Wednesday, March 4, 2015

Draft National Health Policy 2015: Note for the Sub-group on Human Resources in Health and Medical Education

Health and healthcare provision are highly human resource intensive activities and hence human resources form the central core for structuring and designing healthcare systems. Human resources in health range from highly skilled super-specialists and professionally qualified public health managers to front line service delivery providers like doctors, nurses, a wide variety of paramedics and other support staff all of whom have critical roles and responsibilities at the various levels of healthcare delivery.

Thus a health policy document addressing human resource issues would need to engage with a wide array of issues ranging from training and education, certification and licensing, mentoring, public service recruitment, locational policies, ethical practices, quality management, retention policies, integration of various functions and levels of care, use of technology, career progression and updating of knowledge and skills and regulation.

This note is structured in the above context and keeping the terms of reference for this sub-group in mind:

Gaps and Challenges
Healthcare systems are rapidly changing globally as well as in India. In India we have a paradox of healthcare institutions which are of a global standard and used by the local elite and “medical-tourists” from across the world and a wide array of differential quality of public and private health services used by the aam aadmi. The human resources in these institutions range from professionally qualified to untrained and unqualified. Poor regulation and oversight of the health sector in the country has resulted in the current scenario, and often even the qualified and trained practitioners provide care which could be irrational and professionally and ethically unacceptable. The gaps and challenges must thus be viewed in this context.

Often it is indicated that we do not have enough numbers of health human resources, especially doctors and nurses or that we do not produce adequate numbers. This is used as a logic for setting up more medical and nursing colleges. Globally countries which provide universal access to healthcare have 2 to 3 physicians (GPs + specialists) per 1000 population and 6 to 9 nurses per 1000 population. In India, excluding AYUSH we have about 1 physician per 1000 population and 1.5 nurse (2 if we include ANM etc) per 1000 population. This ratio may look like a deficit and enforce an argument for increasing production of these professionals. This is actually a false deficit, especially for doctors. If we add the AYUSH doctors then our ratio moves up to 2 per 1000. If we look at production then we are producing over 50000 allopathic doctors per year and over 2 lakh nurses per year. The deficit is primarily there because of the out-migration that has been happening for years.
If the production of these human resources is reined in from a perspective of public service then each year we would have two additional MBBS doctors per existing PHC and 2 lakh nurses per year for the public health system. All it needs is a political will to introduce a policy of compulsory public service as well as integration of medical and health education with the public health delivery system. The suggestion in the draft health policy of converting district hospitals into teaching hospitals is very appropriate provided it is also linked to admissions from within the district. If the district hospitals are deficient in terms of faculty and required infrastructure then they could in the transition be linked to an existing teaching hospital as their mentor or alternatively students from the existing teaching hospitals could be posted in the district hospitals for clinical work and the latter would become an extension of the teaching hospital.

In the case of a number of specialties there are indeed huge shortages and these may require expansion but such expansion must be solely to strengthen public health systems.

Compulsory public service should be for atleast two years in a sub-centre or PHC (rural or urban) after which they could be posted in District or rural/subdistrict hospitals and get preferential access to PG/specialist medical education or pursue a career in the public health system. For strengthening primary healthcare a separate cadre of BSc Community Health as suggested in the draft health policy should be created and they would ultimately form the backbone of the public health system at the subcentre and PHC level. The same should be done in the case of nurses.

Thus we really don’t need a substantial enhancement of medical and nursing education institutions but a restructuring of admissions and recruitment and demanding a social return in the form of compulsory public service. The compulsory public service policy should be extended to other professionals like management school graduates being brought in to work as health program managers etc.

Another major challenge confronting the public health system is attracting doctors and nurses to join the public health system and then retaining them. It goes without saying that the public health system needs a substantial overhaul to make it attract professionals. Infrastructure, maintenance, supplies, staffing, incentives, work environment, participatory decision-making, governance etc. all need to be considerably improved to make public health institutions attractive places to work in. Compensation packages and payment mechanisms need a fresh look. For instance doctors need not be salaried employees but could be contracted in like in the UK NHS and paid on capitation basis. Thus an appropriate doctor identified to work at say a sub-centre level to provide GP services can be provided a list of families to cater to and be paid on capitation basis a fixed amount per family per year (ofcourse without being allowed to do private practice). Those working in difficult and remote areas should be given additional benefits both monetary and non-monetary.

Further a dedicated national and/or state medical and health cadre should be created on the lines of the IAS cadre or the army or railways medical cadre that provides similar benefits and work cultures and environment. There should also be a provision for rotation of functionaries. Thus those working in PHCs should get opportunities to spend time in hospitals and vice-versa, those working in rural areas should have urban postings and those working in urban settings should get rural postings etc. Clear and transparent career progression paths should be available for all- doctors, nurses, paramedics, community health workers etc..

Medical and nursing education curricular is another challenge. It requires a major overhaul. As suggested above it should be integrated with the service delivery system so that the students learn in an environment of the reality scenario and not just the portals of the medical school. This integration will initself contribute to creating graduates who have grounded knowledge and experience, help imbibe values and ethics that are humane and result in a socialization of the professional into a socially concerned being who respects the value of public service and develops social responsibility.

While public health education to train public health professionals and managers is on the increase the public health system lacks a strategy to rein them into the public health system. The latter is still obsessed with medical doctors becoming public health managers. This needs to be separated as roles in the public health system. Medical doctors must largely play clinical and related roles and leave program management to trained public health managers. This is presently a huge gap and would need considerable investment. Without such investment it would be difficult to set up a universal access healthcare system.

Quality, Management and Governance
The quality of healthcare delivery critically depends on the knowledge and skills of the human resources. Apart from the deficit in infrastructure, supplies etc. the quality deficit is also significantly due to poor knowledge and inadequate skills provided during medical education. The latter results in poor confidence levels and consequently affects quality of care. As suggested above integration of medical and nursing education with service delivery across various levels will expand the canvass of the trainee and provide and exposure and experience which will help build the needed confidence and consequently improved quality of care. Further post-medical/nursing education CMEs become critical for knowledge and skill upgradation and hence quality.

Another major challenge is the management and governance structure of the public health system. The present bureaucratic method of functioning and management is not conducive to the health professional/workers environment. It impedes their efficiency, quality and effectiveness and curtails their autonomy and role in planning and decision-making. Each health institution should be managed and governed autonomously so that those working in these institutions, who are grounded there and understand the local realities, are able to independently take decisions which would make them responsible and have a stake in the system.

Ethics and Accountability
Medical practice deals with human lives directly and hence value systems by which the medical professionals function have to be clear and transparent. Thus inculcation of ethical values is integral to the health profession. This is presently very weak and a huge challenge both during their education and training as well as in their practice. Atleast in the public health system there are some rules and regulations and norms which impinge positively on such values but in the private sector due to commercialization of medical practice there is a complete absence of ethics. Thus orientation into ethical values is the cornerstone for making medical practice rational, malpractice-free and responsible. Ethics education has to be both a central part of medical curricular as well as of CME and this would require setting up of an independent mechanism to assure this.
Similarly accountability of the public health system and its workers to the community they serve is very important. This has to be a mutual system wherein communities support the health workforce in building their confidence by taking up their issues and challenges with the health administration, and the health workers act responsibly towards the communities they serve. The community based monitoring and planning system under NRHM in Maharashtra is a good example of how community oversight has created a responsible and accountable healthcare system in the districts where this is working. The impact has been huge and the confidence of the people in the public health system has improved significantly and the confidence of the health workers in serving and being responsible to the communities they serve has increased and this has helped strengthen the public health system substantially.

6th Jan 2014