Does India have adequate number of Health Workers?

Posted on December 8, 2008


A successful UHC initiative requires emphasis on both the hard (funds, facilities) and the soft (nurses, physicians) infrastructure. So as we debate how India can achieve UHC coverage we must not lose sight of the fact that India must have adequate number of health workers. The question then is: what’s this adequate number of health workers and how does India currently fare. 

To answer that question I turned to the excellent database that the World Health Organisation (WHO) maintains. I have used average life expectancy at birth for both sexes as the proxy variable for the quality of healthcare services that citizens of a country enjoy. I have then looked at the impact of 3 variables that affect life expectancy – the per capita income (corrected for PPP), the number (more specifically the density) of health workers and the ratio of number of nurses & midwifery personnel to physicians. I could find data for 193 countries. For most countries the data is for years between 2004 and 2006. It is reasonable to argue that these 4 variables do not/will not see dramatic changes over a short span of 3-4 years and hence the data for various countries, though not strictly comparable, is adequately comparable.

table-21I divided the countries into life expectancy quartiles. The results are in the adjacent table and show the median values for the 4 variables.

It is obvious that people live longer in richer countries. Then again, looking at the changes across quartiles, specifically the first and the second, we see the greater impact increase in health worker density has on life expectancy as compared to the impact of increase in income. There is a threshold value for health worker density, crossing which allows a country to make dramatic improvement in the quality of healthcare delivered. The WHO postulates that this threshold value is 25. However there is another equally, perhaps more, important insight. Increasing the health worker density is good but this increase must be through increase in numbers for both nurses and physicians. Merely increasing the number of nurses (relatively easier to do) without commensurate increase in number of physicians may not yield the desired results.

table-3How does India score? The adjacent table below shows the same data for India and some countries to compare with.

One correction to the India data is in order. The WHO data takes into account only allopathic doctors. India has thriving and successful alternate medicinal systems which add to the pool of skilled and recognized physicians. The Central Bureau of Health Intelligence‘s National Health Profile 2007 provides the number of both the registered allopathic doctors and the registered AYUSH (Ayurveda, Unani, Siddha, Naturopathy & Homeopathy) doctors. Thus the total number of registered doctors in India in 2006 is 1.4M and this increases India’s health worker density to 26 per 10,000 population and reduces the ratio of nurses & midwifery personnel to physicians to 1.1.

Amongst the rising economies (the so called BRIC countries), India and Russia are in the 2nd quartile and Brazil and China are in the 3rd. With incomes 67% to 89% lower than the US and UK, China and Brazil do a spectacular job of providing quality healthcare to its citizens.  (P.S. The conundrum is Russia, given that it has a higher density of health workers and higher per capita income than both Brazil and China and has higher physician density than Brazil yet has lower life expectancy. It could perhaps be explained by the fact that both Brazil and China have well established universal healthcare initiates which are missing in both India and Russia)

table-4Even amongst its 2nd quartile peers, India lags on life expectancy. The silver lining, however, is that India not only has an acceptable health worker density, she perhaps has a little leeway in allowing an increase in the nurses & midwifery personnel to physicians ratio while achieving some quick gains.

If India were to set a goal, for 2020, of bettering the quality of healthcare for its citizens to the next level (graduate to the 3rd quartile) through achieving a health worker density of 40 and a ratio of nurses & midwifery personnel to physicians of 2.5, the adjacent table captures the challenge she faces:

This does not look like a difficult challenge to meet. The government needs to:

  1. Continue its policy of recognizing the alternate medicinal systems and encourage and support research and development of these systems.
  2. Encourage establishment of quality nursing education institutes and provide adequate financial and technical support.