For several years, the World Health Organization has listed India among the countries with a health workforce crisis. The shortfall in the human resources for health is reflected across multiple categories—doctors, nurses, allied health professionals and community health workers. The 12th Five-Year Plan (2012-17) proposes to scale up the production of doctors and nurses, even as the National Health Mission aims to train and deploy more community health volunteers in both rural and urban areas. As the burden of non-communicable diseases, including cardiovascular diseases and diabetes, is superimposed on the continuing concerns of infectious diseases and endangered maternal and child health, the need for a larger and better skilled health workforce becomes even more urgent.
However, there are three major challenges that create uncertainty about the health system’s ability to fill the human resource gaps within the next five years.
First, the fiscal constraints imposed by India’s slowing economic growth are threatening to cut the promised increase in allocation for health. This would hamper the plans for expanding the institutional capacity for training more health workers.
Second, even if more institutions are opened to train a larger number of doctors and nurses, their lag time for producing sufficient numbers will be longer than five years, due to the duration of the training programmes and shortage of faculty.
Third, even if more numbers are produced, there is no assurance that the doctors will be ready to serve in the rural areas.
There is a potential solution which can address both the need for more human resources in primary healthcare and the need to create more jobs to stimulate a sagging economy. This lies in training and deploying a large number of technology-enabled community health workers and allied health professionals, to perform many of the public health and basic clinical functions required in primary healthcare. This will help to overcome the shortage of doctors in rural areas and also increase access to such services for the poor and near-poor in urban areas.
There is adequate evidence, from India and abroad, of the effective contribution made by non-physician healthcare providers to improved delivery of essential health services and achievement of better health outcomes. In Gadcharoli, Maharashtra, Abhay Bang has demonstrated how trained community health workers can reduce child mortality. In Tanjavur, Tamil Nadu, Nachiket Mor is showing how health extension workers can supplement the skills of physicians in improving the delivery of primary healthcare. Mid-level health workers in Chhattisgarh proved even better than doctors in treating primary care conditions, especially malaria.
Global experience, too, bears this out. Trained nurses in South Africa and community health workers in Iran have been shown, in well designed studies, to improve the detection and control of high blood pressure and diabetes. I have recently seen how nurses are efficiently managing primary health centres in Rwanda.
Indeed, much of the front-line care of HIV/AIDS sufferers in Africa is delivered by non-physicians. Health extension workers in Ethiopia have energized the health system and are providing a model for many low-income countries. Assisted by eminent economist Jeff Sachs, several African nations are now embarking on an effort to train a million community health workers to transform primary healthcare.
Fortunately, technological advances make it easy for non-physicians to play a greater role than before. Handheld devices, fitted with point of care diagnostics and loaded with decision support systems, and mobile phones, equipped for tele-consultations with physicians, are among devices that can greatly empower front-line health workers. Several ongoing studies in India suggest a vast potential for cost-effective management of many health conditions through mhealth services delivered by trained community health workers.
Shifting many of the primary care functions to the non-physicians can also create many new jobs. A recent study by the Public Health Foundation of India (PHFI) estimated that the country needs to train and deploy 6.4 million more allied health professions (excluding doctors and nurses), to meet international norms.
By creating several million jobs for allied health professionals and community health workers, personally gainful and socially useful employment can be opened up for many young people waiting to enter the labour market. Since many of these occupations are highly suitable for women, gender empowerment, too, can be advanced. More jobs will mean less poverty and more consumer spending, which will fuel the economy. Better primary healthcare will also mean less personal expenditure and lower governmental spending on healthcare, since the need for expensive secondary and tertiary healthcare services is reduced.
Changing the dynamic of the labour market in health services to one favouring greater employment of non-physicians will, therefore, have the dual benefits of improving the health outcomes at the population level and galvanizing the economy at the national level.
The author is president of the Public Health Foundation of India.