Health workforce status in India: A qualitative analysis of parliamentary questions documented in the last two decades

ABSTRACT

Background:

Unequal health workforce distribution is a major issue in India that causes health inequality and difficulties in health delivery. There have to be optimal numbers of all health workers including doctors, staff nurses, and paramedical staff like radiographers, pharmacists, attenders, ANMs, and ANWs for the effective working of health Institutions.

Introduction:

The parliament is a powerful organization in a democratic country where member representatives from different parts of the country can raise questions or debates on crucial issues of the nation. These submitted documents form a major source of data for policy analysis.

Materials and Materials:

Questions on health workforce shortage were collected from the official websites of Lok Sabha and Rajya Sabha and thematic analysis was done with inductive reasoning. Themes and subthemes were categorized and questions were coded into nodes using Max QDA software.

Results:

A total of 1016 questions (0.18%) were asked with 577 (0.17%) questions from Lok Sabha and 441 (0.19%) from Rajya Sabha. A total of 208 unique parliamentarians from 26 unique states/UTs had submitted questions on the current theme.

Discussion:

The questions were of competing interests with the majority of questions on recruitment in the government health sector and strategies needed for balancing the inequality in workforce distribution. More questions with stronger representation are needed for the sub-themes of rural and tribal scenarios, shortage of specialists, women staff, and paramedical staff, which could help in correcting the lacunae in the national healthcare system.

Introduction

The WHO defines health workers as “all people engaged in actions whose primary intent is to enhance health”. They are the core building blocks of a nation’s healthcare system and proper investment in expanding the health workforce can deliver improved health outcomes, global health security, and economic growth.[1] However, most of the low- and low- to middle-income countries (LLMICs) continue to suffer from serious gaps in the health workforce.[2] A recent 2020 WHO mid-term review of progress on the Decade for health workforce strengthening in SEAR 2015-2024, mentions that India needs at least 1.8 million doctors, nurses, and midwives to achieve the minimum threshold of 44.5 professional health workers per 10,000 population. Also, the labor force-based estimate (NSSO 2017–18) of doctors to nurse ratio is barely 1:1.3. Health worker distribution is highly skewed in rural and urban areas across public and private sectors.[3,4]

Large-scale production of health workers in big cities has given rise to a struggle for survival leading to unemployment in the urban areas and deprivation of healthcare due to the lack of doctors in the rural regions. On the other side, the Organization for Economic Cooperation and Development (OECD) countries benefit immensely from the bulk emigration of Indian-trained doctors and nurses from India.[5] The COVID-19 pandemic has further exposed the acute shortage of health workers in India’s health system with a constant deficiency of trained personnel across various tertiary hospitals. There is an immediate need to assess these lacunae and balance them with appropriate measures. The present study aims to assess the parliamentary questions submitted in the Lok Sabha and Rajya Sabha on health workforce dynamics between January 2001 and December 2022 and analyze the content qualitatively.

Material and Methods

The present qualitative analysis was carried out by the Standards for Reporting Qualitative Research (SRQR) guidelines recommended by the EQUATOR network. The questions on the shortage of doctors, that were available on the official websites of the upper (Rajya Sabha) and lower houses (Lok Sabha) were collected. The advanced search engines of Rajya Sabha and Lok Sabha were used to search for the terms, ‘doctors’, ‘nurses’, ‘health care workers’, ‘medical staff’ and ‘paramedical staff”. The questions that were relevant to the shortage/inadequacy/lack of health workforce documented between the years January 2001 and December 2022 were included. The transcripts were downloaded and organized using Max QDA (Qualitative data analysis software version 2020.4 developed by VERBI software, Germany). The questions were classified according to the descriptive data namely the date and year of the question, the name and electoral constituency of the parliamentarian, the ministry to which the question was posed, and the title of the question. Thematic analysis of the content was done using open coding along with inductive reasoning. A total of 1016 questions on the current topic were coded into nodes and a total of 412 nodes were obtained. These nodes were manually exported to MS Excel and further coding was done manually using Braun and Clarke’s phases for thematic analysis. From the thematic analysis, five main themes were identified. Sub-themes were categorized for each theme and examples of questions falling under all the themes are given in Table 1. The study is a retrospective study based on data readily available from public platforms and so was exempted from obtaining ethical approval from the Institutional review board. Study Proposal presented date 11.01.2023.

Table 1.

Examples of questions grouped under each theme and sub-theme

Themes and sub-themes	Examples of Questions
Health workforce status and distribution
Doctor-patient population ratio	Whether the doctor–population ratio as per the World Health Organization, if so, the details thereof, and if not, the reasons?
Health workforce audit	The total number of doctors and nurses registered in the country and the number of them registered during the last year, gender-wise and state/UT-wise?
Rural and tribal scenario	Whether there is a shortage of doctors in the country and if so, the details thereof along with the positions lying vacant in the tribal aspirational districts and their impact on the health system of the country
Ayush, Ayush Clinics	Whether there is an acute shortage of Ayush practitioners in government hospitals?
Specialist census	There is an acute shortage of doctors and surgeons in various streams across the country?
Dentists, veterinarians, Paramedical fleet	Whether there is a large-scale shortfall of lab technicians, pharmacists, and other health workers including ANMs, ANWs in PHC and CHCs
Women healthcare providers	Whether there is an acute shortage of lady doctors/specialists in National Rural health missions across the country
Recruitment status in the Government health sector
AIIMS, PHC/CHC/RHC, CGHS Dispensaries, railways, ESIC, Safdarjung, NHRM, etc.,	Whether there is an acute shortage of doctors in CGHS wellness centers of Maharashtra and Uttar Pradesh
Medical Institutions Statistics
Lack of Medical colleges	Whether the government proposes to increase the number of medical colleges to bridge the gap and meet the shortage of doctors?
Lack of Medical seats	Whether the government has taken any steps to increase the number of medical seats in colleges/Institutions? I yes, the details of the last three years in this regard?
Brain-drain and Resignation	Whether a large number of doctors go abroad and settle after getting their degrees from India? Steps taken by the government to check this brain-drain of highly qualified doctors?
Vacant posts	Whether there are large vacancies in faculty posts of government-run medical colleges and what is the distribution of vacancies state/UT-wise?
Unwillingness to work in rural areas	Whether a percentage of doctors/surgeons/super specialists avoid being posted in rural/tribal areas leading to a shortage in those regions?
Impact on national health delivery
Long waiting hours, negligence, covid crisis, fatalities	Is the government aware of the fact that the shortage of medical doctors in the country causes an impact on the quality of medical treatment in the country?
Strategies and Solutions
Policy Implementation	Whether the government considering exploring possibilities in coordination with states to create a separate cadre of Indian Medical services to attract super specialist doctors in government services?
Recruitment Drive	What are the state/UT-wise remedial measures taken to fill up vacant posts across government sectors including PHC, CHC, and RHC?
Retirement age	Whether the government seek the assistance of retired medical professionals and propose to increase the retirement age of skilled doctors to meet the shortage of doctors?
Training and Skill development	Whether the government propose to blend nursing courses with skills in India?
Rural Training	Whether the government propose to bring a national policy making it mandatory for all MBBS/PG doctors to work in rural areas for three years?
Voluntary Organizations	Whether the government is planning to provide medical services through certain voluntary organizations due to a shortage of doctors in scheduled tribe-dominated areas and what are the criteria for selection of these voluntary organizations?

Results

The total number of questions submitted in all ministries across all categories in both houses between 2001 and 2022 was 5,59,083. A total of 1016 questions (0.18%) were asked collectively on the shortage of doctors and health workforce in both houses. The total number of questions asked in the given period on all topics and to all ministries in the Lok Sabha amounted to 3,23,318. The total number of questions on the current topic asked in Lok Sabha was 577 (0.17%). The total number of questions documented from 2001 to 2022 in all ministries and on all issues in the Rajya Sabha was 2,35,765. The number of questions on the shortage of doctors and health workforce was 441 (0.19%). A majority of 955 questions (93.8%) were submitted to the Ministry of Health and Family Welfare (MOHFW) followed by 36 (3.5%) questions to the Ministry of AYUSH and 27 (2.7%) questions to the Ministry of Labour and Employment.

Out of a total of 30,926 questions asked on all topics across both houses to the MOHFW, a total of 955 questions (3.1%) were on the current topic. A total of 208 unique parliamentarians from 26 states had submitted questions out of whom the maximum number of questions (24 questions) was posed by Mr. Uday Pratap Singh from Mainpuri Constituency, Uttar Pradesh. The top five sub-themes and the number of questions submitted under each of them are given in Table 2.

Table 2.

Top Five sub-themes and their year-wise distribution

Theme	Total No of questions	Order of Priority	Year-wise Distribution of Questions
			2001–2005	2006–2010	2011–2015	2016–2022
Recruitment in government facilities	283 (25.8%)	01	27	41	90	125
Workforce Audit	110 (10.8%)	02	06	25	16	63
Rural and Tribal	92 (9.1%)	03	02	25	26	39
Policy Implementation	86 (8.5%)	04	04	12	25	47
Specialist Census	85 (8.3%)	05	07	14	23	41

A. Health workforce-Status and distribution

The first theme is on health workforce status and distribution with nine sub-themes. This is the most represented theme in the last two decades with a maximum of 474 questions asked from 26 unique states/union territories (UT). The total number of questions asked on the first sub-theme, “doctor–population ratio” was 45 questions. The parliamentarians repeatedly questioned the existing doctor–population ratio in the country and whether the ratio is as per the norms of the World Health Organization (WHO). They quoted excerpts from WHO reports that highlighted the shortage of physicians, nurses, and midwives in India. A total of 110 questions were asked on employee statistics across public health sectors and this is the most represented sub-theme under health workforce status and distribution. Parliamentarians raised questions on the availability of a UT/state-wise census for health professionals. A few members from the states of Chhattisgarh, Maharashtra, Lakshadweep, and Bihar asked about their district-wise census and were concerned about whether regular auditing is being carried out efficiently in the nation. There was a robust representation of 92 questions on the sub-theme “rural and tribal scenario”. Questions were regarding the shortage of health workforce in rural regions, remote and hilly tribal districts, and whether there exists health inequality due to the same. Members from North Eastern states posed six questions on the lack of doctors and paramedical forces in minority-dominated areas of Assam and other northeastern states.

A total of 10 unique states/UTs had asked a total of 44 questions on Ayush and Ayush clinics. Members questioned whether there is an acute shortage of Ayush and paramedical staff including Ayush drug inspectors in various districts and states. Questions on Ayush and Ayush clinics were submitted to the Ministry of Ayush only. A total of 85 questions were submitted on the shortage of specialist doctors. Questions were submitted to the MOHFW followed by the Ministry of Labour and Employment. Members expressed their concern about the shortage of specialist physicians in ESI hospitals. Questions on the lack of paramedical staff amounted to 58 questions with a maximum of questions (19 Q) documented between 2011 and 2015. Questions were asked on the reason for the acute shortage of trained paramedical personnel like staff nurses, assistant matrons, lab technicians, radiographers, and pharmacists. Questions were asked on the number of vacancies for veterinarians in state veterinary hospitals. About 19 questions were submitted on the shortage of trained women staff in hospital setups. The shortfall of women staff in RHCs, and CHCs in the states of Rajasthan, Bihar, Jharkhand, UP, Himachal Pradesh, and Maharashtra was raised by respective members. Reduced numbers of female obstetricians in rural PHCs were highlighted and solutions were demanded.

B. Recruitment status in government health sectors

The most represented theme in the entire analysis is recruitment status in government sectors. A total of 283 questions from 22 unique states/UTs were documented. The theme comprised the health workforce in all government-run setups like PHCs, CHCs, RHCs, CGHS, ESIC, AIIMS, RHC, railways, NHRM, etc., Although only 27 questions were raised between 2001 and 2005, there was a steady rise in questions after that. In the recent six years, a total of 115 questions have been submitted on the lack of doctors and nurses in government sectors.

C. Medical Educational Institutions Statistics

This theme is subdivided into five sub-themes namely: lack of medical colleges, lack of medical seats, brain drain, posts lying vacant in colleges, and unwillingness to work in rural areas. A total of 56 questions were submitted on this topic with the maximum number of questions asked on brain drain (19 Q). There was a meager representation of this theme between 2001 and 2010. However, the number of questions increased after that with maximum representation from Punjab, Jharkhand, and Bihar. Members enquired about the government’s plan to increase the number of medical colleges and medical seats.

D. Impact on National health delivery

A total of 27 questions were submitted on topics that dealt with the impact of health delivery caused by to lack of a health workforce in hospitals across the country. Questions discussed the increase in health inequality with the semi-urban, rural, and tribal areas taking a toll due to a deficiency in trained health staff. A rise in fatalities due to a lack of special clinics and specialist services was also asked by a few members.

E. Strategies and solutions

Under strategies and solutions; policy implementations, recruitment drive, the retirement age of skilled workers, training and skill development, compulsory rural training, and voluntary organizations were discussed. A sizeable number of 175 questions were submitted on all of these topics. Members suggested various strategies like providing robust training to all health workers and strengthening the skilled workforce.

Discussion

Parliamentary questions documented on the theme of shortage in the health workforce between 2001 and 2022 were analyzed in this study. Only a total of 1016 questions (0.18%) were asked on this theme in 22 years which does not do justice to such a fundamental topic that deals with regulation of national health delivery. The documented questions had mild overlapping and yet were of varying competing interests and heterogenicity.

The percentage of existing vacancies in the government health sector has always been on the rise. According to the Rural Health Statistics 2021–22 report, the allopathic doctors at PHCs have seen a 50.9% increase in the past 10 years but are still 3.1% short of the required numbers. In urban PHCs, there is a vacancy of 18.8% doctors, 16.8% pharmacists, 16.8% lab technicians, and 19.1% staff nurses.[6] A considerable number of 262 questions were submitted on this theme with the majority of representation between 2016 and 2022 (115 Q). Members from Telangana raised concern about the number of PHCs across the state that have a lack of staff and do not fulfill the parameters laid by Indian Public health standards.[7] Questions on the lack of recruitment drive in public service undertakings like SCCL, SAIL, Bharat Coal Limited, and railways were also represented only to an average extent.

The CGHS provides comprehensive healthcare to around 34 lakh employees including pensioners. As per recent reports submitted by the Ministry of Health and Family Welfare (2023), there is a 22% vacancy in posts for allopathic medical staff and 39% vacancy in posts for non-gazette staff in CGHS nationally.[8] However, there was a sub-optimal representation of questions on the lack of staff in CGHS dispensaries. Just a handful of members from districts of Delhi, Gujarat, Tamil Nadu, Bihar, and Assam had raised their concerns. Stronger representation by members from all states/UTs can lead to a vigorous recruitment drive for filling vacancies in all public undertakings and government health sectors.

Yet another lacuna in the Indian healthcare system is the acute shortage of specialists across public health sectors. According to RHS 2021–2022, there is a shortfall of 83.2% of surgeons, 74.2% of obstetricians and gynecologists, 79.1% of physicians, and 81.6% of pediatricians.[6] Only 85 questions have been submitted in both houses on this theme over a two-decade timeline which is daunting considering the magnanimity of the crisis. Only 14 unique states had submitted questions interrogating the lack of specialists in their constitutions. The states of Andhra. Telangana, Jharkhand, Uttarakhand, Punjab, Goa, Arunachal Pradesh, Assam, Mizoram, Tripura, Sikkim, and Nagaland did not submit even a single question despite the staggeringly low levels of specialist doctors in the country. These statistics suggest a lesser involvement and lack of awareness of parliamentary members on the current sub-theme.

There has been a positive correlation between the percentage of parliamentary representation and the corresponding policy implementations related to the ministry of AYUSH. A good number of 36 questions were submitted on Ayush-related issues in a short span of six years (2016–2022) that led to the launch of three striking policies namely, the National Commission for Indian System of Medicine Bill (2019), the National Commission for Homoeopathy Bill (2019) and the National Commission for allied and healthcare professionals bill (2021) in such a short span. This confirms the positive correlation between the extent of parliamentary representation on topics and the subsequent execution of policies and strategic solutions. Figure 1 shows the list of healthcare-related policies implemented by the government between 2001 and 2023. A small number of questions (27 Q) were addressed on the theme of “impact on national health delivery”. A few members raised queries on the impact of health workforce deficiencies on the health system like the inability to provide care to remote/tribal regions, lack of effective out-patient disposal, and inefficiency to handle endemic, pandemic crises due to lack of doctors and supporting staff. The meager representation of this topic shows the lack of awareness among parliamentarians on these issues.

Figure 1.

List of Health-related policies implemented by the Government of India between 2001 and 2023

Under the theme, “strategies and solutions”, members have proposed novel plans like increasing the retirement age of HW, introducing compulsory rural training for all health science graduates, launching a revolutionary “Indian Medical service” that can serve as a dedicated wing for healthcare workers, launching a Nursing services scheme to benefit staff nurses, increasing incentives for workers willing to serve in remote/tribal areas and flagship schemes to augment medical strength in all levels of healthcare. Accordingly, over 17 national policies have been launched in the past 22 years with a high rollout of active schemes in the recent 5 years. [Table 3] These results suggest that the members had good knowledge of policy planning and could propose novel solutions to national issues shortly.

Table 3.

Number of questions asked on a set of sub themes and the number of policies launched between 2001-2023

Themes	No of Questions	Policies Implemented (or) Improvements in the concerned area
Doctor-Population Ratio	45	• 0.5:1000 in 2001
		• 1:1800 in 2013
		• 1:834 in 2023
Existing vacancies	21	• No of doctors recruited in PHCs in 2006: 20308
		• No of doctors recruited in PHCs in 2011: 26329
Specialist census	85	• Specialist doctors in CHCs in 2005: 3550
		• Specialist doctors in CHCs in 2022: 4485
		• No of PG seats in 2014: 31,185
		• No of PG seats in 2021: 55,595 (78% increase)
Women staff	19	• National Policy for Empowerment of Women, 2001
Lack of Medical colleges	10	• No of medical colleges in 2001: 189
		• No of medical colleges in 2011: 314
		• No of medical colleges in 2014: 381
		• No of medical colleges in 2021: 595 (72% increase)
Ayush, Ayush clinics	44	• National commission for Indian system of medicine bill, 2019
		• National Commission for Homoeopathy Bill, 2019
		• National Commission for Allied and Healthcare Professionals Bill 2021
Lack of Medical seats	14	• MBBS seats in 2014: 51,348
		• MBBS seats in 2021: 88,370
		• MBBS seats in 2023: 1,01,043
Novel policies/strategies	86	• 2002 National Blood Policy
		• 2002 National Policy on Indian System of Medicine and Homeopathy
		• 2002 National Health Policy
		• 2003 National Policy for Access to Plasma-Derived Medicinal Products from Human Plasma for Clinical/Therapeutic Use
		• 2005 National Rural Health Mission
		• 2006 National Programme for Prevention and Control of Deafness (NPPCD)
		• 2007 National Tobacco Control Programme (NTCP)
		• 2008 National Programme for Prevention and Control of Fluorosis (NPPCF)
		• 2010 National Programme on Prevention and Control of Diabetes, CVD and Stroke
		• 2010 National Programme for Health Care in Elderly (NPHCE)
		• 2014 National Oral Health Programme
		• 2012 National Pharmaceutical Pricing Policy
		• 2013 National Policy for Children
		• 2017 National Health Policy
		• 2018 National Health Protection Mission, Ayushman Bharat Yojana
		• 2023 National Dental Commission Bill
		• 2023 National Nursing and Midwifery Commission Bill

The health administration of a country can never be complete without discussions on medical educational Institutions and their numbers. According to the current analysis, questions on the lack of medical educational Institutions and lack of medical seats were marginally represented. Despite the modest number of questions submitted on these sub-themes, there has been a 72% increase in medical colleges and a robust increase in the medical UG seat matrix. The launch of the National Medical Commission in 2019 largely contributed to the regulation of seat allocation and regulatory aspects of new and existing medical colleges. However, there is a southward predominance in the geographic distribution of these colleges with 44% of all medical seats distributed between the states of Karnataka, Andhra, Telangana, Tamil Nadu, and Kerala. India stands next to the US in the production of medical undergraduates yet there are inequalities in manpower distribution with a large number of vacant posts in many suburban, rural, and tribal RHCs, PHCs, and CHCs.[9,10] On the other hand, there is high competition for jobs in government hospitals distributed in developed cities. The hesitation of fresh graduates to take up jobs in remote/suburban and rural areas is a primary cause for existing vacancies especially in primary health care. The role of primary care physicians in the health scenario of a country is huge and it is mandatory that their vacancies are filled with due priority. General primary care providers and specialty doctors should be given better pay and incentives to encourage them to work in suburban and rural regions. Also, recent trends show a higher employment of contractual employees More funds need to be channelized to increase the number of regular positions in PHCs.

Other factors that cause a dearth in the health workforce are resignations from central/state government-run hospitals and mass emigration to Western countries. The policymakers have to focus on steps that can make government jobs seem more lucrative like an increase in recruitment age, higher pay grades with good incentives, additional incentives for working during trivial times, proper leave manifesto, etc., Such topics need to be prioritized with stronger representation coupled with in-depth parliamentary discussions. In the current analysis, the poorly represented sub-themes were the specialist census, dentists, veterinarians, and paramedical fleet and women staff. These aspects of healthcare deserve more attention and representation by the members of parliament, which can provide strategies to eradicate health inequalities.[11]

Conclusion

Inadequate staff in various suburban, rural, tribal, and apprehensive borderline regions has been a perennial issue that needs immediate attention. Though the routine responsibilities of a medical staff revolve around patient care and health promotion, effective execution of these would not be entirely possible without the assistance of harmonious health policies. More ardent representation of these crucial issues by parliamentary members of affected districts can pave the way for streamlining protocols and initiating funds as per cause. The current analysis of data gave surprising results in certain sub-themes which showed a good correlation between the percentage of questions raised and the number of solutions evoked in the form of policies in the past two decades. The current work could serve as a tool to understand the strength of queries raised in the parliament and can be a guide to prioritize issues on healthcare manpower resources. However, there are a few limitations to this study. The keyword search and subsequent data collection entirely depended on the archive of questions on the websites of the parliamentary houses. It is possible that a few data were not updated on the websites causing a marginal over/underestimation of submitted questions. Questions were carefully selected based on keyword search, however, questions discussing similar issues but without the selected keywords could still be present despite scrutiny. Further analysis of parliamentary questions and debates on the health workforce have to be conducted to provide insight for effective policy planning in the future.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.