Odisha Development Conclave – Odisha 2016 Human Resources for Health: Future Directions Prof. Sanjay Zodpey, MD, PhD Vice President – Academics, Public Health Foundation of India, New Delhi, Director – Indian Institute of Public Health, Delhi SZ_ODC_ODISHA_ Session on Human Resources and Governance in Health Care

Availability, competence and motivation of health workers is critical SZ_ODC_ODISHA_

3 Health systems are crux in designing, implementing and monitoring health programs and delivering quality health services A strong and vibrant health system is essential Yet, such systems are impossible without health workers who are the ultimate resource of health systems

A simple message: Health workers save lives! SZ_ODC_ODISHA_

HRH Scenario: Global, National, Provincial SZ_ODC_ODISHA_

Why do we need sufficient HRH? SZ_ODC_ODISHA_

Health workforce in the spotlight Source: Global Health Workforce Alliance and World Health Organization SZ_ODC_ODISHA_

Health workforce in the spotlight SZ_ODC_ODISHA_ Global shortage Source: Global Health Workforce Alliance and World Health Organization

Global gap of health professionals is large and increasing every year A deficit of 7.2 million professional health workers in 2012 will rise to 12.9 million by Source: Global Health Workforce Alliance and World Health Organization. 2013

Health workforce is in the spotlight 10 Source: Global Health Workforce Alliance and World Health Organization Inequitable distribution

Global Health Workforce Challenges Health workforce shortage Skill mix imbalance Mal-distribution [and migration] Negative work environments Weak knowledge base SZ_ODC_ODISHA_ *Reference: Chen L et al. Human resources for health: overcoming the crisis. Lancet 2004; 364: 1984–90

WHO threshold of 22.8 per 10,000 Considering only doctors, nurses and midwives, HRH density comes out to be 20.7 per 10,000 population Source: NSSO, SZ_ODC_ODISHA_ HRH density (Doctor, Nurse and Midwife) – major India states (per 10,000 population) HRH insufficiency in India 12

WHO threshold of 22.8 per 10,000 Considering only doctors, nurses and midwives, HRH density comes out to be 20.7 per 10,000 population Source: NSSO, SZ_ODC_ODISHA_ National average close to WHO minimum threshold HRH density (Doctor, Nurse and Midwife) – major India states (per 10,000 population) HRH insufficiency in India 13

Dissecting India’s HRH insufficiency 14 Source: World Health Organization. The world health report: 2006: working together for health.. Rao KD, Bhatnagar A, Berman P. So many, yet few: Human resources for health in India. Human resources for health Aug 13;10(1):1. Team Discussions

HRH Response: Global and India SZ_ODC_ODISHA_

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HRH reforms in Employee life- cycle SZ_ODC_ODISHA_ Attraction Increasing number of education institutes in Health Engaging private sector in HRH Recruitment Compulsory rural service for rural residents being pre-requisite for admission Pre-condition of working in rural/tribal areas for PG admissions Development Pre-condition of working in rural/tribal areas for getting promotion Task shifting Creation of new cadres/courses Separation Revision in service rules Retention Monetary incentives related to HRH Revision in service rules Creation of new cadres/courses Employee life-cycle

Compulsory rural posting after completion of MBBS - MBBS students undertake a compulsory rural service (which range between one year to a maximum of five years) in lieu of a seat in the program - This reform is predominantly designed for medical doctors Pre-condition of working in rural/tribal areas for PG admissions - Opportunity for in-service health department staff for PG education and specialist training - Useful when the states offering this reform have an adequate supply of PG seats Pre-condition of working in rural/tribal areas for getting promotion - Giving preferential promotion on working in rural/ tribal areas - States like Odisha, Punjab, J&K and Karnataka have also included this reform as part of their transfer rules Monetary incentives - Monetary benefits to incentivize those personnel who agree to undertake work in geographical areas/ locations/ health posts which are traditionally under-served. HRH Reforms for addressing insufficiency: 8 Broad buckets SZ_ODC_ODISHA_

Task-shifting - Help health systems deliver vital and essential services, even in the absence of formally qualified specialists - Training MBBS doctors to undertake the work of medical specialists through bridge courses like EmOC Creation of new cadre/ course - New courses or creation of a new cadre within the health system - Chhattisgarh has taken the lead - Chhattisgarh Rural Medical Corp (CRMC) - Alternate models like DHS, CPS, Dawn courses exist for training specialists Revision in service rules - Administrative rules regarding the recruitment and retirement of HRH were modified to better suit the local situations within states Private Sector participation - Contracting health personnel in NHM and national programmes; - Empanelment of hospitals in publicly funded health insurance; - Public-private joint ventures to open medical colleges and hospitals; - Subsidies and incentives for establishing independent units in sub-urban and remote areas SZ_ODC_ODISHA_ HRH Reforms for addressing insufficiency: 8 Broad buckets

SZ_ODC_ODISHA_ Odisha HRH Plan and Progress: Appreciable efforts Separate and dedicated unit for human resource management in health – State Human Resource Management Unit Development of separate directorate of public health and directorate of nursing Development of clinical and public health cadre Restructuring of cadres for doctors and allied health staff Recruitment of doctors through OPSC and ad-hoc both and posting through counselling

SZ_ODC_ODISHA_ Odisha HRH Plan and Progress: Appreciable efforts Policies for attraction and retention of doctors – Place based monetary incentives, 50% PG seats for in-service candidates, additional marks for PG entrance for working in hard to reach areas Capacity building of in-service doctors for clinical and public health specialties Commitment by government to recruit additional allied health staff in coming five years and their regularization after six years of service NHM support for recruiting additional staff, capacity building and providing incentives

Odisha: Challenges for the future (some examples) Production Limited scope for increasing number of seats for doctors in existing institutions Getting required number of faculties for new institutions in public sector Maintaining quality of education in new institutions (both public and private) 22 SZ_ODC_ODISHA_

Odisha: Challenges for the future (some examples) Recruitment and posting Ensuring continuation of service by doctors after recruitment and posting Getting required number of applications for recruitment of allied health staff in certain districts (problem of coverage of primary and secondary education) Inter-district variation in recruitment time for various allied health staff Ensuring funds for salaries of additional allied health staff to be recruited over coming five years (Political economy of Department of Finance) 23 SZ_ODC_ODISHA_

Odisha: Challenges for the future (some examples) Attraction and retention Incentives meant for attraction and retention may not ensure performance High turn over of doctors in remote areas as they will enroll for PG courses Uncertainty of employee response to strategies for attraction and retention 24 SZ_ODC_ODISHA_

Advancing the HRH agenda: Future scope for Odisha SZ_ODC_ODISHA_

HRH reformsOutcome achievedEase of implementation Compulsory rural posting after completion of MBBS + Pre-condition of working in rural/tribal areas for PG admissions +++ Pre-condition of working in rural/tribal areas for getting promotion +++ Monetary incentives ++ Task-shifting + Creation of new cadre/ course ++ Revision in service rules ++ Private sector participation + = Yes, = Partially, X = Needs additional documentation/ No +++ = easily implementable, ++ = moderately implementable, + = implementable with difficulty Review of HRH Reforms SZ_ODC_ODISHA_

Way Forward 1. Development of comprehensive HR policy so as to provide strategic direction 2.Development of clinical and public health cadres with improved career progression as well as accountability for doctors and allied health staff 3.Development of district hospital as an unit for production of health staff a.DNB (degree) courses for producing specialist doctors b.CPS (diploma) course for producing specialist doctors that can be posted at CHCs and sub-district hospitals c.Courses for producing staff nurses, lab technicians, pharmacists, physiotherapists, hospital managers, and so on d.Multi-skilling of existing staff such as LTs, AYUSH doctors, staff nurses, etc. 4.Development of web based dynamic system for human resource management 5.Monitoring, supervision and evaluation of HRM interventions done over a period of time – learning for future actions 27 SZ_ODC_ODISHA_

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SZ_ODC_ODISHA_ Thank you! 29