Human resources for health: Covid-19 initiated several conversations around the shortcomings of the health systems globally ranging from their incapability to manage the large volumes of admissions to the lack of access to basic medical facilities, tests, and treatment options.
A core underlying problem plaguing the healthcare community for decades is the shortage and inequitable distribution of healthcare workers. Broadening the scope of the idea, human resources for health (HRH) go beyond healthcare workers and are defined by the World Health Organization (WHO) as “people engaged in actions that primarily enhance health”.
Global HRH shortage and disparities in their distribution across regions and countries have been well-known and one of the most important systemic problems for policymakers and planners. Achieving a certain minimum threshold of HRH has been a priority for nations worldwide. WHO and the United Nations recognize the importance has placed adequate HRH high on the health and development agenda and urged countries to do the same.
Cross-country analyses have shown that increased HRH density (i.e., HRH personnel per 10000 people) is associated with decreased child and maternal mortality, decreased disease burdens, and improved immunization. Over the course of the past several years, such data have been used to calibrate a minimum number of required HRH for a population of 10,000 (threshold of HRH requirement). The notion is that below this threshold the regions will fail to attain a desirable level of health care coverage in the population.
2006 WHO report that came during the Millennium Development Goals (MDG) era estimated that a minimum of 22.8 doctors, nurses, and midwives (a group referred to as skilled HRH) are needed for every 10,000 people to ensure that 80% of births are assisted by skilled birth attendants – a crucial health care coverage target.
This report estimated a shortage of nearly 4 million skilled HRH personnel globally. Fifty-seven countries including India fell short of meeting the threshold in 2006. If we use the modeled data from the Institute for Health Metrics and Evaluation (IHME), India had 11 doctors, nurses, and midwives per 10,000 people in 2006 falling quite below the required threshold.
Ten years later, in 2016, WHO devised a global strategy to improve health through adequate investments ensuring availability. Accessibility, acceptability, service utilization, and quality of HRH. The report widened the spectrum of factors used to estimate the threshold for required HRH. Instead of births assisted by skilled birth attendants.
A composite Sustainable Development Goal (SDG) tracer indicator was devised consisting of 12 indicators including non-communicable disease management, antenatal care, skilled birth attendance, immunization, sanitation, and family planning among others. Attainment of the median score (25% of the SDG tracer indicators achieved) was used to decide the threshold of required HRH to be 44.5 doctors, nurses, and midwives per 10,000 people.
This report found a global shortage of 11.6 million skilled HRH personnel as of 2013. And forecasted that the shortage would only decrease to 9.9 million by 2030. In 2016, with 15 skilled HRH personnel per 10,000 people, India was below the SDG threshold. Since then India has prioritized achieving 45 skilled HRH personnel per 10,000 people under the SDG-3 target for 2030.
More recently, the Institute for Health Metrics and Evaluation (IHME) leads the Global Burden of Diseases (GBD) studies. Modeled estimates for 16 HRH cadres across 204 countries for 1990-2019. And came up with a new threshold for the minimum requirement. Here, an effective coverage index constructed in collaboration with WHO that captures universal healthcare coverage (UHC) was used. This index was composed of 23 indicators corresponding to multiple health services for promotion, and prevention.
And treatment of communicable and non-communicable conditions for population groups from all stages of life. To achieve a UHC effective coverage score of 80 out of 100. The minimum required HRH per 10,000 population was 20.7 doctors (physicians). 70.6 nurses and midwives, 8.2 dentistry personnel, and 9.4 pharmaceutical personnel. This study has added to the existing knowledge in multiple ways. First, it looked at HRH cadres beyond doctors, nurses, and midwives.
Second, it provided cadre-wise requirement thresholds, which could be useful in deciding investments in cadre-mix across countries. Third, it used data modeled for about 3 decades at the country level to come up. These thresholds compared to the previous reports that used cross-sectional (single-year) data at WHO regional levels.
Globally, the study found a shortage of over 37 million skilled HRH personnel – 6.4 million doctors. And 30.6 million nurses and midwives in over 150 countries. In 2019, India had 6.2 doctors and 10.1 nurses and midwives per 10,000 people largely trailing the thresholds.
HRH scarcity in India is a chronic problem. India has consistently lagged behind the MDG, SDG, and UHC targets. Significant scale-up in the form of the creation of new seats. And retaining every possible HRH personnel is immediately needed to achieve health for all by 2030.
The article has been authored by Madhurima Vuddemarry, MBBS student. Rajarshi Chhatrapati Shahu Maharaj Government Medical College, Kolhapur, and a researcher at ASAR. Siddhesh Zadey, co-founding director, ASAR and Commission Fellow, Lancet Citizens’ Commission for Reimagining Health Systems. Human resources for health.