Human Resources in Healthcare and Health Outcomes in India

Growth of Workforce in the Healthcare Sector

The total workforce engaged in the healthcare sector in India in 1991 was 1.9 million that rose to 2.35 million in 2001 and further to 4.6 million in 2011 (see Table 1). The addition (increment) of workforce in the healthcare sector during 1991–2001 was merely 0.45 million, but it was the phenomenal addition/increment of 2.25 million that almost doubled the total workforce in the healthcare sector during the decade of 2001–2011. The comparison of the rate of growth in population and that of workforce in the healthcare sector across states indicates that while the rate of growth in population has decelerated during the two decades, between 1991 and 2011, the rate of growth in workforce in the healthcare sector has accelerated (see Table 1). The rate of growth in workforce in the healthcare sector in India was almost similar to that of its population during the 1990s, but it was four times higher than that of the population during 2001–2011.

Health Workers per 1,000 Population: Density as a Measure of Availability and Adequacy

The density when standardized as number of health workers available per 1,000 population, revealed that for three census years (1991, 2001 and 2011) the density was recorded as 2.25 and 2.28 and 3.80 health workers respectively. This trend informs of a marginal improvement on this standardized measure during the 1990s which is quite remarkable during the last decade. This could be due to the rising health workforce, along with a decline in population growth rates during the decade 2001–2011.

Disproportionate Urban Concentration of Health Workers

The density of health workers in rural areas has been lower when compared with that of urban areas. In fact, the density of health workers in urban areas showed a marginal decline during 1991–2001 due to the fact that the rate of growth in urban health workers was not keeping pace with that of urban population during this period. Again, there was a remarkable improvement in terms of growth in rural health workers and its density during 2001–2011. But it could not alter the rural disadvantage in terms of having lower density. A large proportion of workforce engaged in the healthcare sector in India is disproportionately concentrated in its urban space. Urban areas sharing less than one-third of total population have more than half of the workforce engaged in healthcare (see Table 1). Conversely, rural areas with more than two-thirds of total population of the country have less than half of the workforce engaged in healthcare services. This is not withstanding a certain improvement in rural areas during the last decade.

The rate of growth in health workforce in rural India (8.95%) between 2001 and 2011 is almost eight times higher than that of its rural population (1.17%). In urban areas, the growth of health workforce (5.53%) is merely two times higher than that of its population (2.80%). In the previous decade there has not been much difference between rate of growth of health workers and population either in rural or urban areas of the country. The rate of growth in rural health workers between 1991 and 2001 was two-thirds of what the urban health workers witnessed during the period. Such pattern is reversed during 2001–2011 wherein the rate of growth in urban health workers was 60 per cent of that of the rural.

When decadal change in terms of absolute addition/increment (i.e., number of people/workers added from the base to reference years) was examined, the urban areas contributed little above one-third of the total population added between 1991 and 2001, and around half of it between 2001 and 2011. In case of health workers, more than two-thirds (70%) of health workers that were added to total workforce engaged in health activities during the 1990s were concentrated in urban areas, but such a urban concentration appeared to be little lower during the 2000s wherein the urban share was little less than half (46%) of the total increment. The ratio of increment in the decade 2001–2011 to the previous decade (1991–2001) is 0.8 in case of absolute increment of population but the increment of health workers in 2001–2011 was nine times higher than that of the increment in the previous decade (1991–2001). In urban areas, such ratio between the last and the previous decade is 1.3 times in case of population and 3.3 times in respect of health workforce.

On the whole, the growth of workforce engaged in the healthcare sector is impressive during the last decade (2001–2011) when compared with the previous decade. But still the rural disadvantage persists in this regard. The urban space is having an explicit relative advantage in this regard where its share of health work force outweighs its share of population which in turn exceeds the minimum need-based requirement. Therefore there is a need for geographical redistribution or redeployment of health workers between rural and urban areas.

Shortage of Health Workers: Reference to WHO’s Minimum Requirement

When referred to WHO’s standard basic/threshold minimum of 4.45 health workers per 1,000 population, even the density of total workers (including non-medical staff) in the country’s healthcare sector falls short of such minimum requirement. Given the size of population in India and WHO’s threshold (of 4.45 health workers per 1,000 population), it would have required nearly 3.73, 4.58 and 5.39 million skilled workforce for its healthcare services in India respectively for the years 1991, 2001 and 2011. The shortage of healthcare workers in India is conspicuous; it was 1.85 million in 1991, 2.23 million in 2001 and 0.79 million in 2011 (see Motkuri et al., 2017). As we elaborate in the following sections, the shortfall would be even more if only skilled health professionals, that is, excluding the non-medical staff are considered.

Such a minimum requirement when qualified independently between rural and urban areas, urban areas would far exceed the minimum requirement, leaving the rural space falling far short of it. Visibly such shortage is quite severe in the rural areas when contrasted against the shortage depicted at the national level. Therefore, apart from making up for the shortage in health workforce, there needs to be an emphasis on its redistribution or redeployment.

Surge in Health Workforce during 2001–2011 Explained: ASHAs or Growth of the Private Sector?

The surge in terms of doubling of the workforce engaged in the health sector could be due to growth in the private sector in healthcare services or induction of ASHAs or otherwise. In fact, engaging ASHAs, at least one per village, is one of the important components of the Government of India’s National Rural Health Mission (NRHM) launched in 2005. In order to implement NRHM in rural India, a large number of ASHA workers since then have been inducted and made part of the rural healthcare system. The countryside consists of more than 6 lakh villages and the count would be much more if the number of hamlets is taken into account.

As per the Government of India’s report the total number of ASHAs engaged by all the states/union territories (UTs) increased from 7.06 lakh in 2009 to 8.90 lakh in 2013 (GOI, 2014). If we take an approximate of 8.0 lakh ASHAs for the year 2011, they account for little above one-third of the total health workers added (increment) between 2001 and 2011. Their contribution is relatively large in rural areas; it was around two-thirds of increment in rural health workforce during 2001–2011.

The economic reforms introduced in 1991 facilitated growth of the private sector in most of the industries and services sectors including the healthcare services (Duggal et al., 2012). Although the Government of India has since the mid-1980s actively encouraged the formal private healthcare sector through direct and indirect incentives and policy measures, it took shape during the post-reform period (Duggal et al., 2012; see Chakravarthi et al., 2017). In terms of the growth in the private healthcare sector, the 1990s was just a beginning but its impact got multi-fold since the turn of the 21st century. The private healthcare sector in India is a heterogeneous mix ranging from individual practitioners to small and medium hospitals and the corporate commercial hospital sector (Duggal et al., 2012; Chakravarthi et al., 2017). As it is observed, the trend in the healthcare industry during the 2000s indicates that large-scale enterprises in this regard are growing faster than small and medium ones (see Hooda, 2015). For instance, one of the giant corporate healthcare institutions Apollo began its service in the 1980s and expanded multifold geographically within and outside India. Apollo Hospitals’ recent annual report claims that it has patients from 120 countries around the globe (see Apollo Hospitals, 2016). The growing demand inducing the healthcare industry and market has led multinational companies to enter into the Indian market and begin their operations (see Chakravarthi et al., 2017).

Therefore, the remarkable growth of workforce engaged in healthcare activities observed for the decade 2001–2011 is partly due to the expanding private healthcare sector in India. Giant corporate bodies are engaging huge number of healthcare professionals and other skilled health workers along with non-medical workers. There has not been much effort in assessing the size and strength of the private healthcare sector especially in respect of its human resources. Apollo Hospitals’ recent annual report claims that it has more than 9 thousand beds capacity and nearly 60,000 dedicated healthcare providing staff (including doctors and other paramedics) in its group of hospitals across cities in the country (see Apollo Hospitals, 2016). There are many such corporate and non-corporate multi-specialty hospitals in India, along with clinics and nursing homes. Most of these private healthcare institutions are largely concentrated in urban areas.

It is interesting to note that there is a spatial difference in accounting for these two important factors in surge witnessed in the growth of healthcare workforce in rural and urban areas. While the induction of ASHA workers accounted for the large portion of increment in the rural health workforce during the last decade (2001–2011), it is the growth of the private sector in healthcare that contributed largely for the growth of urban health workforce during this period.

Regional Variations: Across Major States

In the federal structure of the Indian Constitution, public health is a state subject—although national policymaking and providing funds to states for implementing it rests with the union government. The responsibility largely lies with governments of respective states which vary in their policies, resources and political priorities, and hence the performance. In this regard to bring out inter-state differences, state-level analysis is carried out. Therefore, going beyond verification of the national aggregate, regional variation in this perspective is quite large with a huge variation across states in terms of the rate of growth of population and health workers, along with the number of health workers available per 1,000 population (see Table 2).

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Table 2.

Density of Health Workers (per 1,000 Population) and Growth of Population and Health Workers between 1991 and 2011: Majors States in India

S. No.	State	1991–2001		2001–2011		Density of HW
		Pop	HW	Pop	HW	1991	2001	2011
1	2	3	4	5	6	7	8	9
1	Andhra Pradesh (United)	1.37	2.30	1.05	6.80	2.1	2.3	4.0
1a	Andhra Pradesh (Residual)	–	–	0.92	7.22	–	2.0	3.8
1b	Telangana	–	–	1.23	5.12	–	2.7	4.2
2	Assam	1.75	1.27	1.59	10.71	1.8	1.8	4.2
3	Bihar	1.86	0.90	2.29	7.16	1.4	1.1	1.8
4	Chhattisgarh	–	–	2.06	4.22	–	1.8	2.3
5	Gujarat	2.06	1.89	1.78	7.97	2.3	2.2	4.1
6	Haryana	2.53	1.93	1.83	6.49	2.6	2.4	3.8
7	Himachal Pradesh	1.63	(–)1.20	1.22	10.62	3.1	2.4	5.7
8	Jammu & Kashmir	2.77	–	2.14	10.90	–	2.2	5.0
9	Jharkhand	–	–	2.04	7.59	–	1.4	2.4
10	Karnataka	1.63	1.91	1.46	7.45	2.3	2.4	4.3
11	Kerala	0.90	3.33	0.48	6.59	3.7	4.7	8.5
12	Madhya Pradesh	2.81	2.95	1.87	7.43	1.7	1.9	3.2
13	Maharashtra	2.07	2.90	1.49	5.52	3.3	3.6	5.3
14	Odisha	1.52	0.17	1.32	11.60	1.8	1.6	4.2
15	Punjab	1.85	1.86	1.31	6.11	3.0	3.0	4.7
16	Rajasthan	2.53	1.80	1.95	7.45	1.9	1.8	3.0
17	Tamil Nadu	1.11	1.36	1.46	7.22	2.4	2.5	4.3
18	Uttarakhand	–	–	1.74	6.77	–	2.5	4.1
19	Uttar Pradesh	2.30	1.93	1.86	6.67	1.6	1.5	2.3
20	West Bengal	1.65	2.14	1.31	6.25	2.6	2.7	4.4
21	NCT of Delhi	3.93	3.92	1.94	3.62	6.6	6.6	7.8
All India		1.97	2.13	1.64	6.95	2.2	2.3	3.8
CV (Major States excl. Delhi)						26.7	36.3	35.9

Source: Authors’ calculations based on census data.

Notes: Figure represent rural and urban combined; For the state of Jammu and Kashmir in fact there was no Census conducted in 1991, but the estimated population figures are available with RGI and so we made a rough estimation based on that; The united Andhra Pradesh was bifurcated in the year 2014 into residual state of Andhra Pradesh and Telangana state. The separate state level averages for these two states for the years 2001 and 2011 were based on their district level information; CV—coefficient of variation (%).

Similar to the national scene, it is true for states as well regarding the contrast between growth in population and its health workforce. While the population growth rate decelerated, growth of health workforce accelerated during the two decades period between 1991 and 2011 (see Table 2). Moreover, unlike the situation observed in the 1990s, the rate of growth in health workforce during 2001–2011 was considerably higher than that of population and it is true for most of the states. The rate of growth in health workforce during the 1990s across states was less than 4 per cent. It was even lower among most of the states except Kerala and New Delhi. But during 2001–2011 some of the states namely, Assam, Himachal Pradesh, Jammu and Kashmir and Odisha witnessed a double digit rate of growth in their healthcare workforce. Except the state of Chhattisgarh, all the remaining states registered a rate of growth in their health workforce in the range of 5 to 8 per cent. Reading the ratio of rate of growth in health workers to that of population returns a national average of 4.2. States which stands above the national average are: Kerala (13.7), Odisha (8.8), Himachal Pradesh (8.7), Assam (6.7) united Andhra Pradesh (6.5), Karnataka (5.1), Jammu and Kashmir (5.1), Tamil Nadu (4.9), West Bengal (4.8), Punjab (4.7) and Gujarat (4.5) which could be considered as states with advantage in capacity of health workforce. The rest of the states may be termed as disadvantaged in this regard.

While contrasting the population growth rates with that of growth rates of health workforce, the decade of 1991–2001 exhibited small and marginal difference across states and a similar pattern was seen in the progress made in density of health workforce (available per 1,000 population) during this period (see Table 2). Due to considerably high rate of growth in health workforce over and above that of population during 2001–2011, the density of health workers across states shot up substantially ranging from 1.5 to 2.5 times higher by the year 2011 over the base (i.e., 2001). It is true for most of the states in India with varying rate of improvement. As observed above, the surge in healthcare workforce is partly due to the induction of ASHA workers while implementing the NRHM since 2005 and partly because of the growth of private healthcare sector. As is the case of variation in rate of improvement across states, the contribution of ASHA workers and growth in the private sector varies from state to state.

The variation (as measured by CV) in density across states increased between 1991 and 2001 but marginally reduced thereafter by 2011. However, the distance between the lowest densities to that of the highest increased throughout the two decades. The highest density observed among major states was three times that of the lowest one in 1991; it was four times in 2001 and five times in 2011.

Alternative Evidence

In an illuminating in-depth study by Anand and Fan (2016) based on occupational classification (NCO) data of Census 2001, that was carried out at state as well as district level, observed that in India there were 2.1 million health workers, of which 0.82 million (or 39.6%) were doctors, 0.63 million (or 30.5%) were nurses and midwives, and 0.024 million (or 1.2%) were dentists. Of all doctors, 77.2 per cent were allopathic and 22.8 per cent were of AYUSH category. Other categories of health workers were pharmacists, ancillary health professionals, and traditional and faith healers, who comprised 28.8 per cent of the total health workforce. This study observed the density of health workers at the national level was 79.7 doctors per lakh population, 61.3 nurses and midwives per lakh population and dentists were just 2.4 per lakh population (Anand & Fan, 2016). The urban–rural ratio was 1.45 as 59.2 per cent of total health workers were located in urban areas, whereas only 27.8 per cent of the population resided in the rural areas. The study further observed that the ratio of urban density to rural density for doctors was 3.8, for nurses and midwives it was 4.0 and for dentists it was 9.9 (Anand & Fan, 2016).

The same study reveals a startling reality of unqualified nature of most of health workers in the Indian healthcare system. It was observed that of all the cadres of health workers in 2001 less than half (48.6%) of them had secondary education and above. Further, a striking reality was that health workers with medical qualifications (medical diploma/degree) were less than a quarter (23.3%) of the total health workers in India in 2001 (Rao et al., 2016). It is alarming that even among those reported as allopathic doctors about one-third of them had educational level below secondary schooling. Regarding the medical qualification of allopathic doctors, only 42 per cent of them had such medical education. With respect to nurses and midwives, about two-thirds (67%) of them had studied up to secondary level and only 9.9 per cent of them had medical professional qualifications (Rao et al., 2016). It indicates that Indian healthcare system comprises such a large proportion of unqualified workforce.

The study (Anand & Fan, 2016) brought out inter-state differences as follows. There was a six-fold inter-state difference between the highest and lowest density of all health workers (see Anand & Fan, 2016). Certain categories of health workers were highly concentrated in particular states. For instance, West Bengal had 30.6 per cent of all homeopathic doctors, Uttar Pradesh had 37.5 per cent of all Unani doctors and Maharashtra had 23.0 per cent Ayurvedic doctors. Kerala had 38.4 per cent of all the medically qualified nurses available in the country. In some states the fraction of AYUSH doctors was much higher wherein it was 41.7 per cent in Tripura, 40.5 per cent in Odisha and 38.1 per cent in Kerala (Anand & Fan, 2016). Anand and Fan’s (2016) study found a negative correlation ⁸ between the percentage of nurses in the health workforce and the percentage of doctors across states. Further, the study found that the density of all health workers in a state was positive but imperfectly correlated with the per capita income of the state ⁹ . The study infers that better-off states seem to afford more doctors plus nurses per capita ¹⁰ and more dentists per capita. ¹¹

Further, another study in the recent past by Rao et al. (2016) based on NSSO 68th round EUS in 2011–2012, taking into account occupational classification of workers (NCO), estimated the density of health professionals and skilled health workers. This study considered only those health workers who were qualified while matching the occupation and educational qualification of the workers covered under the survey. This study measured the density per 10,000 population. It is very well discernible from the estimates offered by this study that density of all cadres of qualified health professionals and health workers together observed for the year 2011–2012 appeared to be lower than that observed for the year 2001. In fact, the estimates based on two different sources (Census and NSSO) and methods being strictly not comparable make trend comparison unreliable. The Census 2001 presented combined both the qualified and unqualified health professionals and other health workers whereas the study by Rao et al. (2016) based on NSSO’s survey of 2011–2012 presented their estimates of qualified health professionals.

According to the study (Rao et al., 2016) there were 1.4 million unqualified health workers in India representing 56.4 per cent of its total health workforce estimated for the year 2011–2012. The percent of unqualified ones in various cadres of health professionals are as follows: 42.3 per cent of allopathic doctors, 58.4 per cent of nurses and midwives, 27.5 per cent of dentists, 56.1 of AYUSH practitioners and 69.2 per cent health associates (see Rao et al., 2016). Moreover, presence of such unqualified health professionals is quite large in rural areas (71.2%) which surprisingly are to the tune of (48.8%) in urban area as well (Rao et al., 2016). Indeed, prevalence of unqualified and largely unlicensed PMPs attending to certain basic healthcare services is not a rare phenomenon in rural India and there are lakhs of such unqualified doctors in many cases at least one per village (see Narayana, 2004; 2006).

Growth of Skilled Health Workers/Professionals in India during the 2000s

Following the above studies an attempt is made in understanding the changes in the availability of health workers or professionals in India between two Censuses (2001 and 2011) and that based on NCO. However, due to brevity and limited purpose of present exercise and to avoid repeating the analysis of Anand and Fan (2016), a brief description of the situation is described above. Unlike the Anand and Fan (2016) study where the density of health workers was measured for lakh population, the present study computed health workers per 1,000 population to maintain consistency with the analysis already conducted above based on NIC-based classification of workers. Our focus herein is to present growth and density (per 1,000 population) of NCO based health workers of all cadres together (All) along with that of doctors and nurses including mid-wives (D&NMW), of allopathic doctors (AD), and of nurses including midwives (see Table 3).

What is obvious from the Table 3 is that the size of health workers or various cadres of all the health professionals have increased during the last decade (2001–2011). The total size of skilled health workers that served in India had increased from 2.1 million in 2001 to 3.8 million in 2011 with a net addition of 1.7 million skilled health workers during the period.¹² The rate of growth in all cadres together is 6.3 per cent between 2001 and 2011 (see Table 3). Such a high rate of growth in number of all the skilled health workers in various cadres combined is four times higher than the rate of growth in population (1.64%) during the decade (2001–2011) and hence there was a remarkable improvement in the density of health workers in India during the period. However, some of the sub-categories/cadres of health workers especially AYUSH and pharmacists have registered a negative growth between 2001 and 2011, indicating the decline in the size of health professionals in this cadre/category during the decade. Accordingly, density of these cadres of AYUSH and pharmacists in India has declined.

The negative rate of growth in AYUSH practitioners pulled down the rate of growth in all the doctors including AYUSH and allopathic (to 1.97%). Otherwise, allopathic doctors have registered a rate growth at 3.3 per cent during the period and accordingly their density had improved but it was still less than one per 1,000 population at the national level. When compared to the situation of density of doctors in developed countries such as Germany, UK, and USA and developing countries like China, it is very low in India (see Figure 1). It shows that the density of doctors in India is three to four times lesser than that of developed countries (Motkuri et al., 2017). Indeed the situation of availability of doctors against the requirement in India is abysmally low and should be a matter of grave concern for policymakers in this regard.

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Figure 1.

Source: WHO.

There is a very high rate of growth (12.6%) registered for the cadres of nurses and midwives, during the period 2001–2011 (see Table 3). As a result, the share of nurses and midwives in the total skilled health workers in the country had increased from 30.5 per cent in 2001 to 54.3 per cent in 2011. It needs to be mentioned that the cadre of nurses and midwives includes both qualified and unqualified ones. The qualified and trained ones are those that hold appropriate diplomas or degrees in medical sciences that qualify them to engage in the profession (see Appendix). The unqualified are those without any certification (diploma or degree) or training in medical sciences but merely reported as being engaged in this profession. We guess that a major portion of the high rate of growth in nurses and midwives cadre was due to this unqualified nature of professionals in the cadre. In fact, both the studies that were mentioned above (Rao et al., 2016 and Anand and Fan, 2016) have exhibited such a trend. The study by Rao et al. (2016) showed that more than half (58%) of this cadre of nurses and midwives in 2011–2012 were unqualified. The other study (Anand and Fan, 2016) referring to the situation in 2001, observed that there only 10 per cent of the cadre of nurses and midwives had medical professional qualifications.

In rural areas there is phenomenal increase in number of ASHA workers in the healthcare system while implementing NRHM since 2005, although may not have medical qualifications but are engaged in the sector for a purpose and are included in the cadre that is in the sub-category of ‘midwifery associates’. This sub-category in fact indicates such a surge. Hence, it confirms our assertion made above on the high rate of growth of health workers in general (NIC-based) and especially in the cadre of nurses and midwives in India is due to surge in the number of ASHAs engaged in rural areas.

When the rate of growth in the workforce (Table 1) that was engaged in the healthcare sector (NIC-based) and that of (Table 3) all the cadres of skilled health workers/professionals (NCO-based) was compared, it was higher in the former classification (NIC) of health workers. The NIC-based workforce in the healthcare sector includes all the (NCO-based) skilled health workers consisting of doctor, nurses and midwives, pharmacists, other ancillary health professionals, along with other supporting staff consisting of administration, accounts and all other supporting activities. There must be the growth of supporting staff engaged in the healthcare sector higher than the skilled health professionals. Moreover, although remarkably a higher rate of growth in skilled health workers is an encouraging feature of the Indian healthcare sector, it is a cause of concern as it is engulfed with the phenomenon of unqualified health professionals, it is a cause of concern.

One could also observe the disproportionate distribution of skilled healthcare professional and workers in India by location, gender and social groups (Figure 2). While the rural areas contributed more than two-thirds of the country population, they accounted for less than one-third of total doctors, and little more in respect of nurses and other paramedics. Better availability for rural areas is midwifery category which is largely due to surge of ASHA workers after NRHM. By gender, the cadres of nurses and midwifery (largely ASHA) was largely occupied by females but their representation in the cadre of doctors and other paramedics was very low. By social group, the representation of SC/STs was also very low among important cadres (doctors, other paramedics and nurses) except in the midwifery cadre.

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Figure 2.

Source: Authors’ calculations based on Census 2011.

NCO-based Shortage of Health Professionals/Workers

As observed above, referring to WHO’s threshold (norm) minimum of 4.45 skilled health workers/professionals per 1,000 population shortage of such skilled health workers in India is discernible given the availability of such workforce based on NCO. The estimated shortage of such skilled health workers was ‘2.51 million in 2001 and 1.59 million in 2011’. The NCO-based estimate of shortage of skilled health workers in 2011 is observed to be double that of the NIC-based one (0.79 million). It is more appropriate to consider the shortage based on NCO over the NIC because the latter consists of non-medical staff. It was due to high growth of such non-medical staff in the healthcare sector over medical professionals during 2001–2011 that doubled the shortage of skilled workforce (medical staff). Further, according to WHO norm there must be ‘one doctor and 2.5 nurses per 1000 population’ but the actual availability in India leaves a ‘deficit of 0.21 million doctors and more than 2.0 million nurses’ (excluding midwifery category which consists of ASHA workers) in 2011. Moreover, the worrying dimension relates to the considerable proportion of unqualified medical staff in the skilled health workers as well. It further increases the shortage of skilled health workers in case we consider only the qualified skilled health workers.

Change and Variation in Density of Health Workers across States

The density in terms of all cadres of NCO-based skilled health workforce together available per 1,000 population varied across states and the gap between the lowest density to highest is more than four-fold in 2001 and 2011 (see Table 4). However, as CV metric indicates, the variation across states has declined during the period. Top five states in terms of relatively high density of all the skilled health workers in 2001 were: Delhi (4.7), Kerala (3.9), Maharashtra (2.9), Punjab (2.7) and Himachal Pradesh (2.6). And the bottom five states in 2001 were: Bihar (1.1), Uttar Pradesh (1.3), Rajasthan (1.4), Assam (1.5) and Jharkhand (1.5). In 2011 the state of Kerala (7.0) attained a high density and stood top among the Indian states. It was followed by Delhi (5.6), Himachal Pradesh (5.3), Maharashtra (4.2) and Jammu and Kashmir (4.0). The five states that were at the bottom in 2011 were: Bihar (1.6), Chhattisgarh (1.7), Jharkhand (1.8), Uttar Pradesh (2.0) and Gujarat (2.6). The five states that registered a better performance in term of improvement in density of skilled health workers in 2011 over the base (2001) were: Kerala followed by Himachal Pradesh, Assam, Jammu and Kashmir and Karnataka.

The density of only allopathic doctors is very low across states. In 2001 it was less than one per 1,000 population in all major states except Punjab and Delhi. The improvement in density of allopathic doctor over decade seems to be marginal. Even by 2011, most of the states had less than one allopathic doctor per 1,000 population, except in Delhi, Maharashtra, Punjab, Haryana, Uttarakhand, Jammu and Kashmir and Karnataka. Moreover, as shown by the metric of CV, the variation across states in terms of density of allopathic doctor had in fact increased during the decade of 2001–2011.

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Table 4.

Density of Health Workers (NCO-based Cadres) across Major States in India (Number of HW per 1,000 Population)

S. No.	State	All		D&NMW		NMW		AD		Dentists		AYUSH
		2001	2011	2001	2011	2001	2011	2001	2011	2001	2011	2001	2011
1	2	3	4	5	6	7	8	9	10	11	12	13	14
1	Andhra Pradesh	2.1	3.7	1.4	2.3	0.6	1.6	0.8	0.6	0.01	0.04	0.09	0.05
2	Assam	1.5	3.7	1.0	3.1	0.6	2.7	0.3	0.4	0.01	0.01	0.12	0.08
3	Bihar	1.1	1.6	0.7	1.4	0.2	1.0	0.4	0.4	0.01	0.01	0.11	0.06
4	Chhattisgarh	1.7	1.7	1.0	1.3	0.5	0.6	0.4	0.7	0.01	0.02	0.13	0.07
5	Gujarat	1.7	2.6	1.1	2.1	0.5	1.3	0.4	0.5	0.02	0.05	0.20	0.21
6	Haryana	2.0	3.1	1.5	2.3	0.4	1.1	0.8	1.1	0.05	0.08	0.23	0.09
7	Himachal Pradesh	2.6	5.3	1.6	4.3	0.7	3.4	0.6	0.8	0.05	0.09	0.29	0.14
8	Jammu & Kashmir	2.2	4.0	1.3	3.1	0.6	2.0	0.7	1.0	0.04	0.08	0.07	0.06
9	Jharkhand	1.5	1.8	1.1	1.5	0.6	1.0	0.4	0.5	0.01	0.01	0.09	0.07
10	Karnataka	2.1	3.8	1.5	3.1	0.6	2.1	0.7	1.0	0.04	0.09	0.12	0.08
11	Kerala	3.9	7.0	2.8	5.2	1.9	4.0	0.6	0.9	0.07	0.14	0.38	0.35
12	Madhya Pradesh	1.6	3.0	1.1	2.4	0.4	1.8	0.5	0.6	0.01	0.02	0.15	0.06
13	Maharashtra	2.9	4.2	2.2	3.4	1.0	2.1	0.8	1.3	0.04	0.07	0.36	0.08
14	Odisha	2.0	3.2	1.5	2.8	1.1	2.3	0.3	0.3	0.01	0.01	0.18	0.15
15	Punjab	2.7	3.8	2.0	2.9	0.6	1.5	1.1	1.3	0.05	0.09	0.23	0.12
16	Rajasthan	1.4	3.0	1.0	2.7	0.5	2.1	0.4	0.5	0.02	0.03	0.14	0.11
17	Tamil Nadu	2.2	3.4	1.5	2.5	0.8	1.8	0.6	0.7	0.03	0.08	0.14	0.06
18	Uttarakhand	2.2	3.9	1.6	3.2	0.6	2.1	0.8	1.0	0.03	0.06	0.23	0.10
19	Uttar Pradesh	1.3	2.0	1.0	1.7	0.2	1.0	0.6	0.6	0.01	0.02	0.13	0.05
20	West Bengal	2.4	3.6	1.6	2.9	0.6	2.0	0.7	0.7	0.02	0.02	0.30	0.22
21	NCT of Delhi	4.8	5.6	3.4	4.2	1.5	1.9	1.6	2.1	0.13	0.18	0.35	0.14
All India		2.0	3.2	1.4	2.5	0.6	1.7	0.6	0.7	0.02	0.04	0.18	0.10
CV		39.7	37.3	42.3	34.8	56.7	42.8	46.6	51.6	90.8	80.5	50.2	64.9

Source: Authors’ calculations based on census data.

Notes: It is based on NCO; Main and marginal categories combined; Rural and urban combined; D&NMW—doctors (physicians and surgeons) of all categories and nurses including the midwives; AD—allopathic doctors; NMW—nurses including the midwives.

Similarly, the density of Nurses and Mid-wives in 2001 was less than one excepting in Kerala, Delhi, Maharashtra and Odisha. There is a remarkable improvement in 2011 in terms of density of nurses and mid-wives across states. The states improved remarkably and have at least two nurses and mid-wives per 1000 population in 2011 were: Kerala (4.0) followed by Himachal Pradesh (3.4), Assam (2.7), Odisha (2.3), Uttarakhand (2.1), Maharashtra (2.1), Karnataka (2.2), Rajasthan (2.1), Jammu and Kashmir (2.0) and West Bengal (2.0).

Ratio of Nurses and Midwives to Doctors

Regarding the composition of the health workforce, there seems to be an ideal ratio of nurses to doctors which should not be less than one, meaning there needs to be more than one nurse per doctor (Rao et al., 2016). At the national level it was below one in 2001 but improved during the decade and observed to be 2.1 in 2011. However, this ratio varies widely across states. In the year 2001, most of the states except Odisha (2.4), Kerala (1.9), Assam (1.4), Tamil Nadu (1.16) and Jharkhand (1.13), had density of nurses less than that of doctors indicating an undesirable ratio of nurses to doctors (see Table 4). With the remarkable improvement witnessed during the 2000s, owing to different factors, most of the states attained density of nurses more than that of doctors, indicating ratio of nurse to doctor more than one. In 2011, such a ratio was observed to be highest in the state of Assam (6.7) followed by Odisha (4.9), Himachal Pradesh (3.7), Rajasthan (3.5) and Kerala (3.3). In three states namely, Chhattisgarh, Delhi and Haryana, the ratio of nurse to doctors still remains below one in 2011.

Further, the relationship between the ratio of nurse and midwives to the density of doctors across states and UTs in India in rural and urban areas for the years 2001 and 2011 established through running a bi-variate regression shows the monotonic but non-linear (reciprocal) relationship (see Figure 3). The relationship indicates that where the density of doctors is high, there the ratio of nurse and midwives to density of doctors is low and vice versa. It follows Anand and Fan (2016) study’s observation, that there is a suggestive substitution between the availability of nurses and midwives and the doctors across states in India.

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Figure 3.

Source: Authors’ estimates.

Educational Levels and Health Workers Density

The above analysis clearly elicits the deficiency in quantum and composition of the health workforce which largely depends on its generation/creation that could possibly be linked with overall educational development of the region that ensures supply of qualified and trained health professionals. Therefore, we verify the association between educational development and density of health workers across states in India. As the training and production of qualified health professionals and the other skilled health workers depend on the education system and development, the latter is critical in supplying such health workers. The variable constructed for representing the educational development is the percentage of adult (15 years and above age) population with educational level of higher secondary (HS) and above. It would have been ideal if state-wise enrolment or number of seats available for degree and diploma courses and training related to medical, clinical or any healthcare related subjects were considered for this purpose. In the absence of a readily available indicator of the kind, proxy for the same is considered for the purpose of present analysis.

An exploratory linear bivariate regression of health worker density (dependent variable) against the educational development (independent variable) indicates that there is a significantly positive association between the two (see Figure 4). It shows a non-linear monotonic relationship consisting of an asymptote of health workers density after a certain threshold level of educational development. Therefore, one could argue that for complying with an ideal health worker density, there is a need for a threshold of educational development that would ensure generation and supply of skilled workforce for the healthcare sector.

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Figure 4.

Source: Authors’ estimation based on Census of India information.