https://doi.org/10.33698/NRF0210 Dilip Saikia
Abstract : Availability of nurses in the rural health centres is a major concern in India. The number of nurses is not sufficient to meet the health care needs. Objective of the study is to examine the current situation of the nursing workforce in the public health sector in rural India. Study is based on secondary data. Data related to nursing & workforce was drawn from bulletin of rural health statistics 2006, 2014-15 published by ministry of Health & Family Welfare, Govt. of India. Data related to population was drawn from population projections for India & States 2001-2026. We found that although the numbers of nurses and midwives in the public health centres in rural India have been increasing during the last decade still the sector has suffered from acute shortage of nurses. The density of nurses and nurse–doctor ratio is abysmally low compared to the global norms. There is widespread variation in the distribution of nurses across states/union territories. Besides, a considerable percentage of sanctioned posts are remained unfilled at all levels, and another sizable proportion of the required posts remained non-sanctioned across states/union territories. There has been rapid expansion of number of educational institutions and training capacity of nurses in India during the last two decades, but the quality of education in private institutes remains a serious concern. The paper emphasises for urgent needs to address the nursing shortage in the public health centres in rural India.
Keywords
Nursing workforce, density, shortfall, vacancy, regional disparity.
Correspondence at
Dilip Saikia
Assistant Professor, Darrang College, Tezpur, Assam, India
Introduction
Nurses are an important segment of health care providers. They constitute almost half of all the manpower in the field of health care in most countries.1-2 They are the “front line” staff in most health systems,3 and they have significant contribution in the recovery of patients in terms of delivering safe and effective patient care.2 Therefore, sufficient numbers of nurses vis-à-vis other health staffs are required to maintain acceptable standard of health care. There is ample evidence in the literature for the negative impact of nurse under staffing; the adverse effects being increased mortality rates, postoperative complications, increased accident rates and patient injuries, infection rates, and increased incidence of violence against staff etc.3 Studies show that a high nurse-to-patient ratio affects quality of treatment, high stress level, and mental exhaustion among nurses, leading to increase in mistakes, accidents, and ultimately increase in malpractices.4 There has been a severe shortage of nursing workforce worldwide,3 the shortage being estimated to be 2.4 million just in India.5 The primary and secondary health sector of India alone required an additional midwives in rural areas (4.13 per 10,000 population) is just one-fourth of the urban areas (15.9 per 10,000 population).8
Against the above background, this paper seeks to examine the current scenario of the nursing workforce in the public health sector in rural India.In this paper an effort has been made to analyse the size and composition, and distribution of nursing workforce in the public sector in rural India. Following that the shortage and vacancy position of nursing workforce in rural public sector has been examined, and then the production capacity of nursing workforce in the country.
Data and Methods
The study is based on secondary data. 0.35 million nurses.6 The World Health Data on the actual staff positions, required Statistics 2011 reports that India has a density of 13 nurses and midwives per number of posts, sanctioned posts, vacancy positions, and shortfall of nurses and 10,000 population.7 India also has an midwives in the rural public health centres adverse nurse-doctor ratio; 2.19 nurses and midwives per doctor in 2005.7 Yet only an estimated 40 percent of registered nurses are active because of low recruitment, migration, attrition, and drop-outs due to poor working conditions.6 One striking feature of the nursing workforce in India is the skewed distribution towards the urban areas. In 2001, only 40 percent nurses and midwives reside in rural areas, serving over 70 percent of India’s population.8 Further, more than 50 percent of nurses and midwives – both in rural and urban areas – are employed in the private were drawn from the Bulletin on Rural Health Statistics 2006 and 2014-15 published by the Ministry of Health and Family Welfare, Government of India.10-11 Population data were collected from the Population Projections for India and States 2001–2026 published by the Registrar General and Census Commissioner, Government of India.
The analysis carried out in this paper is descriptive. We analyse the current scenario of nurses and midwives in terms of number and distribution based on recent data. Densities of nurses and midwives, sector.9 That the nurses tend to work in nurse/midwife-to-population ratio, and urban areas rather than rural areas and in the private sector rather than public sector implies that there are fewer nurses available in rural public health sector. This is reflected from the fact that the density of nurses and nurse/midwife-to-doctor ratio have been computed to examine the numerical adequacy of nurses and midwives. The Gini coefficient is used to estimate inter-state inequality in the distribution of nurses and midwives. The shortage is calculated as the difference between the required number of nurses and midwives, which is calculated using the prescribed population norms, and the actual staff position. Vacancy is calculated as the difference between the sanctioned posts and the actual staff position.
Nursing Workforce in Rural India: A Brief Overview
In the public health system in India, which consist of three tiers namely sub- centres, primary health centres (PHCs), and community health centres (CHCs), several cadres of nursing and midwifery workforce are deployed at various levels. The auxiliary nurse midwife (ANM) and male health worker, manning one sub-centre, are the first interface of the formal health care system with the community. There will be one staff nurse, two additional staff nurses on contractual basis, one ANM, one lady health visitor (LHV) and one male health assistant in the PHCs, and seven staff nurses in the CHCs. Table 1 shows the existing staffing pattern of nurses and midwives in the public health centres. However, the existing staffing of nurses and midwives in the rural health centres is less than the recommendation of the Indian Public Health Standards. It is worthwhile to note that the nurses in public health system in India are either graduates or diploma holders,9 and there are no specialist nurses in clinical areas.6
Table 1: Staffing Pattern of Nurses and Midwives in the Rural Health Centres
| Health center | Population Norm# | Existing Staffing Pattern † | Recommended Under IPHS † |
| Sub-Centres | 5000 (3000) | 1(+1) auxiliary nurse midwife 1health worker male | 1(+1) auxiliary nurse midwife 1health worker male |
| PHCs | 30000 (20000) | 1(+2) staff nurse
1 auxiliary nurse midwife 1 lady health visitor 1 health assistant male |
3(+1) staff nurse
1 auxiliary nurse midwife 1 lady health visitor 1 health assistant male |
| CHCs | 120000 (80000) | 7 staff nurse | 10 staff nurse |
Source: Bulletin on Rural Health Statistics in India 2014-15.
Note: # Figures in the parenthesis indicate the population norm in the hilly/tribal/difficult areas.
† Figures in the parenthesis indicate the number of additional workers on contractual basis.
Size and Composition of Nursing Workforce in Rural Areas
The total number of nurses and midwives in the public sector in rural India are estimated at 358,899 in 2015 compared to 260,785 in 2005 (Table 2). They constitute the majority of the public health workforce in the rural India; around 83 percent during 2005–2015. Within the nursing and midwifery workforce, ANMs have the highest share, followed by staff nurses and male health workers. Between 2005 and 2015, the number of staff nurses and ANMs increased, whereas the number of LHVs, male health workers, and male health assistants decreased. Thus, between 2005 and 2015, the workforce-to- population ratio has declined for the total nurses/midwives, staff nurse, and ANMs, but the ratio has increased for LHVs, male health workers, and male health assistants. In 2015, the workforce-to-population ratio is 1:2414 for total nurses/midwives, 1:13319 for staff nurses, 1:4083 for ANMs, 1:64781 for LHVs, 1:15564 for male health workers, and 1:68500 for male health assistants.
The combined density of nurses and midwives was 4.1 per 10,000 population in 2015 compared to 3.3 in 2005.Looking at the density of different cadres we observe that between 2005 and 2015 the density has 0.15), male health workers (from 0.80 to 0.64), and male health assistants (from 0.26 to 0.15).
The nurse–doctor ratio was 2:1 in 2015 compared to 1:1 in 2005; including midwives the ratio was 11:1 for both the years. This indicates that the rural public health centres in India have a skewed mix of nurses and doctors. Although there is no national norm for a nurse–doctor ratio, the World Development Report 1993 recommends that the nurse–doctor ratio should exceed 2:1 as a minimum and a ratio of 4:1 or higher is regarded as best for cost- increased for staff nurses (from 0.37 to effective healthcare.12 Thus, India’s rural 0.75) and ANMs (from 1.70 to 2.45), whereas decreased for LHVs (from 0.20 to health sector is still far from the desirable norm of four nurses per doctor.
Table 2: Availability of Nurses and Midwives in the Rural Health Centres
| Number of Nurses and Midwives | Nurse/Midwife-to- population ratio | Density per 10,000 population | ||||
| 2005 | 2015 | 2005 | 2015 | 2005 | 2015 | |
| Staff Nurse at PHCs and CHCs | 28930 | 65039 | 27013 | 13319 | 0.37 | 0.75 |
| ANM at SCs and PHCs | 133194 | 212185 | 5867 | 4083 | 1.70 | 2.45 |
| LHV at PHCs | 15546 | 13372 | 50269 | 64781 | 0.20 | 0.15 |
| Health Worker Male at SCs | 62881 | 55657 | 12428 | 15564 | 0.80 | 0.64 |
| Health Assistant Male at PHCs | 20234 | 12646 | 38623 | 68500 | 0.26 | 0.15 |
| All | 260785 | 358899 | 2997 | 2414 | 3.34 | 4.14 |
Source: Bulletin on Rural Health Statistics in India, 2006 and 2014-15.
Regional Distribution of Nurses
There are significant disparities in the distribution of nurses and midwives across states/ union territories (UTs). Table 3 shows the combined density of nurses and midwives by states/UTs for 2005 and 2015. The total number of nurses and midwives per 10,000 population varies from 1.6 in Bihar to over 22 in Mizoram in 2005, and from 0.7 in Delhi to 28 in Mizoram in 2015.Thus, the combined density of nurses and midwives in the highest density state (Mizoram) is about 14 times that of the lowest state (Bihar) in 2005 and 41 times that of the lowest density state (Delhi) in 2015. The Gini coefficient, which is a measure of distributional inequality, of
|
Table 3: State-wise Density of Nurses and Midwives (per 10,000 population)
the combined density of nurses and midwives across the states/UTs found out to be 0.262 in 2005 and 0.327 in 2015; implying that inter- state disparity in the distribution of nurses and midwives increased over the years.
Looking at the combined density of nurses and midwives in each of the state/UT we observe that the states/UTs with low density than the national level are Bihar, Uttarakhand, Jammu and Kashmir, West Bengal, and Chandigarh in 2005; and Delhi, Uttar Pradesh, Bihar, Daman and Diu, Uttarakhand, Jharkhand, Madhya Pradesh, and Odisha in 2015.In 2015, the states/UTs having more than 10 nurses and midwives per 10,000 population include Mizoram, Lakshadweep, and Andaman and Nicobar Islands; between 7–10 nurses and midwives per 10,000 population include Manipur, Arunachal Pradesh, Dadra and Nagar Haveli, Sikkim, Puducherry, Meghalaya, Tamil Nadu, Chandigarh, and Jammu and Kashmir; and between 5–7 nurses and midwives per 10,000 population include Nagaland, Kerala, Himachal Pradesh, Chhattisgarh, Assam, Karnataka, Rajasthan, Punjab, and Tripura.Between 2005 and 2015, density of nurses and midwives has declined in seven of the high-focus states namely Uttar Pradesh, Himachal Pradesh, Sikkim, Jharkhand, Madhya Pradesh, Chhattisgarh, and Rajasthan, and in Delhi, Goa, Daman and Diu,and Puducherry among the non high-focus states and UTs.
Shortfall of Nurses in Rural Areas
There is gross inadequacy of nursing and midwifery workforce in the rural health centres in India.The shortage of nurses and midwives can be seen from the fact that out of the 153,655 sub-centres functioning in 2015, 5.3 percent (8,138) are without an ANM, 46.5 percent (71,433) are without a male health worker, and 3.3 percent (5,053) are without both ANM and male health worker(Figure1).The distressing fact is that the percentage of sub-centres functioning without ANM and male health workerhas increased during the 2005–2015.
Source: Bulletin on Rural Health Statistics in India, 2006 and 2014-2015
Source: Bulletin on Rural Health Statistics in India, 2006 and 2014-15.
Figure 1: Percentage of Sub-Centres Functioning without Nurse and Midwife
Figure 2 reports the shortfall of nurses and midwives in the rural health centres in 2005 and 2015. It is evident that, as on March 2015, there is shortage of 20.5 percent of staff nurses at PHCs and CHCs, 5.2 percent of ANMs at sub- centres and PHCs, 49.2 percent of LHVs at PHCs, 63.8 percent of male health workers at sub-centres, and 61.3 percent of male health assistants at PHCs. Between 2005 and 2015, the percentage shortage of LHVs, male health workers, and male health assistants has considerably increased, whereas that of staff nurses and ANMs declined.
4: State-wise Shortfall and Vacancy of Nurses and Midwives (in percentage) in Rural Health Centres, 2015 Source: Bulletin on Rural Health Statistics in India, 2006 and 2014-15. The shortage of LHV, male health worker and male health assistant are widespread across the states/UTs, whereas not many states/UTs have faced shortage of staff nurse and ANM (Table 4). The states with shortage of nurses and midwives higher than the national average are mostly the high-focus states. The shortage of LHVs at PHCs is more than 75 percent in Tripura, Dadra and Nagar Haveli, Daman and Diu, Kerala, Arunachal Pradesh, Jharkhand, West Bengal, Jammu and Kashmir, Nagaland, Bihar, and Lakshadweep; between 50–75 percent in Himachal Pradesh, Mizoram, Uttarakhand, Assam, Goa, Karnataka, Gujarat, Madhya Pradesh, Andaman and Nicobar Islands, Puducherry; and between 30–50 percent in Odisha, Uttar Pradesh, Rajasthan, Chhattisgarh, Meghalaya, Haryana, and Tamil Nadu.The shortage of male health worker at sub-centresis above 75 percent in Delhi, Nagaland, Puducherry, Uttarakhand, Jharkhand, Bihar, Chandigarh, Rajasthan, Uttar Pradesh, Dadra and Nagar Haveli, and Jammu and Kashmir; between 50–75 percent in West Bengal, Tamil Nadu, Arunachal Pradesh, Meghalaya, Andhra Pradesh, Karnataka, Haryana, Goa, Madhya Pradesh, Himachal Pradesh, Andaman and Nicobar Islands; and between 30–50 percent in Odisha, Tripura, Punjab, Maharashtra, and Chhattisgarh.The shortage of male health assistant at PHCs is above 75 percent in
| States | Staff Nurse at PHCs & CHCs | ANM at
SCs & PHCs |
LHV
at PHCs |
HW(M)
at SCs |
HA[M] at PHCs | |||||
| S | V | S | V | S | V | S | V | S | V | |
| High focus States | ||||||||||
| Arunachal Pradesh | 33.7 | + | 26.1 | + | 96.6 | + | 69.9 | + | 38.5 | + |
| Assam | + | + | + | + | 62.6 | 0.0 | 26.6 | + | 100.0 | 0.0 |
| Bihar | 26.8 | + | + | + | 81.0 | 57.9 | 89.0 | 49.7 | 98.7 | 96.2 |
| Chhattisgarh | 19.5 | 39.4 | 4.6 | 4.1 | 41.0 | 40.4 | 31.7 | 31.4 | 57.3 | 56.8 |
| Himachal Pradesh | 39.3 | 22.5 | 22.1 | 9.8 | 74.6 | 13.0 | 52.6 | 51.3 | 86.2 | 36.1 |
| Jammu & Kashmir | 3.4 | 26.7 | + | 1.2 | 82.1 | 27.4 | 76.6 | 25.2 | 88.2 | 15.7 |
| Jharkhand | 25.1 | + | + | + | 95.1 | 95.1 | 90.3 | 90.3 | 91.7 | 91.7 |
| Madhya Pradesh | + | 13.4 | + | + | 55.7 | 28.5 | 53.3 | 44.4 | 75.4 | 39.6 |
| Manipur | + | 10.5 | + | 9.3 | 24.7 | 14.7 | 10.5 | 19.6 | 23.5 | 12.2 |
| Meghalaya | + | 0.0 | + | 14.2 | 40.9 | 3.0 | 68.9 | + | 32.7 | 8.6 |
| Mizoram | + | + | + | + | 66.7 | 77.7 | + | + | 61.4 | 74.4 |
| Nagaland | + | + | + | + | 81.3 | + | 100.0 | 0.0 | 58.6 | + |
| Odisha | 68.1 | + | + | + | 45.4 | 38.7 | 47.0 | 22.0 | 100.0 | 0.0 |
| Rajasthan | + | 31.2 | 3.0 | 26.3 | 45.1 | 47.0 | 87.2 | 22.9 | 97.5 | 71.1 |
| Sikkim | + | + | + | + | 20.8 | 20.8 | 21.8 | 21.8 | 54.2 | + |
| Tripura | + | 0.0 | 57.0 | 0.0 | 100.0 | 0.0 | 43.6 | 0.0 | 55.0 | 0.0 |
| Uttar Pradesh | 50.5 | 1.9 | 1.2 | 13.2 | 45.2 | 49.3 | 84.6 | 65.3 | 72.7 | 83.4 |
| Uttarakhand | 31.9 | + | 13.2 | 24.4 | 65.0 | 26.8 | 95.7 | 91.4 | 69.7 | + |
| Non-high focus States | ||||||||||
| Andhra Pradesh | 8.7 | 12.8 | + | 16.5 | + | 15.0 | 68.6 | 48.2 | 100.0 | 0.0 |
| Goa | + | + | 34.8 | 0.0 | 57.1 | 18.2 | 58.9 | 0.0 | 100.0 | 0.0 |
| Gujarat | 22.4 | 33.3 | 25.5 | 4.6 | 56.2 | 49.6 | 28.3 | 20.6 | 39.5 | 30.4 |
| Haryana | + | 5.5 | + | + | 38.0 | 15.9 | 54.0 | 46.7 | 49.5 | 31.3 |
| Karnataka | 16.3 | 8.1 | 22.7 | 3.1 | 56.2 | 73.1 | 63.2 | 41.8 | + | 41.8 |
| Kerala | + | + | + | + | 98.4 | 0.0 | 25.7 | 0.0 | + | + |
| Maharashtra | 41.5 | 21.2 | + | 9.2 | 0.6 | 24.7 | 36.8 | 14.8 | 10.6 | 5.9 |
| Punjab | + | 12.9 | + | 7.0 | 8.7 | 20.3 | 42.1 | 42.2 | 33.3 | 30.0 |
| Tamil Nadu | + | 10.1 | 15.9 | 15.2 | 37.5 | 26.1 | 73.8 | 21.1 | + | 37.8 |
| West Bengal | + | 14.9 | + | 8.7 | 86.3 | 12.0 | 75.0 | 72.6 | 91.2 | 72.0 |
| Union Territories | ||||||||||
| A & N Islands | + | 3.1 | + | 7.4 | 50.0 | 0.0 | 63.1 | 0.0 | 100.0 | 0.0 |
| Chandigarh | + | + | + | + | 0.0 | 0.0 | 87.5 | 87.5 | 0.0 | 0.0 |
| D & N Haveli | + | + | + | + | 100.0 | 0.0 | 83.9 | 0.0 | 100.0 | 0.0 |
| Daman & Diu | 17.7 | 0.0 | + | + | 100.0 | 0.0 | 15.4 | 8.3 | 33.3 | 0.0 |
| Delhi | + | + | + | 14.9 | + | 41.7 | 100.0 | 0.0 | 100.0 | 0.0 |
| Lakshadweep | + | 0.0 | + | 0.0 | 75.0 | 0.0 | 0.0 | 0.0 | 100.0 | 0.0 |
| Puducherry | + | + | + | 0.0 | 50.0 | 7.7 | 100.0 | 0.0 | + | 0.0 |
Source: Bulletin on Rural Health Statistics in India 2014-15.
Notes: S– Shortfall (as percentage of required posts), V– Vacancy (as percentage of sanctioned posts). + indicates surplus, SC– sub- centre, PHC– primary health centre, CHC– community health centre, ANM– auxiliary nurse midwife, LHV– lady health visitor, HW– health worker, HA–health assistant, M– male, F– female.
Andhra Pradesh, Assam, Delhi, Goa, Odisha, Andaman and Nicobar Islands, Dadra and Nagar Haveli, Lakshadweep, Bihar, Rajasthan, Jharkhand, West Bengal, Jammu and Kashmir, Himachal Pradesh, and Madhya Pradesh; between 50–75 percent in Uttar Pradesh, Uttarakhand, Mizoram, Nagaland, Chhattisgarh, Tripura, and Sikkim; and between 30–50 percent in Haryana, Gujarat, Arunachal Pradesh, Daman and Diu, Punjab, and Meghalaya.
Vacancy Position of Nursing Workforce in Rural Health Centres
A significant percentage of the required posts of nurses and midwives remained non-sanctioned (Figure 3). In 2005, 27 percent required posts of staff nurse at PHCs and CHCs, 17.4 percent required posts of ANM, 15 percent required posts of LHV at PHCs, 44 percent required posts of male health workerat sub-centres, and 16 percent required posts of male health assistant at PHCs remained non- sanctioned.However by 2015, all the required posts of staff nurse and ANM got sanctioned, whereas the percentage of non- sanctioned posts of LHVs, male health workers, and male health assistant has declined.
Figure 3. Percentage of Required Posts Non-Sanctioned in Rural Health Centres Source: Bulletin on Rural Health Statistics in India, 2006 and 2014-15.
Even out of the sanctioned posts, a considerable percentage of posts are unfilled at all levels (Figure 4). In 2015, the percentage of vacant posts was 16 percent for staff nurses at PHCs and CHCs, 10.5 percent for ANMs at sub-centres and PHCs, 42 percent for LHVs at PHCs, 40.7 percent for male health workers at sub-centres, and 47 percent for male health assistants at PHCs. Once again, the states with a higher percentage of vacant posts of nurses and midwives than the national average are mostly the high-focus states (Table 4).
Source: Bulletin on Rural Health Statistics in India, 2006 and 2014-15.
Figure 3. Percentage of Required Posts Non-Sanctioned in Rural Health Centres
Nursing Training Facility
The size of nurses and midwives is determined by education and training capacity. The number of educational institutions and training capacity of nursing and midwifery personnel in India have expanded rapidly in the last two decades.13-14 Table 5 shows the number of institutions and production capacity of nursing and midwifery personnel in India as on 31st October 2012. There were 659 general nursing and midwifery (GNM) and 485 auxiliary nurse midwifery (ANM) training institutes in 1997,13 which increased to 2670 (with 109224 admissions capacity) and 1642 (with 46719 admissions capacity), respectively, in 2012.15 Likewise, the number of recognised institutes offering Bachelor of Science in Nursing (B.Sc) degree has increased from 187 in 2004 to 1578 (with 80245 admissions capacity) in 2012, institutes offering Post Basic Bachelor of Science in Nursing (P.B.B.Sc) degree increased from 38 to 696 (with 22655 admissions capacity), and institutes offering Master of Science in Nursing (M.Sc) degree increased from 34 to 535 (with 10026 admissions capacity) over the same period.15
The nursing and midwifery training institutes are unevenly distributed across India. The southern states of Andhra Pradesh, Karnataka, Kerala, and Tamil Nadu, which together account for one-fifth of India’s population, have 55.4 percent of nursing colleges and 48.8 percent of GNM training institutes; whereas the poorer states such as Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, and the eight north-eastern account for half of the countr y’s population, have only approximately one-fourth of nursing colleges and GNM training institutes.13 One striking feature of nursing and midwifery education in India is the predominance of the private sector. In 2012, 83–95 percent of nursing and midwifery institutes and admissions capacity are in the private sector (Table 5). However, there are serious concerns on the quality of education in the private institutes. A large number of private nursing colleges in India are run for profit, with serious shortages in faculty, infrastructure, and quality of education.7 The Report of the National Commission on Macroeconomics and Health reports that, in 2004, 61.2 percent of nursing schools/colleges in India are unsuitable for teaching.6
Table 5: Number of Nursing Institutions and Admission Capacity
(As on 31st October 2012)
| Number of Institutes | Admission Capacity | |||||
| Government | Private | Total | Government | Private | Total | |
| GNM | 209 | 2461 | 2670 | 7986 | 101238 | 109224 |
| (7.8) | (92.2) | (7.3) | (92.7) | |||
| ANM | 270 | 1372 | 1642 | 7519 | 39200 | 46719 |
| (16.4) | (83.6) | (16.1) | (83.9) | |||
| B.Sc(N) | 93 | 1485 | 1578 | 5157 | 75088 | 80245 |
| (5.9) | (94.1) | (6.4) | (93.6) | |||
| P. B. B.Sc(N) | 33 | 663 | 696 | 1080 | 21575 | 22655 |
| (4.7) | (95.3) | (4.8) | (95.2) | |||
| M.Sc(N) | 31 | 504 | 535 | 612 | 9414 | 10026 |
| (5.8) | (94.2) | (6.1) | (93.9) | |||
Source: Indian Nursing Council (Retrieved 24 November 2015, from http://www.indiannursingcouncil.org)
Notes: GNM– general nurse midwife, ANM– auxiliary nurse midwife, B.Sc(N)– bachelor of science in nursing, P. B. B.Sc(N)– post basic bachelor of science in nursing, M.Sc(N)–master of science in nursing. Figure in the parenthesis shows the percentage of the total. Additionally, the educational institutions are clustered around the cities. This exacerbates the shortage of nurses and midwives in the rural areas, since the nursing graduates trained in the urban environments are ill-prepared and unmotivated to practice in the rural areas.7
Discussion
The aim of the paper has been to analyse the current scenario of nursing and midwifery workforce in the public health sector in rural India. We find that although the numbers of nurses and midwives in the public health sector in rural India have been increasing during the last decade, there is gross inadequacy of nurses and midwives in the sector. The densities of nurses and midwives and nurse/midwife–doctor ratio is abysmally low compared to the global norms. There is widespread variation in the distribution of nurses and midwives across states/UTs.
The past decade has seen disappearance of certain nursing and midwifery cadres such as LHV, male health worker, and male health assistant. This has aggravated the shortages of these cadres, although the shortages of staff nurse and ANM have declined. The shortage of LHV, male health worker and male health assistant are widespread across the states/UTs, whereas not many states have faced shortage of staff nurse and ANM. There is also a serious problem of vacancies of sanctioned posts at all the levels coupled with a sizable proportion of the required posts remained non-sanctioned across states/UTs.
In the last two decades, the there has been rapid expansion of number of educational institutions and training capacity of nursing and midwifery personnel in India, leading to a growing stock of nurses and midwives in the country. However, the quality of education in private institutes remains a serious concern. The shortage of nurses and midwives has huge repercussions on the health care services provided to the people, leading to poor health outcomes. Therefore, the health policy-makers in India need to take a serious look at the shortage of nurses and midwives in the rural health centres.
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