Do health policies address the availability, accessibility, acceptability, and quality of human resources for health? Analysis over three decades of National Health Policy of India

Abstract

Background: Human Resources for Health (HRH) are crucial for improving health services coverage and population health outcomes. The World Health Organisation (WHO) promotes countries to formulate holistic policies that focus on four HRH dimensions-availability, accessibility, acceptability, and quality (AAAQ). The status of these dimensions and their incorporation in the National Health Policies of India (NHPIs) are not well known.

Methods: We created a multilevel framework of strategies and actions directed to improve AAAQ HRH dimensions. HRH-related recommendations of NHPI-1983, 2002, and 2017 were classified according to targeted dimensions and cadres using the framework. We identified the dimensions and cadres focussed by NHPIs using the number of mentions. Furthermore, we introduce a family of dimensionwise deficit indices formulated to assess situational HRH deficiencies for census years (1981, 2001, and 2011) and over-year trends. Finally, we evaluated whether or not the HRH recommendations in NHPIs addressed the deficient cadres and dimensions of the pre-NHPI census years.

Results: NHPIs focused more on HRH availability and quality compared to accessibility and acceptability. Doctors were prioritized over auxiliary nurses-midwives and pharmacists in terms of total recommendations. AAAQ indices showed deficits in all dimensions for almost all HRH cadres over the years. All deficit indices show a general decreasing trend from 1981 to 2011 except for the accessibility deficit. The recommendations in NHPIs did not correspond to the situational deficits in many instances indicating a policy priority mismatch.

Conclusion: India needs to incorporate AAAQ dimensions in its policies and monitor their progress. The framework and indices-based approach can help identify the gaps between targeted and needed dimensions and cadres for effective HRH strengthening. At the global level, the application of framework and indices will allow a comparison of the strengths and weaknesses of HRH-related policies of various nations.

Keywords: Deficit indices; Health system strengthening; Human Resources for Health; India; National Health Policy; Policy analysis.

Fig. 1

Framework of strategies and actions for strengthening HRH availability, accessibility, acceptability, and quality dimensions. HRH Human Resources for Health. Strategies/actions highlighted in green apply to more than one dimension. Shared dimension(s) are mentioned at the end of the highlighted strategies/actions as abbreviation(s) in the superscript. Av availability, As accessibility, Ap acceptability, Q quality

Fig. 2

A Dimensionwise distribution of HRH-related recommendations of NHPI—1983, 2002, and 2017. Numbers written inside the bars denote the number of recommendations. HRH Human Resources for Health, NHPI National Health Policy of India. B Cadrewise distribution of HRH-related recommendations of NHPI 1983, 2002, 2017. *Other includes mid-level practitioners, community health workers, and multi-purpose workers. **Non-cadre-specific recommendations apply to all HRH cadres. HRH Human Resources for Health, NHPI National Health Policy of India, HRH Human Resources for Health, AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy, ANM auxiliary nurse-midwife

Fig. 3

Availability Deficit (AvD) for pre-NHPI census years 1981, 2001, 2011 according to Bhore and HLEG thresholds. Dashed lines indicate the longitudinal changes in deficit. Solid vertical lines indicate availability deficits. Availability deficits for AYUSH were not calculated using Bhore Committee Report due to the unavailable requirement threshold. HRH Human Resources for Health, NHPI National Health Policy of India, HLEG High-Level Expert Group, AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy, ANM auxiliary nurse-midwife

Fig. 4

Accessibility Deficit (AsD) for pre-NHPI census years 1981, 2001, 2011. Dashed lines indicate the longitudinal changes in deficit. Solid vertical lines indicate Accessibility Deficit. HRH Human Resources for Health, NHPI National Health Policy of India, AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy, ANM auxiliary nurse-midwife

Fig. 5

Acceptability Deficit (ApD) for pre-NHPI census years 1981, 2001, 2011 according to Bhore and HLEG thresholds. Dashed lines indicate the longitudinal changes in acceptability deficit. Solid vertical lines indicate an acceptability deficit. Nursing cadres include ANM and nurses. Supporting cadres include pharmacists along with nursing cadres. ApD (sex-mix) was not calculated for ANMs as an ANM by definition is a female health worker. HRH Human Resources for Health, NHPI National Health Policy of India, HLEG High-Level Expert Group, ANM auxiliary nurse-midwife

Fig. 6

Quality deficit (QD) for pre-NHPI census years 1981, 2001, 2011. Dashed lines indicate the longitudinal changes in quality deficit. Solid vertical lines indicate quality deficit. Combined quality deficits for nurses and ANMs were calculated as proportions of qualified HRH were not available for these cadres separately. HRH Human Resources for Health, NHPI National Health Policy of India, AYUSH Ayurveda, Yoga and Naturopathy, Unani, Siddha and Homeopathy, ANM auxiliary nurse-midwife