19 categories in the NCO-68 codes were pertinent to the health workforce. These were grouped according to the comparable categories listed in Appendix 1. The 2001 Census used the NCO (2004) codes to categorise workers, with 20 codes characterising the health workforce. These were grouped according to the categories listed in Appendix 1. A. Missing Values and Imputation Some of the individuals classified as employed in the NSSO data had missing NCO codes. On cross-tabulating the missing NCO codes with the NIC codes, the missing values pertaining to health workers were identified. These individuals (health workers) were assigned to health worker groups (see Appendix 1) based on the information collected on their educational degrees and their NIC codes. There was a group of non-physician health workers who, based on their NIC codes, were identified as working in the hospital but could not be further classified and were placed in the category called “Other Hospital Staff”. B. Combining and Splitting Health Worker Categories To makes NSSO and Census estimates comparable, one NCO-2004 code in the Census, “Health Professionals except Nursing”(NCO code 2229) had to be split into two. This was required as the category consisted of two very different kinds of health workers: health officer, hospital administrator and osteopathic physician - who are allopathic doctors, and sidha physicians, naturopath and other physicians and surgeons - who are classified as other traditional health workers (see table below). Copyright - PHFI, World Bank "); array_files[252]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures2_page2.html","2008-10-29","6K","Print Version-Annexures2-Page2 ","",""," Print Version-Annexures2-Page2 Annex 2:Adjustments and Imputations made to NSSO and census data (Contd...) NSSO-NCO (1968) Census-NCO (2004) 078 Public Health Physicians 078.10 Health Officer 2229.10 2229 Health Professionals (except Nursing) 2229.10 Health Officer 2229.15 Administrator, Hospital 2229.30 Physician, Osteopathic 2229.20 Naturopath 2229.40 Physician, Sidha 2229.90 Physician & Surgeons, Other 078.10 079.10 071.20 079.90 079 Other Physicians 079.10 Naturopath 079.20 Chiropodist 079.90 Physician & Surgeons, Other 2229.20 3226.30 2229.90 Thus, code 2229 in the Census is a combination of 078 and 079 in the NSSO. Thus, to split 2229 into public health physicians and other physicians, a formula of 078/ (078+079) was applied to derive the proportion of 1:4. This proportion was used to split all relevant Census estimates Copyright - PHFI, World Bank "); array_files[253]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures3.html","2008-10-29","42K","Print Version-Annexure3 ","",""," Print Version-Annexure3 Annex 3:Size and density (per 10,000 population) of the Health Workforce in India Estimate NSSO Census Government Estimates Category NCO Classification Number Density NCO Classification Number Density Number Density Allopathic Physicians & Surgeons Allopathic Doctor 454,233 4.08 Allopathic Physician/Surgeon 676,756 6.07 660,856 5.93 Public Health Physician 22,461 0.20 Total 476,694 4.28 Total 676,756 6.07 660,856 5.93 Dentists Dentist 26,336 0.24 Dentist 22,962 0.21 55,344 0.50 AYUSH Ayur 134,015 1.20 Ayur 115,934 1.04 Unani 28,361 0.25 Unani 10,822 0.10 Homeopathy 125,391 1.13 Homeopathy 69,732 0.63 Total 287,767 2.58 Total 196,488 1.76 726,370 6.52 Nurses, Midwives & Related Professionals Nurse 298,230 2.68 Nursing Professional 15,490 0.14 Nursing, Sanitary Asst. 379,602 3.41 Nursing Associate Professional 530,443 4.76 Midwives 111,841 1.00 Midwives 99,504 0.89 0.00 Sanitarian 178,151 1.60 Total 789,673 7.09 Total 823,589 7.39 1,422,452 12.77 Pharmacists & Related Pharmacist 114,926 1.03 Pharmaceutical Asst. 72,349 0.65 Pharmaceutical Asst. 239,276 2.15 Total 187,275 1.68 Total 239,276 2.15 Dieticians & Nutritionists Dietician & Nutritionist 260 0.00 Dietician & Nutritionist 3,587 0.03 Opticians & Optometrists Optician & Optometrist 3,539 0.03 Optometrist 13,678 0.12 Medical Asst. & Tech. Medical Asst. & Tech. 168,159 1.51 Medical Equipment Operator 16,240 0.15 Medical Assistant 99,010 0.89 Total 168,159 1.51 Total 115,250 1.03 Dental Assistants Dental Assistant 10,002 0.09 Dental Assistant 2,658 0.02 Physiotherapist Physiotherapist Physiotherapist 7,265 0.07 Modern Health Associate Prof. 15,396 0.14 Total 0 0.00 Total 22,662 0.20 Other Traditional Health Workers Trad. Health Worker 81,363 0.73 Trad. Medicine Practitioner 11,756 0.11 Faith Healer 651 0.01 Health Prof. except Nursing 38,911 0.35 Total 81,363 0.73 Total 51,318 0.46 Other Hospital Staff Other Hospital Staff 165,753 1.49 Other Hospital Staff NA NA All All Health Workers 2,196,821 19.72 All Health Workers 2,168,223 19.46 S "); array_files[254]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures4.html","2008-10-29","32K","Print Version-Annexures4 ","",""," Print Version-Annexures4 Annex 4:Health Worker Density by Area (Per 10,000 Population) Estimate NSSO Census Category NCO Classification Rural Urban NCO Classification Rural Urban Allopathic Physician/Surgeons Allopathic Doctor 2.23 8.87 Allopathic Physician/Surgeon 3.28 13.34 Public Health Physician 0.18 0.25 0.00 0.00 Total 2.42 9.12 Total 3.28 13.34 Dentists Dentist 0.15 0.47 Dentist 0.06 0.59 AYUSH Ayur 0.81 2.22 Ayur 0.60 2.17 Unani 0.13 0.57 Unani 0.04 0.24 Homeopathy 0.56 2.60 Homeopathy 0.39 1.23 Total 1.51 5.38 Total 1.04 3.64 Nurses, Midwives & Related Professionals Nurse 1.04 6.92 Nursing Professional 0.08 0.28 Nursing, Sanitary Assistant 2.29 6.32 Nursing Associate Professional 2.33 11.07 Midwives 0.94 1.18 Midwives 0.68 1.44 0.00 0.00 Sanitarian 1.03 3.08 Total 4.27 14.42 Total 4.13 15.88 Pharmacists & Related Pharmacist 0.72 1.83 Pharmaceutical Asst. 0.28 1.61 Pharmaceutical Asst. 1.33 4.28 Total 1.00 3.44 Total 1.33 4.28 Dieticians & Nutritionists Dietician & Nutritionist 0.00 0.01 Dietician & Nutritionist 0.02 0.06 Opticians & Optometrists Optician & Optometrist 0.03 0.03 Optometrist 0.04 0.34 Medical Assistants & Technicians Medical Asst. & Technician 1.14 2.46 Medical Equipment Operator 0.05 0.40 0.00 0.00 Medical Assistant 0.43 2.08 Total 1.14 2.46 Total 0.48 2.48 Dental Assistants Dental Asst. 0.04 0.21 Dental Asst. 0.01 0.06 Physiotherapists Physiotherapist 0.00 0.00 Physiotherapist 0.02 0.18 0.00 0.00 Modern Health Associate Prof. 0.10 0.24 Total 0.00 0.00 Total 0.12 0.43 Other Traditional Health Workers Other Traditional Health Workers 0.62 1.02 Traditional Medicine Practitioner 0.09 0.13 0.00 0.00 Faith Healer 0.00 0.01 0.00 0.00 Health Professional except Nursing 0.18 0.78 Total 0.62 1.02 Total 0.28 0.92 Other Hospital Staff Other Hospital Staff 0.56 3.90 Other Hospital Staff All Health Workers All Health Workers 11.74 40.46 All Health Workers 10.78 42.03 Source: National Sample Survey Organisation 2004-05; Census of India 2001 Copyright - PHFI, World Bank "); array_files[255]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures5.html","2008-10-29","31K","Print Version-Annexures5 ","",""," Print Version-Annexures5 Annex 5:Density of Female Health Workers by Area Category NCO Classification Density (Per 10,000 Population)Density (Per 10,000 Females) Rural Urban Total Rural Urban Total Allopathic Physicians & Surgeons Allopathic Physician/Surgeon 0.22 3.12 1.03 0.47 6.45 2.14 Dentists Dentist 0.01 0.16 0.05 0.02 0.32 0.10 AYUSH Ayur 0.05 0.42 0.15 0.11 0.86 0.32 Unani 0.00 0.03 0.01 0.00 0.05 0.02 Homeopathy 0.03 0.27 0.10 0.07 0.56 0.21 Total 0.08 0.71 0.26 0.18 1.47 0.54 Nurses, Midwives & Related Professionals Nursing Professional 0.06 0.22 0.11 0.13 0.46 0.22 Nursing Associate Prof.=3231 1.92 9.01 3.89 4.01 18.63 8.11 Midwives 0.62 1.30 0.81 1.29 2.69 1.68 Sanitarian 0.32 0.98 0.50 0.66 2.02 1.04 Total 2.92 11.51 5.31 6.10 23.80 11.06 Pharmacists & Related Pharmaceutical Asst. 0.10 0.49 0.21 0.20 1.02 0.43 Dieticians & Nutritionists Dietician & Nutritionist 0.01 0.03 0.01 0.01 0.07 0.03 Opticians & Optometrists Optometrist 0.00 0.02 0.01 0.01 0.05 0.02 Medical Asst. & Tech. Medical Equipment Operator 0.01 0.04 0.02 0.02 0.09 0.04 Medical Assistant 0.10 0.47 0.20 0.20 0.97 0.42 Total 0.11 0.51 0.22 0.22 1.06 0.46 Dental Assistants Dental Asst. 0.00 0.01 0.01 0.00 0.03 0.01 Physiotherapists Physiotherapist 0.00 0.06 0.02 0.01 0.13 0.04 Modern Health Associate Prof. 0.02 0.07 0.04 0.05 0.14 0.07 Total 0.03 0.13 0.06 0.06 0.27 0.11 Other Traditional Health Workers Traditional Medicine Practioners 0.01 0.02 0.01 0.01 0.03 0.02 Faith Healer 0.00 0.00 0.00 0.00 0.00 0.00 Health Professional except Nursing 0.04 0.19 0.08 0.08 0.40 0.17 Total 0.04 0.21 0.09 0.09 0.44 0.19 All All Health Workers 3.51 16.91 7.24 7.34 34.96 15.08 Source: Census of India 2001 Copyright - PHFI, World Bank "); array_files[256]=new Array(0,1,"./Print_Version_Paper_1/Print_Version_Annexures6.html","2008-10-29","88K","Print Version-Annexures6 ","",""," Print Version-Annexures6 Annex 6:Health Worker Density (Per 10,000 Population) by State State All Health Workers Allopathic Physician Nurse & Midwife Ayush Dentist Pharmacist Others Other Traditional NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census NSSO Census INDIA 19.72 19.46 4.28 6.07 7.09 7.39 2.58 1.76 0.24 0.21 1.68 2.15 3.12 1.42 0.73 0.46 Andhra Pradesh 23.54 21.31 4.52 7.84 11.48 7.54 1.60 0.90 0.18 0.12 1.43 2.37 1.97 1.66 2.35 0.88 Arunachal Pradesh 15.08 26.83 1.97 3.17 6.10 17.92 0.00 0.29 0.00 0.19 4.70 2.50 2.30 1.98 0.00 0.78 Assam 7.93 14.37 0.16 2.83 3.93 6.18 0.66 1.15 1.23 0.06 0.50 2.24 0.55 1.28 0.89 0.63 Bihar 9.55 10.19 2.06 3.96 2.73 2.80 1.21 1.02 0.06 0.04 0.27 1.88 2.89 0.43 0.33 0.06 Chhattisgarh 14.89 15.81 2.59 4.09 9.01 5.74 0.43 1.20 0.00 0.07 0.55 1.19 1.19 2.77 1.13 0.75 Delhi 10.20 44.56 1.53 15.03 8.34 15.80 0.00 3.22 0.00 1.02 0.12 4.44 0.21 4.43 0.00