Supply Side Analysis of Human Resources for Long Term...

Supply Side Analysis of Human Resources for Long Term Availability

of Health Providers, Department of Health and Family Welfare

(DoHFW), Government of Orissa (GoO)

Report (Final)

-------------------------------------------------------------------------------------------------------------------

Prepared by - Profs. Andrew Dutta, S. Peppin (Team Leader), Snigdha Pattnaik and Subhajyoti Ray

Xavier Institute of Management

Bhubaneswar-751013

ABBREVIATIONS

AIIMS All India Institute of Medical Sciences

ANM Auxiliary Nurse Midwives

AYUSH Ayurveda, Yoga & Naturopathy, Unani, Siddha and Homoeopathy

B.Sc. (N) Bachelor in Nursing

BDS Bachelor of Dental Surgery

CDMO Chief District Medical officer

CHC Community Health Centre

DFID Department for International Development

DHS Directorate of Health Services

DMET Directorate of Medical Education and Training

DoHFW Department of Health and Family Welfare

GDP Gross Domestic Product

GNM General Nursing and Midwives

GoI Government of India

GoO Government of Orissa

HIV Human Immunodeficiency Virus

HR Human Resource

IMA Indian Medical Association

IMC Act Indian Medical Council Act

IMR Infant Mortality Rate

IPE Infrastructure Professionals Enterprise

IPHS Indian Public Health Standards

LHV Lady Health Visitor

M.Sc. (N) Master of Science in Nursing

MBBS Bachelor of Medicine, Bachelor of Surgery

MD Doctor of Medicine

MDG Millennium Development Goals

MMR Maternal Mortality Rate

MS Master of Surgery

NRHM National Rural Health Mission

OHSP Orissa Health Sector Plan

OPSC Orissa Public Service Commission

OSMA Orissa Medical Services Association

P.B. B.Sc. (N) Post Basic Bachelor in Nursing

PHC Primary Health Centre

PPH Public Primary Health

PPP Public Private Partnership

SC Sub-Centre

SD Sub Division

SHRMU State Human Resource Management Unit

SRS Sample Registration Survey

TB Tuberculosis

TMST Technical and Management Support Team

TN Tamil Nadu

VD Venereal Disease

WB West Bengal

WHO World Health Organization

XIMB Xavier Institute of Management, Bhubaneswar

Acknowledgement

1. We are extremely grateful to Infrastructure Professionals Enterprise (IPE) and

Options Consulting Services Ltd., UK for giving us an opportunity to undertake this

study.

2. We place on record our sincere appreciation and gratitude to the members of

Technical and Management Support Team (TMST) supporting the implementation of

Orissa Health Sector Plan (OHSP) for their timely advise and guidance. Ms. Alison

Dembo Rath, Team Leader, TMST and Dr. Ramesh Durvasula, Dy.Team Leader, TMST

have provided valuable input and suggestions at various stages of this study. We are

truly thankful to them. We are also grateful to Mr. Jeetendra Patnaik for his help in

generating GIS Maps and Mr. Sudarshan Panda for his administrative support.

3. Dr. D. Nayak, Team Leader, State Human Resource Management Unit, Government of

Orissa has been a constant source of strength and support. His insightful comments

and suggestions have helped us immensely to complete this study. We extend our

heartfelt gratitude to him.

4. We are grateful to Fr. P.T. Joseph, S.J, Director, XIMB for his encouragement and

support to undertake this important study. We also thank the staff attached to

Administration and Finance Departments at XIMB for their support.

5. We have received excellent cooperation and support from the Department of Health

and Family Welfare, particularly the DMET, NRHM, and the CDMOs and their teams in

the districts which were selected for this study. This study would not have been

completed without their support and cooperation. We are extremely grateful to all of

them.

6. We also thank the private sector health institutions which helped us in this study.

7. We place on record the administrative and research assistance provided by Ms.

Swetelina Das and Mr. Swarup Sahoo.

Study Team, XIMB

CONTENTS

Table of Contents Page No.

Executive Summary 1

Introduction 10

1. Context & Climate of Health Sector Reform 11

2. Methodology 20

3. Supply side Analysis of Human Resources for

Long Term Availability of Health Providers 24

4. Ten Year Forecast of Health Personnel 31

5. Need-Supply Gap analysis 55

6. Adequacy vs Availability of Human Resources 59

7. Leveraging Human Resources in Health: Some

Lessons from other states for Orissa

66

8. Recommendations and Conclusion 69

References 72

Annex 1: Tables presenting the Ratio of Availability as

per IPHS norms

Annex 2: GIS Maps

LIST OF TABLES AND FIGURES

LIST OF TABLES

NO. TABLE PAGE

1. Selected Key Indicators for Orissa 11

2. Comparative Picture of Selected Demographic, and Health Indicators 12

3. Establishment of Medical Colleges 12

4. Incidence of Hunger, Poverty, Malnutrition and Availability of Public Health 13

5. State-wise Number of Government Hospitals and Beds in Rural and Urban Areas

(Including CHCs) in India (as on 1st March, 2007) 13

6.

State-wise Number of Allopathic Doctors with Recognised Medical Qualifications

(under IMC Act) and Registered with State Medical Councils in India (2000 to

2007)

14

7. State Council-wise total number of Nursing educational institutions in different

nursing courses in India (as on 31st March, 2006) 15

8. State-wise Number of Health Assistants (Female)/Lady Health Visitor (LHV) At

Primary Health Centres (PHCs) in Rural Areas of India (as on March, 2007) 15

9. State-wise Number of Health Assistants (Male) At Primary Health Centres (PHCs)

in Rural Areas of India (as on March, 2007) 16

10. State-wise Number of Health Worker (Female)/ANM At Sub-centres and Primary

Health Centres in Rural Areas of India (as on March, 2007) 116

11. State-wise Number of Health Worker (Male) At Sub-centres in Rural Areas of India

(as on March, 2007) 17

12. State-wise Number of Laboratory Technicians at Primary Health Centres (PHCs)

and Community Health Centres (CHCs) in Rural Areas of India (as on March, 2007) 17

13. State-wise Number of Nurse Midwife/Staff Nurse at Primary Health Centres (PHCs)

and Community Health Centres (CHCs) in Rural Areas of India (as on March, 2007) 18

14. State-wise Shortfall in Health Infrastructure (SCs, PHCs and CHCs) as per 2001

Population in India (as on March, 2007) 18

15. Health Sector Reform Climate 19

16. Intake capacity of students in Public and Private Institutes in Orissa for the year

2007 25

17. Production capacity of Specialists (2007) 27

18. District wise vacant position of Doctors (2009) 25

19. Supply factors and estimate 29

20. Percentage of Specialists in Orissa (2008) 30

21. Forecast for number of Doctors in the Public Sector 31

22. Forecast for number of Doctors in the Private Sector and Total 32

23. District wise Doctor forecast in Public Sector 33

24. Specialization wise forecast 35

25. Gap in Need:Supply for Doctors 37

26. Vacancy position of Nurses (GNM) (2009) 39

27. Current Nurse to Doctor Ratio 40

28. Supply forecast of Nurses for the next 10 years 41

29. Gap in Nurse Need and Supply 41

30. Vacancy position of ANM (2009) 43

31. Supply projection of ANM 44

32. Gap in Need: Supply for ANMs 44

33. Vacancy Position of Lab Technicians (2008) 46

34. Current Ratio of Lab Technicians to Doctors 47

35. Forecast Supply of Lab Technicians 48

36. Supply, Need and Gap of Lab Technicians 49

37. Vacancy position of Pharmacists (2008) 50

38. Current Estimated Position of Pharmacists 51

39 a Forecast Supply of Pharmacists ((Assuming 50% intake of capacity) 52

39. b Forecast Supply of Pharmacists (Assuming 100% intake of capacity) 53

40. Supply, Need and Gap of Pharmacists

53

41. Vacancy in the three Government Medical Colleges as on October, 2009

56

42. Gap Analysis: Doctors (2009) 61

43. Gap Analysis: GNMs(2009) 62

44. Gap Analysis: ANMs (2009) 63

45. Gap Analysis: Lab.Technicians (2009) 64

46. Gap Analysis: Pharmacists (2009) 65

LIST OF FIGURES

NO. FIGURE PAGE

1. Gap as Percentage of Need 6

2. Gap as Percentage of Need (WHO-Norm) 6

3. Distribution by year of birth of Doctors 27

4. Projected supply of Doctors in Orissa 32

5. Specialization-wise forecast 35

6. Need-Supply gap for Doctors 38

7. Need-Supply gap for GNMs 42

8. Need-Supply gap for ANMs 45

9. Need-Supply gap for Lab. Technicians 49

10. Need-Supply gap for Pharmacists 54

11. Percentage of Vacancy in the Government Medical Colleges as on October 2009 57

12. Percentage of Vacancy among faculty 57

13. Gaps as a percentage of Need 58

14. Gaps as a percentage of Need (WHO-GoI norms) 58

15. Year wise distribution of sanctioned strength and in position of Doctors 59

16. Year wise distribution of sanctioned strength and in position of GNMs 59

17. Year wise distribution of sanctioned strength and in position of ANMs 59

18. Year wise distribution of sanctioned strength and in position of Lab. technicians 60

19. Year wise distribution of sanctioned strength and in position of Pharmacists 60

1

Supply Side Analysis of Human Resources for Long Term Availability of

Health Providers, Department of Health and Family Welfare (DoHFW),

Government of Orissa (GoO)

EXECUTIVE SUMMARY

1. Infrastructure Professionals Enterprise (IPE) and Options Consulting Services Ltd., UK on behalf of the

Department for International Development (DFID) established a Technical and Management Support

Team (TMST) to support implementation of Orissa Health Sector Plan (OHSP). In order to strengthen

this support, TMST, at the behest of Department of Health and Family Welfare (DoHFW), Government

of Orissa (GoO), entered into a contract with Xavier Institute of Management, Bhubaneswar (XIMB) to

undertake a study on the “Supply Side Analysis of Human Resources for Long Term Availability of

Health Providers, Department of Health and Family Welfare (DoHFW), Government of Orissa (GoO)”.

2. This study has three broad objectives. They are, to assess the present and future (10 years) supply and

requirements for essential health personnel for rural health services in Orissa, to estimate the HR gap

for present and future requirements against norms/standards disaggregated by functions and matched

specialties/cadres and to suggest long term viable options to meet the shortfall for rural healthcare.

3. The context of the study included some selected socio-demographic and economic variables indicating

Orissa’s position against some other states. The context also included the health sector reforms

initiated in India and Orissa in particular and the establishment of Medical Colleges in Orissa and the

other states during pre and post independence period.

4. The methodology included desk review, stakeholder interviews, case studies, use of forecasting models

for supply and demand forecast. Some of the methodological challenges encountered were, absence of

time-series data, lack of documentation of healthcare professionals and absence of centralised record

keeping. Therefore, guess estimates had to be used in many instances. Some of the key findings of this

study are presented below.

5. The number of seats available for MBBS degree is far less as compared to Kerala and Tamil Nadu. It is

evident from the study that medical education was totally neglected during the decades 1970s-1990s.

Though many Medical Colleges were set up in the current decade, Kerala and Tamil Nadu are far ahead

of Orissa. Till four years ago, Orissa had only three government Medical Colleges.

6. The shortfall in manpower in Orissa as compared to some of the selected states is very evident across

all cadres. However, the notable among them are the Doctors, Laboratory Technicians and GNM/Staff

Nurses.

Supply side analysis of HR for Health in Orissa - XIMB Page 2

7. Considering the presence of large tribal population, which also live in remote and most inaccessible

areas, shortfall in sub-centres and community health centres pose a major challenge for health

development in Orissa.

8. Orissa is one of the leading states for initiating health sector reforms, and out of nine initiatives, four

are related to human resources. However, human resource reforms that have been introduced are

mostly related to incentives and capacity building and they have not systematically and directly

addressed the issue of increasing the number of manpower to meet the shortfall.

9. This study reports that though the decadal growth rate for Orissa reveals a positive trend as compared

to other states, the socio-demographic, and economic and health indicators are highly unfavorable.

Results indicate that though the population served per government hospital is less as compared to

other states, the population served per government hospital bed is quite high in Orissa.

10. The presence of private sector health care providers can be seen to be very high or almost negligible

depending on the urbanization of the area. Highly urbanized areas like Bhubaneswar and Cuttack have

significant private sector presence while districts like Koraput and Keonjhar have an insignificant

presence of private sector. Field visits revealed the near absence of private sector health care providers

in remote and interior areas of the state. A notable observation has been the fact that, in the visited

districts, most of the private practitioners are public sector Doctors as well.

11. Complete forecast of the supply for the entire public sector and the private sector in the non-urban

areas in Orissa is provided in this report. Thereafter the private sector supply in the urban areas (like

Bhubaneswar and Cuttack) is added to get a complete forecast for the whole state. The decadal growth

of population in Orissa is approximately 15.94%1. Distributing the growth evenly over the 10 years, we

arrive at estimates of population and the derived demand for Doctors, and the gap in demand and

supply. Based on the assumptions made for projection and the norms given by IPHS, the demand

supply gap is expected to last till 2016, after which the supply of doctors in the state will exceed the

demand as per IPHS norms. However, another measure of need - supply mismatch is based on the

existing all India Doctor population ratio. The all India Doctor to population ratio is estimated at 1:1666

(plan panel rediff.com/money/2008/apr/07panel.htm). IndiaStat.com reports an all India Doctor to

population ratio of 1:1825. We have also used the WHO norm2.

12. An attempt was made to anlayse the trend in terms of sanctioned strength vs in position of doctors,

GNMs, ANMs, Lab. Technicians and Pharmacists for the period data was available. In the case of

doctors, Sanctioned strength more or less remains constant and the doctors in position is declining. In

fact the gap is widening. In the case of GNMs and ANMs, It is encouraging to see the sharp increase in

1

Trends of Population Growth in Orissa http://orissagov.nic.in/e-

magazine/Orissareview/aug2004/engishPdf/Pages34-37.pdf

2 Quoted in Park’s Text Book of Preventive and Social Medicine by Park. K (2005) Banarsidas Bhanot, Jabalpur and by

Bapat Ravindra (2008) Impact of Physician Emigration on Host Country and Health Care System, www.docstoc.com/docs


Ration decided for preparing

availability maps for each

district.

1. Doctors:

> 0.75 - Green

0.60 - 0.75 - Yellow

0.50 - 0.59 - Orange

< 0.50 - Red

2. Pharmacists, Lab. Technicians,

GNM & ANM

> 0.90 - Green

0.70 to 0.90 - Yellow

< 0.70 - Red

Ration decided for preparing IPHS

maps for each district.

1. Doctors:

> 0.75 - Green

0.60 - 0.75 - Yellow

0.50 - 0.59 - Orange

< 0.50 - Red

2. Pharmacists, Lab. Technicians,

GNM & ANM

> 0.90 - Green

0.70 to 0.90 - Yellow

< 0.70 - Red

2009-2010 both for sanctioned strength and in position as compared to the previous year, though

there was a sharp decline in the year 2008. Similar trend is found for Lab. Technicians. In the case of

Pharmacists, the gap widened in 2008 and closed in 2009-2010.

13. Three scenarios are given using IPHS norms and Doctor to population ratio and WHO nrom. As per IPHS

norms, Orissa will be able to bridge the gap between need and supply by 2015. However, as per the

other two norms there will still be a shortfall of Doctors (16928 as per all India ratio and 4357 as per

WHO norms) even by 2018. Though this scenario seems bleak, it is possible to change this if sincere

efforts are made to set up more Medical Colleges. Considering the current interest and the number of

Medical Colleges established in the last five years as compared to the earlier decades, if the

government wishes, it can change this depressing scenario.

14. Similarly, for GNMS too three scenarios are presented using 2:1 nurse to doctor ratio, IPHS norms and

WHO norms. Gap is found in all the three scenarios and the gap is highest as per Nurse to Doctor ratio.

15. For ANMs, Lab Technicians and Pharmacists only the IPHS and WHO norms are used. For ANMs the gap

will be there till 2018 and the gap is highest as per IPHS norms.

16. To forecast the supply of Lab Technicians, the existing number of Lab Technicians in the state has been

estimated and then the total production capacity has been added. For Lab Technicians 2.2% of the

current public sector stock is deducted annually to adjust for retirements etc. The percentage reduction

per year (i.e. 2.2%) is assumed to be equal to the percentage of Doctors retiring per year for the public

sector. It is also clear from the study that over a period of ten years, Orissa will have added just 317 Lab

Technicians. As the study reports by 2018, as per IPHS and WHO norms, the percentage of shortfall will

be 43.0 and 69.15 respectively.

17. Compared to the Lab Technicians,

the projected increase in the

number of Pharmacists in Orissa

over a period of ten years is quite

encouraging. This is the only

cadre of human resources which

has more supply than the need

and hence the challenge is how

to leverage this important human

resource to improve the health

system in Orissa.

18. Attempt was also made to create

districts maps indicating the ratio

of availability/current position


and requirement as per IPHS norms for each cadre for the year 2006 and 2009. (The maps for the year

2010 are yet to be generated and they might show a slightly encouraging scenario as the sanctioned

strength and in position for cadres other than doctors is better than the previous years.)

19. In the case of ANMs, the number of districts with highest ratio of availability came down from 27 in

2006 to 11 in 2009. The Map for the year 2009 clearly indicates the districts with maximum and

moderate availability. From policy perspective, it is necessary to explore why some districts which had

high ratio of availability in 2006 had reduced availability in the year 2009. Not a single meets the IPHS

norms.

20. In the case of GNMs, in 2006, 25 districts had GNMs in the ratio of 09 and above. But in 2009, similar

ratio cannot be found in any district .This shift seems to a disturbing scenario considering the role

played by the GNMs in the health sector. Four districts have the lowest ratio of availability. The district

which had the highest availability ratio in 2006 has slipped to have medium availability ratio in 2009.

Not a single district meets IPHS norms.

21. In the case of doctors, the number of districts with high ratio of availability came down from 23 in 2006

to 8 in 2009. There was no district in 2006 with the lowest availability ratio in 2006. But in 2009, 8

districts are found in this category. At the same time, availability ratio has also improved in some

districts. Only three districts meet the IPHS norms. Surprisingly, not a single district from the coastal

region meets this norm.

22. In the case of Lab. Technicians, the number of districts with high ratio of availability came down from

24in 2006 to 21 in 2009. Some districts with highest and medium availability ratio in 2006 had reduced

availability ratio in 2009. Not a single district meets IPHS norms.

23. Pharmacists is the only cadre which shows improved availability ratio from 11 in 2006 to 24 in 2009.

Not a single district is found to have lowest availability ratio in 2009. As compared to other cadres, in

the case of Pharmacists, only 6 districts are not able to meet the IPHS norms.

24. Health sector has always suffered from shortfall in human resources. Such shortfall can be seen at

different levels - global, national and regional. In Orissa, as evident from the data we have gathered,

the shortfall is very acute. One of the factors that is said to be the major cause of this shortfall is the

supply of human resources. Therefore, it is necessary to look at the factors affecting the supply.

25. Pascal et al3 present three set of factors affecting the supply of human resources in health. They are (1)

education/professional training choice, (2) participation in the health labour market and (3) migration.

According to them the “decision to undertake professional training is an investment decision” and

therefore, return on investment weighs heavily on the minds of the graduates wanting to opt for

medical education and the actors willing to invest in setting up medical institutions, particularly the

3 Pascal et al (2004): “Imbalances in the Health Workforce”, Department of Human Resources for Health, WHO, Geneva,

www.humanresources-health.com/content/2/1/13


private players. Besides this “human capital” approach, the other factors affecting the decision are the

“socio-psychological” factors such as the social value the society attaches to medical profession and the

personal satisfaction derived from caring for the sick.

26. Participation in the labour market, according to them, is determined by the individual’s trade-off

between labour and leisure as “they decide how much of their time to spend working for pay or

participating in leisure activities”. Many studies, as quoted by them, suggest that increased wages may

attract increased labour participation, though in some cases it doesn’t. In the case of Orissa, the leisure

factor during the working hours needs to be interpreted differently as in most of the government run

health institutions4, the labour force is absent, particularly the Doctors, and they are engaged in private

practice or other economic related activities.

27. Migration is also a significant factor affecting the supply of human resources in health. According to

them, migration is linked to both economic and socio-psychological and institutional factors.

28. Against this backdrop, our study reveals the following types of imbalances.

a) Intra and inter profession imbalances: This set of imbalances is found among the Doctors, Nurses,

Lab Technicians and Pharmacists, as also imbalances within a profession, e.g. shortage of specialists

among Doctors.

b) Geographic imbalances: These are disparities found in different regions and districts and between

rural and urban regions.

c) Institutional and services imbalances: These are differences in health workforce supply between

health care facilities, as well as between services.

29. Though we have looked at the institutional imbalances in detail, it is also important to see the same in

the three Medical Colleges, which are crucial to the supply of human resources. The imbalances are

quite striking. It is surprising to note that not a single faculty position is lying vacant in SCB Medical

College, Cuttack. VSS Medical College, Burla has more vacant positions among Professors and Associate

Professors, where as in the case of MKCG Medical College, Berhampur, vacancy is more pronounced in

the case of Assistant Professors and Lecturers/Tutors. The maximum vacancy is found in the case of

Lecturers/Tutors followed by Associate Professors, Assistant Professors and Professors.

30. The overall gap in supply among the Doctors, Nurses (GNMs), ANMs, Pharmacists and Lab Technicians

is indicated in the figures given below. In figure 1 two scenarios are presented for Doctors. According to

IPHS norms, from 2016onwards, there will not be any gap. However, as per Doctor-population ratio

and as per the WHO-GoI norms, the gap will continue to exist. The only cadre, which will not have gap

is the Pharmacists. According to WHO-GoI norms, as indicated in figure 2, the maximum gap is found

among Lab. Technicians, followed by Doctors, GNMs and ANMs.

4 However, Doctors are fully engaged in Hospitals attached to Medical Colleges and in some of the District Headquarter

Hospitals.


31. While ensuring adequacy of human resources poses a major problem, what can be said as a serious

issue for Orissa is the availability. The following figures present the number of Doctors sanctioned

against the number of Doctors in position for the period 2004-2009. It is clear that there is a marginal

decline in the number of posts sanctioned. However, the decline is more for the number of Doctors in

position.

32. Trends available for GNMs, ANMs, Lab. Technicians and Pharmacists suggest that the gap between the

sanctioned strength and in position is very marginal.

33. Three sets of gaps are generated from the data made available.

1. Ratio of availability between the year 2006 and 2009: Looking at the trends in sanctioned strength

and in position, certain assumptions were made to arrive at the desirable ratio of availability.

Accordingly the following ratio was identified for each cadre for each district.

Doctors:

> 0.75 – Green (High)

0.60 - 0.75 – Yellow (Moderate)

0.50 - 0.59 – Orange(Medium)

< 0.50 - Red (Low)

Figure 1: Gap as a percentage of Need (IPHS norm) Figure 2: Gap as a percentage of Need (WHO- norm)


Pharmacists, Lab. Technicians, GNM & ANM


0.70 to 0.90 – Yellow (Moderate)

< 0.70 - Red (Low)

Based on this ratio GIS maps are generated for each district. The maps are given at annex 1.

2. Requirement as per IPHS norms: Using IPHS norms, the gap is identified for each cadre in each

district. The maps generated as per IPHS norms are also given in annex 1.

The maps indicate the following. (1)No consistent policy, (2) cadre and district variations, (3)

only for the Pharmacists the scenario has improved, (4) minimum shift is found only in the case

of Lab. Technicians, (5) while all the districts for all the cadres do not meet IPHS norms (except

Pharmacists and Doctors), some districts suffer from extreme low ratio which needs immediate

attention.

3. Requirement as per WHO norms adopted/suggested for India: Tables 42-46 present the gaps

for all the cadres for all the districts. The following summary inferences can be made from

these tables.

• Gap is found in all the districts with high degree of inter district variations.

• Inter cadre variations is also present

• The projected supply for the year 2009 is far less than the number required as per the norm.

• It is also possible to identify the gap in the tribal and hilly districts

34. In order to leverage human resources in health, we looked at the experiences of some other better

performing states. The experiences of some of the states we have studied reveal the following.

I. To augment the shortage of human resources in health, we need a strong and consistent political

commitment for public health.

II. Both short term and long term strategies are required. The short term strategy is to leverage existing

human resources. This includes enhancement, substitution, delegation, innovation, transfer,

relocation and liaison5. Partnering with the private actors is another short term strategy. The long

term strategy, of course, is to increase the number of seats and formulating and implementing

appropriate HR policy to ensure adequate and consistent supply of human resources to achieve better

health outcomes, particularly in the rural and unreached areas.

III. Creating suitable and adequate infrastructure has played an important role in achieving better health

outcomes. In the states we have reviewed, we find that there is a strong commitment to ensure that

the money available for improving the infrastructure under NRHM and other sources is spent with

accountability and on time.

IV. While ensuring supply is a big challenge, what perhaps has played a more critical role is the overall

development scenario. For example, high level of literacy, better nutrition, communication (road),

5 Quoted in the article by Karl Krupp and P. Madhivathanan, “Leveraging Human Capital to Reduce Maternal Mortality in

India: enhance public health system or public-private partnership?”


supply of water and electricity and better sanitation facilities are vital to achieve better health

outcomes, as can be seen in the case of Tamil Nadu, Kerala, Andhra Pradesh and Karnataka.

Therefore, any strategy to augment the supply of human resources for health has to be linked to the

overall development scenario of the state. For Orissa, this is extremely critical and thus calls for

serious inter-sectoral coordination.

V. As suggested by Hongoro et al, the available strategies in the developing countries have difficulties.

For example, it takes at least 5 years to produce a Doctor and 3 years to produce a Nurse. In view of

these difficulties, it may be necessary to focus on auxiliary cadres, skill substitution and enhancement.

There is enough evidence to prove that Nurses can be safe and effective in place of Doctors.6

VI. Absenteeism is very seriously addressed in states like Tamil Nadu and Kerala. Instead of waiting for an

opportunity to punish the absenting health personnel, what they have done is to create an enabling

environment for increased attendance and participation7. The heath sector reform experiences in

Andhra Pradesh too demonstrate this point.

VII. The number of seats available for MBBS degree is far less as compared to Kerala and Tamil Nadu,

which also have better health indicators such as IMR and MMR. The fact that Orissa did not think of

starting many Medical Colleges, as in the case of Tamil Nadu and Kerala, is quite intriguing. Till four

years ago, Orissa had only three government Medical Colleges. Therefore, the climate of medical

education in Orissa needs a thorough review.

35. Based on the learning from other states and the gaps which we have identified for human resources for

health in Orissa, some recommendations are suggested. Notable among them are the following:

I. For Orissa, the immediate step to be taken is skill enhancement (“upgrading a particular job by

increasing the skill level of workers or enhancing the role with additional responsibilities”),

substitution (“exchanging one type of worker for another-training Nurses to take on the role of

Doctors in primary health care delivery”) and relocation (“shifting particular services from one health

care sector to another”).

II. There is a need to increase the number of institutions offering medical education, particularly for

nursing education.

III. Conducting OPSC exams every six months to fill up the vacancy, enhancement of facilities for learning

in the Medical Colleges, and appointment of faculty as suggested by Medical Students Union are some

of the suggestions which need immediate attention.

6 Charles Hongoro and B. McPake, “How to Bridge the Gap in Human Resources for Health”, www.thelancet.com, Vol 364,

October 16, 2004

7 For details refer, P.Padmanaban, “Innovations in Primary Health Care with NRHM Support in Tamil Nadu, to know Tamil

Nadu’s experience


IV. The seat capacity for Post Graduate course should be increased by at least 50% from the year 2010

and be linked to satisfactory completion of rural service.

V. MBBS candidates from other States with degrees from recognized Medical Colleges should be

permitted to apply for Post Graduate course in the State with a mandatory stipulation of serving the

rural areas for at least 3 years in order to successfully complete the degree.

VI. The salary, perks and other allowances being given to Doctors, Nurses and Paramedical staff needs to

be given a thorough and critical review to see how it can be modified to attract people.

VII. In the absence of time-series data, it is suggested that a new format be designed and used to identify

the gaps in human resources at different levels of the health system - Sub-centre, PHC, CHC, SD

Hospitals and District Head Quarter Hospitals.


INTRODUCTION

Infrastructure Professionals Enterprise (IPE) and Options Consulting Services Ltd., UK on behalf of the

Department for International Development (DFID) have established a Technical and Management Support

Team (TMST) to support the implementation of Orissa Health Sector Plan (OHSP).

In order to strengthen this support, TMST entered into a contract with the Xavier Institute of Management,

Bhubaneswar (XIMB) to undertake a study on the “Supply Side Analysis of Human Resources for Long Term

Availability of Health Providers, Department of Health and Family Welfare (DoHFW), Government of Orissa

(GoO)”. This report is prepared as part of this agreement.

This report has eight parts:

Part One deals with the context used for this study.

Part Two presents the methodology used for the study.

Part Three deals with the supply side of Doctors, Nurses, ANMs, Lab Technicians and Pharmacists.

Part Four presents the ten year forecast of Doctors, Nurses, ANMs, Lab Technicians and Pharmacists.

Part Five presents the need-supply gap analysis

Part Six analyses the human resources in the context of adequacy and availability

Part Seven tells what Orissa can leverage from the experiences of other states

Part Eight presents the key findings, suggestions and conclusions.


1. CONTEXT & CLIMATE OF HEALTH SECTOR REFORM

The issues related to human resources for health in Orissa are amply explained in some of the documents

available with the Department of Health and

Family Welfare, (DoHFW) Government of Orissa

(GoO)8. While we may use diverse factors to

posit this study, an attempt is made to select a

few variables which are more closely related to

the need/demand and supply for human

resources. Therefore the factors selected to

understand the context are the changing

demographic and socio-economic profile in

Orissa and some selected factors related to

human resource and infrastructure in health. An

attempt is also made to present a comparative

picture of these factors between Orissa and

some other states selected on the basis of their

performance and proximity to Orissa.

Accordingly, states like Tamil Nadu (TN) and

Kerala are selected for their best performance

and the other states, West Bengal (WB), and

Chhattisgarh are selected to present information

on how the neighbouring states are performing.

The projected population for the year 2016 for Orissa is 42479000 (Male: 21438 and Female: 21041). The

current population growth rate (1991-2001) for Orissa is 16.259. Though the decadal growth rate for

Orissa reveals a positive trend as compared to other states, some of the socio-demographic, economic and

health indicators given in Table 110

are highly unfavourable and threatening. It may also be useful to see

some of the selected indicators of Orissa in comparison to other states in Table 2 below.

8

Orissa State Integrated Health Policy-2002, Orissa Vision 2010: A Health Strategy, 2003 and State Health

Systems: Orissa, by Meena Gupta, Indian Council for Research on Intersectoral Economic Relations, 2002

9 DoHFW, GoO

10 Source: Source: National Health Profile, Central Bureau of Health Intelligence, DoH&FW, GoI

Table 1. Selected Key Indicators for Orissa

IMR (2008) 71

MMR (2008) 303

Birth Rate (2006) 21.9

Death Rate (2006) 9.3

Sex Ratio 972

Literacy Rate 63.1

Percent of People living below Poverty

Line 46.4

Per capita State Domestic Product (Rs.) 17299

Employment in the organized sector 765.5

Percent of Households having Electricity 26.91

Percent of Households not having Toilet 79.54

Percent of Households Having Safe

Drinking Water 64.2

Source: National Health Profile, Central Bureau of Health

Intelligence, DoH&FW, GoI and SRS Data, 2008


Table 2 clearly indicates the difference between Orissa and the other states. The number of seats available for

MBBS degree is far less as compared to Kerala and Tamil Nadu, which also have better health indicators such as

IMR and MMR. This is also evident from the establishment of Medical Colleges in Orissa over the last six

decades.

Table 3: Establishment of Medical Colleges

State

Decades

Pre-

Independence 1950s 1960s 1970s 1980s 1990s 2000 onwards Total

Chhattisgarh 0 0 1 0 0 0 2 3

Kerala 0 2 2 0 1 1 16 22

Orissa 1 (1944) 1 1 0 0 0 3 6

Tamil Nadu 3 (1835, 1838 &

1942) 2 4 0 4 4 15 32

West Bengal 4 (1838, 1916 &

1948) 2 2 0 0 0 2 10

Total 8 7 10 0 5 5 38 73

Source: Medical Council of India

It is evident from table 3 that medical education was totally neglected during the decades 1970s-1990s.

Though many Medical Colleges have been set up in the current decade, Kerala and Tamil Nadu are far

ahead of Orissa. Till four years ago, Orissa had only three government Medical Colleges. Therefore, the

climate of medical education in Orissa needs a thorough review.

Table 2: Comparative Picture of Selected Demographic, and Health Indicators

Sl.No States Population Percentage No. of MBBS

seats (2008)

IMR

(2008) MMR (2008)

1 Chhattisgarh 20795956 2.03 150 59 335 (including MP)

2 Kerala 31838619 3.1 2500 13 95

3 Orissa 36706920 3.57 707 71 303

4 Tamil Nadu 62110839 5.88 3665 35 111

5 West Bengal 80221171 7.81 1255 37 141

Sources: SRS Bulletin 2008, Medical Council of India and Census of India-2001


Table 4: Incidence of Hunger, Poverty, Malnutrition and Availability of Public Health

Sl.

No State

Inadequate

food (%)

2004-2005

Poverty - % of

population

2005-2006

Malnutrition under 3 yrs.

Underweight

children (%) 2005-2006

Public health %

household access

to toilet

1 Chhattisgarh 2.2 40.9 52.1 18.7

2 Kerala 2.3 15 28.8 96

3 Orissa 5.3 46.4 44 19.3

4 Tamil Nadu 0.3 22.5 33.2 42.9

5 West Bengal 9 24.7 43.5 59.5

Source: Economic Survey of India, 2008

As indicated in the table 4, poverty, hunger and lack of accessibility to toilets are some of the factors

directly linked to heath and hence, planning for human resources in health cannot be done in isolation.

Table 5: State-wise Number of Government Hospitals and Beds in Rural and Urban Areas (including CHCs) in India

(As on 01.03.2007)

State/UTs

Rural Hospitals Urban Hospitals Total Hospitals Projected

Population

as on

1.3.2007

(In ‘000s)

Population

Served Per

Govt.

Hospital

Population

Served Per

Govt.

Hospital

Bed

Reference

Period Number Beds Number Beds Number Beds

Chhattisgarh 116 3514 22 2051 138 5565 22934

(21553) 156181 3873 01.09.2004

Kerala 173 12450 77 15945 250 28395 33535 134140 1217 01.01.2008

Orissa 1623 5882 84 8668 1707 14550 39276 23009 2699 01.01.2008

Tamil Nadu 533 25078 48 22120 581 47198 65629 112959 1391 01.01.2008

West Bengal 99 5171 284 44510 383 49681 86125 224869 1734 01.01.2008

India 6955 154031 3021 328491 9976 482522 113124 2339

Source: Indiastat.com

This table indicates that though the population served per government hospital is less as compared to

other states, the population served per government hospital bed is quite high in Orissa. This also indicates

the role government hospitals play in Orissa. Though Orissa has more hospitals than Kerala and Tamil

Nadu, the number beds available In Orissa is far less than the ones we can see in the other two states.

The following tables (Tables 6 - 13) present the status of health professionals available for Orissa, in

comparison with the states of Chattisgarh, Kerala, Tamil Nadu and West Bengal; as well as all India figures.

The shortfall in manpower in Orissa is very evident across all cadres. However, the notable ones among


them are the Laboratory Technicians and GNM/Staff Nurse cadres. These two cadres are very crucial for

health delivery. In the later part of this report, we shall also discuss the cadre wise and district wise

shortfall in manpower in Orissa.

Table 6: State-wise Number of Allopathic Doctors with Recognised Medical Qualifications (under

IMC Act) and Registered with State Medical Councils in India (2000 to 2007)

State Medical

Councils 2000 2001 2002 2003 2004 2005 2006 2007

Chhattisgarh 1 101 285 470 654 899*

Travancore -

Cochin (Kerala) 29087 30173 31353 31353 33418 34561 35477 35477

@

Orissa 14009 14315 14640 14707 14973 15219 15573 15728*

Tamil Nadu 63434 65771 68209 70357 72077 73211 75415 77780*

West Bengal 49261 49941 50794 51961 53068 53521 54513 55200*

India 555550 577094 607075 625423 643964 660856 682646 696747

Source: Ministry of Health and Family Welfare, Govt. of India.

Abbr.: IMC: Indian Medical Council.

Note: Figures are Provisional

1: Data as on 31st December of the year concerned.

*: Incomplete Information Received.

**: Information not received.

$: Chhattisgarh Medical Council started Registration Work in Year 2002.

#: Jharkhand Medical Council started Registration Work in Year 2003.

##: Delhi Medical Council established in Year 2000. @

: Information not received for the concerned year, previous year information repeated.

2 : Figures 7644 , the registration done by the Mahakoshal medical council up to 06.06.1979, has been added

in the annual figure of year 2002 in MP medical council, Bhopal vide letter dated 23.01.2003 received from the

registrar, M.P. Medical Council, Bhopal.

3: After merging of the Hyderabad Medical Council with Andhra Pradesh Medical Council from 1992, separate

registration is not done by Hyderabad Medical Council and its constant figures of 13888 is being added with

Andhra Pradesh figures in the above table.

Orissa, next to Chhattisgarh, has the least number of Allopathic Doctors registered with the State Medical

Council.


Table 7: State Council-wise Total Number of Nursing Educational Institutions in Different Nursing

Courses in India (as on 31st March 2006)

States A.N.M. G.N.M. B.Sc. (N) M.Sc. (N) P.B. B.Sc.(N)

Chhattisgarh 1 1 9 1 0

Kerala 14 137 59 3 5

Orissa 16 20 8 0 1

Tamil Nadu 11 102 49 33 9

West Bengal 20 38 5 2 2

India 271 1312 580 77 62

Source: Nursing Council of India

Abbr.:

A.N.M.: Auxiliary Nurse Midwives

G.N.M.: General Nursing and Midwives

B.Sc. (N): Bachelor in Nursing

M.Sc. (N): Master in Nursing

P.B.B. Sc. (N): Post Basic Bachelor in Nursing

Orissa has only 20 schools for GNMs. This can be compared to Tamil Nadu and Kerala which have the

largest number of schools for GNM. This again indicates Orissa’s neglect for nursing training.

The following tables (7-12) present the short fall in the Health Assistant (Female), Health Assistant (Male),

Female Health Worker/ANM, Laboratory Technicians and Nurse Midwife/Staff Nurse positions.

Table 8: State-wise Number of Health Assistants (Female)/Lady Health Visitor (LHV) At Primary

Health Centres (PHCs) in Rural Areas of India (as on March, 2007)

States/UTs Required1 (R) Sanctioned (S) In Position (P) Vacant (S-P) Shortfall (R-P)

Chhattisgarh 518 779 709 70 *

Kerala 909 830 740 90 169

Orissa 1279 726 726 0 553

Tamil Nadu 1181 1668 1612 56 *

West Bengal 922 1726 1227 499 *

India2 22370 18029 15546 2497 7142

Source: Ministry of Health & Family Welfare, Govt. of India

Abbr.: NA: Not Available.

Note: *: Surplus.

1: One per each existing Sub Centre and Primary Health Centre.

2: For calculating the overall percentages of vacancy and shortfall, the States/UTs for which manpower

position is not available, should be excluded.


Table 9: State-wise Number of Health Assistants (Male) At Primary Health Centres (PHCs) in Rural

Areas of India (as on March, 2007)


Chhattisgarh 518 3551 2940 611 *

Kerala 909 802 794 8 115

Orissa 1279 176 168 8 1111

Tamil Nadu 1181 384 303 81 878

West Bengal 922 1496 550 946 372

All India2 22370 25981 20234 5747 6261

Source: Ministry of Health & Family Welfare, Govt. of India.


Note: *: Surplus.




Table 10: State-wise Number of Health Worker (Female)/ANM At Sub Centres and Primary Health

Centres in Rural Areas of India (as on March, 2007)


Chhattisgarh 5210 4335 3667 668 1543

Kerala 6003 5670 5634 36 369

Orissa 7206 7121 6768 353 438

Tamil Nadu 9864 10367 10351 16 *

West Bengal 11278 10356 9900 456 1378

India2 167642 161445 147439 14180 21157


Abbr.: ANM: Auxiliary Nurse Midwife.

Note: *: Surplus.





Table 11: State-wise Number of Health Worker (Male) At Sub-centres in Rural Areas of India (as on

March, 2007)

States/UTs Required1 (R) Sanctioned (S) In Position (P) Vacant (S-P) Shortfall R-P)

Chhattisgarh 4692 3818 2852 966 1840

Kerala 5094 4346 4266 80 828

Orissa 5927 4911 3392 1519 2535

Tamil Nadu 8683 5062 1503 3278 7180

West Bengal 10356 9660 5178 4482 5178

All India2 145272 92791 62881 29653 77615



Note: *: Surplus.




Table 12: State-wise Number of Laboratory Technicians at Primary Health Centres (PHCs) and

Community Health Centres (CHCs) in Rural Areas of India (as on March, 2007)


Chhattisgarh 636 633 348 285 288

Kerala 1016 368 336 32 680

Orissa 1510 344 311 33 1199

Tamil Nadu 1417 1108 955 153 462

West Bengal 1268 1413 1031 382 237

All India2 26415 15773 12101 3672 9795



Note: *: Surplus.





Table 13: State-wise Number of Nurse Midwife/Staff Nurse at Primary Health Centres (PHCs) and

Community Health Centres (CHCs) in Rural Areas of India (as on March, 2007)


Chhattisgarh 1344 676 540 136 804

Kerala 1658 2811 3064 * *

Orissa 2896 657 637 20 2259

Tamil Nadu 2833 NA NA NA NA

West Bengal 3344 944 858 86 2486

All India2 50685 36036 29776 6727 17262



Note: *: Surplus.




Table 14 presents the shortfall in health infrastructure in Orissa and other selected states. Considering the

presence of large tribal population, which also live in remote and most inaccessible areas, shortfall in sub-

centres and community health centres pose a major challenge for health development in Orissa.

Table 14: State-wise Shortfall in Health Infrastructure (SCs, PHCs and CHCs) As per 2001 Population in India

(As on March, 2007)

States/UTs

Total

Popu-

lation in

Rural

Areas

Tribal

Popu-

lation in

Rural

Areas

Sub-Centres (SCs) Primary Health

Centres (PHCs)

Community Health

Centres (CHCs)

Req-

uired

In

Position

Short-

fall

Req-

uired

In

Position

Short-

fall

Req-

uired

In

Position

Short-

fall

Chhattisgarh 16648056 6264835 4164 4692 * 659 518 141 164 118 46

Kerala 23574449 350019 4761 5094 * 791 909 * 197 107 90

Orissa 31287422 7698358 7283 5927 1356 1171 1279 * 292 231 61

Tamil Nadu 34921681 551143 7057 8683 * 1173 1181 * 293 236 57

West Bengal 57748946 4136366 12101 10356 1745 1993 922 1071 498 346 152

India 742490639 77338597 158792 145272 20855 26022 22370 4833 6491 4045 2525


Notes: The requirement is calculated on the basis of final total and tribal population of Census, 2001 in rural areas

using the prescribed norms. All India shortfall is derived by adding state-wise figures of shortfall ignoring the existing

surplus in some of the states.

*: Surplus...

It is very clear from the tables presented above that there is a significant shortfall in health professionals

across the state. Moreover, when one compares the figures to other states that have more favourable

health indicators, like Kerala and Tamil Nadu, the shortfall is even more glaring. Thus, the fact that there is

a need for reform in the Health sector in the state and that immediate and transformational action needs

to be taken is glaringly obvious.


CLIMATE OF HEALTH SECTOR REFORM11

: Health sector reforms12

do provide enough insight to understand

the context of supply side of human resources in health. Various reform initiatives are undertaken in most

of the states. Table 15 presents the number of health sector reform initiatives undertaken in the selected

states. It is clear from this table that Orissa is one of the leading states for initiating health sector reforms

and out of nine initiatives; four are related to human resources. However, human resource reforms that

have been introduced have been mostly related to incentives and capacity building and they have not

systematically and directly addressed the issue of increasing the number of manpower to meet the

shortfall.

Table 15: Health Sector Reform Climate13

Sl.

No. Reform Initiative

States and Number of Initiatives

Orissa AP Chattis-

garh

Jhar-

khand Kerala

Tamil

Nadu

West

Bengal

1. Infrastructure and Equipment 2 1 1 1 1

2. Logistics 2 1 1

3. Financial Management Systems

4. Monitoring, Evaluation and Quality

Control 1 1

5. Public-Private Partnership 1 3 6

6. Management Structures and System 1

7. Social Marketing and Franchising 1 1 1

8. Inter-Sectoral links 1

9. Health Information system 1 1 1

10. Access to Service and Coverage 1 2 2 1 4

11. Health Financing 1

12. Human Resources 4 1 2 1

13. Community Participation 1 1 2 1

14. First Referral Units 5

15. Convergence Among Development

Partners

16. Total 9 6 4 8 5 19 8

11 WHO has published the experiences of health sector reforms in nine states in India, including Orissa.

However, these experiences do not sufficiently address the supply side of human resources.

12 Roberts et al suggest five control knobs- Behaviour, Regulation, Organisation, Payment and Financing- necessary for

initiating reforms in the health sector. (See Roberts J. Marc et al (2004) “Getting Health Reform Right: A Guide to

Improving Performance and Equity”, OUP, New York

13 Source: National Health Profile-2007, Central Bureau of Health Intelligence, DoH&FW, GoI


2. METHODOLOGY

The following methods were used for this study.

2.1 DESK REVIEW:

Secondary data from various sources has been collected for this study. Out of the different sources two

sets of data are of particular importance. The first set is the quantitative data taken from various

government sources related to health care and medical institutions (both public and private), intake of

medical and para-medical students, short fall in human resources, and short fall in health infrastructure.

Though some of them are used as part of this text, most of them are given in annex 1 as tables with

number and titles. The second set of data includes the various articles and reports related to health sector

reform, human resources in health and models for assessing the supply side of human resources. The titles

of these articles /documents reviewed are given in annex 2. The second set of data has helped us in

understanding the key issues and strategies related to human resources in health, and the models for

analysing supply side of human resources.

2.2 STAKEHOLDER INTERVIEWS:

In-depth interviews were held with various stakeholders. Some of them include, Chief District Medical

Officers (CDMOs), Principals of Medical College, President of Medical College Students’ Association, key

staff of DoH&FW, Doctors in private hospitals, staff in government hospitals, Presidents (state level) of

Indian Medical Association (IMA), Pharmacy Council of India and , Nursing Council of India, Orissa Medical

Services Association (OSMA), selected representatives of undergraduate and post graduate students in

government Medical Colleges and Doctors who left the public service to join the private sector. Primary

data significantly augmented the understanding of health workforce supply in the state. Overall five

districts have been identified for primary data collection for the entire study. They are - Khurda, Keonjhar,

Bolangir, Jagatsingpur and Koraput. Visits were made to the head quarter hospital, community health care

centre (at least one) and primary health care center (at least one) of the selected districts and private

hospitals. Both qualitative and quantitative data were collected as part of the field visits. For the

quantitative data during the field visit, a format was designed to assist the staff in the hospital

(government) to give us the relevant data. The box below shows the summary findings of the different

interviews conducted with the stakeholders.


a. The following are the significant findings from the interviews of CDMOs of various districts:

• The existing capacity of Medical Colleges in the state to supply Doctors is grossly inadequate with an increase of around

200 seats being an immediate requisite.

• The salary structure offered to the Doctors in the state is much lower than that offered to Doctors in other states as well

as the OAS officials within the state.

• The female Doctors face additional problems at the workplace, the most prominent being lack of proper housing facilities.

• More often than not the posts of program officers remain vacant for various reasons.

• Contract Doctors typically join the same place from where they retired.

• Only 10-15% of the fresh pass-outs from the Medical Colleges in the state join the state government service every year.

• There is a marked absence of inclination to work in the government service with the most conspicuous being the

complete lack of desire to work in the remote/rural areas.

b. The following are the significant findings from the interviews of Doctors serving at various levels of healthcare in the state

(District Hospital, PHC/CHC etc.):

• An estimated 12,000 Doctors need to be recruited gradually in order to maintain the established standard population

Doctor ratio of 3000:1.

• The various reasons adding to the reluctance of Doctors working in the public sector in Orissa are:

i. Disparity in the salary structure as well as other perks as compared to the Doctors in other states as well as the OAS

officers within the state.

ii. Lack of proper facilities in the hospitals.

iii. Discouraging infrastructure of the places of posting (remoteness of the areas, lack of proper housing facilities, etc.).

iv. Lack of transparency in the existing transfer policy.

v. The existing promotion policy is not explicit with many Doctors being awarded very late promotions.

• These reasons force the Doctors in the public sector to take up private practice with the involvement being up to 70% of

the total workforce.

• There is a severe shortage in the nursing staff capacity across the districts.

• The retirements estimated by the month of November, 2009 is an alarming 200-300 which needs to be taken care of at

the earliest.

2.3 FORECASTING MODEL:

Among the many documents consulted for understanding the supply and demand side for human

resources in health, the two documents that provided good insight are, “Models for Projecting Human

resources for Health” by WHO, 2001 and “Health Human Resources” by Gita Proudman, McMaster

University and University of Toronto, 2000. The supply forecast model discussed subsequently has been

used to forecast the supply of mainly four types of health workforce namely – Doctors, Nurses, Lab

Technicians and Pharmacists. Depending on the baseline data available and estimated, these have been

further disaggregated at Rural/Urban level and specialization level.


The basic model is as follows:

SUPPLY FORECAST

S t+1 = St + It - Ot

where

St = Available supply of Doctors in the region during time period t

S t+1 = Doctor supply in time period t+1

It = Inflow of Doctors to the region in time t

Ot = Outflow of Doctors in time period t.

The Inflow and outflow of Doctors will be estimated separately as given below.

Inflow

It = NLt + IMt + OIt where

NLt = New licensees

IMt = In-migration from other regions

OIt = Other inflows (from other sectors, other types of health workforce etc.)

Outflow:

Ot = Rt + OMt + OOt where

Rt = Number retiring in time t.

OMt = Out migration to other regions

OOt = Other outflows (resignations, joining other sectors, deaths etc)

2.4 DEMAND FORECAST

In order to fully utilize the supply forecast data for policy inputs and future scenario generation, the

demand for health workforce in the next ten years will also be estimated. In view of the project duration

and scope, demand forecast will be undertaken using the following methods

1) Economic criteria – forecast GDP per capita – Convert into health worker demand using benchmarks,

like other states (Tamil Nadu) and other developed countries.

2) Population to personnel ratio – Future Population will be estimated using simple growth models

(exponential growth model or borrowed from other studies). Thereafter acceptable population to

personnel ratios (e.g. WHO, States with better health infrastructure) the demand for health workforce

will be forecasted.


2.5 METHODOLOGICAL CHALLENGES FACED BY CONSULTANTS

• No time-series data was available at the healthcare institutions.

• There was a lack of proper documentation of healthcare professionals.

• Guess estimates had to be used in many instances (e.g. age profile of healthcare professionals).

• There was no centralized record keeping.


3. SUPPLY SIDE ANALYSIS OF HUMAN RESOURCES FOR LONG TERM

AVAILABILITY OF HEALTH PROVIDERS

The following supply side factors14

were mentioned in our proposal submitted earlier for the study.

1. The likelihood and scope for establishing new educational and training institutes in Orissa.

Currently there are three public and three private Medical Colleges in Orissa15

and the annual

intake is 750. The three private Medical Colleges have come up in the last four years and some of

them are planning to open branches in other parts of Orissa16.

2. Projected intake of students in the existing institutions

3. Inflow of medical and health personnel to Orissa

4. Migration (inter and intra state) of health personnel

5. Trends in unmet service needs in terms of regions, rural-urban and tribal and non-tribal

communities

6. Trends in attrition from promotion, transfers and retirements

7. Trends in absenteeism : There are large number of Doctors on roll, but hardly attend duties

Though all these factors were considered for understanding the supply, for forecasting only the first

three factors were considered as the other factors were found to be very insignificant.

3.1. SUPPLY OF DOCTORS (PRODUCTION CAPACITY)

The supply of Doctors, Nurses, Lab Technicians, and Radiologists and Pharmacists has been the main foci

of the study. Consequently we tried to understand the existing level of human resource available in the

state for each of the aforesaid categories of health workers and also to estimate what are the additions

and deletions to the existing stock on an annual basis. A key ingredient to this analysis is the production

capacity of the state. As we can see from the table below, with the opening of private colleges, by the year

2012, the supply of Doctors and Nurses would have increased significantly in the state.

14

Some of the other factors the study tam considered during the course of the study are, (1) enabling factors such as

faculty positions in the three government Medical Colleges and , (2) political commitment to promote medical education .

15 Other institutes training paramedical staff will also be studied

16 Hi-Tech is planning to start one in Rourkela. Biju Patnaik Institute of Medical Sciences and Research in

Jagatpur, Cuttack by Sahyog and three more under PPP, as announced recently by the GoO.


Another aspect of production of human resources for health is the production of specialist Doctors. Based

on the intake capacity of all the three government Medical Colleges in the state, the following Table 17

shows the production of specialists in the state.

Table 17: Production capacity of Specialists (2007)

Specialization No. Specialization No.

MD – Anesthesiology 12 MD - Psychiatry 02

MD - Bio-Chemistry 03 MD - Radiotherapy 08

MD - Dermatology ,

Venereology & Leprosy 04

MD - Social & Preventive Medicine /

Community Medicine 04

MD - Forensic Medicine 04 MD - Tuberculosis & Respiratory Diseases 04

MD - General Medicine 38 MD/MS - Anatomy 02

MD - Microbiology 05 MD/MS - Obstetrics & Gynecology 22

MD - Paediatrics 20 MS - ENT 04

MD - Pathology 06 MS - General Surgery 26

MD - Pharmacology 04 MS - Ophthalmology 10

MD - Physiology 03 MS - Orthopedics 06

Source: DMET, GoO

Table 16: Intake capacity of students in Public and Private Institutes in Orissa for the year 2007

GOVERNMENT COLLEGE PRIVATE

COLLEGE

TOTAL

(public + private) COURSE SCBMCH,

Cuttack

VSSMCH,

Burla

MKCGMCH,

Berhampur

Total

Public

MBBS 150 150 150 450 300*

(from 2012)

450, 750*

(from 2012)

BDS 20 20 350 370

GNM + B.Sc.

Nursing 100 50 70 220 495

715, 915*

(*additional capacity

of 200 from 2013)

Radiology 10 10 10 30

Lab. Technician 20 20 20 60

D-Pharmacy 60 60 1840 1900

ANM 640 280 920

Source:orissahealth.org, orissagov.nic.in/finance/Orissa_budget_at_a_glance_2007-

DMET, GoO, 2010

08/Orissa_budget_at_a_glance/chap_13.pdf,

http://angul.nic.in/Approved%20list%20-%20ANM.pdf


On joining the public sector: Exit Interview of passing out student

Of the 107 students 30% cleared the PG entrance examination the same year of

passing out. A further 40% cleared the PG entrance examination the following

year. About 12-15 students joined the public sector on a contractual basis with

only one student joining the same year as passing out with the remaining joining

the following year. The rest have either joined private sector hospitals on a

contractual basis or are undergoing coaching for the PG examinations in various

cities like Hyderabad, Delhi etc.

In the following section we examine the supply of Doctors in both public and private sector and the

variables influencing the supply.

The supply of Doctors was estimated separately for private and public sectors in order to obtain the

overall supply of Doctors for the state. Specialization wise disaggregation of supply and district level

forecast were computed thereafter.

3.1.1 PUBLIC SECTOR

As mentioned earlier the

supply was estimated by

considering the main sources of

additions and deletions to the

available stock of Doctors. The

estimates of these factors and

reasons thereof are given

below.

a) Fresh recruits in the public sector (up to 2012) – Interviews with CDMOs and exit interviews of

students reveal that approx 15% of fresh pass outs from Medical Colleges actually join the public

health services.17

b) Fresh recruits in the public sector (after 2012) - It is assumed that with 300 more Doctors being

produced in the private sector from 2012 onwards, the flow of public sector production to public

service is likely to increase because of market forces. We also assume that none of the private sector

educated Doctors will join public service. Consequently we assume that 50% of the public sector

production will join public services as they will have to compete with those coming from private

colleges, who will be mostly interested in joining the private sector.

c) Retirements – Approximately 2.2% of existing base of 2009 will retire every year from the public

service. It has been estimated based on the data on age distribution of Doctors obtained from OCMR.

It is further assumed that 50% of the retirees take up contractual assignment in the public sector.

17

The interview with the CDMO, Bolangir revealed that when his batch passed out in 1975, 90% of then joined

the government service; but 80% of them left after two months.


d) Actual stock – The actual number fulltime Doctors in the public sector is estimated by taking into

consideration the total sanctioned strength and the vacancy. The secondary data for 2008 collected at

the district level reveals the total stock as 3387.

Table 18: District wise vacant position of Doctors (2009)

District S.S I.P C.V

Angul 130 61 69

Balasore 178 153 25

Baragarh 132 92 39

Bhadrak 114 72 42

Bolangir 158 124 34

Boudh 54 30 24

Cuttack 216 154 62

Deogarh 47 22 25

Dhenkanal 136 75 61

Gajapati 81 31 50

Ganjam 262 227 35

Jagatsinghpur 109 70 39

Jajpur 138 112 26

Jharsuguda 65 42 23

Kalahandi 174 105 69

Kandhamal 139 75 64

Figure 3: Distribution by year of Birth of Doctors


Table 18: District wise vacant position of Doctors (2009)

District S.S I.P C.V

Kendrapara 116 46 70

Keonjhar 198 98 100

Khurda 151 94 57

Koraput 156 65 91

Mayurbhanj 87 51 36

Malkangiri 259 215 44

Nabarangpur 112 43 69

Nayagarh 121 78 43

Nuapada 70 36 34

Puri 158 128 30

Rayagada 116 58 58

Sambalpur 143 131 12

Subarnapur 75 45 30

Sundergarh 191 152 39

Total 4086 2685 1400

Source: Directorate of Health Services, GoO

Both quantitative data and interviews of with CDMOs indicate that other variables (like death, early

resignations, inflow of Doctors qualified from other states) have insignificant contribution to the flow of

Doctors.

3.1.2 PRIVATE SECTOR

The presence of private sector health care providers can be seen to be very high or almost negligible

depending on the urbanization of the area. Highly urbanized areas like Bhubaneswar and Cuttack have

significant private sector presence while districts like Koraput, Keonjhar etc. have an insignificant presence

of private sector. We discuss the estimates of the size of the private sector under the heads of non-urban

and urban areas.

Non-urban districts

Field visits revealed the near absence of private sector health care providers in remote and interior areas

of the state. Based on the data collected from field visits to districts and interviews with CDMOs it is


estimated that the size of the private sector is 7.3% of the total size. The estimates for urban areas like

Bhubaneswar and Cuttack are given separately. A notable observation has been the fact that most of the

private practitioners are public sector Doctors18

as well, in the visited districts19

.

Urban Areas

In order to estimate the size of private sector in areas like Bhubaneswar and Cuttack, field visits were

made to 4 large private hospitals. In a sample of 4 private hospitals it was found that altogether 520 beds

have 420 Doctors. We assume total capacity of 1000 beds up to 2013 and 150020

beds thereafter to

project number of private sector Doctors in these urban areas.

The following table summarizes the estimates of the various components contributing to supply of

Doctors.

Table 19: Supply factors and estimate

Factor affecting supply Estimated number or percentage

Fresh recruits in public sector (up to 2012) 15% in 2009 with 5% increase every year of public

sector production (reaching 30% in 2012)

Fresh recruits in public sector(after 2012)

50% of public sector production in 2013 and going up

to 80% in 2013

300 additional posts created under OHSDP

Retirements 2.2% of existing workforce in the public sector.

50% take up contractual work.

Private sector entrants 50% of the graduates that remain

Size of Private sector in urban areas 808 using a ratio of 0.808 doctors per bed

Size of private sector in non-urban areas 7.3% of the total

Total production 450 up to 2012, 750 up to 2015, 1250 from 2016

onward

3.1.3 SUPPLY OF SPECIALISTS

18

In Bolangir, the director of one of the leading private hospitals is an Asst. Professor in Burla Medical College

19 For example, in Keonjhar, sanctioned posts of Doctors in public sector is 117 and there are only 14 Doctors

working in the private sector.

20 This does not take into account the proposed new Medical Colleges –AIIMS, three colleges under PPP and

one private medical college by Sahyog group


Field trips also revealed the distribution of doctors across the various specialties in the public sector. Based on

actual staff position in the government sector in the visited districts the following estimates are obtained for

specialization wise distribution.

Table 20: Percentage of Specialists in Orissa

Specialization As a percentage

of total specialist

As a percentage of

total doctors

Medicine 14.29 4.55

Pediatric 26.53 8.44

O & G 30.61 9.74

Surgery 14.29 4.55

Orthopedic 4.08 1.30

ENT 2.04 0.65

Skin& VD 2.04 0.65

Dental 2.04 0.65

Ophthalmology 2.04 0.65

Anaesthesiology 2.04 0.65

Total 100 31.81

Other specialists like neurosurgery were absent or present only in insignificant numbers.


4. TEN YEAR FORECAST OF HEALTH PERSONNEL

4.1 FORECASTED SUPPLY OF DOCTORS

Utilizing the estimates discussed in the previous section we can now forecast the ten year supply of doctors

using the base figure of 3387 as the total number of doctors in the public sector in the beginning of 2009.

We forecast the supply for the entire public sector of the state and the private sector in the non-urban areas.

Thereafter the private sector supply in the urban areas (like Bhubaneswar and Cuttack) is added to get a

complete forecast for the whole state.

The following table presents the forecast for the total public sector in the state and private sector in the non-

urban areas.

Table 21: Forecast for number of doctors in the Public Sector

Year

Number at

beginning of

the year

(2)

Number of

new

Joinees

(3)

Number

retiring

(4)

Number

joining on

contractual

work

(5)

Total public

sector

(6)

2009 5196 68 114 57 5206

2010 5206 90 114 57 5239

2011 5239 113 114 57 5295

2012 5295 135 114 57 5372

2013 5372 225 114 57 5540

2014 5540 248 114 57 5731

2015 5731 270 114 57 5943

2016 5943 455 114 57 6341

2017 6341 520 114 57 6804

2018 6804 520 114 57 7267

Note

Number at the beginning of the year is estimated by adding 4258(source: SHRMU) number of doctors and 638

(source: DMET)in position doctors in the 3 public sector medical colleges.


The following table adds the forecast for the private sector in the urban areas to the last two column of the

table above to arrive at an overall forecast for the state.

Table 22: Forecast for number of doctors in the Private Sector and Total

Year

Private sector all

non-urban areas

(2)

Private sector urban

areas

(3)

Total Private

Sector

(4)

Total supply

State

(4) + Table 21,

Column (6)

2009 571 808 1378 6585

2010 560 808 1368 6607

2011 551 808 1359 6653

2012 694 808 1502 6874

2013 655 808 1462 7003

2014 656 1212 1867 7598

2015 658 1212 1870 7813

2016 831 1212 2043 8384

2017 828 1212 2039 8844

2018 862 1212 2073 9340

Figure 4: Projected supply of Doctors in Orissa


4.1.1 DISTRICT LEVEL FORECASTS

The forecast at the state level can be used to forecast the supply at district levels. The relevant figure for this is

the total supply at the district levels excluding the private sector supply in the urban areas.

Table 23: District wise – Doctor forecast in public sector

District 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Angul 118 119 120 122 126 130 135 144 155 165

Balasore 297 299 302 306 316 327 339 361 388 414

Baragarh 178 180 181 184 190 196 204 217 233 249

Bhadrak 140 140 142 144 149 154 159 170 182 195

Bolangir 240 242 245 248 256 265 274 293 314 336

Boudh 58 59 59 60 62 64 66 71 76 81

Cuttack 299 300 304 308 318 329 341 364 390 417

Deogarh 43 43 43 44 45 47 49 52 56 60

Dhenkanal 145 146 148 150 155 160 166 177 190 203

Gajapati 60 60 61 62 64 66 69 73 79 84

Ganjam 440 443 448 454 468 484 502 536 575 614

Jagatsinghpur 136 137 138 140 144 149 155 165 177 189

Jajpur 217 219 221 224 231 239 248 265 284 303

Jharsuguda 81 82 83 84 87 90 93 99 106 114

Kalahandi 204 205 207 210 217 224 232 248 266 284

Kandhamal 145 146 148 150 155 160 166 177 190 203

Kendrapada 89 90 91 92 95 98 102 109 117 124

Keonjhar 190 191 193 196 202 209 217 231 248 265

Khurdha 182 183 185 188 194 201 208 222 238 254

Koraput 126 127 128 130 134 139 144 154 165 176


On specialization: Exit Interview of a passing out MBBS student

A student pursuing his PG in the medical colleges in Orissa is

entitled to a monthly stipend of Rs.19,000, Rs.20,000, and Rs.

21,000 in the first, second and third years respectively.

An interesting thing to note is that the stipend amount being paid

in Orissa is comparatively more than that being paid in other states

like Andhra Pradesh etc. where the stipend amount is Rs.12-15,000

per month. This is an important factor encouraging more students

from outside states to come for PG courses in Orissa. In fact some

departments like O&G at SCB Medical College is dominated by

students from the southern states.

District 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Malkangiri 99 100 101 102 105 109 113 120 129 138

Mayurbhanj 417 420 424 430 444 459 476 508 545 582

Nabrangpur 83 84 85 86 89 92 95 102 109 116

Nayagada 151 152 154 156 161 166 173 184 198 211

Nuapada 70 70 71 72 74 77 80 85 91 97

Puri 248 250 252 256 264 273 283 302 324 346

Rayagada 112 113 114 116 120 124 128 137 147 157

Sambalpur 254 256 258 262 270 280 290 309 332 355

Subarnapur 87 88 89 90 93 96 100 106 114 122

Sundergarh 295 297 300 304 314 324 336 359 385 411

Total 5206 5239 5295 5372 5540 5731 5943 6341 6804 7267

*the supply of Khurda and Cuttack districts will be further augmented by the total number of private sector

doctors in the year estimated for the urban areas.

4.1.2 SPECIALISATION WISE FORECAST

There are two possible alternatives for forecasting specialization wise supply of doctors. One could use the

specialization wise production as well to project the specialization wise numbers, however as many specialists

prefer to work outside the state (as they belong to states other than Orissa) this is likely to overestimate the

supply.

The other alternative is to use the

current specialization-wise distribution

of doctors to forecast the future supply.

Overall 31.81 percent of the doctors

are estimated to be specialists as

indicated in table in section 1.3.

Utilizing the proportion of each

specialist in the current population we

can arrive at the following table for the

future. This however does not include


the private sector in the urban areas.

Table 24: Specialization wise forecast

Year

Specialization

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018

Medicine 299 300 302 312 318 345 355 381 402 425

Pediatric 556 558 562 580 591 641 660 708 747 788

O & G 641 644 648 670 682 740 761 817 861 910

Surgery 299 300 302 312 318 345 355 381 402 425

Orthopedic 86 86 86 89 91 99 101 109 115 121

ENT 43 43 43 45 45 49 51 54 57 61

Skin& VD 43 43 43 45 45 49 51 54 57 61

Dental 43 43 43 45 45 49 51 54 57 61

Ophthalmology 43 43 43 45 45 49 51 54 57 61

Anaesthesiology 43 43 43 45 45 49 51 54 57 61

Total 2095 2102 2117 2187 2228 2417 2486 2668 2814 2972

As already mentioned other specialist’s are present in insignificant numbers. The figure 3 below depicts the

specialization wise supply of doctors in the state.

Figure 5: Specialization wise Forecast


4.1.3. EXAMINING NEED SUPPLY GAP.

The decadal growth of population in Orissa is approximately 15.94%21

. Distributing the growth evenly over the

10 years we estimate the annual population of the state. Following this the need of doctors is estimated using

three different norms/rations. The IPHS norms, the existing all India doctor to population ratio and the norms

prescribed by WHO. The gap in need and supply is subsequently estimated.

A) The IPHS norms are

• IPHS recommends 7 doctors per CHC

• One CHC per 80000 to 120000

• 22 doctors per 31-50 bed hospital

• 2 MO per PHC and one PHC per 20000 to 30000 population

Estimating Need from Norms

• Calculate the number of CHC needed using the norm 1 CHC per 100,000 population and multiply

by 7

• Calculate the number of PHC needed using 1 PHC per 25,000 population and multiply by 2

• Assume 1000 doctors needed for in the state for manning all other levels of public health facilities

(e.g. district hospitals)

B) The all India doctor to population ratio used is 1:1825

C) The WHO22

recommended doctor to population ratio is 1:3500

21

Trends of Population Growth in Orissa http://orissagov.nic.in/e-

magazine/Orissareview/aug2004/engishPdf/Pages34-37.pdf

22 Quoted in the Annual Report 2007, Ministry of Health and FamilyGovernment of India


Table 25: Gap in need –supply for Doctors

Year Supply

Population

projected

(in

millions)

Need

for

doctors

(IPHS

Norms)

Gap

as per

IPHS

norms

Gap as

percent

of need

(IPHS)

Need for

doctors

(using

1:1825 as

doctor to

population

ratio)

Gap as

per all

India

ratio

Gap as

percent

of need

(All

India

ratio)

Need

of

doctors

as per

WHO

norms Gap

Gap as

percent

of need

(as per

WHO

norms)

2009 6585 41.94 7291 706 9.69 22983

16398 71.35 11983 5398 45.0

2010 6607 42.57 7385.5 779 10.54 23327

16720 71.68 12163 5556 45.7

2011 6653 43.21 7481.5 828 11.07 23676

17023 71.90 12346 5692 46.1

2012 6874 43.85 7577.5 703 9.28 24030

17156 71.39 12529 5655 45.1

2013 7003 44.51 7676.5 674 8.78 24389

17386 71.29 12717 5715 44.9

2014 7598 45.18 7777 179 2.30 24754

17156 69.31 12909 5311 41.1

2015 7813 45.85 7877.5 64 0.82 25124

17311 68.90 13100 5287 40.4

2016 8384 46.54 7981 -403 0 25500

17116 67.12 13297 4913 36.9

2017 8844 47.23 8084.5 -759 0 25881

17037 65.83 13494 4651 34.5

2018 9340

47.94 8191 -

1149 0 26268 16928 64.44 13697 4357 31.8

Negative sign indicates surplus of doctors as per norms.

It is seen that based on the assumptions made for projection and norms given by IPHS the demand supply gap

is expected to last till 2015. However, another measure of need –supply mismatch is based on the existing all

India doctor population ratio. The all India doctor to population ratio is estimated at 1: 1666 (plan panel

rediff.com/money/2008/apr/07panel.htm). IndiaStat.com reports an all India doctor to population ratio of

1:1825. Using either of the estimates it is very clear that the doctor to population ration in Orissa is

significantly lower than all India average. Also based on WHO norms we see that the gap between and supply

as projected in figure 5 is quite large.


Thus, as per Doctor to population ratio and WHO-GoI norm, there will still be a huge shortfall of doctors even

by 2018. This is a matter of serious concern considering the role doctors play in order to achieve better health

outcomes. Though this scenario seems bleak, it is possible to change this if sincere efforts are made to set up

more medical colleges. Considering the current interest and the number of medical colleges established in the

last five years as compared to the earlier decades, if the government wishes, it can change this depressing

scenario.

Figure 6: Need-Supply Gap for Doctors


4.2. A FORECASTED SUPPLY OF NURSES (GNM)

Data on nurses concur with the view that supply of nurses is well before the requirement which in turn is

affecting the health care services. The vacancy position of nurses is given in the table below.

Table 26: Vacancy position of Staff Nurses (2009-10)

District Name Sanctioned

strength In position Clear vacancy

ANGUL

129 86 44 BALASORE

155 144 10 BARAGARH

86 55 31 BHADRAK

93 101 -7 BOLANGIR

148 77 70 BOUDH

42 26 25 CUTTACK

524 430 82 DEOGARH

54 36 19 DHENKANAAL

146 131 13 GAJAPATI

80 52 37 GANJAM

403 310 81 JAGATSINGHPUR

66 68 -2 JAJPUR

91 75 16 JHARSUGUDA

58 47 12 KALAHANDI

180 93 87 KANDHAMAL

128 81 49 KENDRAPADA

100 99 1 KEONJHAR

195 183 12 KHURDHA

267 239 27 KORAPUT

141 102 41 MALKANGIRI

234 232 0

81 48 33



strength

In position Clear vacancy

NABARANGPUR

79 41 40 NAYAGARH

142 106 34 NUAPADA

54 36 20 PURI

167 151 14 RAYAGADA

76 56 27 SAMBALPUR

278 237 34 SONEPUR

50 25 26 SUNDERGARH

236 202 33

Total 4483 3569 909

Source: Directorate of Health Services, GoO, May, 2010

The above analysis implies an overall vacancy percentage of 4%. Further, the existing production capacity of

nurses including both private and public sectors is 715. Further the nurse doctor ratio is very low at 0.5 in the

public sector. In the private sector this ratio based on sample data of 4 large hospitals works out to a slightly

better at 0.96. According to WHO the minimum nurse to doctor ratio should be 2 which is clearly way beyond

the current levels in the state of Orissa.

Table 27: Current Nurse to Doctor Ratio

Sector Doctors Nurses Nurse/Doctor ratio

Public 5196 2689* 0.517

Private (4 hospitals) 420 405 0.964

*Includes 535 new posts under OHSDP

Interviews with CDMOs, observations and interviews with nursing sisters that were conducted, revealed that

almost all the nurses are locally recruited. Further, the outflow from Orissa to other states happens to the

tune of 5% - 7%. The main reasons for nurses leaving their jobs and/or out going to other states is marriage

and/or better pay. Using these estimates the supply of nurses for the next 10 years has been projected. This is

shown in table 28 below.


We examine the need – supply gap in GNMs under various norms in the following table.

Table 29 : Gap in Nurse Need and Supply

Year Supply

of

Nurses

Need

based on

projections

of doctors

(2 per

doctor)

Gap Gap as a

percentage

of need

(Projected

supply)

Need as

per

IPHS

norms

for

doctors

(2 per

doctor)

Gap Gap as a

percentage

of need

(IPHS)

Need

as per

WHO

GAP Gap as a

percentage

of need

(WHO)

2009 3977 13169 9192 69.80 14582 10605 72.73 8388 4411 52.59

2010 4453 13214 8761 66.30 14771 10318 69.85 8514 4061 47.70

2011 4901 13307 8406 63.17 14963 10062 67.25 8642 3741 43.29

2012 5322 13748 8426 61.29 15155 9833 64.88 8770 3448 39.32

2013 5918 14005 8088 57.75 15353 9435 61.46 8902 2984 33.52

2014 6478 15196 8718 57.37 15554 9076 58.35 9036 2558 28.31

Table 28: Supply forecast of Nurses for the next 10 years

Year Supply at the

beginning of the year

Exits during the

year New Recruits

Supply at

the end of the year

2009 3470 208 715 3977

2010 3977 239 715 4453

2011 4453 267 715 4901

2012 4901 294 715 5322

2013 5322 319 915 5918

2014 5918 355 915 6478

2015 6478 389 915 7004

2016 7004 420 915 7499

2017 7499 450 915 7964

2018 7964 478 915 8401


2015 7004 15627 8623 55.18 15755 8751 55.54 9170 2166 23.62

Year Supply

of

Nurses

Need

based on

projections

of doctors

(2 per

doctor)

Gap Gap as a

percentage

of need

(Projected

supply)

Need as

per

IPHS

norms

for

doctors

(2 per

doctor)

Gap Gap as a

percentage

of need

(IPHS)

Need

as per

WHO

GAP Gap as a

percentage

of need

(WHO)

2016 7499 16768 9270 55.28 15962 8463 53.02 9308 1809 19.43

2017 7964 17687 9723 54.97 16169 8205 50.75 9446 1482 15.69

2018 8401 18680 10279 55.03 16382 7981 48.72 9588 1187 12.38

The following figure presents the data graphically

It can be clearly seen that the GNM supply will always be short of demand irrespective what norm is applied to

estimate the need.

Figure 7: Need-Supply Gap for GNMs


4.2. FORECASTED SUPPLY OF AUXILIARY NURSES (ANMS)

Table 30: Vacancy position of ANM (2009-10)


strength

In position Clear

vacancy

ANGUL 249 198 51

BALASORE 456 396 60

BARAGARH 344 278 66

BHADRAK 300 227 73

BOLANGIR 359 317 42

BOUDH 101 95 6

CUTTACK 532 495 37

DEOGARH 77 50 27

DHENKANAAL 262 234 28

GAJAPATI 248 185 63

GANJAM 698 558 140

JAGATSINGHPUR 323 272 51

JAJPUR 422 356 66

JHARSUGUDA 113 101 12

KALAHANDI 380 358 22

KANDHAMAL 265 231 34

KENDRAPADA 331 313 18

KEONJHAR 539 432 107

KHURDHA 343 320 23

KORAPUT 457 429 28

MALKANGIRI 823 692 131

MAYURBHANJ 239 210 29

NABARANGPUR 407 389 18

NAYAGARH 259 219 40

NUAPADA 150 144 6

PURI 378 340 38

RAYAGADA 355 327 28

SAMBALPUR 287 213 74

SONEPUR 134 121 13

SUNDERGARH 648 510 138

Total 10479 9010 1469


The above data implies an overall vacancy percentage of 4.5%. Further, the existing production capacity of

ANM including both private and public sectors is 920. However, when we look at the need and the supply

projection, the gap percentage in 2009 is 66.58 and it will be reduced to 58.42 in 2018. The following tables

and the figure present this scenario.


In the following table we estimate the need based on IPHS norms and WHO norm and then compare with the

projected supply. To calculate ANM need as per IPHS norms we use the following formula

ANM need (IPHS) = Number of sub-centre *2 + Number of CHC + Number of PHC.

According WHO norms and as recommended by GOI the number of ANM required are 1 per 5,000 population in plain

area and 3,000 population in tribal and hilly areas. We assume 1 per 4000 for the whole state.

Table 32: Gap in Need-Supply for ANMs

Year Supply

(projected)

Population

(in

millions)

Need

(IPHS)

Gap Gap as

percentage

of need

(IPHS)

Need -

WHO

(GOI)

GAP Gap as

percentage

of need

(WHO)

2009 7709 41.94 23067 15358 66.58 10485 2776 26.48

2010 8166 42.57 23414 15248 65.12 10643 2477 23.27

2011 8596 43.21 23766 15170 63.83 10803 2207 20.43

2012 9000 43.85 24118 15118 62.68 10963 1963 17.91

2013 9380 44.51 24481 15101 61.68 11128 1748 15.71

2014 9738 45.18 24849 15111 60.81 11295 1557 13.78

2015 10073 45.85 25218 15145 60.06 11463 1390 12.13

2016 10389 46.54 25597 15208 59.41 11635 1246 10.71

Table 31: Supply projection of ANM

Year Existing levels at

year beginning

Exits during the

year

New Joinees End of year

supply

2009 7222 433 920 7709

2010 7709 463 920 8166

2011 8166 490 920 8596

2012 8596 516 920 9000

2013 9000 540 920 9380

2014 9380 563 920 9738

2015 9738 584 920 10073

2016 10073 604 920 10389

2017 10389 623 920 10686

2018 10686 641 920 10964


Year Supply

(projected)

Population

(in

millions)

Need

(IPHS)

Gap Gap as

percentage

of need

(IPHS)

Need -

WHO

(GOI)

GAP Gap as

percentage

of need

(WHO)

2017 10686 47.23 25977 15291 58.86 11808 1122 9.50

2018 10964 47.94 26367 15403 58.42 11985 1021 8.52

Figure 8: Need-Supply Gap for ANMs


4.3. FORECASTED SUPPLY OF LAB TECHNICIANS

The district wise vacancy position of lab technicians is given below.

Table 33: Vacancy Position of Lab Technicians (2009-10)

District Sanctioned In position Vacancy

Angul 48 43 5

Balasore 58 53 5

Baragarh 55 53 2

Bhadrak 32 29 4

Bolangir 66 54 12

Boudh 16 13 3

Cuttack 67 72 -5

Deogarh 17 16 1

Dhenkanal 48 45 3

Gajapati 32 33 0

Ganjam 102 87 15

Jagatsinghpur 35 42 -7

Jajpur 41 25 16

Jharsuguda 27 17 10

Kalahandi 64 50 14

Kandhamal 67 55 12

Kendrapada 39 33 6

Keonjhar 83 77 6

Khurdha 66 59 7

Koraput 66 41 25


Mayurbhanj 32 20 12


District Sanctioned In position Vacancy

Nabrangpur 40 33 7

Nayagada 38 31 7

Nuapada 21 14 7

Puri 77 41 36

Rayagada 51 45 6

Sambalpur 74 64 10

Subarnapur 24 19 5

Sundergarh 93 85 9

Total 1593 1344 252


The data indicates an overall vacancy percentage of 6.6%. Besides the high vacancy percentage the allocation

of disease-wise allocation of lab technicians is also not optimal.

Table 34: Current Ratio of Lab Technicians to Doctors

Sector Doctors Lab technicians Lab technicians

/Doctor ratio

Public 5196 936* (includes 40

under OHSDP) 0.181

Private (4 hospitals) 420 99 0.236

To forecast the supply of lab technicians, the existing number of lab technicians in the state has been

estimated and then the total production capacity has been added. For lab technicians 2.2% of the current

public sector stock is deducted annually to adjust for retirements etc. The percentage reduction per year (i.e.

2.2%) is assumed to be equal to the percentage of doctors retiring per year for the public sector.


Table 35: Forecast Supply of Lab Technicians

Year Beginning of

year supply

Exits during

the year New recruits

End of year

supply

2009 1201 26 60 1162

2010 1235 26 60 1197

2011 1270 26 60 1232

2012 1304 26 60 1268

2013 1338 26 60 1303

2014 1373 26 60 1338

2015 1407 26 60 1373

2016 1441 26 60 1408

2017 1476 26 60 1444

2018 1510 26 60 1479

One can easily understand the annual increase in the number of lab technicians from the data. It is also clear

from the data that over a period of ten years, Orissa will have added just 325 lab technicians. Hence, the

challenge lies in interventions to increase this number to meet the demand.

While the supply of Lab. technicians presents a grim picture, let us look at the gap in terms of the need vs

supply. We estimate the need of lab technicians using two standards namely the IPHS norms and the GOI

norms derived from WHO. IPHS requires one Lab technician per CHC and per PHC. We project number of CHC

needed and PHC needed based on population. Add two hundred Lab. technicians for other hospitals (IPHS

norms require 5 Lab technician per 31-50 bed hospital). On the other hand as per WHO – GOI norms 1 lab

technician is needed per 10000 population.


Table 36: Supply, Need and Gap of Lab technicians

Year Population Lab

technicians

supply

Lab technicians

need (IPHS)

Gap (IPHS) Gap as

percentage

of need

(IPHS)

Need based

on WHO-GOI

GAP (WHO-

GOI)

Gap as

percentage

of need

(WHO)

2009 41.94 1162 2297 1135 49.41 4194 3032 72.29

2010 42.57 1197 2329 1132 48.60 4257 3060 71.88

2011 43.21 1232 2360 1128 47.80 4321 3089 71.49

2012 43.85 1268 2393 1125 47.01 4385 3117 71.08

2013 44.51 1303 2425 1122 46.27 4451 3148 70.73

2014 45.18 1338 2459 1121 45.59 4518 3180 70.39

2015 45.85 1373 2493 1120 44.93 4585 3212 70.05

2016 46.54 1408 2527 1119 44.28 4654 3246 69.75

2017 47.23 1444 2561 1117 43.62 4723 3279 69.43

2018 47.94 1479 2597 1118 43.05 4794 3315 69.15

The gap in supply of lab technicians and the estimated need persists throughout the forecasting horizon.

Figure 9: Need-Supply Gap for Lab. Technicians


4.4. Forecasted Supply of Pharmacists

The existing supply of Pharmacists and the vacancy status in the public sector is given below.

Table 37: Vacancy position of Pharmacists (2009-10)

Districts Sanctioned In position Vacancy

Angul 49 48 1

Balasore 94 94 0

Baragarh 63 61 2

Bhadrak 58 56 2

Bolangir 67 67 0

Boudh 16 14 2

Cuttack 156 149 7

Deogarh 13 12 1

Dhenkanal 59 59 0

Gajapati 33 33 0

Ganjam 155 151 4

Jagatsinghpur 50 48 2

Jajpur 70 58 12

Jharsuguda 25 24 1

Kalahandi 75 74 1

Kandhamal 65 64 1

Kendrapada 57 56 1

Keonjhar 89 89 0

Khurdha 101 110 -9

Koraput 83 83 0



Mayurbhanj 57 53 4

Districts Sanctioned In position Vacancy

Nabrangpur 52 52 0

Nayagada 55 55 0

Nuapada 29 29 0

Puri 82 79 3

Rayagada 56 53 3

Sambalpur 81 79 2

Subarnapur 29 27 2

Sundergarh 98 87 11

Total 2049 1978 71


The implied vacancy percentage is 2.85% which is the least among all categories of health service personnel

covered in this study.

To estimate the future supply of Pharmacists we examined the current doctor to Pharmacist ratio in public

and private sectors separately. This allowed the estimation of the current stock of Pharmacist in the state.

Thereafter we added the annual production and deducted the depletion from the stock to project the future

supply.

*includes 9 posts created under OHSDP

Furthermore interviews with a leading medicine shop owner in Bhubaneswar (who is also a Pharmacist) and

secondary information from pharmacy council reveals the following about pharmacy college intake and pass

outs.

• There are many vacant seats in most pharmacy colleges. In 2009 this number is estimated at 50%.

• Approximately 10-15 % of students are from outside Orissa.

Table 38: Current Estimated Position of Pharmacists

Sector Doctors Pharmacists

Public 5196 1943*

Private 808

171 * (estimated based on survey data of

89 Pharmacists for 420 docs and 520 beds

and assuming 1000 beds)

Total 2105


• After passing out

o 50% of the students join govt./private hospitals

o 25% become medical representatives

o 15% join or open a medicine shop

o The remaining join organizations outside the state

The estimated percentages have been used to arrive at the total active Pharmacist production available to the

state on a yearly basis as shown in the table below.

Table 39a: Forecast Supply of Pharmacists (Assuming 50% intake of capacity)

Year

Supply at the

beginning of

the year

Retirements Active

production

Supply at the end of the

year

2009 2084 46 475 2513

2010 2513 46 475 2943

2011 2943 46 475 3372

2012 3372 46 475 3801

2013 3801 46 475 4230

2014 4230 46 475 4659

2015 4659 46 475 5088

2016 5088 46 475 5517

2017 5517 46 475 5947

2018 5947 46 475 6376

Compared to the lab technicians, the projected increase in the number of Pharmacists in Orissa over a period

of ten years is quite encouraging.


Table 39b: Forecast Supply of Pharmacists (Assuming 100% intake of capacity)

Year

Supply at the

beginning of

the year

Retirements Active production Supply at the end

of the year

2009 2084 46 920 2958

2010 2958 46 920 3833

2011 3833 46 920 4707

2012 4707 46 920 5581

2013 5581 46 920 6455

2014 6455 46 920 7329

2015 7329 46 920 8203

2016 8203 46 920 9077

2017 9077 46 920 9952

2018 9952 46 920 10826

The following table brings out the gap under both scenarios of intake.

Table 40: Supply, Need and Gap of Pharmacists

Year Population Supply Need (IPHS) Gap (IPHS) Gap as

percentage of

Need (IPHS)

Need (WHO-

GOI)

GAP(WHO) Gap as

percentage

of Need

(WHO)

2009 41.94 2513 2257 -256 NA 4194 1681 40.08

2010 42.57 2943 2289 -654 NA 4257 1314 30.87

2011 43.21 3372 2320 -1052 NA 4321 949 21.96

2012 43.85 3801 2353 -1448 NA 4385 584 13.32

2013 44.51 4230 2385 -1845 NA 4451 221 4.97

2014 45.18 4659 2419 -2240 NA 4518 -141 NA

2015 45.85 5088 2453 -2635 NA 4585 -503 NA

2016 46.54 5517 2487 -3030 NA 4654 -863 NA

2017 47.23 5947 2521 -3426 NA 4723 -1224 NA

2018 47.94 6376 2557 -3819 NA 4794 -1582 NA


Note: IPHS requires one Pharmacist per CHC and per PHC. We project number of CHC needed and PHC needed

based on population. Add 160 Pharmacists for other hospitals. (IPHS norms require 4 Pharmacist per 31-50

bed hospital)

It is only in this category of health workforce that supply is expected to meet the need even if the intake

capacity is utilized at 50%.

Figure 10: Need-Supply Gap for Pharmacists


5. NEED VS SUPPLY GAP ANALYSIS

The health sector has always suffered from shortfall in human resources. Such shortfalls can be seen at

different levels - global, national and regional. In Orissa, as evident from the data we have gathered, the

shortfall is very acute. One of the factors that is said to be the major cause of this shortfall is the supply of

human resources. Therefore, it is necessary to look at the factors affecting the supply.

Pascal et al23

present three sets of factors affecting the supply of human resources in health. They are (1)

education/professional training choice, (2) participation in the health labour market, and (3) migration.

According to them the “decision to undertake professional training is an investment decision” and

therefore, return on investment weighs heavily on the minds of the graduates wanting to opt for medical

education and the actors willing to invest in setting up medical institutions, particularly the private

players. Besides this “human capital” approach, the other factors affecting the decision are the “socio-

psychological” factors such as the social value the society attaches to medical profession and the personal

satisfaction derived from caring for the sick.

Participation in the labour market, according to them, is determined by the individual’s trade-off between

labour and leisure as “they decide how much of their time to spend working for pay or participating in

leisure activities”. Many studies, as quoted by them, suggest that increased wages may attract increased

labour participation, though in some cases it doesn’t. In the case of Orissa, the leisure factor during the

working hours needs to be interpreted differently as in most of the government run health institutions,

the labour force is absent, particularly the Doctors, and they are engaged in private practice or other

economic related activities.

Migration is also a significant factor affecting the supply of human resources in health. According to them,

migration is linked to both economic and socio-psychological and institutional factors.

Against this backdrop, let us analyse the imbalances and shortfall we have found in human resources for

health in Orissa. Our study reveals the following types of imbalances.

1. Intra and inter profession imbalances: This set of imbalances are found among the Doctors, Nurses,

Lab Technicians and Pharmacists and the imbalances within a profession, e.g. shortage of specialists

among Doctors.

2. Geographic imbalances: These are disparities found in different regions and districts and between

rural and urban regions.

3. Institutional and services imbalances: These are differences in health workforce supply between

health care facilities, as well as between services.

23

Pascal et al (2004): “Imbalances in the Health Workforce”, Department of Human Resources for Health, WHO, Geneva,

www.humanresources-health.com/content/2/1/13


We have looked at the institutional imbalances in detail in the previous section. However, it is also

important to see the same in the three Medical Colleges, which are crucial to the supply of human

resources.

Table 41 presents the overall shortfall in all the three Medical Colleges for each category of faculty. Figures

12 and 13 present the percent vacancy among the faculty, in general and cadre wise, respectively. The

imbalances are quite striking. It is surprising to note that not a single faculty position is lying vacant in SCB

Medical College, Cuttack. VSS Medical Collge, Burla has more vacant positions among Professors and

Associate Professors, where as in the case of MKCG, vacany is more pronounced in the case of Assitant

Professors and Lecturers/Tutors.

The maximum vacancy is found in the case of Lecturers/Tutors followed by Associate Professors, Assistant

Professors and Professors.

Table 41: Vacancy in the three Government Medical Colleges as on October, 2009

Medical College

Faculty

SCBMC, Cuttack MKCGMC,

Berhampur VSSMC, Burla Total

SS CV SS CV SS CV SS CV

Professor 43 0 34 4

(11.76%) 34

12

(35.29%) 111

16

(14.41%)

Associate Professor 45 0 73 21

(28.76%) 67

22

(32.83%) 185

43

(23.24%)

Assistant Professor 98 0 99 36

(36.36%) 48

11

(22.91%) 245

47

(19.18%)

Lecturer/Tutor 69 0 91 38

(41.75%) 72

28

(38.88%) 232

66

(28.44%)

Total 255 0 297 99

(33.33%) 221

73

(33.03%) 773

172

(22.25

Source: DMET, GoO, SS: Sanctioned strength, CV: Current Vacancy


Finally let us look at the overall gap in supply among the Doctors, Nurses (GNMs), ANMs, Lab Technicians

and Pharmacists as given in figures 13 and 14.

In figure 13 we show gap in supply as a percentage of need computed based on all India Doctor to

population ratio and IPHS norms for doctors and IPHS norms for the other categories of health workforce

covered in this study. As per IPHS norms, the gap for the Doctors is expected to last till 2015. Figure 14

shows the gap percentage when need is computed based on WHO-GOI norms. It is clear from this figure

Figure 11: Percentage of Vacancy in the Government

Medical Colleges as on October 2009

Figure 12: Percentage of Vacancy among faculty


that except for Pharmacists, the gap will continue to exist for all cadres till 2018. The highest gap is found

among Lab. Technicians, followed by Doctors, GNMs and ANMs.

Figure 13: Gap as a Percentage of Need (IPHS norm)

Figure 14: Gap as a Percentage of Need (WHO-GOI norms)


6. ADEQUACY VS AVAILABILITY OF HUMAN RESOURCES

While ensuring adequacy of human resources poses a major problem, what can be said as a serious issue for

Orissa is the availability. The following figures present the number of Doctors sanctioned against the number

of Doctors in position for the period 2004-2009. It is clear that there is a marginal decline in the number of

posts sanctioned. However, the decline is more for the number of Doctors in position.

Trends are also available for GNMs, ANMs, Lab. Technicians and Pharmacists. As indicated in the figures given

below, the gap between the sanctioned strength and in position is very marginal.

Figure 16: Year wise Distribution of Sanctioned Strength

and In position of GNMs

Table 17: Year wise Distribution of Sanctioned Strength and In

position of ANMs


Three sets of gaps are generated from the data made available.

4. Ratio of availability between the year 2006 and 2009: Looking at the trends in sanctioned strength and in

position, certain assumptions were made to arrive at the desirable ratio of availability. Accordingly the

following ratio was identified for each cadre for each district.

Doctors:


0.60 - 0.75 – Yellow (Moderate)

0.50 - 0.59 – Orange(Medium)

< 0.50 - Red (Low)

Pharmacists, Lab. Technicians, GNM & ANM


0.70 to 0.90 – Yellow (Moderate)

< 0.70 - Red (Low)

Based on this ratio GIS maps are generated for each district. The maps are given at annex 1.

5. Requirement as per IPHS norms: Using IPHS norms, the gap is identified for each cadre in each district. The

tables for IPHS norms are given at annex 1. The maps generated as per IPHS norms are given in annex 2. The

maps indicate the following. (1)No consistent policy, (2) cadre and district variations, (3) only for the

Pharmacists the scenario has improved, (4) minimum shift is found only in the case of Lab. Technicians, (5)

while all the districts for all the cadres do not meet IPHS norms (except Pharmacists and Doctors), some

districts suffer from extreme low ratio which needs immediate attention.

6. Requirement as per WHO norms adopted/suggested for India: Tables 42-46 present the gaps for all the

cadres for all the districts. The following summary inferences can be made from these tables.

Table 18: Year wise Distribution of Sanctioned Strength

and In position of Lab. Technicians Table 19: Year wise Distribution of Sanctioned Strength and In

position of Pharmacists


• Gap is found in all the districts with high degree of inter district variations.

• Inter cadre variations is also present

• The projected supply for the year 2009 is far less than the number required as per the norm.

• It is also possible to identify the gap in the tribal and hilly districts

Table 42: GAP Analysis - Doctors (2009)

SL

NO

District Name Population,

2009 (In

Million)

No. of

Doctors

required as

per nrom**

No. of Doctors

(In Position)

Gap = Column 4-

5 (%)

Forecasted

Supply for the

year 2009

1 2 3 4 5 6 7

1 Angul 1.30 372 61 311 (84%) 118

2 Balasore 2.31 661 153 507 (77%) 297

3 Baragarh 1.54 439 92 347 (79%) 178

4 Bhadrak 1.52 435 72 363 (83%) 140

5 Bolangir 1.53 436 124 312 (72%) 240

6 Boudh * 0.43 122 30 92 (75%) 58

7 Cuttack 2.67 764 154 610 (80%) 299

8 Deogarh 0.31 89 22 67 (75%) 43

9 Dhenkanal 1.22 348 75 273 (78%) 145

10 Gajapati * 0.59 169 31 138 (82%) 60

11 Ganjam 3.58 1024 227 797 (78%) 440

12 Jagatsinghpur 1.21 345 70 275 (80%) 136

13 Jajpur 1.85 530 112 418 (79%) 217

14 Jharsuguda 0.58 166 42 124 (75%) 81

15 Kalahandi * 1.52 436 105 331 (76%) 204

16 Kandhamal * 0.74 212 75 137 (65%) 145

17 Kendrapada 1.49 425 46 379 (89%) 89

18 Keonjhar 1.78 510 98 412 (81%) 190

19 Khurdha 2.14 612 94 518 (85%) 182

20 Koraput * 1.35 385 65 320 (83%) 126

21 Malkangiri * 0.55 157 51 106 (67%) 99

22 Mayurbhanj * 2.54 725 215 510 (70%) 417

23 Nabrangpur * 1.16 332 43 289 (87%) 83

24 Nayagada 0.99 282 78 204 (72%) 151

25 Nuapada 0.61 173 36 137 (79%) 70

26 Puri 1.71 489 128 361 (74%) 248

27 Rayagada * 0.94 269 58 211 (78%) 112

28 Sambalpur 1.06 303 131 172 (57%) 254

29 Subarnapur 0.62 176 45 131 (75%) 87

30 Sundergarh * 2.09 597 152 445 (75%) 295

Total 41.94 11983 2685 9298 (78%) 5204

* Tribal and Hilly Area

** 1 per 3.500 population (Source: Suggested norms for health personnel, WHO-Govt. of India)


Table 43: GAP Analysis - GNM (2009)

SL

NO


2009 (In Million)

No. of GNM

required as

per norm**

No. of GNM (In

Position)

Gap = Column 4-

5 (%)

Forecasted

Supply for the

year 2009

1 2 3 4 5 6 7

1 Angul 1.30 260 38 222 (85%) 54

2 Balasore 2.31 462 73 389 (84%) 104

3 Baragarh 1.54 307 31 276 (90%) 44

4 Bhadrak 1.52 304 36 268 (88%) 51

5 Bolangir 1.53 305 65 240 (79%) 93

6 Boudh * 0.43 85 13 72 (85%) 19

7 Cuttack 2.67 535 410 125 (23%) 586

8 Deogarh 0.31 63 14 49 (78%) 20

9 Dhenkanal 1.22 244 64 180 (74%) 91

10 Gajapati * 0.59 118 20 98 (83%) 29

11 Ganjam 3.58 717 234 483 (67%) 334

12 Jagatsinghpur 1.21 241 20 221 (92%) 29

13 Jajpur 1.85 371 27 344 (93%) 39

14 Jharsuguda 0.58 116 17 99 (85%) 24

15 Kalahandi * 1.52 305 76 229 (75%) 109

16 Kandhamal * 0.74 148 57 91 (62%) 81

17 Kendrapada 1.49 297 35 262 (88%) 50

18 Keonjhar * 1.78 357 77 280 (78%) 110

19 Khurdha 2.14 428 115 313 (73%) 164

20 Koraput * 1.35 269 61 208 (77%) 87

21 Malkangiri * 0.55 110 40 70 (64%) 57

22 Mayurbhanj * 2.54 508 110 398 (78%) 157

23 Nabrangpur * 1.16 233 28 205 (88%) 40

24 Nayagada 0.99 197 69 128 (65%) 99

25 Nuapada 0.61 121 19 102 (84%) 27

26 Puri 1.71 342 92 250 (73%) 131

27 Rayagada * 0.94 188 24 164 (87%) 34

28 Sambalpur 1.06 212 175 37 (18%) 250

29 Subarnapur 0.62 124 17 107 (86%) 24

30 Sundergarh * 2.09 418 97 321 (77%) 139

Total 41.94 8388 2154 6234 (74%) 3078


** 1 per 5,000 population (Source: Suggested norms for health personnel, WHO-Govt. of India)


Table 44: GAP Analysis - ANM (2009)

SL

NO

District Name

Population,

2009 (In

Million)

No. of ANM

required as

per norm**

No. of ANM

(In Position)

Gap = Column

4-5 (%)

Forecasted

Supply for the

year 2009

1 2 3 4 5 6 7

1 Angul 1.30 260 161 99 (38%) 172

2 Balasore 2.31 462 329 133 (29%) 351

3 Baragarh 1.54 307 228 79 (26%) 243

4 Bhadrak 1.52 304 213 91 (30%) 227

5 Bolangir 1.53 305 253 52 (17%) 270

6 Boudh * 0.43 142 72 70 (49%) 77

7 Cuttack 2.67 535 364 171 (32%) 389

8 Deogarh 0.31 63 43 20 (32%) 46

9 Dhenkanal 1.22 244 173 71 (29%) 185

10 Gajapati * 0.59 197 183 14 (7%) 195

11 Ganjam 3.58 717 461 256 (36%) 492

12 Jagatsinghpur 1.21 241 234 7 (3%) 250

13 Jajpur 1.85 371 276 95 (26%) 295

14 Jharsuguda 0.58 116 80 36 (31%) 85

15 Kalahandi * 1.52 508 270 238 (47%) 288

16 Kandhamal * 0.74 247 185 62 (25%) 197

17 Kendrapada 1.49 297 219 78 (26%) 234

18 Keonjhar * 1.78 595 360 235 (39%) 384

19 Khurdha 2.14 428 234 194 (45%) 250

20 Koraput * 1.35 449 327 122 (27%) 349

21 Malkangiri * 0.55 183 172 11 (6%) 184

22 Mayurbhanj * 2.54 846 589 257 (30%) 629

23 Nabrangpur * 1.16 388 307 81 (21%) 328

24 Nayagada 0.99 197 173 24 (12%) 185

25 Nuapada 0.61 121 116 5 (4%) 124

26 Puri 1.71 342 257 85 (25%) 274

27 Rayagada * 0.94 313 253 60 (19%) 270

28 Sambalpur 1.06 212 185 27 (13%) 197

29 Subarnapur 0.62 124 97 27 (22%) 104

30 Sundergarh * 2.09 697 408 289 (41%) 435

Total 41.94 10214 7222 2992 (29%) 7709

** 1 per 5,000 population in plain area and 3,000 population in tribal and hilly areas (Source: Suggested

norms for health personnel, WHO-Govt. of India)



Table 45: GAP Analysis - Lab. Technician

SL

NO


2009 (In

Million)

No. of Lab.

Technicians

required as per

norm**

No. of Lab.

Technicians (In

Position)

Gap = Column

4-5 (%)

Forecasted

Supply for the

year 2009

1 2 3 4 5 6 7

1 Angul 1.30 130 18 112 (86%) 40

2 Balasore 2.31 231 18 213 (92%) 40

3 Baragarh 1.54 154 9 145 (94%) 20

4 Bhadrak 1.52 152 8 144 (95%) 18

5 Bolangir 1.53 153 19 134 (88%) 42

6 Boudh * 0.43 43 4 39 (91%) 9

7 Cuttack 2.67 267 24 243 (91%) 53

8 Deogarh 0.31 31 4 27 (87%) 9

9 Dhenkanal 1.22 122 19 103 (84%) 42

10 Gajapati * 0.59 59 8 51 (86%) 18

11 Ganjam 3.58 358 27 331 (92%) 60

12 Jagatsinghpur 1.21 121 7 114 (94%) 15

13 Jajpur 1.85 185 6 179 (97%) 13

14 Jharsuguda 0.58 58 3 55 (95%) 7

15 Kalahandi * 1.52 152 15 137 (90%) 33

16 Kandhamal * 0.74 74 15 59 (80%) 33

17 Kendrapada 1.49 149 7 142 (95%) 15

18 Keonjhar * 1.78 178 27 151 (85%) 60

19 Khurdha 2.14 214 5 209 (98%) 11

20 Koraput * 1.35 135 12 123 (91%) 27

21 Malkangiri * 0.55 55 4 51 (93%) 9

22 Mayurbhanj * 2.54 254 36 218 (86%) 80

23 Nabrangpur * 1.16 116 8 108 (93%) 18

24 Nayagada 0.99 99 7 92 (93%) 15

25 Nuapada 0.61 61 4 57 (93%) 9

26 Puri 1.71 171 34 137 (80%) 75

27 Rayagada * 0.94 94 13 81 (86%) 29

28 Sambalpur 1.06 106 22 84 (79%) 49

29 Subarnapur 0.62 62 6 56 (90%) 13

30 Sundergarh * 2.09 209 29 180 (86%) 64

Total 41.94 4194 418 3776 (90%) 924


** 1 per 10,000 population (Source: Suggested norms for health personnel, WHO-Govt. of India)


Table 46: GAP Analysis - Pharmacists (2009)

SL

NO


2009 (In

Million)

No. of

Pharmacists

required as per

norm**

No. of

Pharmacists (In

Position)

Gap = Column

4-5 (%)

Forecasted

Supply for the

year 2009

1 2 3 4 5 6 7

1 Angul 1.30 130 46 84 (65%) 65

2 Balasore 2.31 231 34 197 (85%) 48

3 Baragarh 1.54 154 61 93 (60%) 87

4 Bhadrak 1.52 152 57 95 (63%) 81

5 Bolangir 1.53 153 67 86 (56%) 95

6 Boudh * 0.43 43 14 29 (67%) 20

7 Cuttack 2.67 267 152 115 (43%) 216

8 Deogarh 0.31 31 11 20 (65%) 16

9 Dhenkanal 1.22 122 59 63 (52%) 84

10 Gajapati * 0.59 59 33 26 (44%) 47

11 Ganjam 3.58 358 155 203 (57%) 220

12 Jagatsinghpur 1.21 121 49 72 (60%) 70

13 Jajpur 1.85 185 67 118 (64%) 95

14 Jharsuguda 0.58 58 21 37 (64%) 30

15 Kalahandi * 1.52 152 74 78 (51%) 105

16 Kandhamal * 0.74 74 65 9 (12%) 92

17 Kendrapada 1.49 149 56 93 (62%) 79

18 Keonjhar * 1.78 178 69 109 (61%) 98

19 Khurdha 2.14 214 94 120 (56%) 133

20 Koraput * 1.35 135 83 52 (39%) 118

21 Malkangiri * 0.55 55 53 2 (4%) 75

22 Mayurbhanj * 2.54 254 128 126 (50%) 182

23 Nabrangpur * 1.16 116 50 66 (57%) 71

24 Nayagada 0.99 99 54 45 (45%) 77

25 Nuapada 0.61 61 25 36 (59%) 35

26 Puri 1.71 171 81 90 (53%) 115

27 Rayagada * 0.94 94 56 38 (40%) 79

28 Sambalpur 1.06 106 79 27 (25%) 112

29 Subarnapur 0.62 62 24 38 (61%) 34

30 Sundergarh * 2.09 209 87 122 (58%) 123

Total 41.94 4194 1904 2290 (55%) 2701


** 1 per 10,000 population (Source: Suggested norms for health personnel, WHO -Govt. of India)


7. LEVERAGING HUMAN RESOURCES IN HEALTH: Some Lessons from other

states for Orissa

Importance of human resources in health, particularly in public health is amply explained in various

reports and documents24

prepared for both the developed and developing countries. However, what is

not sufficiently studied is the supply side of human resources25

. Our study has revealed serious shortfall in

human resources in health for Orissa across all cadres and districts, particularly the KBK districts which

have been the forte for development interventions by various state and non-state actors. It has also given

the disturbing scenario for the next ten years. Therefore, before we give our suggestions and

recommendations, it may be useful to have a look at the experiences of some of the better performing

states, particularly Tamil Nadu and learn from the strategies they have adopted to deal with shortfall in

human resources in health.

The best performing states, such as Tamil Nadu and Kerala reveal a strong commitment to public health.

As part of this study, we looked at the reasons why these states continue to demonstrate high standards

in public health as compared to other states. We found that the most critical factor that has contributed

to the promotion of public health is the commitment of the state. For example, the government of Tamil

Nadu has been consistent in promoting Public Primary Health Model26

(PPH). Besides the strong political

will, the government of Tamil Nadu has also taken the following steps in terms of human resource policies

for medical cadres.

1. Multi skill training to Doctors, Nurses and other para medical staff

2. Compulsory posting in rural areas with better facilities and incentives linked to higher education

3. Payment of full salary to PG students so that they can come back and serve in the public sector

4. Increasing the role of staff Nurses and incentivizing them

5. Ensuring that all the primary health centres stay open 24 hrs a day

24

Many reports and documents highlighting both the importance of human resources in health and the supply side

dimension. The list is given at annex 2.

25 One useful document we found in this regard is “Nurses in Victoria: A Supply and Demand Analysis-2003-04-2011-12,

Service and Workforce Planning, Victorian Government, Department of Human Services, Melbourne, Victoria, 2004

26 The following documents provide evidence: (1) Pia Malaney, “Health Sector Reform in Tamil Nadu: Understanding the

Role of the Public Sector”, Centre for International Development, Harvard University, 2004 (2) WHO, “Health Sector

Reforms in India-Initiatives from Nine States”, (3) Karl Krupp and P. Madhivanan, “ Leveraging Human Capital to Reduce

Maternal Mortality in India: enhance public health system or public-private partnership?”, Human Resources for Health,

2009 and (4) P.Padmanaban, “Innovations in Primary Health Care with NRHM Support in Tamil Nadu,


6. Developing an enabling environment for community participation

7. Making available excellent women/patient friendly infrastructure at PHCs

8. Delivering what is promised

9. Fixing accountability

The other initiatives can be found, particularly for improving maternal health, in the sources cited above.

Another experience that Orissa could learn from is from the state of Gujarat. To address the need of public

health, particularly to promote maternal health, the government of Gujarat adopted the Chiranjeevi

Yojana. Under this scheme, above 700 private OB/Gynaecology specialists practicing in rural areas were

used for providing obstetric gynaecology services to the rural population. This was based on Public Private

Partnership.

In the case of Andhra Pradesh, strengthening of referral units and fixing of service norms played an

important role in improving public health outcomes.

The experiences of some of the states we have studied reveal the following.

1. To augment the shortage of human resources in health, we need a strong and consistent political

commitment for public health.

2. Both short term and long term strategies are required. The short term strategy is to leverage

existing human resources. This includes enhancement, substitution, delegation, innovation,

transfer, relocation and liaison27

. Partnering with the private actors is another short term strategy.

The long term strategy, of course is to increase the number of seats and formulating and

implementing appropriate HR policy to ensure adequate and consistent supply of human

resources to achieve better health outcomes, particularly in the rural and unreached areas.

3. Creating suitable and adequate infrastructure has played an important role in achieving better

health outcomes. The states we have reviewed, we find that there is a strong commitment to

ensure that the money available for improving the infrastructure under NRHM and other sources

is spent with accountability and on time.

4. While ensuring supply is a big challenge, what perhaps has played a more critical role is the overall

development scenario. For example, high level of literacy, better nutrition, communication (road),

supply of water and electricity and better sanitation facilities are vital to achieve better health

outcomes, as can be seen in the case of Tamil Nadu, Kerala, Andhra Pradesh and Karnataka.

Therefore, any strategy to augment the supply of human resources for health has to be linked to

27

Quoted in the article by Karl Krupp and P. Madhivanan, “Leveraging Human Capital to Reduce Maternal Mortality in

India: enhance public health system or public-private partnership?”


the overall development scenario of the state. For, Orissa, this is extremely critical and thus calls

for a serious Intersectoral coordination.

5. As suggested by Hongoro et al, the available strategies in the developing countries have

difficulties. For example, it takes at least 5 years to produce a Doctor and 3 years to produce a

Nurse. In view of these difficulties, it may be necessary to focus on auxiliary cadres, skill

substitution and enhancement. There is enough evidence to prove that Nurses can be safe and

effective in place of Doctors.28

6. Absenteeism is very seriously addressed in states like Tamil Nadu and Kerala. Instead of waiting

for an opportunity to punish the absenting health personnel, they have created an enabling

environment for increased attendance and participation29

. The heath sector reform experiences in

Andhra Pradesh also demonstrate this point.

7. The number of seats available for MBBS degree is far less as compared to Kerala and Tamil Nadu,

which also have better health indicators such as IMR and MMR. The fact that Orissa did not think

of starting many Medical Colleges, as in the case of Tamil Nadu and Kerala, is quite intriguing. Till

four years ago, Orissa had only three government Medical Colleges. Therefore, the climate of

medical education in Orissa needs a thorough review.

28

Charles Hongoro and B. McPake, “How to Bridge the Gap in Human Resources for Health”, www.thelancet.com, Vol

364, October 16, 2004

29 For details refer, P.Padmanaban, “Innovations in Primary Health Care with NRHM Support in Tamil Nadu, to know Tamil

Nadu’s experience


8. RECOMMENDATIONS AND CONCLUSION

Based on the learning from other states and the gaps in human resources for health we have identified for

Orissa, the following recommendations are suggested. These are intended to serve as immediate areas of

attention and policy framing for results to appear within a time horizon of 3 years from now.

1. The immediate need is to evolve a strategy to leverage the existing human resources. While

attempts can be made to ensure adequacy as per norms, it is important to ensure that the

available human resources are encouraged to work in the public system. Enhancement,

substitution, delegation, innovation, transfer, relocation and liaison are some of the interventions

suggested by various scholars who have looked into addressing the issue of shortfall. For Orissa,

the immediate step to be taken is skill enhancement (“upgrading a particular job by increasing the

skill level of workers or enhancing the role with additional responsibilities”), substitution

(“exchanging one type of worker for another-training Nurses to take on the role of Doctors in

primary health care delivery”) and relocation (“shifting particular services from one health care

sector to another”).

2. There is a need to increase the number of institutions offering medical education, particularly for

nursing education.

3. The student intake at the MBBS level (in the three government Medical Colleges) needs to be

increased by at least 100%, from the present 450 to 900 from the year 2010. However, it is also

equally important to evolve suitable policy to attract the Doctors and other cadre to serve in the

rural areas. The experience of Tamil Nadu in this regard can be seen a model to emulate.

4. The imbalances (vacancies) found in all the three government Medical Colleges must be

immediately filled up so that the quality of the medical education does not suffer.

5. A mandatory ‘Rural Internship’ should form an integral part of the MBBS course whereby the

domicile students would be given their final degree after completion of 3 years of rural medical

service in a District as deemed fit by the DoHFW, Govt. Of Orissa. Students from other States will

have to serve for at least a period of one year. However, appropriate enabling environment and

incentives must also be created similar to what is being done in Tamil Nadu.

6. The choice of Districts for Rural Internship can be based on rank preferences given by the students

during their final year. These can be matched with the DoHFW’s requirements emerging from the

need in various Districts.

7. Conducting OPSC exams every six months to fill up the vacancy, enhancement of facilities for

learning in the Medical Colleges and appointment of faculty as suggested by Medical Students

Union.


8. The seat capacity for Post Graduate course should be increased by at least 50% from the year

2010 and be linked to satisfactory completion of rural service.

9. MBBS candidates from other States with degrees from recognized Medical Colleges should be

permitted to apply for Post Graduate course in the State with a mandatory stipulation of serving

the rural areas for at least 3 years in order to successfully complete the degree.

10. The salary, perks and other allowances being given to Doctors, Nurses and Paramedical staff needs

to be given a thorough and critical overview to see how it can be modified to attract people.

11. Disturbance Allowances should be given to Doctors, Nurses and Paramedical staff for serving in

medical units that are not connected with pucca roads.

12. Private Medical Colleges, private nursing training institutes and training institutes for paramedical

staffs should be permitted to start operations after satisfactory Due Diligence from the DoHFW.

13. Medical and paramedical students successfully passing out from private institutes should be

subjected to mandatory Rural Internship as mentioned in points (5) and (6) above.

14. The services of AYUSH Doctors can be better leveraged if they are given opportunities for skill

enhancement. The public opinion about them needs a change as they are not fully accepted by

the community. This is evident from the PHCs we visited. At the same time, private hospitals are

engaging them as trainees30

.

15. While serious attempts are being made to increase the infrastructure for health, the progress is

very slow. In his recent address at the Multi-Stakeholder meet for MDG held at XIMB, the Mission

Director, NRHM wondered why there is tolerance among the public towards the slow progress in

completing the infrastructure facilities at district hospitals and primary health centres in spite of

sanctioning sufficient grant from NRHM31

. There are evidences of the new equipments not being

fully utilized and/or maintained due to lack of skills and funds. Therefore, creation of

infrastructure alone is not enough. Enough and appropriate systems must be created for utilizing

and maintaining the equipments and facilities.

16. If we have to use the Control knobs suggested by Roberts et al for health sector reforms, Orissa

needs to use more of the knobs related to Behaviour and Regulation.

17. In the absence of time- series data, it is suggested that a new format is designed and used to

identify the gaps in human resources at levels of health system-sub centre, PHC, CHC, SD Hospitals

and District Head Quarter Hospitals.

30

In one of the private hospitals in Bolangir, an AYUSH Doctor is appointed and the director of this private hospital is an

Assistant Professor in Burla Medical College

31 We witnessed the situation at the Chudapalli PHC in Bolangir district


Conclusion: In order to achieve better health outcomes, the government of Orissa needs to examine

its commitment to public health and the need to fill the gap in the supply side of human resources in

health. The findings of this study show that the supply of health professionals in the state of Orissa is a

matter of grave concern. There is a wide gap between the demand for health professionals and their

supply. Good quality health professionals are becoming increasingly scarce in the government health

system. Moreover, young Doctors prefer to either join private service or move out of the state. Unless

drastic steps are taken at this point, the situation will only get worse instead of improving.

The health services in the state can improve only if there is a strong political will to take corrective

measures and ensure quality competent and committed personnel are made available. Therefore, the

need is to make the health services attractive enough to ensure that the department is able to attract

and retain the best Doctors, Nurses and para-medical personnel. It is imperative that the GoO and

DoHFW think out-of-the-box in terms of radical interventions that can be made to ensure that the

supply of health professionals are adequate and also available to meet the demand that is already in

existence. It is only then the Millennium Development Goals will be attained.


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