The density of health workers, in terms of the number of doctors, nurses and midwives per 10,000 population, has always told us that India has far fewer nurses and midwives than needed. The absolute numbers have increased over the years, however, the ratio has remained low as population growth continues to outpace that growth. Measures such as integrating ASHAs into healthcare workers and families providing bedside nursing in hospitals hide some of this acute shortage in the public health system.
The Covid pandemic has shown us that more inpatient services are needed at the primary and secondary level of care and that ad hoc arrangements made through the contractual hiring of nurses and ANMs to fill this gap lead to violations and exploitation of labor law. Some states have witnessed strikes and walkouts as harassed nurses refuse to work low wages or long hours. At the other end of the career path, creating and filling senior nursing positions (there are no positions specifically for midwives) has been a futile process, fraught with procedural muddles. senior nurses are in the salary bracket to qualify and those who have a university education and are unwilling to relocate. The absence of nurses in the decision-making bodies of health systems and the lack of long-term planning for nursing and midwifery have led to this capacity gap. For example, although midwives are included in nursing training, staff nurses can be placed in any department of the hospital. This gives flexibility to hospital administrators for the placement of nurses in various departments, but leads to a decline in the skills of midwives to such an extent that it is now difficult to find nurses who wish to specialize in a field. area of ââpractice, as promotions and salaries do not take such specialized practice into account. For hospitals, the government still uses the Personnel Inspection Unit (SI Unit) figures for nurses despite the High Powerd Committee on Nursing suggesting changes. Nursing superintendents at most hospitals admit they are chronically understaffed. As of 2021, there is no comprehensive data on nursing or midwifery staff in state hospitals, and public and private hospitals are not required to provide their nurse: patient ratio data on an annual basis.
A comprehensive analysis of the nursing workforce is needed to recommend improvements and prevent the brain drain of this profession to foreign countries where scholarships and midwives are attractive professions within their healthcare system. Recommendations should start at the highest level within the Ministry of Health and Family Welfare, DGHS and most of the Health and Family Welfare Directorates and Medical Directorates, starting with the inclusion of a greater number of nurses or midwives in decision-making and the filling of all nursing and midwifery positions with nurses and not kept on an ad hoc basis or officiating by doctors.
This document looks briefly at the global workforce plans developed by WHO and the barriers to achieving the goals of the RHS Vision2030 numbers in our mixed health system.
Preparations to improve nursing and midwifery services to meet national commitments set for the achievement of universal health coverage (UHC), achievement of health and wellness goals, and development of the Global Health Workforce Strategy. health 2030 started early in India. Members of the High Level Panel of Experts on Universal Health Coverage (HLEG 2010) who reported to the Chairman of the Planning Commission, reviewed the numbers and submitted a 15-year timeline. Almost 10 years later, I am now taking this opportunity to re-evaluate the progress of HRH in nursing and midwifery and to see what processes are in place and explain why progress has been delayed despite recommendations made for better progress in nursing and midwifery. career, monetary rewards and suggested additional training and responsibility for these essential professionals within our mixed health system (public and private).
An assessment of gender and its implications for UHC is essential. One of the simplistic actions would be to increase the number of nurses and midwives and achieve gender equality in our formal workforce to meet India’s SDG-5 goals. Nursing and midwifery can be attractive careers for young women if gender barriers are lifted. Today, nurses and midwives struggle to balance a full-time career while maintaining culturally prescribed and socially acceptable gender roles. An adequate nursing workforce means that each nurse covers more patient care than expected and work schedules are less flexible. For example, when there is a shortage of nurses, shift work becomes more rigid and the lack of predictability and long working hours lead to burnout. Over time, although working conditions have improved, the overall participation of women in the workforce is declining and there is evidence that higher management positions, union leaders and greater capacity to operate. action by nurses to claim their rights suggests that much remains to be done.
Gender issues must be taken into account if we are to strengthen nursing and midwifery and increase its number and the quality of work, given that over 85% of nurses and 100% of nursing assistants are women. Of the HLEG’s top three gender recommendations for UHC, the second is the recommendation on recognizing the role gender plays in the life of a health care provider.
âRecommendation 2: Recognize and strengthen the central role of women in the delivery of health care both in the formal health system and in the home. Address the concerns of women workers regarding safety, transport, housing, hygiene and sanitation; as well as maternity benefits, their need to meet within the district and end sexual harassment; Increase the number of professional women in higher management positions through better career paths. Ensure the representation of women in all health management structures, including nurses; Offer more community care programs. Day care centers, palliative care, home care and ambulatory care services that can support the delivery of home health care â.
To understand the progress made in popularizing access to nursing and midwifery, in the area of ââincentives to enter the labor market, a framework is provided in the âGlobal Strategy on Human Resources for Health: Workforceâ. work 2030 âfrom the WHO. The challenge India faces in meeting the nursing workforce goals can be interpreted using this diagram to address policy levers on the demand and supply side for production and supply. increased use of HRH.
This framework helps us understand the policy levers that shape labor markets in HRH. I would like to use this document to expand on what I see as the issues related to expanding nursing and midwifery. Starting from the value placed on education, we question the viability of education loans as a means of providing HRH, especially for nursing care. It should be noted that the cost of graduate nursing training in the private sector does not allow the repayment of the student loan even in 15 years, if he is employed as a nurse in a small private hospital given the current cost of living. Taking the case of female employees, especially nurses and midwives, I would like to further explore some of the incentives and disincentives to employment in the public and private sectors and suggest why emigration is becoming such an attractive option.
A review of the past 10 years of annual rural health statistics which provide figures on HRH employment in primary health care. It is observed that the posts of obstetricians, and other medical specialists at the level of CHCs and rural hospitals have remained vacant, while the posts of nurses and ANM are generally filled, some states even suffer from a shortage of doctors. . The reasons for these two different employment tragedies between allopathic doctors versus nurses and midwives are due to differences in the pay structure between the public and private sectors. In terms of income, the incentives are such that doctors can earn more in the private sector while nurses earn more in public sector health facilities. Although public sector physicians in many states may practice or receive an additional non-practice allowance (meaning that additional income from practicing outside of their role in the public health care system is considered), many still chose to work in the private sector where they have more control over their income thanks to a complex incentive system in the healthcare industry that highlights the physician as the leader of the healthcare team. health and income generator. Nurses, on the other hand, are likely to be paid better in the public sector than in the private sector. These are also the same reasons why the private sector in India is experiencing high turnover of nurses and the cycle continues with low investment in nursing within the private sector since the industrial model does not see a high return on investment. . The shocking report that most private sector hospital chains are against paying for nursing at least ??20,000 per month is eloquent proof of upholding quality nursing care as a value proposition. We must do better to plan for the future.
(The article was written by Leila Varkey Sc.D, Center for Catalyzing Change and Associate Commissioner of the Lancet Commission on Reimagining India’s Health Care System.)