Human Resources for Health in India: Strategic Options for Transforming Health Systems Towards Improving Health Service Delivery and Public Health

Abstract

Introduction:

The health workforce is the channel for delivering health interventions to populations. A critical mass of health professionals is necessary to manage a health system and is often a crucial limiting factor in the delivery of quality health services. India’s current situation, juxtaposed with its medium-term and long-term HRH (human resources for health) requirements, necessitates reassessing the policy levers that are available at the national level.

Objective:

To suggest strategic options to recommend India’s way forward to meet challenges related to health service delivery and public health with an HRH focus.

Methodology:

We reviewed and compared studies from different countries which focused on strengthening HRH at the national level. A two-step approach towards identifying and selecting HRH strategic options was adopted: desk review and discussions. A list of strategic options for reforming the current state of HRH in India was developed on the basis of lessons learnt from the review. These options were then scored and plotted on a grid (for innovation, disruption, difficulty of implementation, budget for implementation, importance and time period for implementation) in discussion with experts.

Result:

Based on the lessons learnt, eight strategic options were suggested for India: instituting a national HRH body; developing partnership models for the public sector and the private sector; setting benchmark HRH ratios; allocating at least 2.5% of the GDP to health; allocating at least 25% of all development assistance for health to HRH; halving the current levels of disparity in health worker distribution between urban and rural areas; evaluating HRH support through the National Health Mission (NHM); and maintaining a live register of HRH.

Conclusion:

The research is timely as India moves towards the implementation of the Sustainable Development Goals (SDGs) with a particular focus on universal health coverage (UHC) and Ayushman Bharat Yojana. The suggested strategic options for the way forward shall help India in dealing with the current health crisis to emerge with a strong public health system.

Keywords

Health workforce human resources for health India health policy health service delivery strategic options health system transformation

Introduction

The World Health Organization (WHO) recognises that knowledge, skills and motivation among the workforce is critical for achieving universal health coverage (UHC) (WHO, 2020). The health workforce is the channel for delivering health interventions to populations, but health worker numbers continue to be inadequate at the global level. Liu et al. estimated that the global demand for health workers may rise to 80 million workers by 2030, which would be twice the number of health workers estimated to be available in 2013 (Liu et al., 2017). However, as per the Global Health Workforce Alliance, the global shortage of skilled health professionals (midwives, nurses and physicians) is estimated to increase by 12.9 million by 2035 (Campbell et al., 2013). While the supply of health workers is expected to reach 65 million over the same period, we expect a worldwide net shortage of 15 million health workers (Liu et al., 2017). This shortage of human resources for health (HRH) can impede the delivery of essential health services (Liu et al., 2017; Scheil-Adlung, 2013) and slow the progress towards the attainment of Sustainable Development Goal (SDG) targets (Miseda et al., 2017) in regions of HRH shortage. Health policymakers are challenged to ensure delivery of public health interventions when systems are faced with numerical shortages of health workforce (WHO, 2000).

Apart from the shortage in number, HRH management, motivation (attraction and retention), competence, supply, inequitable distribution and appropriate skill mix are HRH challenges that pose a threat to a country’s health system (McCaffery, 2011). However, countries have time and again taken measures to manage these issues through appropriate policy interventions. Some of these interventions may include richer benefits, such as health insurance, vacation time, tuition reimbursement, flexible hours, signing bonuses, etc. (American Hospital Association, 2001) Health workers in developing countries are usually underpaid and thus demotivated and dissatisfied (Zurn, 2004). Health professionals’ motivation levels can potentially affect the delivery of health services (Weldegebriel, 2016).

Health service delivery is part of the health system tasked with providing treatment and supplies to patients (Transparency International Health Initiative, 2020). The providers of health services are organisation(s) or persons who actually deliver the service (Belgian Government, 2020). Some concepts, such as access, availability, utilisation and coverage, have often been used parallelly to reveal whether people are receiving the services they need (Shengelia et al., 2003; Tanahashi, 1978). The providers use healthcare delivery systems (HDSs) for delivering these services. As stated by Van der Zee et al. (2004), HDSs is the organised response of society to the health problems of its population (Van der Zee et al., 2004). The universal building blocks of HDSs are described as governance, financing, human and capital resources, quality assurance and healthcare provision (Stevens et al., 2017).

Public health is an integral part of health service delivery, as it aims to promote greater health and well-being in a sustainable way while strengthening integrated public health services and reducing inequalities (WHO, 2020). Public health professionals delivering these services include those responsible for providing essential public health services regardless of the organisation in which they work (DHHS, Public Health Service, 1994). These include almost all physicians, dentists and nurses, and additionally many other health, environmental and public safety professionals (Gebbie et al., 2002). Given the importance of public health for a country’s preparedness towards health emergencies, epidemics and efforts to achieve universal health coverage, the task of ensuring that this workforce is prepared with skills and knowledge to face both identified and emerging public health challenges is immense (Gebbie et al., 2002).

The Indian health system witnessed rapid reforms after the launch of the National Health Mission (NHM; erstwhile National Rural Health Mission [NRHM]). India continues to face challenges on the availability of health professionals. Its ratio of 0.96 doctors and 0.9 nurses per 1,000 population (Zopdey et al., 2019) is lower than the WHO-estimated global average of 1 doctor (Deo, 2016) and 3 nurses (WHO, 2018) per 1,000 population. This shortage of health professionals points towards the fact that capacity building needs to pick up pace to meet even the existent health needs of the Indian population. Uneven geographic distribution and availability of health professionals is a challenge. In the past, there have been periodic attempts to incentivise rural health jobs and make rural postings compulsory, but with limited success (Press Trust of India, 2012). The outflow of trained health professionals to foreign countries in the past, especially doctors (Sinha, 2012) and nurses (Thompson & Walton-Roberts, 2018), has also been identified as a contributing factor in worsening the HRH shortage in the country.

The National Health Policy 2017 outlined several new initiatives that influence health service delivery and public health (Ministry of Health & Family Welfare, 2017). Notably, it recommended strengthening the delivery of primary health care, through establishment of ‘Health and Wellness Centers’ as the platform to deliver Comprehensive Primary Health Care, and called for a commitment of two-thirds of the health budget to primary health care, providing a fillip to the service provision at the point of care. The supply side of the system with regard to tertiary care is being strengthened with initiatives under the District Hospital Strengthening (National Health Mission, 2019), as well as through the establishment of new AIIMS (All India Institute of Medical Sciences) institutions (Kunju, 2019) across the country, which enables access to quality tertiary healthcare services to underserved areas (Thakur, 2017). The proposal of setting up a public health management cadre and the focus on strengthening of district hospitals for meeting the shortage of medical specialists are other HRH initiatives outlined in the National Health Policy 2017 to overcome the paucity of trained public health specialists and clinical specialists which are demonstrating progress.

The current COVID-19 pandemic is a public health emergency (WHO, 2020). The shortage of health professionals can impact the response of the health system in responding to the pandemic. The country needs adequate numbers of frontline health workers—from physicians and nurses to laboratory technicians. Within India, state-wide inequities exist not just in numbers but also in health infrastructure (hospital beds) and equipment (personal protective equipment, ventilators) (Singh et al., 2020). Medical supplies’ shortage and inadequate testing capacity are major issues as well (Bhardwaj, 2020). Thus, under-investment in the public healthcare system poses a great challenge to India’s COVID-19 containment plans which, as per epidemiologists and public health experts, can be met through increasing expenditure in the public health system (Chetterje, 2020).

A critical mass of health professionals is necessary to manage a health system and is often a crucial limiting factor in the delivery of quality health services. India’s current situation, juxtaposed with its medium-term and long-term HRH requirements, necessitates reassessing the policy levers that are available at the national level. This article aims to suggest strategic options for India’s way forward to meet challenges related to health service delivery and public health, with an HRH focus.

Methodology

We reviewed and compared public health studies from different countries which focused on strengthening HRH at the national level. We reviewed the literature—which included case studies, research articles and reports—showcasing successful HRH interventions with strong government support and involvement and commitment by all stakeholders, especially health departments, professionals (including coordinators, managers, academicians, researchers, primary care providers), health authorities and the private sector. The pros and cons of the HRH interventions were weighed to suggest strategic HRH options in India’s context for transforming health systems.

We undertook a two-step approach for identifying and selecting the strategic HRH options that would be most suited in the Indian context. The first step was undertaking a thorough desk review to analyse the existing literature on the HRH situation and interventions with a focus on India and other similar developing countries to develop a compendium of potential options. Here, we included any type of research article or report that described health policy and planning strategies, strategic options for HRH (past experiences, past, current and future policies), the best practices, way forward and ways of implementation—published within the last two decades (i.e., during 2000–2020). We also searched for literature related to ‘HRH’ shortfall, distribution, performance, quality, governance, estimation, forecasting, management systems, leadership, partnership, finance and education. We searched for relevant literature mainly within the context of developing countries with upper- and lower-middle-income economies, like India, which suffer from a heavy burden of diseases (Swaminathan et al., 2019). This included published, peer-reviewed primary research, as well as commentaries, editorials and review papers. We also included grey literature (unpublished reports and evaluations) if it included descriptions of HRH policies and strategies and their implementation. We included literature that described HRH policies/strategic options that have worked in any aspect of primary, secondary or tertiary levels of healthcare and any disease or health issue. Overall, we included published and unpublished papers reported in English. In contrast, we excluded papers not focused on HRH. Furthermore, we excluded papers not reported in the English language. A total of 72 articles were reviewed, which included 37 research articles, an additional 30 reports and 5 news articles, as identified by the research team.

The second stage comprised discussions with public health experts, academicians and policymakers. These experts were selected on the basis of their work experience, job role, type of organisation and contribution to the field of HRH in India. Thus, a review of the potential options from the lens of ‘potential of effectiveness’ and ‘felt need’ was undertaken. The strategic options were subjectively appraised and then considered for selection in the review. Wherever possible, the evidence supporting the effectiveness of the interventions was also reviewed by the authors.

A list of strategic options for reforming the current state of HRH in India was developed, and the options were scored on a scale of 1–5 (5 being the highest) for the following parameters: innovation; disruption; difficulty of implementation; budget for implementation; and importance and time period for implementation. The authors discussed, scored, plotted and reviewed these options on a grid on the basis of their perceptions, guided by the literature and their experience. The description of the parameters is provided in Table 1.

Table 1.

Description of Parameters for Strategic Options for Human Resources for Health(suggested way forward).

Sr. No. Parameters Description Indicator

1 Innovation How creative/new/innovative the suggested option is Y-axis

2 Disruption How much disruption/disturbance the suggested option is likely to create within the current Indian health systems Colour of the object’s outline (black to red) red∝disruptive

3 Difficulty of implementation How difficult the implementation of the option would be in terms of infrastructure/numbers of health professionals/existing policies X-axis

4 Budget for implementation How much investment the suggested option would require (in comparison to other suggested options) Size of object size ∝ budget

5 Potential for change/impact How much impact can be produced by the option Potential for change/impact of the outline of the object thickness ∝ potential for impact

6 Time period for implementation Expected time period for implementation of the suggested option, such as short-term (1–2 years), mid-term (2–3 years) and long-term (3–5 years) Colour of object

Source: Authors own.

A graphic was created with the available strategic options, and the extremities of the grid were classified into two categories, namely:

Quick wins—low in innovation and less difficult to implement

Transformation opportunities—high in innovation and difficult to implement

Deciding attributes for proposed strategic re-forms for India’s HRH policy framework

On the basis of the reviewed literature, the authors agreed that the (to-be) proposed strategic reforms for India’s HRH policy framework should align with the global HRH response, such that it strengthens the HRH needs and to create a stronger multi-sector orientation with an equity-oriented agenda.

Results

India continues to grapple with HRH issues pertaining to numerical and distributional imbalances, inadequate training and technical skills, improper deployment, inefficient skill mix of health workforce, often coupled with poor personnel management, non-existence of career structures, inadequate staff supervision, lack of motivation, poor working environment and lack of opportunities for personnel development (Nandan & Agarwal, 2012). As reported in a study published in 2012, the density of doctors, nurses and midwives was reported to be around 23 per 10,000 population (Rao et al., 2012). A new estimate generated by Karan et al., published in 2019, estimated this density to be 20.6 per 10,000 population (Karan et al., 2019). While the overall workforce density remains the same at the country level, geographical inequities and urban–rural inequities persist. Multiple factors, such as regulatory mechanisms, duration and scope of pre-service education or training at the place of work, quality of infrastructure, equipment and consumables, continuing education and training, regulation, management, supervision, performance incentives and the perceptions of communities towards them, influence the quality of the performance of health workers, that is, their effectiveness and efficiency (Campbell et al., 2013).

Thus, to suggest a way forward for policymakers, we developed this framework based on strategic HRH options to assist governments and health agencies in planning, developing and implementing effective strategies for achieving a sustainable health workforce and UHC. Inspired from the GHWA’s HRH Action Framework (Global Health Workforce Alliance and World Health Organization, 2020) this HRH Strategic Options The framework analyses HRH issues and provides recommendations on the basis of six parameters of feasibility for adopting a suggested way forward (strategic HRH option). These six parameters are innovation, disruption, difficulty of implementation, budget for implementation, potential for change/impact and time period for implementation. This framework is targeted to help address workforce shortages, inequitable distribution of health workforce, low absorption and poor retention (especially in rural/remote areas), among other challenges. It suggests strategic options for the way forward, based on rectifications in HRH planning, management and forecasting processes. The strategic HRH options developed for India from the lessons learnt from this review are explained in this section.

Lessons learnt: Health workforce planning, being a critical and important activity, should be conducted by expert panels set up by the government for different categories of healthcare workers—such as in Japan (Ono et al., 2013)—or by a multi-stakeholder government–industry committee—such as in Netherlands (Van Greuningen et al., 2012)—or by a permanent, dedicated national planning agency—such as in Thailand (Jongudomsuk et al., 2012)—or by the government itself—such as in South Africa (National Department of Health, 2015). Both the United Kingdom and Australia have transitioned to locating the HRH planning function within government from having dedicated agencies (Smith et al., 2018).

Way forward: Strategic option 1—A national HRH body would be a difficult step to implement within the current national mechanisms and fiscal space. However, such a novel institution can be set up either as a technical-support unit within the Ministry of Health and Family Welfare (MoHFW) or as an independent institute to undertake HRH research, guide policy development and support the building of capacity in HRH.

Lessons learnt: Globally, public–private partnerships (PPPs) have been widely used for leveraging the skills, expertise and resources of the private sector, because noncommunicable diseases (NCDs) continue to rise, particularly in low- and middle-income countries (LMIC), due to increased availability of tobacco, alcohol and unhealthy foods and a poorly regulated health industry (Moodie et al., 2013). The partnership may explore expertise and resources of the private sector to support public sector delivery—such as in South Africa’s between Biovac Institute and National Department of Health (NDoH) to cover research and development, manufacturing and supply of vaccines (Walwyn & Nkolele, 2018). Similarly, PPPs can be beneficial in responding to the health emergencies such as COVID-19. Coronavirus testing was undertaken by private laboratories as well to support the public health infrastructure in the United States, Norway and Portugal (Roser et al., 2020).

Way forward: Strategic option 2—Evolving PPP models for HRH has been tried and implemented previously as well, and thus it would be a quick and easy option and, if it works, would improve health coverage and service delivery within the country.

Lessons learnt: For effective monitoring and strengthening of national health systems, identification of a set of HRH benchmarks and indicators is most crucial (WHO, 2008). Thus, there is a need for clear and updated staffing norms in order to link the HRH planning exercise to implementation and ensure equity in HRH distribution (Department of Health—South Africa, 2015). Right staffing norms would also help the government plan for incremental coverage transcending from expressed demand (minimum level) to need (more comprehensive coverage) (Smith et al., 2018). Currently, WHO’s Workload Indicators of Staffing Needs (WISN) tool is used in several countries, such as Tanzania (Mbwele et al., 2012), Namibia (McQuide et al., 2013), Uganda (Namaganda et al., 2015), South Africa (Daviaud & Chopra, 2008), etc. However, WISN is being criticised for its non-generalisability, as service delivery may be affected by the topography, climate and population density of each area (Doosty et al., 2019). Thus, there is a need to benchmark HRH ratios within the Indian scenario using the best available data from governmental and other sources.

Way forward: Strategic option 3—Benchmarking HRH ratios in the national context would be a less difficult option to implement, as it is dependent on the availability and validity of HRH data.

Lessons learnt: The Abuja Declaration of 2001 recommended that governments allocate 15% of their budgets to the health sector to achieve a certain level of health system performance (Jowett et al., 2016). However, it has been reiterated that a target of government spending on health of at least 5% of the GDP must be set for progressing towards UHC (Mcintyre et al., 2017). When compared with that of the countries such as the United States (16.9%), Germany (11.2%), France (11.2%) and Japan (10.9%), India’s health expenditure as a share of its GDP (including government and out-of-pocket expenditure) is at 3.6%, which is lower than the average for Organisation for Economic Co-operation and Development (OECD) countries (8.8%) (OECD, 2019). Among the BRICS (Brazil, Russia, India, China and South Africa) countries, India spends the least, and Brazil spends the highest at 9.2%, followed by South Africa at 8.1%, Russia at 5.3% and China at 5% (OECD, 2019).

Way forward: Strategic option 4—At least 2.5% of the GDP should be allocated to health (as government expenditure). A significant portion should be allocated towards overcoming the existing workforce’s shortages and investing in their skill building.

Lessons learnt: As suggested in the Global Strategy on Human Resources for Health, high-income countries should ensure that at least 25% of all development assistance for health is allocated to HRH (WHO, 2016). According to the World Bank’s Poverty and Shared Prosperity 2018 report, India, with a Gini coefficient of 0.51 (in 2013) (Jain-Chandra et al., 2016), has been listed as the country with the most poor people in the world (World Bank, 2018). Furthermore, it has been forecasted that post COVID-19 in India, around 12 million people would be pushed into extreme poverty (Mahler et al., 2020). Thus, in order to tackle the projected increase in inequality, which would gradually translate into the access to and availability of health services, there is a need to allocate at least 25 per cent of all development assistance for health to HRH.

Way forward: Strategic option 5—Allocating at least 25 per cent of all development assistance for health to HRH would have a very high impact, as it would lead to HRH research; basically, it would fund the proposed national HRH body and may cause high disruption due to budget involvement.

Lessons learnt: In India, the rural population constitutes approximately 71% of the total population (2016), whereas only 36% of all health workers are in rural areas (Karan et al., 2019). People living in rural areas have lower access to health care compared to those who live in urban areas. If we analyse this from the health infrastructure perspective, among the 25,778 government hospitals in India (2019), 83% are in rural areas; however, these rural hospitals only hold 37% of the total government beds (Central Bureau of Health Intelligence, 2019). Some health indicators reflect the disparity, as overall only 75% of rural births are now supervised, as compared to 89% of urban births, and the infant mortality rate is relatively higher in rural areas (Karan et al., 2019) than in urban areas (Press Trust of India, 2012; CBI, 2019).

WHO recommends certain measures to increase health worker distribution in rural areas through making amends in educational policies (such as targeting admission policies to enrol students with a rural background and rural postings), service regulations (compulsory service requirements in rural and remote areas), financial incentives (such as hardship allowances, grants for housing, free transportation, paid vacations, etc.), personal support (improved sanitation, electricity, telecommunications, schools, etc.) and professional support (career development programmes and provision of senior posts in rural areas) (WHO, 2010).

Way forward: Strategic option 6—Halving the current levels of disparity in health worker distribution between urban and rural areas would reduce disparity/inequity and would also contribute to reduction in out-of-pocket expenditure of poor, who spend most of it to travel to health facilities located in urban areas.

Lessons learnt: Over the past decades, globally, governments and the public sector have made large community-based investments for improving population health. While previous studies on community-based health programmes have found them to be influential, some of them have been reported to not produce significant changes in health outcomes even after 10 years (Roussos & Fawcett, 2000). The Centers for Disease Control and Prevention proposes evaluation focusing on the areas such as implementation, effectiveness, efficiency, cost-effectiveness and attribution of health programmes (U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, Office of the Director—Office of Strategy and Innovation, 2011). The International Health Regulations (IHR, 2005) were evaluated in 19 technical areas under four broad themes—prevention, detection, response and points of entry (PoE)—and other IHR hazards (chemical and radiation) were evaluated through a Joint External Evaluation (JEE) exercise undertaken by WHO for the African region. It was observed that the JEE stimulated participatory, open debate both during the internal self-assessment and during the JEE (Talisuna, 2019).

Way forward: Strategic option 7—The NHM has been India’s flagship public health programme since 2005. It provides financial assistance to states, which includes assistance to recruit and retain staff for the delivery of health services. States are expected to submit proposals for approval on a yearly basis to the NHM. There is a provision to recruit contractual health professionals to supplement the work undertaken by the health department. These initiatives can provide efficient returns if they are part of a holistic HRH vision of the states. These contractual staff may be deployed to overcome distributional imbalances and overcome skill mix gaps. However, challenges surrounding personnel management, career structure and opportunity for personal development continue to challenge contractual staff routed through the NHM (Nandan & Agarwal, 2012).

Lessons learnt: Systematic management of data pertaining to health professionals is critical for all aspects of effective and efficient HRH planning. Policymakers or HRH experts would require data from several different organisations, government data sets and regulatory bodies for a proper health workforce planning model. However, this process would be cumbersome and difficult to replicate regularly, as it would require large resources in order to consolidate and create a baseline data set or live register at the national level.

If we see examples of health workforce data from other countries, such as in Netherlands, all medical specialists and general practitioners who want to practise in the country are registered by the Medical Registration Committee (Greuningen, 2016). However, all registered specialists might not be actively working, and this information is thus sometimes difficult to recover (Greuningen, 2016). In South Africa, the health professionals’ data from public and private health sectors are housed in a variety of institutions, from regulatory bodies, like the Health Professions Council of South Africa (HPCSA), to the bodies like the Board of Health Care Funders (BHF), which is tasked with issuing practice numbers to enable healthcare providers to claim from health funders (Smith et al., 2018). In India, the regulatory bodies like the Medical Council of India (MCI) and the Indian Nursing Council (INC) should have the full list of registered health professionals, ordered by specialisation. These data sets need to provide an up-to-date view of whether a professional is located in the public or private sector (or both) and also report about emigration, death and retirement of health professionals or those who are registered but inactive.

Way forward: Strategic option 8—Live registry of HRH would consolidate the much-needed data on health professionals under one board/council for India.

The suggestions for the way forward (i.e., strategic options) emerged from the review and the lessons learnt have been plotted (Figure 1) on the axes of innovation and difficulty in implementation by the authors. These strategic options have been classified under WHO’s six health system building blocks (Table 2).

Figure 1.
Source: Authors own.

Table 2.
The Way Forward—Strategic Options for India’s Framework for Human Resources for Health.

Strategic Option Number Strategic Options

Strategic Option Number Strategic Options

Leadership and governance

1 Institute a national HRH body (develop normative guidance, support operations, research to identify evidence-based policy options and provide technical cooperation).

2 Evolve public–private partnership models for HRH.

HRH numbers

3 Benchmark HRH ratios as per the country’s needs.

Sustainable financing

4 Allocate at least 2.5% of GDP (as government expenditure) to health.

5 Allocate at least 25% of all development assistance for health to HRH.

Service delivery

6 Halve the current levels of disparity in health worker distribution between urban and rural areas.

Data and evaluation

7 Evaluate HRH support through the NHM.

8 Maintain a live register of HRH.

Source: Authors own.

Discussion

Since India’s independence, the Indian health sector has made enormous strides. Between 1960 and 2018, there has been an increase of 28 years in India’s life expectancy, that is, from 41.4 years (in 1960) to 69.4 years (in 2018) (World Bank, 2020). However India’s health system is under great stress due to the rising burden of communicable and non-communicable diseases, unknown infectious disease threats, such as the COVID-19 pandemic, and high levels of vector-borne diseases, such as dengue and acute encephalitis syndrome (Narain, 2016).

The recent COVID-19 has exposed India’s under-invested and understaffed public healthcare system (Chetterje, 2020). In a pandemic situation, especially within large geographic areas that report a significant number of cases, globally we have witnessed health resources and infrastructure being overwhelmed. Such instances were reported in Italy and other countries. In such situations, there is an urgent need to redeploy skilled workforce from areas with lower cases, as well as undertake innovative steps to efficiently deliver services. Health workers are at the front line of the COVID-19-outbreak response. However, due to improper training and lack of skills, they are exposed to several hazards that put them at risk of infection (WHO, 2020). The hazards include pathogen exposure, strenuous working hours, psychological stress, exhaustion, occupational burnout, stigma and physical and psychological violence (WHO, 2020).

We recommend a transformative way forward to meet India’s challenges related to health service delivery and public health—focusing on HRH. These strategic options lay down solutions that would help India meet its public health challenges in the interim. However, there are three guiding questions that need to be asked of the policymakers: first, how would these strategic options be implemented in the health system (implementation); second, who would be the key stakeholders responsible to implement these strategies (key stakeholders); and third, by when should India implement these strategies to achieve UHC and ensure access to care for all (target year). We have attempted to answer these questions by providing a road map for setting priorities in health service delivery and public health in India.

Strategic option 1: Institute a national HRH body (develop normative guidance, support operations research to identify evidence-based policy options and provide technical cooperation)

Instituting an overarching body for HRH would strengthen the capacity of Indian researchers to conduct policy-relevant research in the areas of healthcare finance, economic evaluation, public health insurance and health policy analysis. The national body should have an arm’s-length relationship with policymakers in and outside MoHFW in order to maintain policy relevance and scientific integrity and independence. Currently, the country lacks expertise in estimation and forecasting for HRH. Also, such complex analysis needs knowledge and consideration about India’s demographic and epidemiological burden of disease transitions. Thus, to build forecasting and planning capacity in the country, instituting a national HRH body, department or unit within MoHFW or at university levels would be helpful. There is a need for dedicated modules/short-term courses in HRH/workforce estimation to help policymakers understand, develop and improve HRH policy and strategies that quantify health workforce needs, demands and supply (Public Health Foundation of India, 2011; Zopdey et al., 2011). The key stakeholder in implementing this strategy would be Government of India.

Strategic option 2: Evolve public–private partnership models for HRH

In order to harness the full potential of collaboration with the private sector, it would be important to impose greater social accountability on private providers for making a certain proportion of private services available to the poor (Sengupta & Nundy, 2005). Private practitioners should be contracted to avail their services to serve in the public sector—especially to overcome shortages in specialist services, such as surgery, anaesthesia, gynaecology and medicine (Mureithi et al., 2018). The government of India, regulatory bodies, professional associations, state health systems and district health systems may serve as key stakeholders in implementing this strategy at least by the year 2022.

Strategic option 3: Benchmark HRH ratios as per the country’s needs

Though the Indian Public Health Standards (IPHS) and National Accreditation Board for Hospitals & Healthcare Providers (NABH), norms exist in the country for health facilities under the public and private sectors, but a revision is suggested for the same considering: the current and future burden of diseases; demographic and epidemiological transitions; impact of health policies on service delivery; quality and equity; prioritisation of underserved areas; health workforce and expenditure; level of services; and the productivity of health workers (Birch, 2015). Implementation of this strategy has to be undertaken by MoHFW, regulatory bodies, professional associations and research organisations involving HRH experts and academicians, at least by 2022.

Strategic option 4: Allocate at least 2.5% of GDP (as government expenditure) to health

The Indian health system should increase its spending on strengthening of its supply pipeline of trained health workforce and absorption of these trained professionals into government-funded posts distributed equally across the country. These trained health professionals would serve as the seeds for health facilities and support staff. Thus, there could be gradual development of health facilities and infrastructure across the country through ensuring systemic funding into the health-professional need–supply system. As suggested in the National Health Policy 2017, there is a need to increase the government’s health expenditure as a percentage of GDP from the existing 1.15% to 2.5% by 2025 (Ministry of Health & Family Welfare, 2017). Key stakeholders for implementing this strategy would be the NITI (National Institution for Transforming India) Aayog, MoHFW and health financing experts (Ministry of Health & Family Welfare, 2017).

Strategic option 5: Allocate at least 25% of all development assistance for health to HRH

Including the general budget, the government should plan and mobilise resources for HRH investment from both traditional and innovative sources, such as social health insurance, dedicated earmarked funds, ring-fenced excise taxes and corporate social responsibility funding from the extractive industries such as mining and petroleum. Such investments should be consistent and aligned with the broader national health and social protection agenda (WHO, 2016).Government of India, NITI Aayog and health financing experts are the suggested stakeholders for implementing this strategy by the year 2025.

Strategic option 6: Halve the current levels of disparity in health worker distribution between urban and rural areas

To start with, there is a need for redeployment of trained health workforce, focusing on reduction of geographical inequities. Furthermore, future workforce planning should be based more on the substantial elements such as disease burden, fiscal space and existing geo-spatial and social inequities in access to health services. This strategy can be implemented by Government of India (MoHFW) with the involvement of HRH experts by 2025.

Strategic option 7: Evaluate HRH support through the NHM

Though Common Review Missions and Annual Review Missions are undertaken to review the ongoing NHM, there is a need for in-depth assessment of the support provided by the NHM to HRH in terms of numbers and performance of health professionals. Such assessment would assist policymakers judge whether the country is on the right track and whether new directives are required to optimise HRH support through the NHM. Government of India and research organisations, with the involvement of HRH experts, may serve as the key stakeholders and implement this strategy by 2025.

Strategic option 8: Maintain a live register of HRH

MoHFW maintains a database of health workers employed in the NHM through various training cells operating at the state level; however, at the national level, there is a need to maintain an HRH database containing quantitative and qualitative data (e.g., on demographics, education and training and place and type of employment). Also, provisions must also be made to account for health professionals exiting the workforce (through migration, retirement, death, etc.). Here, MoHFW, regulatory bodies, professional associations and research organisations, with the help of HRH experts and academicians, can serve as the key stakeholders and implement this strategy by the year 2025.

Conclusion

This article is timely as India moves towards the implementation of the SDGs with a particular focus on UHC and Ayushman Bharat Yojana. HRH is a critical element to be considered in this context. There is a need to not only enable greater numbers of health professionals to train but also eliminate the substantial inequalities in their numbers between states and sectors. The suggested strategic options for the way forward shall help India in dealing with the current health crisis and emerging with a strong public health system by 2025.

Strategic Option Number	Strategic Options
Strategic Option Number	Strategic Options
Leadership and governance
1	Institute a national HRH body (develop normative guidance, support operations, research to identify evidence-based policy options and provide technical cooperation).
2	Evolve public–private partnership models for HRH.
HRH numbers
3	Benchmark HRH ratios as per the country’s needs.
Sustainable financing
4	Allocate at least 2.5% of GDP (as government expenditure) to health.
5	Allocate at least 25% of all development assistance for health to HRH.
Service delivery
6	Halve the current levels of disparity in health worker distribution between urban and rural areas.
Data and evaluation
7	Evaluate HRH support through the NHM.
8	Maintain a live register of HRH.

Footnotes

Declaration of Conflicting Interests

Funding

The authors received no financial support for the research, authorship and/or publication of this article.

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Sr. No.	Parameters	Description	Indicator
1	Innovation	How creative/new/innovative the suggested option is	Y-axis
2	Disruption	How much disruption/disturbance the suggested option is likely to create within the current Indian health systems	Colour of the object’s outline (black to red) red∝disruptive
3	Difficulty of implementation	How difficult the implementation of the option would be in terms of infrastructure/numbers of health professionals/existing policies	X-axis
4	Budget for implementation	How much investment the suggested option would require (in comparison to other suggested options)	Size of object size ∝ budget
5	Potential for change/impact	How much impact can be produced by the option	Potential for change/impact of the outline of the object thickness ∝ potential for impact
6	Time period for implementation	Expected time period for implementation of the suggested option, such as short-term (1–2 years), mid-term (2–3 years) and long-term (3–5 years)	Colour of object