70243 SlIpportillg Evidence-based Policies am/lmplemefltatioll SOME PRIORITY CHALLENGES OF THE NURSING SECTOR IN INDIA' Shomikho Raha·. PeleT Bennan:, Aarushi Bhatnagar" This note idw/ijies some key areas for priority aetiOIl in rhe cl/rrcntjavorable conlextjor policy ill lite nursing sector ill India. The present policy foclls 011 increasing the numbers of nurses and Ilurse training centers is understandable given the COl/lllly~' l111rse-lo-poplllalioll ratio is VCIY low. Howcvel; based all evidence j;-om Vltar Pradesh and Tamil Nadll. ,hejindillgs presented here suggest/hat slIch afoells on/lumbers a/one are 110t lite priority concerns a/nursing. AN OPPORTUNITY IN NURSING Africa (5.1), this ratio is much higher (WHO Statistics, The opportunity to improve the nursing situation In 2009). If only nurses are conside red, there are government health service delivery in India has never been approximately 0.5 nurses per doctor as compared to 3 and 5 better. A ftcr decades of neglect the Government of Lndia has in USA and UK, respectively.l recognized the role of nursing as pivotal to the perfonnance lncreasing the number of nurses is a worthy policy goa l, but of the National Rural Health Mission (NRHM), and achieving it will require additional interventions to consequently a priority policy issue. It has started a new comp lement the planned expansion of educational capacity scheme, known as the Development of Nursing Services to fonn new nurses. The following are some key areas for during the Xlth Plan period. The scheme has an expeeted priority action, based on national and state-level investiga- outlay ofRs. 2900 crores. This additional financing will be tions of recent experiences with nursing development, used to substant iall y augment the numbers of nurses in the drawing on the cases of Uttar Pradesh and Tamil Nadu. government system through expanding the numbers of nursing education and training institutes, including 24 THE NEED TO IMPROVE THE QUALITY OF ALREADY- centers of excellence, 145 ANM schoo ls, 137 GNM EXISTING NURSE TRAINING SCHOOLS schoo ls, 6 nursing colleges, and 4 regional nursing The Government of Uttar Pradesh (UP) is focusing new instihltes. These new institutions will be complemented by attention on ways to produce more nurses. However, an the strengthening of existing nursing councils and immediate challenge the state faces in the nursing sector is dircctorates administering nursing cadres in 17 states. the short supply of qualified and adequately trained nurse This planned significant increase in the numbers of nurses in staff for teaching at the existing nursing schools providing the health system reflects the realization that the nurse to General Nursing and Midwifery (GNM) diplomas. Such popu lation ratio in India remains inadequate despite the shortages place these institutions precariously close to expansion of nursing manpower in the last six decades, and being, if not al ready, deemed unsuitable for producing especially in the last eight years through the multifold nurses. If the UP state government allocates funds to build increase in private nurse training schools. I While in India new schools without addressing the faculty shortage, it there is one nurse to 2500 people, in developed countries the cou ld face the same situation. The cause of this problem number of people served by a single nurse range from 150 to affects theentirc government-nursing cadre ofthe state. 200. The nurse-doctor ratio in the country is particularly At the root of the problem are the current service nlles that poor in comparison to other midd le-income and developed were adopted in 1996 following the agitation of in-service countries: there are approximatcly 1.6 nurses and midwifes nurses due to the lack of promotions. The resulting service per allopathic doctor, whereas for Brazil (3. 1) and South ru le change omitted any reference to educational . Health workers in sufficient numbers. in the right places. and adequately trained, motivated and supported arc the backbone of an effective, equi table, and efficient health care system. Success in creating and sustaining an effective health workforce in India to achieve national health goals will require sound policy and creative and committed implementation. More and better infomlation 011 human resources tor health in India is olle clement needed to achieve this. This note summarizes recent and ongoing work in support of India 's health work force goals. For the full repon, sec Raha, S. et al ··HRH: A Political Economy and Institutional Analy.~is of the /l1liian Conrext"" HRH Technical Report #2 al\I·\I·\I:hrhindia.org I The World Bank, New Delhi, India; : The World Bank, Washington DC; .. The Public Health Foundation of India. New Delhi qualifications required for postings and app lies to teaching For example, in UP, upon meeting the target of filling the posts in nursing schools. Many of the trainers currently post of one ANM in every SC in the 1990s, government posted in nursing schools in UP fail the minimum eligibility closed the ANM training schools and in tum terminated criteria mandatory in the previous service rule to undertake further production of ANMs. The decision was partly driven such teaching. Instead they secure these posts as a result of by budgetary constraints at the time. The resulting promotions based entirely on 'seniority' criteria that apply consequence and the immediate challenge currently faced , to the nursing cadre as a whole. Moreover, teaching staff in therefore, is to revive teaching institutions that once all government nursing schools in UP no longer have the functioned and bring back trainers to these training centers. training that the Indian Nu rsing Council (INC) deems It is~ again, the poorer NRHM-focus EAG states that have mandatory.l Consequently, the INC has in the recent past suffered most from this effective dc-institutionalization of withheld recognition from all nursing schoo ls under the public health nursing. Attention must be given to restart state government while the UP state authority continued to closed training centers, including educating new ANM recognize these same schoo ls. trainers and providing incentives to them to work in government service. The case of UP is illustrative: an THE GEOGRAPHIC MAL-DISTRIBUTION OF NURSE additional ANM in existing SCs combined with the staffing TRAINING CAPACITY of planned SCs proposed by NRHM would require the States with poor health indicators arc the main focus of induction of approximately 34,000ANMs in the span offive recent policies to increase the number of nursing schools. years. There are currently 20,251 SCs in the state with each However, these states are particularly deficient in cu rrent reportedly staffed by an ANM. The policy therefore aims to nurse training capacity and also face more pervasive more than double the number of ANMs through new weaknesses in institutional and regulatory capacity. training . However, all the 40 ANM Training Centres and 4 The four southern states (with relatively strong institutiona l health schools. which were producing ANMs, Lady Health contexts) have two-thirds of the nursing educational institu- Visitors (LHVs), Public Health Nurses (P I'INs) and PI-IN tions in the country. This disproportion becomes even wider Tutors were closed down in 1992. for higher level nursing cducation as in the case of M.$c. To meet the scale of the proposed ANM production nursing institutions, which typically provide faculty for government should consider recruiting ANM trainers who B.Sc. col leges. Seventy percent of these higher level institu- were forced to change profession with the closure of tions arc in the four southern states with the remaining 30 schools. Neverthe less, inducting former or new trainers into pcrcent again unevcnly distributed in the rest of the country. the system will require new regulations and incentives. This Onc consequcnce of the absence of nursing educational would nornmlly have enta iled amendments in the service institlltions for higher level education in some states is the rules, but in UP no service rules currently exist for the entire near collapse of the lower levels of nursing education. In cadre of public health nursing. The State Government Orissa, for example, the only co llegc of nursing in the stipu lates, for instance, through a 1990 ruling, that government scetor, current ly, has less than thrce qualified promotions can only be officia lly sanctioned if service niles facu lty though it provides undergraduate and postgraduate arc in place. The continued absence of service niles and education (Prakasamma, 2008). In UP, the lone Government delay in framing them leaves these ANM trainers with no College of Nursing offering a Post-Basic B.Sc.(N) degree eareer advancement or promotional avenues. The lack of an docs not have within the state a pool of suitably qualified enabling institutional and incentive environment for ANM nurses from which to draw its faculty. A lso, since the current trainers to join government service, especially in the light of service rules in UP no longer require further education as past record of abrupt closure of schools and extinction of relevant for career progression, very few government jobs when targets arc met , does not bode we ll for expanding emp loyed nurses are inclined towards further education the cad re ofANM , at least for UP. THE NEED TO STRENGTHEN THE ROLE OF PUBLIC POOR CAREER ADVANCEMENT OPPORTUNITIES FOR HEALTH NURSING' AND RELATED TRAINING PUBLIC HEALTH NURSES CAPACITIES Promotional opportunities for nurses arc a concern not only The National Rural Health Mission (NRH M) is calling for in the states with weaker health administrative structures. increasing staffing to 2 Auxiliary Nurse Midw ives (ANMs) This issue should not be overlooked as government moves in every Sub-Centre (SC) and has allocated funds also for an to increase the numbers of nurses. In some states increase in the overa ll number of SCs. Achieving this goal promotions have been delayed due to the infrequency of will require instihllions with teaching staff for the Department Promotional Committees convened to decide production of ANMs. However, in past years, the capacities on the promotion of eligible nurses. This is now further for training in public health nursing have deteriorated more exacerbated by the lack ofinstirutional capacity to provide than even in educational institutions for clinical nursing. In the neccssary additiona l training mandatory in the service some states such instihltions have simply ceased to exist. rules for nurses to be deemed eligible for promotion. I;\[)I \ III .\L II 1131 \ r. \'OIUllll: I • 'Jlllllhl'r ~ ( \llgU,1 ~O()lJl In Tamil Nadu, a state with rela ti vely better functioning training to multi-purpose workers and that the current role is govcrnmcnt administrativc structurcs, thc problem of sti ll not clear. Simply increasing the numbers, without promotions of public hcalth nurses rcmains. Village Health clarity on feasible functions fortheANM , would be unwise . Nurses (VHNs) had not been adequately promoted to Sector Health Nurses (SHNs) and Community Healt h Nurses INSTITUTIONAL REFORM IN THE STATE NURSING (CHNs), because there was a mandatory 22-month further SECTOR training that a VHN was required to undergo in order to be The only High Power Committec of the Oovernmene that cons idered for SHN/CHN posts. The training was not taking reviewed in dctail the principal challenges cxisting in the place for no fault of the nurses, but due to the lack ofinstihl- nursing scctor report ed (1989) the need to reform , not tiona I structure to support such training and the absence of simply strengthen, the directora tes of nursi ng in the States . adequately qualified trainers. With a significant rise in the The Committee recommended that a single directorate of backlog of overdue promotions, the State Government nursing be created with separate functional institutional decided to reduce the months of training required from 22 struchlres for clinical nursing, public health nursing and months to 6 months.s In a subsequent decision two years nursing education within it. Apart from the intention to later,6 the stip ulation of further training even for 6 months bring better governance and accountability to key functions was done away with entirely for consideration ofpromotion of strategic planning and management of the separate of the VHN. While the changes have cased the possibility of nursing cadres, the institutional reform also aimed to enable promotions, it has come at the cost of eliminating further greater voice to nurses in the policy-making process by training that had previously been deemed necessary to removing thc nursing directorates from the largely exclu- perform the added functions ofa SHN/CHN . sive control by doctors. The gradual disappearance of the post of the DPHNO in the districts of most states (i ncluding At lower levels of public health nursing in many other states, Tamil Nadu) is a signal of th e lack of institutional support to the possibility of career advancement has never existed. The the role of supervision of tile publi c heal th nursing cadre. ANMs in most states now no longer need further training to function as the superv ising Lady Hcalth Visitor (L1-IV) . CONCLUSION: POLICY IMPLICATIONS AND There is , however, gcnerally littl e opportunity for further RECOMMENOATIONS FOR ACTION advancement since the posts of Publ ic Health Nurse (PI-IN) There have been in 2009 reviews of the nursi ng workforce and Distri ct Public Health Nurse Officcr (DPHNO) are that the Academy of Nursing Studies at Hyderabad has vacant , if not abandoned. Moreover, there is currently an undertaken in collaboration with the National Health absence of institutions to allow a bridgc-course for an Systems Resource Centre (NHSRC). Four excellent reports experiencedANMlL HV to grad uate to a ONM. The absence on Chhattisgarh , Rajasthan , Bihar and Orissa have already ofsuch institutions do not permit thc use ofa pool of existing been prepared. In drawing on this additional body of work experi enced nurses, and thcir aspirations, to fill the and the findin gs offield research in Uttar Pradesh and Tamil shortages ofGNM-trained nurses ex isting in the system. Nadll that this policy note directly draws upon , we DEVELOPMENT OF NEW ROLES FOR NURSES IN recommend the following actions : RURAL HEALTH CARE? I. Every state needs to ensure that all teaching posts in It is increasingly recognized that mceting the needs of the nurse training schools must be occupied by nurses who rural population for basic health care will have to rel y more have received the mini mum training or education proportionally on nurses and paramcdical workers, than on mandated by the INC for adequate teaching. In the case physicians. But today's nursing education docsn 't prepare of a shortage of qualified nurses in government serv ice, nurses well for independent clinical practice or in public other innovative methods may be considered: (a) health managemcnt to nm a facility. This moment of drawing on qualified nurses existing in the state, but launching expansion of nursing education capacity may currently in the private sector;' (b) recmiting nurses also be a good opportunity to create new types of nurses from states with a greater suppl y of qualified nurses ; or with ski ll s more suited to the cha llenges of managing and (c) establishing a scheme to further train ex isting nurses delivering rural health care. of the state in training schools located in other states. 2. Beyond a focus on increasing ANM numbers, the CLARITY ON ROLE OF ANM current institutional weakness of public health nursing This moment of renewed focus on nursing may also provide in several states needs urgent attention. This requires the opportunity to critically assess the job descriptions of placing priority in: (a) establishing service rules for all existing Illlrsing personncl, especial ly the ANM . Increasing posts in the public health nursing cadre (where still th e numbcrs of ANMs mll st not necessarily be focused on as absent); and (b) providing adequate planning and the sole, or the foremost , immediate challenge the nursing funding to re-estab lish school s for ANM trainers (and sector in the country faces. It is pertinent to note that , over not focus solely on augmenting the number of ANMs). timc, there has becn a dc-skilling of ANMs in clinical I'DI \ 1[1 \L fl I BI \ J. \·OIUllll' 1 • 'JumtK'1 ~ ( \ug\l~l ::!O()l)j 3. In every state an empowered high-level review is to serve the health system wit h a special focus on needed of the career promotional opportunities and the creat ing a more skill ed nurse practitioner that can head eurrent institlltional bottlenecks (such as infrequency of fa ci liti es at lower levels of primary care, where doctors required Committee meetings) that result in inefficient are less likely to be present. and ineffecti ve implementation of existing niles. 6. The manageab le duties of the ANM, based on the 4. To address the inadequate numbers of trained staff training she has received, need to be better defined nurses in the healtl1 system and the poor career especia lly in light of several different and multiple opportunities for existing ANMs, each state should demands derived from the various vert ica l programs. consider the fea sibility of creating institutions that 7. The weak superv isory struchlre for nursing s taft~ both in provide a bridge-course for an experienced ANM/ LHV clinica l and pub lic health cadres, may be partially ex- to graduate to a GNlvI. plained by thc weakness or absence of institutions and 5. Given the current opportunity for advancement of the posts at higher level s such as a Directorate. The nursi ng sector, there should be a serious evaluation of organizational structure proposed by the 1989 Hi gh the ro le and function of nurses the currcnt system Power Commit1ee needs to be addressed by every state produces. This assessment should incl ude a feasibi lity and adjusted, where required, to bring institutional study on how best to re-mould further training of nurses reform by creation of Nursing Directorates in each state. In Tami l Nadu, only two of the 105 nursing colleges, 22 out of the 134 GNM schools and one of the 39 M.Se. nursing institutions are in the public sector. See Note NO.3 in this volume for details on numbers and geographical di stribution. Funher details in World Bank-PHFI , 2008. A ru lly runctional public health nursing cadre is expected to have the fo llowing posts: Auxiliary Nursc Midwives (ANMs) stat ioned at Sub-Centres in vi llages, who receive guidance and supervision rrom a smaller number or Lady Heal th Visitors (LHVs). The Public Health Nurse (PI'IN) posted in the Community Health Centre supervises the LHV and is additionally responsible ror conducting the maternal and child health (MCH) clinics, famil y welrare & immunization clinics on panicular days selected by the di strict. To bccome a PHN, additional training is required, ror which PHN Tutors arc needed. Finally, at the district level, a District Public Health Nurse OOicer (DPHNO) and a deputy DPHNO are tasked to implement quality MCH and family planning services and ror monitoring, supervising, and guiding all public health nursing personnel. The DPHNO provides leadership to the entire community withi n the district, especially in redueing MMR & IMR. The assistance of the Deputy DPHNO is to additionally ensure quality training in AN M training institutions in the district. See G.O. 185. dated 24.08.2005. See G.O. 202, dated 07.06.2007. The 1989 High Power Commillee was the first high-level government body dedicated solely to rocus and review the nursing sector since 1954. It was mandated to make recommendations on the organizational and eadre structures ror eflcctive runctioning or nursing personnel rollowing field-visits to several states. Madhya Pradesh, for instance, has only a single government nursing coll ege that is inadequate to supply the nurses requ ired. Through an innovati ve Swav/alll ball Yojlla , however, the state draws on 28 private nursing colleges to train B.Sc. nurses at government cost who are then required to serve in the government health care system . REFERE NCES Academy of Nursing Studies (ANSWERS), NHSRC. 2009. Study Repons on Nursing Workforce in Challisgarh. Rajasthan. Bihar, Orissa: Current situation. requirements and measures to address shortages. New Delhi . GO I. 1989. Repon orthe High Power Committee on Nursing. Ministry of Health & Family Welfare, New Delhi. Prakasamma. 2008. Presentation on "Non-Governmental Pannerships ror Nursing". Government or India Workshop, Puducherry (18 October). WHO. 2009. World Health Statistics 2009. World Health Organization, Geneva. Editors: Gerard La Forgia, Lead Special ist, HNP Unit, The World Bank, New Delhi; and Krishna D. Rao, Public Hea lth Foundation or india, New Delhi Illdia Health Beal is produced by the Public Health Foundation of India and the World Bank's Health, Nutrition and Population unit located in Delhi. The Notes are a vehicle ror disseminating policy-relevant research, case studies and experiences pertinent to the Indian health system. We welcome submissions from Indian researchers and the donor community. Enquiries should be made to Nira Singh (nsingh2@worldbank.org). Disclaimer: The views, findings, interpretations and conclusions expressed in this policy note are entirely of the authors and should not be auributcd in any manner to the World Bank, its affiliated organizations, members or its Board of Executi ve Directors. the countries they represent or to the Public Health Foundation or India and its Board or Directors.