Perfectionism is the enemy of creation, as extreme self-solitude is the enemy of well-being. - John Updike
Shortage of frontline health workers in Uttar Pradesh.
Originally published at Governance Now. Improving the availability of health workers, particularly at the sub-centre level, has been one of the thrust areas of the national rural health mission (#NRHM).
Back in 2005, most of the sub-centres in the country were run by a single auxiliary nurse midwife (ANM). ANMs were overburdened because of rapid growth in population in previous decades and growing number of central and state sponsored health programmes. Also, because they were the sole functionary at the sub-centre level, they had to manage the sub-centre and perform field visits simultaneously, which adversely affected their performance. To reduce the burden and improve their performance, the NRHM proposed deploying an additional #ANM. The programme also persuaded state governments to enhance the availability of male health workers (MHWs), who are vital to the effective implementation of various national disease control programmes, by filling existing vacant posts.
In 2005, when the NRHM was launched, the public health system in UP was highly inadequate and inefficient with respect to the needs of the population. Since then, the state has received thousands of crores of NRHM funding every year from the central government to improve its healthcare delivery system. However, to what extent it has been put to good use is not known. Media informs us that all is not well in UP. As per reports, the execution of the NRHM in the state has been mired by rampant corruption and misuse of funds. For instance, in 2011, about Rs 100 billion were siphoned off by politicians, bureaucrats and medical officers from the NRHM funds provided to the state. The investigation into this scandal is still underway. Moreover, the state has been unable to utilise thousands of crores allocated to it under the NRHM for the year 2015.
Such reports can make you wonder what is going on in UP’s public health system? Has it been able to realise any of the NRHM dreams of strengthening public health system or the NRHM funds have gone down the drain? In this article, my focus is on health sub-centres, the lowest level of publicly funded health facilities in India. I ask three questions: First, has UP been able to increase the number of sub-centres to match its burgeoning rural population? Second, has it been able to provide an additional ANM and an MHW in all sub-centres as envisaged by the NRHM in 2005? Third, are there enough health worker supervisors in the system?
Number of sub-centres
Let us first have a look at the numerical adequacy of sub-centres. As per the Indian Public Health Standards (#IPHS), ideally, the average population served by a health sub-centre (HSC) should not be more than 5,000 in plain areas and 3,000 in hilly areas.
The terrain in #UP is not undulating, however, the population covered by HSCs is currently well above the IPHS recommendation – about 7,500 people per sub-centre. This calls for setting up more sub-centres in the state. But how many more? The number of sub-centres has increased from 18,577 in 2005 to 20,521 in 2015. Unfortunately, this growth is neither sufficient to stave off the pressure from the burgeoning population nor enough to meet the IPHS recommendation. Currently, there are over 155 million people living rural areas of the state. This means that in order to fulfil the IPHS standard for sub-centres, the state will need to establish additional 10,500 sub-centres.
As for health worker availability, the IPHS recommends that each sub-centre should have at least two ANMs and an MHW. Accordingly, the state should have 41,042 ANMs for its 20,521 sub-centres. Unfortunately, there are only about 23,500 ANMs positioned at HSCs, which means that most sub-centres do not have a second ANM even a decade after the NRHM was launched. This number has remained stagnant over the years. The latest district level household survey reveals that the proportion of sub-centre with two ANMs in UP is the lowest among all states. Even Bihar is ahead of UP. The lack of a second ANM at sub-centres adversely affects the performance of the existing ANM as she is forced to share her time between the headquarters (the sub-centre) and the field (villages). She is neither able to focus on maternal and child health services nor on immunisation, family planning and infectious diseases prevention activities that require her to travel to villages to cover the target population.
MHWs were introduced in the 1970s. They implement several public health measures such as collection of drinking water samples, environmental sanitation, school health, family planning, infectious disease control, adolescent health programmes, and other national health programmes. By 1990, UP was successful in recruiting enough MHWs to serve its population. Soon after, in an unwise move, the government decided to shut down all training schools for male health workers in the state. This is when the shortage of MHWs began to build up.
The crisis that started in the early 1990s has grown despite the fact that the central government, under NRHM, promised to bear the burden recruiting MHWs provided that the state sanction and recruit a second ANM for their sub-centres. In 2005, about 69% sub-centres did not have an MHW. The situation has further deteriorated over the NRHM period. Currently, the share of such sub-centres in the state has risen to 85%. This shortage may have serious implications for the surveillance, treatment, prevention, and control of communicable diseases such as malaria, dengue, chikungunya and Japanese encephalitis in the state.
Health workers’ supervisors
The long-standing shortage of ANMs and MHWs in the state has led to a shortage of their supervisors (lady health visitor and male health assistant) as well. Each primary health centre (PHC), which usually covers six sub-centres, should have a male health assistant to supervise MHWs deployed at sub-centres. Every PHC in the state had a male health assistant in 2005, but unfortunately the situation has deteriorated since then. As of 2015, male health assistants are available only in about 28% of PHCs. The availability of lady health visitors (LHVs) in the state has not improved either. The proportion of PHCs with LHVs has declined from 89.7% in 2005 to 54.7% in 2015. As a result, the burden on existing LHVs has increased as many of them now have to supervise double the number of ANMs.
Cause of the crisis
So, it is natural to ask what is causing this crisis in the state. Why has Uttar Pradesh not been able to improve the availability of its sub-centre level health workers even though the central government has been supportive since the launch of NRHM in 2005?
It seems that the current health worker crisis in the state is largely a result of past health worker recruitment policies. In the 1990s, the government was convinced that they had enough ANMs and MHWs in the system. Therefore, it decided to shut down all its health worker training schools and institutes. However, when NRHM was launched in 2005, the government realised that it needed more health workers to serve its burgeoning population. The attrition of the workforce that was recruited in the 1970s and 1980s was occurring rapidly at that time, so it drew up plans to increase the number of health workers back in 2008. However, the plans never took off.
The state could have recruited health workers for posts rendered vacant by attrition but it chose not to, mainly because training new recruits would require making a massive investment in its training institutions that have been lying defunct since the early 1990s.
None of the 70 ANM training centres in the state are fully functional due to inadequate physical infrastructure and lack of academic and administrative staff. About 60% of all sanctioned posts for tutors at these training centres are vacant. Moreover, none of these training centres has a principal. Similarly, there are about 11 regional health and family welfare training centres and 30 Anchal Prashikshan Kendra to train MHWs. These centres were supposed to restart pre-service training and a decision in this regard was taken in 2008. However, the decision was never seriously implemented. As a result, the shortage of MHWs intensified.
The shortage of LHVs mainly stems from non-recruitment of ANMs and dysfunctional LHV training centres in the state. ANMs who complete five years of service are given six months in-service training at these schools to get promoted to the post of LHV. For training these supervisors, there are four health schools in Lucknow, Allahabad, Agra, and Bareilly. Unfortunately, none of these training centres are currently operational, mainly due to lack of public health nurse (PHN) tutors even though a number of posts are sanctioned and the budget is available. Fresh PHN tutors are not being trained in the state because the only PHN tutor training centre in the state has not been operational since the last 27 years due to various reasons.
The extent of apathy towards the issue of shortage of health workers prevailing in the state government and bureaucracy can be gauged from the fact there has been no increase in the number of sanctioned posts for any of the sub-centre level health workers (except ANMs) or their supervisors during 2005-2015. Even for the ANMs, the number of sanctioned posts is still way below the current requirement as per the IPHS. It is problem that the government should consider urgently because recruitments can be made only against sanctioned posts. It cannot recruit health workers arbitrarily.
Apart from the above mentioned reasons, the huge workforce crisis that the state is witnessing is a result of the lack of vision for its rural public health facilities. Currently, the state does not have any framework for medium- or long-term health workforce planning. It is strange that the state still uses the 1991 census population to calculate the need for health facilities and health workforce. Moreover, the state also lacks a central health workforce database that could help policymakers in keeping an eye on health workforce dynamics in its public health system.
It can be concluded that the state is suffering from a huge shortage of both health facilities and health workers even after a decade since the launch of NRHM. In fact, shortages have intensified over the NRHM period and any effort made to fill vacant positions in the state can be best described as highly inadequate and ineffective. Therefore, the government should seriously take a stock of current shortage and devise a plan to deal with the problem in a phased manner. The immediate task for the state government should be to do whatever it takes to operationalise at least some training schools, if not all, to start filling existing vacant posts as soon as possible. However, if it wishes to end the crisis of basic health workers and their supervisors within the next five years, it should think about operationalising all training schools to their full capacity. Besides, the government should establish more sub-centres and sanction new posts as per the IPHS norms.
Singh is a researcher at Portsmouth-Brawijaya Centre for Global Health, Population, and Policy, University of Portsmouth, UK.
(The article appears in the May 16-31, 2017 issue of Governance Now)
- See more at: http://www.governancenow.com/news/regular-story/parody-of-the-health-mission#sthash.Ur2kEOtr.E7xlBSze.dpuf