1

Human Resources for Universal Health Coverage1

Technical Paper

Dr. D. Thamma Rao

MD, DHA, FAGE, M..Soc. Sci.

Senior Advisor, Universal Health Coverage

1 This technical paper has been supported by the Royal Norwegian Embassy- as part of the PHFI Universal

Health Coverage Grant.

2

Contents

Health Systems and Human Resources for Health

HRH Density - Global and Indian Scenario

HRH Losses

HRH Curricula

HRH Requirements - Population based and Health Facility based Norms

HRH Provision for Universal Health Coverage

HRH Availability

HRH Requirements for XII and XII Five Year Plans

HRH Distributional Inequities

Enhancing HRH for Universal Health Coverage:

Doctors (Allopathy)

Nurses

ANMs (Auxiliary Nurse Midwives)

Health Worker - Male

Dentists, AYUSH doctors, Rural Health Care Practitioners, Pharmacists etc.

Enhancing Capacities and Quality of HRH Education and Trainings

District Health Knowledge Institutes (DHKI)

Public Health Management Courses

Nursing & ANM cadre management

Supportive Management Units

Faculty Development and Training of Trainers (ToTs)

Health Sciences Universities

Implementation Plan:

HRH development and Finances

HRH Policies for Improved Performance

Career Trajectories – Nurses, ANMs, Health Worker – male,

Laboratory Technician and Managerial categories

References:

Annexure - I: Medical Colleges Available and Required

Annexure - II: Summary of Proposed Medical, Nursing & ANM Colleges / Schools

Annexure -III: Medical, Nursing & ANM Colleges / Schools in Districts

List of Tables:

Table - I : Provision of 2 Beds per 1,000 Population – for 2017 and 2022

Table - II : HRH Requirements at Health Facilities by year 2022

Table -III: HRH Gaps at Sub-district Level

Table -IV: Medical Colleges Available and Recommended

Table - V: Nursing Schools & Nursing Colleges Proposed based on Population in Districts (2011)

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Human Resources for Universal Health Coverage

Investment plan for meeting human resources requirements for Universal Health Care

The Human Resources for Health (HRH) in India ranges from the medical specialists, general

duty doctors (allopathy and other systems), dentists, nurses and allied health professionals

including pharmacists, technicians to the frontline ANMs and health workers - male. The

HRH are groups of individuals working as teams and providing the health care at primary,

secondary and tertiary levels in public and private health sectors. The health sector in India is

the second largest employer and is next only to the education sector.1

The health systems across the Indian states are struggling with the dynamic health care

complexities of dealing with multiple disease burdens, escalating health care costs and the

HRH issues such as persisting shortages, uneven distribution and skill-mix imbalances.The

Vision 2022 for Universal Health Coverage is crucially dependent on the provision of

numerically adequate, equitably distributed, appropriately skilled and motivated health work

force to accomplish accessible and equitable health care provision. In order to achieve the

these goals, the key elements of this process are-

i) Situation analysis of HRH availability, distribution, gaps, requirements for 2022, education

and training capacities and their distribution across the states.

ii) Projection of future requirements and challenges in production, retention and performance

iii) Fiscal sustainability including costing of the plan.

Health Systems & Human Resources for Health:

The WHO reported that the countries with highest shortfalls in numbers of doctors, nurses

and midwives are the ones most at risk of not meeting coverage targets.2. The WHO Global

Health Workforce Alliance (GHWA) launched in the year 2006, advocated for a 10 year

scale up plan by national Governments and emphasised that the basic problem is ‘not enough

health workers have been educated, trained and employed’. The GHWA task force for scaling

up education and training of health workforce, reviewed research evidence and innovations

from 10 countries including India, Pakistan and Bangladesh, and advocated for a 10 year

vision focusing on pre-service education with supportive in-service trainings.3

In the past two decades, the health status of the populations and the socio-economic

development in India has been commendable. Globally, India is the largest exporter of

manpower as exemplified by the information technology and industry sectors. Since 1949,

the private health sector has grown from providing 8% of healthcare facilities to encompass

93% of hospitals and 85% of doctors.4

The development of physical infrastructure in the Government sector is primarily on the

population based recommendations of Bhore Committee (1946) 5

. During the past eleven five

year plans, these facilities increased progressively to the present 1,47,069 Sub-Health Centres

(SHC), 23,673 Primary Health Centres (PHC), 4,535 Community Health Centres (CHC)6 and

4

12,760 Hospitals.6 The envisaged targets of a SHC for 5000 population, PHC for 30,000

population and CHC for 1,20,000 population as well as an SHC for 3,000 tribal population,

PHC for 20,000 tribal population and CHC for 80,000 population are to be achieved mainly

due to HRH non-availability.7

The goals set for three decades, by the Bhore committee, in 1946 are yet to be achieved in

terms of a doctor for 2000 population, nurse for 500 population, pharmacist for 2000

population. The envisaged HRH targets of laboratory technician for 30,000 population and

health inspector for 20,000 population (Chadha committee 1963)8, and the team of male and

female health workers for 3,000 to 3,500 population with in a distance of less than 5 kms and

the lady health visitors (LHV) and health assistants- male (Kartar Singh committee 1974)9 are

to be fulfilled. The provision of community link workers of 3,85,572 village health guides

and 5,15,691 traditional birth attendants made available by 1985 have become almost extinct

and the number of male health workers available has dwindled down from 88,344 in 198710

to 52,744 in the year 2010.6 The recommendation of Junganwalla Committee

11 on integration

of health services (1967) for unified cadre, equal pay for equal work, recognition of

additional qualifications, no private practice for in-service HRH. The recommendation of

Mehta Committee,12

to set up Medical & Health Education Commission and University of

Health Sciences in the states has been still under consideration. The availability of adequate

number of nurses and allied health professionals for better utilisation of doctors for the

patient care continues to be far away.

India continues to face severe HRH gaps even after the outstanding health policies and

recommendations of the Expert Committees ranging from Sir Joseph Bhore (1946), Mudaliar

Committee (1961)13

, Chadha Committee (1963), Katar Singh Committee (1974), Shrivastav

Committee (1975)14

, Bajaj Committee(1986)15

, Mukerjee Committee (1995)16

, Task Group

for accreditation, training and integration of private rural medical practitioners (May 2007)17

and Task Force on planning for HRH, Planning Commission (2007)18

. The Shrivastav

Committee (1975) aptly expressed that the ‘health sector development essentially means the

development of human resources rather than material resources’ and advocated for greater

emphasis on human effort for which we have large potential’. The National Health Policy

(1983) advocated for minimal statutory HRH norms, improvement in the ratio of nurses,

doctors and beds, simplified recruitments, mandatory rural postings, in-service trainings for

skills up-gradation, training facilities and remodeling of education and trainings.19

The

National Health Policy of (2002) observed that the decentralized public health service outlets

have become dysfunctional over large parts of the country except in the southern States.20

The non-availability of skilled HRH has a direct impact on health sector outcomes such as

over 20% of the deliveries are outside health facilities in 485 districts and more than 15% of

children are immunised partially in 358 districts.21

The recent initiatives through National

Rural Health Mission (NRHM) contributed for 17% decline in the MMR from 254 in the year

2004-2006 to 212 in 2007-2009 and most significantly in the 8 Empowered Action Group

(EAG) states and Assam. India’s IMR has declined from 57 (2006) to 50 (2009) per 1,000

5

live births.22

This still fall short of the National Population Policy (2000) and NRHM goals of

<30 per 1000 live births (by 2010) and XI Plan goals of 28 per 1,000 live births (by 2012).

Globally, India accounts for half of leprosy cases (1.3 lakhs) and 21% of Tuberculosis (TB)

cases (19 lakh).21

While mortality from communicable diseases has declined, there has been

no decline in incidence. The new sputum positive case detection rates for TB is less than 60%

in 243 districts, the Annual Parasite Index for malaria continues to be above 1.9 in 142

districts and leprosy prevalence rate is more than 1 in 53 districts.10

Non-communicable

diseases are on the rise, in particular coronary heart disease and diabetes.7 Deficiencies in

HRH, both in numbers and skills, are major contributors to the suboptimal performance of

health systems.

HRH Density

The World Health Organisation (WHO) Joint learning initiative (JLI) report on HRH (2004)

attempted to estimate the health manpower and health worker density index of various

countries using the data base compiled by the WHO on major HRH namely physicians,

nurses, midwives, dentists and pharmacists.23

The HRH density, the composite index of

doctors, nurses and midwives per 10,000 population, reflects the overall HRH level in each

country. The JLI has established a threshold of 25 health workers (doctors, nurses and

midwives) per 10,000 population and more recently WHO has endorsed 23 workers per

10,000.24

As per figures most recently reported in the World Health Statistics Report (2011),

the density of doctors in India is 6 and that of nurses and midwives is 13, representing 19

health workers per 10,000.10

India finds itself ranked 52 out of the 57 countries facing an

HRH crisis.25

Based on cumulative data from comparative time periods (2001–2005), India has a doctor:

population ratio of 0.5 per 1,000 population in comparison to 0.3 in Thailand, 0.4 in Sri

Lanka, 1.6 in China, 5.4 in UK, 5.5 in USA and 5.9 in Cuba. The ratio of 2.19 nurses and

midwives per doctor ranks India lower than Sri Lanka (3.94) and Thailand (5.07).26

Review of registration data by the professional councils indicates the availability of one

doctor per 1,953 population and availability of 1.5 nurses/ ANMs for a doctor. This is still a

long way from attaining the norms of one doctor per 1,000 population, and 3 nurses and

midwives per doctor. It is imperative that the admission capacities of these critical cadres be

increased by establishing additional educational institutions in the states with a weak HR

capacity and high HRH requirements. This is in keeping with the recommendations of the

Commission on the Education of Health Professionals for the 21st Century, who have pointed

out that the shortage of health workers is not just a problem of mal-distribution and funding,

but also of appropriate education and training.27

The developed and developing countries are competing leading to migration and same would

continue. In order to meet the shortages, the Association of American medical colleges

recommended 2015 medical colleges and increase their enrolments by 5,000 annually (30%).

6

The Wanless Report of UK has recommended 50 % scaling for doctors, 7% for nurses and

midwives, and 80% of other professionals. The persisting HRH crisis in India has been the

major constraint for progress towards UHC. The HRH shortfalls have resulted in the skewing

of the distribution of several categories of health workers. The vulnerable populations in

rural, tribal and hilly areas continue to be extremely underserved. For example, in 2006, only

26% of doctors were residents in rural areas to serve the 72% of India’s rural population.26

Another study has found that the urban density of doctors is nearly four times, and that of

nurses is three times higher than rural areas.28

The distribution of medical colleges, nursing colleges, nursing and ANM schools,

paramedical institutions is unevenly spread across the states and with wide disparities in

quality of education.29

Five “high HRH production” states represent 31% of the Indian

population but have a disproportionately high share of MBBS seats (58%), nursing colleges

(63%) as compared to the seven “low HRH production” states, which comprise 46% of

India’s population, but far fewer MBBS seats (21%) and nursing colleges (20%). There are

additional trends characterising these state groupings. In high HRH production states, the

share of HRH production by private medical colleges has increased from 33% in the year

1990 to 52% in the year 200617

and to the present 57%. A large number of private colleges

are run for profit with serious shortages in faculty, infrastructure and quality of education.27

The uneven distribution of educational institutions has led to severe HRH imbalances across

the states leading to poor health care outcomes in several districts. The HRH density in the

Indian states varies widely from the lowest of 10 in Bihar to 65 in Chandigarh. The six states

with very low HRH density of 10-15 are Bihar (10), Uttar Pradesh (13), Jharkhand (14),

Rajasthan (14), Assam (14) and Meghalaya (15). The six states with low density of 16 -20 are

Chhattisgarh (16), Madhya Pradesh (16), Gujarat (17), Tripura (18), Haryana (20) and Orissa

(20). The seven states with moderate HRH density of 21 to 23 are Haryana (20), Andhra

Pradesh (21), Jammu & Kashmir (21), Karnataka (21), Uttaranchal (21), Manipur (23) and

Tamil Nadu (23). The HRH density is 24 to 35 in the five states of West Bengal (24)

Himachal Pradesh (26), Arunachal Pradesh (27), Punjab (27), Nagaland (27) and Maharashtra

(29). The seven states/ UTs with highest HRH density of 36 to 65 are Delhi (38), Goa (42),

Kerala (38), Mizoram (46), Sikkim (42), Pondicherry (54) and Chandigarh (65).

States with critical shortages and imbalances of health workers lack the technical capacity to

identify and assess HRH issues regarding the status of the workforce and their performance.

The states in need of HRH strengthening have the most unreliable data and information as

they lack dedicated system for collecting, processing and disseminating comprehensive

timely information on HRH including availability and distribution. The lack of

comprehensive reliable data and the absence of commonly agreed definitions and analytical

tools have made the task of monitoring the health workforce all the more difficult in the states

and districts to maintain a sufficient, sustainable and effective HRH.

The present HRH situation in India is largely attributable to the lack of HRH Development

Policies and HRH management information systems at national and state levels for

7

influencing HRH production, placement, distribution, transparent transfers and promotions,

in-service training, monitoring, supportive supervision and HRH performance. The HRH

policies for enhanced production of sufficient numbers of motivated HRH with adequate

technical competencies to reach out to the populations. This would necessarily include HRH

planning, management, budgeting and quality control mechanisms for educational institutions.

During the last few years, there has been an increasing interest in the relevance of HRH

density to health care outcomes. A study from Chen et al. (2004) observed that higher HRH

density leads to better health care coverage levels in terms of deliveries conducted and

proportion of measles immunisation in children.31

Anand and Bärnighausen examined the

WHO data of 2004, in 198 countries and summarized the relationships between the HRH

density and health care outcomes. They conducted a cross-country multiple regression

analysis of the impact of HRH density on IMR, MMR etc. They have also considered the

socio-economic determinants of health such as female literacy and effects of income. They

found that HRH density (doctor, nurses and midwives) had a significant impact on reducing

mortality rates. The authors observed that HRH density independently affect the health care

outcomes with greater impact on reducing maternal mortality and lesser on IMR and under-5

mortality. They surmised that the availability of specialized and trained personnel for safe

deliveries and abortions reduce the risks in women.32

Speybroeck et al. (2006) conducted

multiple regression analyses of WHO data and replicated some of the methods used by Chen

et al. The authors analyzed data sets from 192 countries and observed general positive

correlation between HRH density and health care outcomes including measles immunisation

coverage. In one of their model iterations, they identified 22.8 health workers per 10,000

population as the threshold for HRH density associated with 80% coverage.33

HRH losses:

The means of assessing levels of international migration being the data of the migrant

worker’s origin, Dumont JC and Zurn P (2007) merged the census data on foreign-born

health professionals living in 24 high-income countries of Organisation for Economic Co-

operation and Development (OECD), including Australia, UK and USA. The finding were

that highest nurses of were from Philippines (1,10,000) and highest number of doctors were

from India (56,000) as immigrant health workforce in the 24 OECD countries, Australia, UK

and USA.34

In another study of 12 countries, it was observed that 2.4% of doctors and 2.1%

nurses and midwifery personnel die prematurely before the age of 60 years.35

Curricula:

The curricula have not kept pace with the changing dynamics of health care and public health

strategies. The ANM curriculum was first prescribed in 1963 and revised twice only in 1997

and 2004. The curriculum GNM (General Nursing and Midwifery) diploma course for nurses

was first prescribed in 1951, and in the past 60 years, was revised thrice only in 1965, 1986

and 2001. Similarly, the B.Sc. (nursing) curriculum first prescribed in 1952 was revised

thrice only in 1970, 1981 and 2004. The trainings are more technologically driven rather than

care driven with focus for improving the health status of our populations. The medical and

8

nursing graduates are more urban oriented as their trainings prepares them for urban settings

and further education in chosen specialities rather than preparing them for service in any of

the three tiers of the primary or secondary or tertiary levels of health care. The WHO-South

East Asia Regional Office study “Inquiry driven strategies for innovation in medical

education in India’ has aptly noted the disconnection between the syllabus and morbidity

patterns.36

The positive initiatives in the recent period are the revision of curriculum for

health worker (male) in the year 2010 and the revision of norms by the Indian Nursing

Council (INC) and Medical Council of India (MCI).

The changes would obviously need policy thrusts for radical reforms in the systems, attitudes

and innovations. The draft National Education Policy in Health Sciences advocating

Education Commission in Health Sciences, the revision of curricula and resolving sharp

regional imbalances (Bajaj committee, 1989) as well as the concept of family and community

oriented practitioner (Shrivastava Committee, 1975) , continues to be more on paper. Similar

is the case of the recommendations of the working group on medical education (2007) for the

Medical and Health Education Committee on the pattern of University Grants Commission,

all India common entrance test for admission and exit of students, national accreditation of

educational institutions, five regional centres for faculty development.

The global independent commission on education of health professionals for the 21st century

conducted research and analysis (2010). The commission articulated for the transformation of

health professional’s education and suggested the major reforms of adopting competency

based curriculum, inter/ trans-professional education, exploiting Information Technology

learning, strengthening of educational resources and promotion of new professionalism.27

HRH Requirements:

The realistic requirements of HRH needs to consider population norms for doctors, nurses etc.

as well as the HRH needs of health facilities to be made available (public and private sectors)

based on requisite provision of beds for the catchment populations. The technical group on

population projections estimated that India’s populations to be 1.19 billion by the year 2011,

1.29 billion by year 2017 and 1.35 billion by the year 2022. 37

The actual population of

census (2011) overshot the projected population for the year 2011 and it is estimated that

India’s populations would be marginally higher than the estimates of 2006, with 1.3 billion

for the year 2017 and 1.37 billion for the year 2022. 38,39

The availability of hospital beds in India is very low of less than 1 bed per 1,000 population

in comparison to far below the global average of 2.9 beds per 1,000 population, 2.2 beds in

Thailand, 2.4 beds in Brazil, 3.1 beds in Sri Lanka, 3.0 beds in China and 3.4 beds in U.K.

The acute need for the increase of beds in the Government sector is implicit in the National

Sample Survey Organisation (NSSO) report- March 2006, where in it reported that the

private sector accounts for 64% of beds and 40% of patients have to borrow money or sell

assets because of hospital expenses.

9

The essential provision of two beds per 1,000 population for the projected population of

1,352 million of the year 2022 would necessitate 27 lakh beds. This provision is to be

incorporated within the population based provision of health centres and hospitals for the

UHC. The number of facilities required was projected by using Indian Public Health

Standards (IPHS) population norms for each facility type (eg. 5000 people per SHC, 3000

people per SHC in tribal/hilly/difficult areas) for SHCs, PHCs and CHCs and Medical

College Hospitals (MCH) respectively, using as denominators the projected populations for

2017, 2020 and 2022. The number of District Hospitals (DH) was determined on the basis of

the number of districts, a number that will likely change only nominally over the next decade.

The number of Sub-District Hospitals (SDH) was determined specifically to fill in the gap in

number of beds required in order to approximate a 2 bed per 1,000 population norm by 2022.

Accordingly, it is envisaged to provide 2 beds per 1,000 population by the year 2022 through

50,591 PHCs, 12,648 CHCs, 4,561 SDHs, 642 DHs and 502 MCHs as indicated in Table-I.

Way Froward for the Provision of 2 Beds per 1,000 Population by year 2022

Table – I: Provision of 2 Beds per 1,000 Population – for 2017 and 2022

Year

(Population in ,000) 2011

(120109) 2017

(1283600)

2020

(1326155) 2022

(1352695)

Facilities Nos. Beds Nos. Beds Nos. Beds Nos. Beds

1 PHCs ( 6 beds ) 23391 140346 32447 194682 41503 249018 50591 303546

2 CHCs ( 30 beds) 4510 135300 7222 216660 9934 298020 12648 379440

3 Sub-district Hospital* (300 beds) 8250 412500 2437 731100 3499 1049700 4561 1368300

4 District Hospital (500 beds ) 521 260500 642 321000 642 321000 642 3,21,000

5 Medical college Hospitals*(750 beds) 315 236250 444 333,000 484 363000 502 376500

Total Beds - 1184896 - 1463442 - 2280738 - 2748786

Required ( 2 beds/1,000 Population) - 2420386 - 2567200 - 2652310 - 2705390

* Both Government and Private sectors

140346 194682 249018

303546

135300 216660

298020 379440

412500

731100

1049700

1368300

260500

321000 321000 321,000

236250 333,000

363000 376500

1184896

1463442

2280738

2748786 2420380

2567200 2652310 2705390

0

500000

1000000

1500000

2000000

2500000

3000000

2011 2017 2020 2022

PHCs ( 6 beds ) CHCs (30 beds )

Sub-dist. Hospital* (300 beds) District Hospital (500 beds )

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HRH Provision for Universal Health Coverage

The World Development Report observed that the crisis is an absolute shortage of health

workers, not just a problem of mal-distribution, and advocated that educating and training of

enough health workers need to be the central part of the solution.43

It is imperative that the

admission capacities need to be further increased by establishing new medical colleges,

nursing colleges, nursing schools, ANM schools, and HW- male schools especially in the

states with very meagre capacities. There is an adequate pool of dentists, doctors in

Ayurvedha, Yoga, Naturopathy, Unani, Siddha and Homeopathy (AYUSH), pharmacists as

well as laboratory technicians and their non-availability in the Government sector is due to

non-creation of posts.

India has 315 medical colleges with an annual production of over 35,500 doctors, 18,000

specialists, 21,500 dentists from 289 dental colleges, 30,086 AYUSH doctors from 492

colleges as well as annual production capacity of 1.7 lakh nurses from 2,233 nursing schools

and 1,418 colleges, 27,384 ANMs from 1,035 schools and 70,542 pharmacists from 1,211

schools and colleges22

but still grappling with severe shortages of doctors, nurses and

midwives. Dentists registered during 2004 to 2009 have increased from 55,000 to over

1,04,000 in a short span of four years.22

The Present AYUSH institutions would sustain the

decadal increase of AYUSH doctors by over 25%. There is an increase of 64% in pharmacy

colleges during the past decade. The data for other paramedical categories is not available as

there are no statutory regulatory councils or boards.

The XI plan initiatives of monetary support by the Government of India for HRH has resulted

in 255% increase of ANM schools and 178% increase of nursing schools and colleges,

starting of M.Sc. (nursing) courses in 349 nursing colleges facilitating annual addition of

7,398 nursing faculty. There is a need for continued support in HRH initiatives for achieving

the NRHM objectives of up-gradation of all PHCs for 24x7 services, CHCs and sub-district

hospitals as first referral units including caesarean section facilities, enhancing the bed

occupancy from the present 20% to over 75% etc. The Task Force on Planning for HRH of

Planning Commission (2007) has endorsed the five times increase in the public spending on

development of HRH 29

as recommended by the National Commission on Macroeconomics

and Health (NCMH).26

The fiscal sustainability of HRH augmentation is the greatest challenge and is not feasible

within the limited duration of a five year plan. The Strategic investments in education for

rapid expansion of HRH and trainings for keeping up the pace with the advancing

technologies would necessitate higher investments. The WHO Global Atlas of the Health

Workforce ‘(GHWA) advocates the critical HRH threshold of 23 doctors, nurses and

midwives per 10000 population and identified that 57 countries are facing HRH crisis and

India is placed 52nd

. It is still a long way to attain the ideal norms of one doctor per minimum

of 1,000 population, and 3 nurses and midwives per doctor. The present institutions are

inadequate to meet the advocated norms of various MOHFW expert committees and the

recent WHO global norms. Additional admission capacities are an absolute need for critical

11

cadres of doctors, nurses, midwives and health worker-male. It is equally important to ensure

high level of quality in educational institutions and upgrade the HRH skills to match the

changing needs of the communities.

HRH Availability:

As per the cumulative number of registered allopathic doctors (8.17 lakh) till the year 2010

by the MCI, the doctor: population ratio is very low of 1 per 1,441 in comparison to 166 in

United Kingdom and 548 in United States of America. The doctor: population ratio is 1:750

in consideration of the combined strength of 15.5 lakh doctors including 7.52 lakh AYUSH

doctors. As per the cumulative registration data of other councils the ratios are 1:11,250 for

dentists, 1:690 for nurses and 1:1,794 for the pharmacists.22

The ratio of pharmacists is

comparable to those of developed countries. The basic data in regard to other allied health

professionals is not available in the absence of councils.

The registration data of the professional councils for doctors, dentists and nurses is

cumulative and excludes attrition losses for death, retirement, migration etc. The data of the

respective councils as on 31st December 2010 indicate the HRH availability of 10.74 lakh

nurses with diploma qualifications, 5.77 lakh ANMs, 6.56 lakh pharmacists and 1.04 lakh

dentists.22

The INC has registered 52,375 LHVs till 31st December 2010 whereas the RHS

2010 compilation of data from all the states indicates that 18,168 LHVs (35%) are only

working at the health centres. The LHVs being employed exclusively in the Government

sector, it is presumable that the remaining 65% would have either retried or died or non-

functional. The situation is similar for other categories as there is no renewal after initial

registration. Hence, it is more appropriate that the professionals registered during the

preceding 36 years for doctors, 38 years for nurses and 40 years for nurses be accounted for,

as the remaining are unlikely to be available especially in organized sectors.

The Census 2001 suggests that there are 2.17 million health workers with the HRH density of

10 in Bihar to 65 in Chandigarh. The self-reporting of 6.8 lakh allopathy doctors in Census

2001 indicates the inclusion of 1.2 lakh non-professionals (22%) as 5.55 lakh allopathy

doctors were only registered with the MCI till the year 2000 including attrition losses. The

health worker per population is skewed as the vulnerable populations in rural, tribal and hilly

areas are extremely underserved with 74% doctors living in urban areas.43

The Ministry of Health family Welfare, annual publications 4,22

provides the HR data of

selective categories sans HRH data of hospitals and medical colleges. The only source of

HRH availability at facilities being the Rural Health Statistics annual bulletin, the HRH

availability for 24 HRH categories at sub-district level facilities (SHC, PHC and CHCs) could

only be assessed for 2010. The HRH availability at these sub-district level facilities is meagre

4.43 lakhs. The weak knowledge base on HRH has been the greatest constraint for any

realistic HRH planning and health system’s strengthening.

12

The acute shortages of HRH as evident as 7,775 SHCs are without ANMs, 35% of SHCs are

without 2nd

ANM, 61% of SHCs (88,455) are without health worker-male, 18% of PHCs are

without doctor, 38% of PHCs are without laboratory technician and 16% of PHC are without

pharmacist.6b

This is mainly due to non- availability of requisite posts at the facilities and

very high vacancies even in the available posts. 6a

The NRHM’s compilation of data from the

states as on March 2010, indicates that 521 district hospitals, 589 SDHs and 1,227 of the

4,535 CHCs are only functioning as First Referral Units (FRU) for emergency services

including caesarean section deliveries and 8,716 PHCs are only functioning as 24x7 PHCs.

HRH Requirements for XII and XII Five Year Plans:

The HRH norms of IPHS (2010)40

, MCI41

and INC42

as well as availability of physical

infrastructure and faculty for the educational institutions and other HRH relevant data were

reviewed. In consideration of the present HRH scenario across the states and the

implementation feasibilities, the HRH staffing pattern suggested is: 4 at the SHC including

new category of rural healthcare practitioner, 24 at the PHC in comparison to 19 in IPHS, 54

at the CHC in comparison to 50 in IPHS, 247 at the sub-district hospital (201-300 beds) in

comparison to 234 in IPHS, 435 at the district hospital (301-500 beds) in comparison to 411

in IPHS and 808 at the 750 bedded medical college hospital in comparison to 796 in MCI

minimum standards. The specific HRH requirements for 32 most critical HRH, by the year

2022 at all these facilities would be 49.7 lakh health workers including 2 lakh managerial

categories for the operationalization of requisite facilities as detailed in Table II.

Table-II: HRH Requirements at Health Facilities by year 2022

Category

SHCs (314547)

PHCs (50591)

CHCs

(12648) SDH

(4561) DH/ Hq.

(642) MCH

(502) Total

HRH

1 ANMs and LHVs 629094 151773 25296 22805 3210 - 832178

2 Health Workers-male 314547 101182 25296 4561 642 - 446228

3 Nurses - 252955 252960 665906 189390 255016 1616227

4 Pharmacists - 151773 50592 36488 7062 7530 253445

5 Technicians and others - 202364 113832 159635 34668 34136 544635

6 Rural Healthcare Practitioners 314547 - - - - - 314547

7 Dentists - 50591 12648 9122 1284 1004 74649

8 Doctor (AYUSH) - 50591 12648 - 1284 - 64523

9 Doctors (Allopathy) - 151773 75888 91220 15408 82830 417119

10 Specialists - (Anaesthesia,

Medicine, Obstetrics, Ophthalmology,

Paediatrics & Surgery) - - 65770 104903 17334 21084 209091

11 Managerial Categories - 101182 50592 31927 8346 4016 196705

Total 1258188 1214184 685522 1126567 279270 405616 4969347

The above HRH for the year 2022 would also provide for the much needed thrust towards

primary health care with 50% of HRH at rural health facilities (SHCs and PHCs), 36% of

HRH at secondary care (CHCs and SDHs) and 14% at tertiary care facilities (DH and

Medical colleges). The HRH requirements for various categories are 12.6 lakh at SHCs, 12

lakh at PHCs, 7 lakh at CHCs (first referral units for rural areas), 11 lakhs at sub-district

hospitals and the remaining 7 lakh for tertiary care at district hospitals and medical college

13

hospitals. The category wise needs would be 16.2 lakh nurses, 8.3 lakh ANMs, 4.5 lakh male

health workers, 2.5 lakh pharmacists, 5.5 lakh technicians and other allied health

professionals, 4.2 lakh doctors (allopathy) and 2.1 lakh specialists in six specialties.

As on March 2010 6a

, the HRH availability at sub-district level (SHCs, PHCs and CHCs) was

4.43 lakhs. To achieve UHC, an additional 25.63 lakh health workers are required at the sub-

district level. To address this paucity of HRH at the sub-district level, it is estimated that an

additional 5 lakh ANMs, 1 lakh LHVs, 4.4 lakh nurses, 3.7 lakh male health

workers/Assistants, 3.1 lakh rural health care practitioners, 1.9 lakh allopathy doctors, 1.2

lakh laboratory technicians and 1.2 lakh pharmacists and 1.4 lakh managerial staff are to be

positioned at the SHCs, PHCs and CHCs as detailed below in Table III.

Table-III: HRH Gaps at Sub-district Level

Category

Required Available HRH for year 2022

Additionally Required

2022 March 2009

(RHS 2009) March 2010

(RHS 2010) For HRH

Gaps 2009 For HRH

Gaps 2010

1 ANMs category (ANM & LHV) 806163 249817 208491 556346 597672

2 Health Workers/Asst. – Male 441025 75415 69339 365610 371686

3 Staff Nurses & Head Nurses 493267 56975 57450 436292 435817

4 Lab Technicians 139126 12904 15094 126222 124032

5 Pharmacists (Allopathy) 139126 20967 21688 118159 117438

6 Radiographers/ DRA 25296 1867 1817 23429 23479

7 Physiotherapists 12648 Not Reported Not Reported 12648 12648

8 Health Educators 63239 3089 3063 60150 60176

9 Rural Health Care Practitioners 314547 1800 1800 312747 312747

10 Dentists 63239 Not Reported Not Reported 63239 63239

11 Doctors (AYUSH) 63239 6323 8900 56916 54339

12 Doctors (Allopathy) 227661 38822 35803 188839 191858

13 Specialists - (Anaesthesia, Medicine,

Obstetrics, Ophth., Paediatrics & Surgery) 65770 5789 6781 59981 58989

14 Managerial Categories 151774 12762 12762 139012 139012

Total 3006120 486530 442988 2519590 2563132

HRH distribution:

In addition to the numerical inadequacies, India faces multiple challenges in terms of

geographic mal-distribution of HRH due to skewed distribution of HRH educational

institutions and quality in education. The ANM schools, nursing schools/colleges, Public

Health Nurse (PHN) and LHV training schools, paramedical training institutions and medical

colleges are unevenly distributed across the states with wide disparities in the quality of

education due to lack of faculty and monitoring mechanisms. Such distribution resulted in

inequities in health care especially in the districts with vulnerable populations. The states of

Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar

Pradesh with 46% of India’s population have 67 medical colleges (27%). The private medical

colleges have increased from 33% in year 1990 to 57% and mostly in the southern states and

Maharashtra. The three states of Bihar, Maharashtra and Uttar Pradesh have 50% of AYUSH

doctors with Bihar having five times more AYUSH doctors than allopath doctors.22

14

Similarly in nursing, the four southern states have 63% of nursing schools in contrast to 20%

in the seven states of Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan,

Uttaranchal and Uttar Pradesh. During the past five years, the situation improved towards

equity with the addition of 539 nursing schools in the twelve states of Gujarat, Haryana,

Himachal Pradesh, Jammu &Kashmir, Jharkhand, Madhya Pradesh, Orissa, Punjab,

Rajasthan, Uttaranchal, Uttar Pradesh and West Bengal as well as 305 ANM schools in the

eight states of Chhattisgarh, Haryana, Jharkhand, Madhya Pradesh, Orissa, Punjab, Uttar

Pradesh and West Bengal.

Enhancing HRH for Universal Health Coverage:

Doctors (Allopathy):

The allopathic doctors registered with the MCI have increased progressively from 61,800 in

the year to 1951 to 8.17 lakhs in year 2010. The development of Indian Systems of Health

lead to the availability of 7.5 lakhs AYUSH doctors and AYUSH doctor: population ratio of

1:1,543. The combined strength of 15.46 lakh doctors (allopathy and AYUSH) provides a

doctor: population ratio of 1:750.7a

These ratios are based on the cumulative registration by

the councils and are exclusive of attrition losses for death, retirement, migration etc. The

review of the actual admissions and passed out candidates from medical colleges during the

preceding 36 years is a better option for availability assessments as the doctors would enter

professional career around 26 years of age. This rationale indicates the availability of 6.2 lakh

doctors and one doctor per 1,953 population in comparison to the higher ratio of 1,441 (36%)

indicated in the National Health Profile (2010) based on the cumulative registrations. 7a

The WHO advocated doctor density of 6 per 10000 population has so far been achieved in the

15 states/ Union Territories of Andhra Pradesh, Chandigarh, Delhi, Jammu & Kashmir, Goa,

Himachal Pradesh, Haryana, Karnataka, Kerala, Maharashtra, Pondicherry, Punjab, Sikkim

Tamil Nadu, Uttaranchal and Uttar Pradesh. The doctor per population is skewed as the

vulnerable populations in rural and tribal areas are underserved with 26% doctors living in

rural areas (Task Force report on Medical Education, 2006)44

.

According to the NCMH (2005), 30% of specialists opt for private sector, 10 % migrate to

other countries and 60% work in public sector. The present annual admission capacities of

35,500 would enable availability of 2.49 lakh additional doctors by year 2022. These

enhanced capacities in the existing medical colleges would still fall much short of the needs

of the year 2022. The envisaged provision of one doctor for 1000 population for year 2022

would need 13.53 lakhs functinally active doctorsn inclusive of 4.2 lakh MBBS doctors and

2.1 lakh specialist at Government facilities.

India’s average annual output per medical college is 100 graduates per college in comparison

to 110 in North America, 125 in Central Europe, 149 in Western Europe, 220 in Eastern

Europe. China with 188 colleges produces 1,75,000 doctors annually with an average of 930

graduates per college.27

The recent MCI initiatives such as enhancement of maximum limit

for annual admissions from 150 to 250 and doubling of postgraduate seats per teacher would

15

marginally reduce these shortages for allopathy doctors. There is a further need to increase

the number of medical colleges for ensuring allopathy doctors in the states and these colleges

should be established in the districts with poor health care outcome indicators.

The present 315 medical colleges provide, on an average, one medical college per 38.41

lakhs population. The populations in 447 districts do not have referral medical college in the

district as the present colleges are located in 195 districts only. In the states with very low

health care outcome indicators, the provision of medical colleges is very low of one each for

115 lakhs population in Bihar, 95 lakhs in Uttar Pradesh, 73 lakhs in Madhya Pradesh and 68

lakhs in Rajasthan whereas Kerala, Karnataka and Tamilnadu have one each for 15 lakhs, 16

lakhs, 19 lakhs populations respectively. The states of Bihar, Chhattisgarh, Jharkhand,

Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh with 46% of India’s

population have 67 medical colleges (27%).

Table –IV Medical Colleges Availability and Requirements

in 15 States with 70% of Indian Population

State/ UT

Districts & Populations Medical Colleges Available & Required

Total >25--50

Lakh

>10-<25

Lakh

< 10

lakh

Existing Required

1/ 25 lakh

Population

(2011)

Shortfall

Recommended

Govt. Private Total 2012-15 2015-17 2017-22 Total

All INDIA 642 150 260 232 155 160 315 484 206 65 64 58 187

1 Assam 27 1 7 19 4 - 4 12 8 4 3 1 8

2 Bihar 38 11 22 5 6 3 9 41 32 9 9 9 27

3 Chhattisgarh 18 2 7 9 3 - 3 10 7 3 3 1 7

4 Gujarat 26 7 15 4 8 8 16 24 8 3 3 2 8

5 Haryana 21 10 - 11 2 3 5 10 5 2 2 1 5

6 J & K 22 - 2 20 3 1 4 5 1 1 - - 1

7 Jharkhand 24 1 12 11 3 - 3 13 10 4 4 2 10

8 Madhya Pradesh 50 - 34 16 6 5 11 29 18 8 8 2 18

9 Maharashtra 35 15 17 3 19 22 41 44 3 1 1 1 3

10 Meghalaya 7 - - 7 - - - 1 1 - - 1 1

11 Odisha 30 1 18 11 3 3 6 16 10 4 4 2 10

12 Punjab 20 2 8 10 3 5 8 11 3 1 1 1 3

13 Rajasthan 35 5 22 8 6 4 10 27 17 6 6 5 17

14 Uttar Pradesh 71 34 34 3 10 11 21 79 58 11 12 26 49

15 West Bengal 19 17 2 - 9 2 11 36 25 8 8 4 20

Total (15 States) 443 106 200 137 85 67 152 358 206 65 64 58 187

* Medical Council of India data as on May 2011

In consideration of the limitations in provision of faculty, it is suggested to provide 187 new

medical colleges for the vulnerable populations in the underserved districts of Uttar Pradesh

(49), Bihar (27), West Bengal (20), Madhya Pradesh (18), Rajasthan (17), Jharkhand (10),

Orissa (10) etc. as detailed in Annexures. This would enable the provision of one medical

college per 25 lakhs population in each of the states in a phased manner during the XII and

XIII Five year plans. This would provide 11.76 lakh doctors by 2022 and the ratio of one

doctor per 1,451 population by year 2022 and one doctor per 1,000 population by year 2027.

16

Nurses:

According to the self-declared occupational data of Census 2001, there are 5,45,933 nurses

and 2,77,655 midwives for the 5,55,550 MCI registered allopathy doctors. This implies the

ratio of 1.48 nurses and midwives in comparison to 3 nurses in the US and 5 nurses in the

UK. The WHO norm of 3 nurses per doctor has been maintained in the seven States/UTs of

Arunachal Pradesh, Kerala, Meghalaya, Nagaland, Orissa, Pondicherry and Tripura. The

highly adverse ratio of less than one nurse per doctor is conspicuous in the states of Bihar,

Uttaranchal and West Bengal. The detailed analysis of nursing institutions42

indicates that

149 districts in 14 of the 18 high focus states do not have any nursing school or college.

The Mudaliar committee (1961) recommended that the nurse: population ratio should be

1:5000 by the year 1971, 1:2000 by year 1981 and 1:1,000 by year 1991. The National Task

Force for Nursing, XI five year plan reported45

that for the year 2004 , the nurse to population

ratio for the year 2004 in India is 1:2,250 in comparison to 1000 in Sri Lanka and 850 in

Thailand and an adverse nurse to doctor ratio of 1:1.5 in comparison to 3:1 in developed

countries. The National Health Profile, based on the INC registered nurses as on 31-12-2010,

has reported the nurse to population ratio of 1:691. These registrations of 10.73 lakh nurses is

for GNM nurse with the diploma qualification and excludes the B.Sc. qualified nurses.22

The

registration data of the Indian nursing council is cumulative and does not include attrition

losses for death, retirement, migration etc. and also the prevalent practices of multiple

registrations on acquiring higher qualifications and migration to other states.

The review of the actual admissions at the nursing colleges (B.Sc.) and nursing schools

(diploma nurses) during the preceding 38 years is the preferred option as the nurses would

start their career around the age of 22 years. This indicates much lesser availability of 6.17

lakh nurses implying the availability of 1.05 nurses per doctor. The provision of 3 nurses and

midwives per doctor would require over 42 lakh nurses by next decade.

The requirements of nurses for the Government facilities for the populations of year 2022 are

assessed to be 16.2 lakhs including 2.53 lakhs for PHCs, 2.53 lakhs for CHCs, 6.7 lakhs for

sub-district hospitals, 1.9 lakhs for district hospitals and 2.6 lakhs for medical college

hospitals. The primary health care provision of 5 per PHC and 19 nurses per CHC would

need 5.1 lakh nurses and currently 57,450 are only in position at PHCs and CHCs.

The present admission capacities of 1.6 lakh per year are too meager to achieve the targets of

3 nurses per doctor and to ensure adequate number of nurses across the health facilities in the

Government and private sectors. The Government of India has identified 154 high focus

districts in 23 states where there is no nurses training institutions including Assam, Bihar,

Chhattisgarh, Jammu & Kashmir, Jharkhand, Madhya Pradesh, Orissa, Rajasthan and Uttar

Pradesh. These shortages have more adverse impact in the districts with high IMR, MMR,

Under 5 Mortality, Underweight children and high incidence of nutritional anemia etc.

17

The number of educational institutions was based upon a district level analysis of existing

schools and colleges (Annexure-II) so as to provide the institutions in districts / states where

there are shortages and duly balanced against a) population norms in terms of coverage of

educational institutions by cadre (one medical college and nursing college per 25 lakh

population, nursing school per 10 lakh population and ANM school per 5 lakh population) ,

b) sensitivity to faculty requirements - nursing and ANM schools are proposed because

faculty needs are readily met, and c) an interest in creating primary health-focused cadres -

ANM schools prioritized in states where institutions are few and public health indicators are

weak and District Health Knowledge Institutes). Projections also ensure practice-pedagogy

linkages, and assume, wherever possible, that ANMs schools will be co-located with CHCs,

nursing schools with Sub-District and District Hospitals, and nursing colleges, with Medical

College Hospitals. Accordingly, it is suggested to provide for 382 additional nursing schools

and 58 nursing colleges during the next ten years as detailed in Table V.

Table-V: Nursing Schools & Nursing Colleges Proposed based on Population in Districts (census 2011)

Available* Seats* Nursing Schools & Colleges Proposed

GNM

Schools

B.Sc.

college Total

GNM Schools

B.Sc. College

Total 2012-15 2015-17 2017-22

Total GNM BSc GNM BSc GNM BSc

India 2233 1418 3651 91858 69098 160956 98 15 93 14 191 29 440

1 Arunachal Pradesh 2 0 2 40 0 40 1 - 1 - - 1 3

2 Assam 9 6 15 588 300 888 4 2 2 3 5 4 20

3 Bihar 10 1 11 426 0 426 30 5 30 3 42 8 118

4 Gujarat 65 31 96 2505 1455 3960 1 - 1 - - - 2

5 Haryana 43 20 63 1670 945 2615 1 - 1 - - - 2

6 Jammu& Kashmir 8 4 12 390 155 545 2 1 2 1 1 - 7

7 Jharkhand 19 5 24 625 230 855 4 1 4 1 6 2 18

8 Madhya Pradesh 125 97 222 5070 4895 9965 3 - 2 - 16 - 21

9 Maharashtra 104 77 181 3044 3480 6524 3 - 2 - - - 5

10 Nagaland 1 0 1 20 0 20 1 - 1 - 1 1 4

11 Orissa 47 14 61 1700 670 2370 4 2 3 2 8 3 22

12 Tripura 3 1 4 120 60 180 1 - 1 - - - 2

13 Uttarakhand 11 10 21 480 480 960 1 - 1 - 2 2 6

14 Uttar Pradesh 141 33 174 6650 2130 8780 40 3 40 2 82 5 172

15 West Bengal 50 15 65 1686 675 20 2 1 2 2 28 3 38

* INC data as on May 2011

ANMs (Auxiliary Nurse Midwives):

The ANMs are primarily envisaged as the front line health worker based at the SHCs, PHCs

and CHCs exclusively for the Government facilities. There are severe shortages of ANMs in

in the states of Bihar, Gujarat, Rajasthan and Uttar Pradesh as over 35% of SHCs are without

2nd

ANM at SHCs (RHS 2009).

A total of 5.76 lakh ANMs are registered by the INC, as on 31st December 2010, and this

exclude the attrition losses for retirement, migration, death etc. As on May 2011, there are

1,035 schools with annual admission capacities of 27,384 excluding the 143 schools for

which the admission capacities have not been indicated. The admission capacities in several

surplus states are underutilised especially in the private sector.

18

The 4 southern states have 63% of nursing schools in contrast to 20% in the 7 states of Bihar,

Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttaranchal and Uttar Pradesh.

The unemployed ANMs in the surplus states are employed in private sector as nurse

assistants. During the past 5 years, the situation improved for equity with the addition of 539

nursing schools in the 12 states of Gujarat, Haryana, Himachal Pradesh, J &K, Jharkhand,

Madhya Pradesh, Orissa, Punjab, Rajasthan, Uttaranchal, Uttar Pradesh and West Bengal.

The primary health care provision of two ANMs at SHC and an ANM at PHCs and CHCs

along with LHV at PHC would require provision of 8.14 lakhs by the year 2022 and presently

2.5 lakh are available. The XI plan support of Rs. 660 crore for new ANM schools has

enhanced the availability to the present level of 2.5 lakh ANM/ LHVs are in position at these

facilities. The shortages of ANMs would continue to predominantly persist in the five states

of Bihar, Jammu & Kashmir, Jharkhand, Rajasthan and Uttar Pradesh.

It is suggested to establish 232 new ANM schools 12 states including 99 in Uttar Pradesh, 46

in Bihar, 28 in Rajasthan, 25 in West Bengal, 15 in Gujarat and 19 schools in 7 other states as

detailed in Annexure - III. It is also essential to strengthen 211 ANM schools to enhance

admission capacities to 40 per batch and biannual admissions (40 per batch) from 2013 as the

course is of 1½ years duration. These efforts would ensure fully meet the future requirements

in all the states.

Health Worker - Male:

During the past two decades, the availability of male health workers has dwindled down

considerably due to inadequacies in training and non-creation of posts. Many States consider

the male health worker category to be a dying cadre and stopped recruitments as well as

creation of requisite posts. During the short span of 5 years during 1982 to 1987, over 88,000

health workers - male were trained and 84,993 were positioned at SHCs. Subsequently their

availability declined to 71053 by year 2001 and 57,439 by year 2009 due to non-creation of

66,220 posts and 22,335 vacancies in the sanctioned posts.9

The provision of one health worker – male (HW-male) at each SHC, PHC and CHC would

require 4.5 lakh HW- male by the year 2022 Annually 6,746 HW-male are being made

available from the existing 103 Multi-Purpose Worker (male) schools and 44 State Institutes

of Health and Family Welfare (SIHFW). There are no HW- male training schools in the six

high focus states of Bihar, Rajasthan, Jammu & Kashmir, Jharkhand, Uttar Pradesh,

Uttarakhand and five north east states. The NRHM approved the allocation of Rs. 47 crore

for the rejuvenation of these training facilities and a monetary support of Rs.915 cores

towards the costs of 53,544 health workers -male in 235 vulnerable districts for a three years

period. This would provide an annual output of 12,000 leading to availability of 1.2 lakh

health workers - male by 2022.

19

Dentists, AYUSH doctors, Rural Health Care Practitioners, Pharmacists etc.:

There are adequate pools of dentists, AYUSH doctors, pharmacists, physiotherapists and

laboratory technicians and non-availability of these professionals in majority of the states is

mostly due to non-creation of posts and vacancies in the existing posts. The provision of

midlevel professionals as frontline workers is highly advisable by envisaging a long term

measure of new cadre of Rural Health Care Practitioners for a cluster of 4 to 6 villages and

nurse practitioners for the vulnerable urban populations. It would be appropriate to design the

3 years course curriculum including field trainings of 50% duration for awarding Bachelor of

Rural Health Care (BRHC). The interim measure of bridge course of one year duration for

the AYUSH doctors, dentists, nurses and paramedical categories is suggested, as many of

these professionals (except nursing) are available in surplus in several states including Bihar,

Gujarat, Madhya Pradesh, Punjab, Rajasthan, Uttarakhand and Madhya Pradesh.

Enhancing Capacities and Quality of HRH Education and Trainings

Strategic investments in education, for rapid expansion of HRH, can enhance the availability

of scientifically sound and socially acceptable professionals for all communities. The present

HRH production capacities are lagging much behind the needs in the states and districts with

poor health care outcomes.

The lack of training facilities even at the district levels for in-service trainings resulting in

inadequately skilled HRH is yet another area of serious concern. The in-service training

needs are enormous across divergent health care programmes. There is an immediate need to

scale up the training capacities in terms of physical infrastructure, trainers, competency

assessments, certification processes and optimum utilization of the trained HRH. The

National Training Strategy (2008) advocated integrated trainings for all the health and family

welfare programmes, annual district training plans and district level trainings at functional

facilities as well as capacity building at districts to train health care providers.46

A. District Health Knowledge Institutes (DHKI): The provision of DHKI in 558 districts

with over 5 lakhs population as the main hub at district hospitals would address the severe

shortage of educational / training infrastructure. The DHKC would enable decentralization of

healthcare education to meet the health needs of local communities by facilitating induction

and in-service trainings; courses for LHV, PHN and Health Assistant Male trainings; bridge

courses for AYUSH doctors, dentists, pharmacists, physiotherapists and nurses to function as

rural health practitioners at SHCs; diploma course in public health nursing, medical

technology (DMT); Bachelor degree courses for rural healthcare practitioners (BRHC),

medical technology (BMT- specialization in medical lab. technology, pathology,

microbiology, cytology, radiology, ophthalmology, operation theatre technology etc.).These

diploma and certificate courses should be recognized by the respective state level nursing and

paramedical councils / boards and degree courses by the state universities of health sciences.

This would enable uniformity in the admissions, curricula, trainings, accreditation

mechanisms and availability of adequately trained HRH for ensuring quality in health care.

20

DHKI would pave way for admission of local candidates and also uniformity in admissions,

curricula, trainings and accreditations. The district District Knowledge Health Institute

(HRMIS) will be used to keep track of progression through training, for various cadres.

B. Public Health Management Courses: A major challenges in the health system has been

in the area of health sector management including public health, hospitals and the

management of a large multi-cadre health work force. The Expert Committee on Public

Health System (1996) 47

, MOHFW reinforced the need to constitute Indian Medical & Health

Services without any further delays the same has been a long felt need and was recommended

as early as 1961 by the Mudaliar Committee. The committee has also observed that the many

of the central health programme managers have no formal education in public health and

management and have never worked in the States leading to poor professional

communication and understanding between the Central and State Government health

programme managers. The states of Andhra Pradesh, Orissa and Gujarat initiated the public

private partnerships by deputing the in-service candidates to the public health management

courses and the same need to be extended to other states.

C. Nursing & ANM cadre management: Nurses and ANMs being the largest category of

HRH, there is a need for enhanced managerial support in terms of nursing positions at

directorates in the states and also in the Ministry of Health and Family Welfare as

recommended by the High Power Committee on Nursing Profession. The provision of

nursing and midwifery management cadres at the national, state and district levels would

enable supportive supervision for nursing and midwifery cadres including nurse practitioners.

D. Supportive Management Units: The lack of managerial support for implementing health

care programmes is a major constraint and there is an urgent need for the provision of health

managers, hospital managers, HRH managers, HMIS managers and Accounts managers.

These managerial cadres would be trained to provide HRH monitoring for performance and

accountability and facilitate decentralised and timely recruitments and needs based

distribution of available HRH. Human Resource management information systems (HRMIS)

at national, state, and district levels managerial structures would enable the monitoring of

HRH availability and provide basic inputs for HRH policies and planning. The introduction

of HR managers at the sub-district hospitals level and higher facilities would ensure effective

HR management and enable technical professionals to focus on clinical care.

E. Faculty Development and Training of Trainers (ToTs): The proposed rapid scaling up

of HRH necessitates exclusive faculty development centres across the country and

accordingly it is suggested to establish 20 regional centres for faculty development, faculty

sharing across institutions and to focus on local needs. All the existing 44 state and regional

institutes of health & family welfare need to be strengthened as the nodal institutes for

training of trainers as well as management trainings of HRH. These institutions need to

establish in the remaining 13 States. It is suggested to implement the scheme in two phases

with thrust in high focus and northeast states and extending the same to other districts with

population of over 10 lakhs.

21

F. Health Sciences Universities in each state (minimum 10 institutions) for all medical,

nursing, pharmacy and allied health professionals courses to ensure uniformity in admissions,

curricula and training on the patterns of Tamil Nadu and Andhra Pradesh for accreditation

mechanisms. The Expert Committee on Public Health System (1996) 48

reinforced in

strongest terms the need to constitute Indian Medical & Health Services without any further

delays the same has been a long felt need and was recommended as early as 1961 by the

Mudaliar Committee. The committee has also observed that the many of the central health

programme managers have no formal education in public health and management and have

never worked in the States leading to poor professional communication and understanding

between the Central and State Government health programme managers.

Implementation Plan:

In light of the lack of production capacity especially in the states with poor health indicators,

there is an immediate need for greater focus of public investment for the creation of

additional educational institutions, while facilitating local production of HRH. The most

feasible option would be to support medical colleges, nursing colleges and allied health

professional colleges at district hospitals, nursing and allied health professional schools at

sub-district hospitals and ANM schools at CHCs in the underserved districts of more than 5

lakh population. These institutions should allot 50% of seats to local candidates in the district,

30% seats for other districts within the state, and the rest of the 20% of seats open to others

(merit based criteria). The existing colleges need to increase annual admission capacities as

per the norms of the councils so as to enhance their outputs. It is feasible to implement the

following strategies during the XII and XIII plan periods in four phases.

A. 2012-2015: Provide, in 172 districts with populations of over 25 lakhs, the requisite

DHKIs to function as nodal centres for HRH induction and in-service trainings and allied

health professional colleges (rural health practitioner course and medical technology course)

at district headquarters. The Government of India need to support 15 new nursing colleges in

7 states and strengthening of 30 nursing colleges, 98 new nursing schools in 15 states and

strengthening of 150 nursing schools, 201 new ANM schools and strengthening of 145 ANM

schools, 10 public health management colleges, strengthening of 25 SIHFWs and 12 faculty

development centres at these institutes and 59 medical colleges in 12 states with severe

shortages of allopathy doctors.

B. 2015-2017: Provide, in 163 districts with populations of over 15 lakhs, the requisite

DHKIs and allied health professional colleges (rural health practitioner and medical

technology course) as well as 14 new nursing colleges and strengthening of 30 nursing

colleges, 93 new nursing schools and strengthening of 100 nursing schools, 31 new ANM

schools and strengthening of 66 ANM schools, 10 public health management colleges,

strengthening of 19 SIHFWs and 8 faculty development centres at these institutes and 70

medical colleges in 13 states with shortages of allopathy doctors and specialists.

22

C. 2017-2020: Provide, in 106 districts with populations of over 5 lakhs, the requisite

DHKIs and allied health professional colleges (rural health practitioner course and medical

technology course) in these districts as well as 15 new nursing colleges, 98 new nursing

schools, 10 public health management colleges, and 40 new medical colleges.

D. 2020-2022: Provide, in 107 districts with populations of over 5 lakhs, the requisite

DHKIs and allied health professional colleges (rural health practitioner and medical

technology courses) in these districts as well as 14 new nursing colleges, 93 new nursing

schools, and 18 new medical colleges in the states with shortages of allopathy doctors.

Table - V : HRH Education & Training Costs (2012 to 2022)

Institutions Unit

Cost (Crore)

Proposed Costs (Rs. Crore)

Total

Costs

2012-

2015

2015-

2017

2017-

2022 Total

2012-

2015

2015-

2017

2017-

2020

2020-

2022

A B C&D A B C D

1 ANM Schools - New* 5 201 31 - 232 1005 155 - - 1160

2 ANM Schools- Strengthening 1 145 66 - 211 145 66 - - 211

4 Nursing Schools – New * 8 98 93 191 382 784 744 784 744 3056

5 Nursing Schools- Strengthening 0.5 150 100 - 250 75 50 - - 125

6 Nursing Colleges - New 10 15 14 29 58 150 140 150 140 580

7 Nursing Colleges - Strengthening 6 30 30 - 60 180 180 - - 360

8 Medical Colleges – New 100 59 70 58 187 5900 7000 4000 1800 18700

9 Public Health Management colleges 10 10 10 10 30 100 100 100 - 300

10 Allied Health Professional Colleges 10 172 163 213 548 1720 1630 2130 - 5480

11

District Health Knowledge Institutes

- Trainings, LHV, PHN, BRHC,

DMT, BMT courses

10 172 163 213 548 1720 1630 2130 - 5480

12 CHW Trainings at DHKIs - 10 lakh

CHW 10 lakh

CHW 20 lakh

CHW - 275 275 275 275 1100

13 LHV Schools – Strengthening 1 16 28 - 44 16 28 - - 44

14 SIHFW & RIHFWs - Strengthening 1 25 19 - 44 25 19 - - 44

15 Faculty Development Centres at

SIHFWs 10 12 8 - 20 120 80 - - 200

16 State Boards 1 35 - - 35 35 - - - 35

17 State Health Sciences Universities 5 25 - - 25 125 - - - 125

Grand Total 1165 795 714 2674 12375 12097 9844 2959 37000

These measures would improve doctor, nurse and midwife, and population ratios there by

enhance the HRH availability both in Government and private sectors as well as providing

adequately skilled manpower and their management has to be bound targets over the next two

five year plan periods. This thrust for the provision of additional HRH educational

institutions and district level training and education facilities in 548 districts with population

of over 5 lakhs would facilitate local availability of adequately trained HRH.

HRH Policies for Improved Performance

The Universal Health Coverage crucially requires that the public health system is able to

attract and retain health professionals, while maintaining high quality, performance and

accountability. This would essentially require HRH divisions, HRH retention policies

including appropriate monetary and non-monetary incentives to retain qualified health

23

workers in underserved areas, HRH governance mechanisms and uniformity in pay structures

across the states. The HRH divisions at national, State and district levels are to be

accountable for transparent HRH policies such as timely recruitments, appointments within

few days of course completion, need based distribution of available health workforce, HRH

management including performance, creation of requisite posts as per the norms,

development of public health cadres from all categories, development of two exclusive

streams of clinical and community health nursing and medical cadres etc. The job profiles

and recruitment rules need to be refined in line with the present needs of for the

implementation of diverse health care programmes and the needs of the communities. The

HRH divisions / cells need to be supported with efficient network of HR Managers and HR

Management Information systems at national, state and district levels for HRH planning,

production, trainings, optimum utilisation, performance monitoring and accountability.

HRH retention through induction and in-service trainings, creation of requisite posts and time

bound filing up vacant positions, improvements of workplace conditions, supportive

supervision, fixed tenure postings in hardship areas, enhanced financial incentives for

services in underserved areas/ districts such as rural compensatory allowance, hardship

allowance on all India services pattern, educational allowance, staff residential complexes at

the vulnerable facilities up to CHCs level, performance incentives and disincentives for

deliverables, state sponsored avenues for upward career mobility through reservation of

seats, study leave and bridge courses, transparent policies for career paths with three time-

bound promotions and contractual appointments based on equal pay for equal work as well as

regularization on completion of 2 to 3 years of good performance etc.

At least till 2020, have a minimum of 50% reservation of seats in educational institutions for

candidates applying from within the district, an additional 30% reservation for candidates

from other districts within the state, and the rest of the 20% of seats being open for other

candidates, provided they sign a bond for serving that district for the next 5 years.

The academic curricula and clinical trainings have not kept pace with the changing dynamics

of the health scenario. The quality of education is of particular concern: recent data from the

5 EAG states show that only 20-25% of ANMs graduating from training programs reported

the ability to conduct a delivery independently. Moreover, between 40 and 55% of GNMs

reported inability to administer immunisation without supervision.48

The medical and nursing

graduates are more urban oriented as their trainings prepares them for urban settings and

further education in their chosen specialities rather than preparing them for service in any of

the three tiers of the primary or secondary or tertiary levels of health care.

Career Trajectories

Nurses and ANMs categories: Presently, an ANM, after completing class X and a one and

a half year diploma course, enters service at about 20 to 22 years of age, has at best one

opportunity for promotion (after six months of training) to become a LHV in their

professional tenure of nearly 40 years. We recommend that ANMs, after promotion as LHVs

24

½ year

Training Experience

1 year 7 years 10 years

M.Sc.

1 year

Training

should be considered for the posts of PHNs, advancing further to District Public Health

Nurses (DPHN) subject to their completion of one year DPHN course. The present lateral

entry of clinical nurses to the posts of PHN could be retained subject to their completion of a

PHN course and a minimum of 5 years working experience in PHCs. The ANM cadre should

be provided with one year courses in midwifery education (diploma in nursing education) so

that they can pursue academic careers at ANM schools and LHV training schools. ANMs

should be provided opportunities to become staff nurses, facilitated through the reservation of

seats in nursing schools. Similarly, CHWs (ASHAs) who are outstanding performers should

be provided with opportunities to advance their careers by reservation of seats in ANM and

nursing schools.

.

Similarly, nurses who complete a three and a half year GNM diploma course or a four year

graduation (B.Sc.) in nursing after class XII and enter the service around the age of 24 years

are provided with promotional posts of Head Nurse, Assistant Nursing Superintendent,

Deputy Nursing Superintendent and Nursing Superintendent. Graduate nurses also have the

opportunities in the teaching cadre to become a Tutor, Lecturer, Associate Professor and

Professor. We recommend that bridge courses be provided for clinical areas such as

operation theatres, ICUs as well as clinical super specialties areas of cardiology and

psychiatry for their professional development as specialist nurse practitioners. The nursing

Public

Health

Nurse

Lady

Health

Visitor

ANM (ANM course

1½ years)

Deputy

Nursing

Supdt.

Assistant

Nursing

Superintendent

Head

Nurse

Nursing

Superintendent

Staff Nurse (GNM

3½ years)

Joint /Additional /

Director (Nursing)

Post Basic

B.Sc. (Nursing)

2 years

Staff Nurse

B.Sc. (Nursing)

4 years Associate

Professor Professor

Tutor Lecturer

ASHA (CHW)

District Public

Health Nurse

25

Management

Training Training ½ yr.

Experience Experience Experience

B. Sc. M. Sc.

Experience Experience Experience

Public Health

qualification

Experience Experience Experience

cadre should also be provided bridge courses in nursing education, nursing administration,

hospital management and health management to enable them to take up the administrative

posts at facility, block, district and state levels.

It is also suggested that the CHWs (ASHAs), based on outstanding performance, be provided

with opportunities to pursue their career in health sector through reservation of seats in ANM

and nursing schools.

Health Worker - male category: The Health Worker- male, after completing class XII and

one year diploma course enters service and is promoted only once in his service span, to a

supervisory role as a Male Health Assistant. We recommend that further promotional

avenues offered to this category with a supervisory post of Health Inspector up to possibly

block level health managers for effective implementation of communicable and non-

communicable disease programmes as well as prevention and control of potential epidemics.

Laboratory Technician categories: The Laboratory Assistant, after completing class XII

and a two year diploma course enters service and is first promoted to laboratory technician

and later as senior lab technician. We recommend that a B.Sc. and M.Sc. qualification may be

made mandatory for the promotion of this category to higher level posts, such as technical

assistants and scientific assistants at district public health laboratories and medical college

hospitals for diagnostic services.

Managerial category: Health managers, with a management degree as a minimum

qualification, who are part of the managerial force can progress in their career paths from the

block level to the district and to state level positions, and after acquiring public health

qualifications, can become a public health manager.

_______

Health worker

(Male)

1 year course

Block Health

Manager Health

Inspector

Health Assistant

Male

Lab.

Technician

Lab. Assistant Diploma Course

2 yrs.

Senior Lab.

Technician

Technical

Assistant

(Lab.)

Block Health

Programme

Manger

Public Health

Manager

State Health

Programme

Mangertor

District Health

Programme

Manger

26

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Division, NHSRC, New Delhi; 2009 – 2010

28

Annexure –I Medical Colleges Availability & Requirement – State wise

State/ UT #

Districts & Populations Medical Colleges Available & Required

Total >25--50

lakh

>10-<25

Lakh

< 10

lakh

Existing Required

1/ 25 lakh

Population

Shortfall

/Surplus

Recommended

Govt. Private Total 2012-15 2015-17 2017-22 Total

INDIA 642 150 260 232 155 160 315 463 65 64 58 187

1 Andaman & Nicobar 3 - - 3 - - - - 0 - - - -

2 Andhra Pradesh 23 20 3 - 13 23 36 34 + 2 - - - -

3 Arunachal Pradesh 16 - - 16 - - - - 0 - - - -

4 Assam 27 1 7 19 4 - 4 12 - 8 4 3 1 8

5 Bihar 38 11 22 5 6 3 9 41 - 32 9 9 9 27

6 Chandigarh 1 - - 1 1 - 1 - 0 - - - -

7 Chhattisgarh 18 2 7 9 3 - 3 10 - 7 3 3 1 7

8 Daman & Diu 1 - - 1 - - - - 0 - - - -

9 Dadra & Nagar 1 - - 1 - - - - 0 - - - -

10 Delhi 9 1 5 3 6 - 6 6 0 - - - -

11 Goa 2 - - 2 1 - 1 - 0 - - - -

12 Gujarat 26 7 15 4 8 8 16 24 - 8 3 3 2 8

13 Haryana 21 10 - 11 2 3 5 10 - 5 2 2 1 5

14 Himachal Pradesh 12 - 1 11 2 - 2 2 0 - - - -

15 J & K 22 - 2 20 3 1 4 5 - 1 1 - - 1

16 Jharkhand 24 1 12 11 3 - 3 13 - 10 4 4 2 10

17 Karnataka 29 6 20 3 10 29 39 24 + 15 - - - -

18 Kerala 14 7 6 1 6 17 23 13 + 10 - - - -

19 Lakshadweep 1 - - 1 - - - - - - - -

20 Madhya Pradesh 50 - 34 16 6 5 11 29 - 18 8 8 2 18

21 Maharashtra 35 15 17 3 19 22 41 44 - 3 1 1 1 3

22 Manipur 9 - - 9 2 - 2 - 0 - - - -

23 Meghalaya 7 - - 7 - - - 1 - 1 - - 1 1

24 Mizoram 10 - - 10 - - - - 0 - - - -

25 Nagaland 11 - - 11 - - - - 0 - - - -

26 Odisha 30 1 18 11 3 3 6 16 - 10 4 4 2 10

27 Puducherry 4 - - 4 7 2 9 - - - - -

28 Punjab 20 2 8 10 3 5 8 11 - 3 1 1 1 3

29 Rajasthan 35 5 22 8 6 4 10 27 - 17 6 6 5 17

30 Sikkim 4 - 3 1 0 1 1 - 0 - - - -

31 Tamil Nadu 32 10 18 4 19 18 37 28 0 - - - -

32 Tripura 4 - 1 3 1 1 2 1 + 1 - - - -

33 Uttarakhand 13 - 3 10 2 2 4 4 0 - - - -

34 Uttar Pradesh 71 34 34 3 10 11 21 79 - 58 11 12 26 49

35 West Bengal 19 17 2 - 9 2 11 36 - 25 8 8 4 20

NB: Assam may depute students to the two surplus medical colleges in Sikkim & Tripura.

Seats may be reserved for students from Bihar, Chattisgarh, Jharkhand, Orissa, Rajasthan and UP

in the states of Karnataka, Kerala, Puducherry and Tamilnadu with surplus medical colleges.

29

Annexure-II: Summary of Proposed Medical, Nursing & ANM Colleges / Schools in States

Districts Population

(2011) Districts

Available Proposed

Medical Colleges

B.Sc.

Nursing GNM Nursing

ANM Schools

Medical Colleges

2012-15 2015-22 2022-25 Total Nursing

ANM Schools

2012-17 BSc GNM BSc GNM BSc GNM

India 1210193422 642 315 1418 2233 1035 187 15 98 14 93 29 191 440 232

1 Andaman& Nicobar 379944 3 0 0 1 1 0 - - - - - - 0 0

2 Andhra Pradesh 84665533 23 36 218 249 45 0 - - - - - - 0 0

3 Arunachal Pradesh 1382611 16 0 0 2 2 0 - 1 - 1 1 - 3 0

4 Assam 31169272 27 4 6 9 10 8 2 4 3 2 4 5 20 10

5 Bihar 103804637 38 9 1 10 35 27 5 30 3 30 8 42 118 46

6 Chandigarh 1054686 1 1 1 1 - 0 - - - - - - 0 0

7 Chhattisgarh 25540196 18 3 42 24 45 7 - - - - - - 0 0

8 Daman & Diu 242911 2 0 0 0 - 0 - - - - - - 0 0

9 Dadra& Nagar 342853 1 0 1 1 - 0 - - - - - - 0 0

10 Delhi 16753235 9 6 12 15 4 0 - - - - - - 0 0

11 Goa 1457723 2 1 3 2 1 0 - - - - - - 0 0

12 Gujarat 60383628 26 16 31 65 26 8 - 1 - 1 - - 2 15

13 Haryana 25353081 21 5 20 43 47 5 - 1 - 1 - - 2 0

14 Himachal Pradesh 6856509 12 2 11 31 6 0 - - - - - - 0 0

15 Jammu & Kashmir 12548926 22 4 4 8 6 1 1 2 1 2 - 1 7 2

16 Jharkhand 32966238 24 3 5 19 18 10 1 4 1 4 2 6 18 2

17 Karnataka 61130704 30 39 322 533 42 0 - - - - - - 0 0

18 Kerala 33387677 14 23 111 224 15 0 - - - - - - 0 0

19 Lakshadweep 64429 1 0 - - - 0 - - - - - - 0 0

20 Madhya Pradesh 72597565 50 11 97 125 92 18 - 3 - 2 - 16 21 0

21 Maharashtra 112372972 35 41 77 104 287 3 - 3 - 2 - - 5 0

22 Manipur 2721756 9 2 4 7 6 0 - - - - - - 0 0

23 Meghalaya 2964007 7 0 2 7 2 1 - - - - - - 0 1

24 Mizoram 1091014 8 0 2 5 3 0 - - - - - - 0 0

25 Nagaland 1980602 11 0 0 1 1 0 - 1 - 1 1 1 4 1

26 Orissa 41947358 30 6 14 47 67 10 2 4 2 3 3 8 22 0

27 Puducherry 1244464 4 9 12 1 2 0 - - - - - - 0 0

28 Punjab 27704236 20 8 85 156 92 3 - - - - - - 0 0

29 Rajasthan 68621012 33 10 132 157 17 17 - - - - - - 0 28

30 Sikkim 607688 4 1 2 1 - 0 - - - - - - 0 1

31 Tamil Nadu 72138958 32 37 144 181 15 0 - - - - - - 0 0

32 Tripura 3671032 4 2 1 3 2 0 - 1 - 1 - - 2 2

33 Uttarakhand 10116752 13 4 10 11 14 0 - 1 - 1 2 2 6 0

34 Uttar Pradesh 199581477 71 21 33 141 73 49 3 40 2 40 5 82 172 99

35 West Bengal 91347736 19 11 15 50 59 20 1 2 2 2 3 28 38 25

30

Annexure-III : Medical, Nursing & ANM Colleges / Schools in Districts

State / Districts Population

(2011)

Districts

(Nos.)

Available Proposed

Medical

Colleges

B.Sc.

Nursing GNM

Nursing ANM Schools

Medical

Colleges 2012-15 2015-17 2017-22 Total

Nursing ANM Schools

BSc GNM BSc GNM BSc GNM

India 1210193422 642 315 1418 2233 1035 187 15 98 14 93 29 191 440 232

I Arunachal Pradesh 1382611 16 0 0 2 2 0 - 1 - 1 1 - 3 0 1 Changlang 147951

- - - - - - 1 - - - - 1 -

2 Lohit 145538

- - - - - - - - - 1 - 1 - 3 West Siang 112272

- - - - - - - - 1 - - 1 -

II Assam 31169272 27 4 6 9 10 8 2 4 3 2 4 5 20 0 1 Nagaon 2826006

- - 1 - 1 1 - - - - - 1 -

2 Dhubri 1948632

- - - - 1 1 1 - - - 1 3 - 3 Sonitpur 1925975

- - 2 - 1 - - 1 - - - 1 -

4 Cachar 1736319

1 - 2 1 - - - 1 - - - 1 -

5 Barpeta 1693190

- - - - 1 - - 1 - - - 1 -

6 Dibrugarh 1327748

1 - 4 1 - - - - - 1 - 1 -

7 Tinsukia 1316948

- - 2 - 1 - - - 1 - 1 -

8 Karimganj 1217002

- - - - 1 - - - 1 1 - 2 -

9 Jorhat 1091295

1 - - - 1 - - - - 1 - 1 -

10 Golaghat 1058674

-

- - 1 - - - - 1 -

11 Lakhimpur 1040644

-

1 - - 1 - - - - 1 -

12 Goalpara 1008959

-

2 1 - 1 - - - - 1 -

13 KarbiAnglong 965280

-

- - - - 1 - - 1 -

14 Baksa 953773

-

- - - - - - 1 1 -

15 Darrang 908090

-

- - - - - - 1 1 -

16 Kokrajhar 886999

-

- - - - - - 1 1 -

17 Udalguri 832769

-

- - - - - - 1 1 -

III Bihar 103804637 38 9 1 10 35 27 5 30 3 30 8 42 118 46

1 PurbaChamparan 5082868

- 1 1 1 1 - - 1 - 2 4 4

2 Muzaffarpur 4778610

1 1 - 1 - - - - 2 3 4

3 Madhubani 4476044

-

1 1 1 1 - 1 - 1 4 3

4 Gaya 4379383

1 1 - 1 - - - - 2 3 4

5 Samastipur 4254782

-

1 1 1 - - 1 - 2 4 2

6 Saran 3943098

-

2 1 - 1 1 1 - 1 4 1

7 PaschimChamparan 3922780

-

1 - 1 1 1 - 1 4 2

8 Darbhanga 3921971

1 2 1 - - - 1 - - 1 2 1

9 Vaishali 3495249

-

1 1 - 1 - 1 1 1 4 1

10 Sitamarhi 3419622

-

1 1 - 1 - 1 1 1 4 1

11 Siwan 3318176

-

1 - 1 - 1 1 1 4 1

12 Purnia 3273127

-

2 1 - 1 - 1 1 1 4 -

13 Katihar 3068149

1

1 - - 1 - 1 - 2 4 1

14 Bhagalpur 3032226

1

1 - - 1 - 1 - 2 4 1

15 Rohtas 2962593

1

3 - - 1 - 1 - 2 4 -

16 Begusarai 254367

-

1 1 - 1 - 1 1 1 4 1

17 Nalanda 272523

-

2 1 - 1 - - 1 2 4 -

18 Araria 206200

-

1 - 1 - - 1 1 3 1

19 Bhojpur 220155

-

2 1 - 1 - - 1 1 3 -

20 Gopalganj 258037

-

1 - 1 - 1 - 1 3 1

21 Aurangabad 211243

-

1 - 1 - 1 - 1 3 1

22 Supaul 2228397

-

1 - 1 - 1 - 1 3 1

23 Nawada 2216653

-

1 - 1 - 1 - 1 3 1

24 Banka 2029339

-

1 - 1 - 1 - 1 3 1

25 Madhepura 1994618

-

1 1 - 1 - 1 - 1 3 1

26 Saharsa 1897102

-

1 - 1 - 1 - 1 3 1

27 Jamui 1756078

-

1 - 1 - 1 - 1 3 1

28 Buxar 1707643

-

1 - 1 - 1 - 1 3 1

31

State / Districts Population

(2011)

Districts

(Nos.)

Available Proposed

Medical

Colleges

B.Sc.

Nursing GNM

Nursing ANM Schools

Medical

Colleges 2012-15 2015-17 2017-22 Total

Nursing ANM Schools BSc GNM BSc GNM BSc GNM

29 Kishanganj 1690948

1

- - 1 - 1 - 1 3 1

30 Khagaria 1657599

-

1 - 1 - 1 - 1 3 1

31 Kaimur (Bhabua) 1626900

-

1 - 1 - 1 - 1 3 1

32 Munger 1359054

-

1 - 1 - 1 - 1 3 1

33 Jehanabad 1124176

-

1 - 1 - 1 - 1 3 1

34 Lakhisarai 1000717

-

1 - 1 - 1 - - 2 1

35 Arwal 699563

-

- - 1 - - - 1 2 1

36 Sheohar 656916

-

- - - - 1 - - 1 1

37 Sheikhpura 634927

-

- - - - 1 - - 1 1

IV Gujarat 6038628 26 16 31 65 26 8 - 1 - 1 - - 2 15

1 Surat 6079231 2 2 6 1 - - - - - - - - 1

2 BanasKantha 3116045 - - - - 1 - 1 - - - - 1 1

3 Bhavnagar 2877961 2 2 3 - 1 - - - - - - - 1

4 Junagadh 2742291 - - 1 3 1 - - - - - - - -

5 SabarKantha 2427346 - 2 4 5 1 - - - - - - - -

6 PanchMahals 2388267 - - 1 - 1 - - - - - - - 1

7 Kheda 2298934 - 1 2 - 1 - - - - - - - 1

8 Dohad 2126558 - - 3 - 1 - - - - - - - 1

9 Kachchh 2090313 1 1 3 - - - - - - - - - 1

10 Anand 2090276 1 1 1 - - - - - - - - - 1

11 Mahesana 2027727 - 2 6 3 1 - - - - - - - -

12 Surendranagar 1755873 1 - 1 - - - - - - - - - 1

13 Amreli 1513614 - - 2 - - - - - - - - - 1

14 Navsari 1330711 - 1 2 - - - - - - - - - 1

15 Tapi 806489 - - 1 - - - - - - - - - 1

16 Narmada 590379 - - 1 - - - - - - - - - 1

17 Porbandar 586062 - - - - - - - - 1 - - 1 1

18 The Dangs 226769 - - - - - - - - - - - - 1

V Haryana 25353081 21 5 20 43 47 5 - 1 - 1 - - 2 0

1 Faridabad 1798954

1 1 3 3 - - - - - - - - -

2 Hisar 1742815

1 2 4 5 - - - - - - - - -

3 Bhiwani 1629109 - - 2 6 1 - - - - - - - -

4 Karnal 1506323 - - 2 2 1 - - - - - - - -

5 Sonipat 1480080 - - 2 3 1 - - - - - - - -

6 Jind 1332042 - 2 1 2 1 - - - - - - - -

7 Sirsa 1295114 - 1 4 6 1 - - - - - - - -

8 Mewat 1089406 - - - - - - 1 - - - - 1 -

9 Palwal 1040493 - - - - - - - - 1 - - 1 -

10 Faridabad 1798954 1 1 3 3 - - - - - - - - -

VI Jammu& Kashmir 12548926 22 4 4 8 6 1 1 2 1 2 - 1 7 2 1 Srinagar 1,69751

2 2 - 1 - - 1 - - - - 1 -

2 Anantnag 1070144

- - - - 1 1 - - - - - 1 1 3 Baramula 1015503

- - - - - - - 1 - - - 1 1

4 Kupwara 875564

- - - - - - - - 1 - - 1 - 5 Badgam 735753

- - - - - - - - 1 - - 1 -

6 Rajouri 619266

- - - - - - - - - - 1 1 - 7 Kathua 615711

- - - 1 - - 1 - - - - 1 -

VIII Jharkhand 32966238 24 3 5 19 18 10 1 4 1 4 2 6 18 2 1 Dhanbad 2682662 1 - 2 - - 1 - - - - - 1 1 2 Giridih 2445203

- - - 1 1 - - 1 - - 1 2 -

3 PurbiSinghbhum 2291032

1 - 3 - - - - - - 1 - 1 1 4 Bokaro 2061918

- - 1 - 1 - - - - 1 1 2 -

5 Palamu 1936319

- - - 2 1 - 1 - - - - 1 - 6 PashcmSinghbhum 1501619

- - - - 1 - 1 - - - - 1 -

32

State / Districts Population

(2011)

Districts

(Nos.)

Available Proposed

Medical

Colleges

B.Sc.

Nursing

GNM

Nursing ANM Schools

Medical

Colleges

2012-15 2015-17 2017-22 Total Nursing

ANM Schools

BSc GNM BSc GNM BSc GNM

7 Garhwa 1322387

- - - 1 1 - 1 - - - - 1 -

8 Godda 1311382

- - - 1 1 - 1 - - - - 1 -

9 Sahibganj 1150038

- - - - 1 - - - 1 - - 1 -

10 Saraikela-Kha 1063458

- - - - 1 - - - 1 - - 1 -

11 Chatra 1042304

- - - - 1 - - - 1 - - 1 -

12 Gumla 1025656

- - 1 - 1 - - - - - - - -

13 Ramgarh 949159

- - - - - - - - 1 - - 1 -

14 Pakur 899200

- - - - - - - - - - 1 1 -

15 Jamtara 790207

- - - - - - - - - - 1 1 -

16 Latehar 725673

- - - - - - - - - - 1 1 -

17 Kodarma 717169

- - - 1 - - - - - - 1 1 -

IX Madhya Pradesh 7297565 50 11 97 125 92 18 - 3 - 2 - 16 21 0

1 Satna 2228619

- 2 3 - 1 - - - - - - - -

2 Dhar 2184672

- - - 2 1 - 1 - - - - 1 -

3 Chhindwara 2090306

- - 1 1 - - - - - - - -

4 Morena 1965137

- 3 - 2 1 - - - - - - - -

5 West Nimar 1872413

- - 1 - 1 - - - - - - - -

6 Chhatarpur 1762857 - 1 2 1 1 - - - - - - - -

7 Shivpuri 1725818 - 4 1 1 1 - - - - - - - -

8 Bhind 1703562 - - 6 3 1 - - - - - - - -

9 Balaghat 1701156 - - 1 1 1 - - - - - - - -

10 Betul 1575247 - - - 1 1 - 1 - - - - 1 -

11 Dewas 1563107 - - - 2 1 - 1 - - - - 1 - 12 Rajgarh 1546541 - - - 1 1 - - - 1 - - 1 - 13 Shajapur 1512353 - - - - 1 - - - 1 - - 1 - 14 Vidisha 1458212 - - 1 1 1 - - - - - - - - 15 Ratlam 1454483 - 1 1 2 1 - - - - - - - - 16 Tikamgarh 1444920 - - - - 1 - - - - - 1 1 - 17 Barwani 1385659 - - - - 1 - - - - - 1 1 - 18 Seoni 1378876 - - - - 1 - - - - - 1 1 - 19 Mandsaur 1339832 1 - - 1 - - - - - - 1 1 - 20 Raisen 1331699 - - - - - - - - - - 1 1 - 21 East Nimar 1309443 - - - 1 - - - - - - 1 1 - 22 Singrauli 1178132 - - - - - - - - - 1 1 - 23 Sidhi 1126515 - - - 1 - - - - - 1 1 - 24 Narsimhapur 1092141 - - - - - - - - - 1 1 - 25 Shahdol 1064989 - - - - - - - - - - 1 1 - 26 Mandla 1053522 - - - 1 - - - - - - 1 1 - 27 Panna 1016028 - - - - - - - - - - 1 1 - 28 Ashoknagar 844979 - - - - - - - - - - 1 1 - 29 Anuppur 749521 - - - 1 - - - - - - 1 1 - 30 Alirajpur 728677 - - - - - - - - - - 1 1 - 31 Dindori 704218 - - - 1 - - - - - - 1 1 -

X Maharashtra 112372972 35 41 77 104 287 3 - 3 - 2 - - 5 0 1 Nanded 3356566

1 - - 7 - - 1 - - - - 1 -

2 Raigarh 2635394

- - - 6 1 - 1 - - - - 1 - 3 Buldana 2588039

- 1 2 6 1 - - - - - - - -

4 Chandrapur 2194262

- - - 6 1 - 1 - - - - 1 - 5 Gondiya 1322331

- - - 4 - - - 1 - - 1 -

6 Hingoli 1178973

- - - - - - - - 1 - - 1 -

XI Meghalaya 2964007 7 0 2 7 2 1 - - - - - - 0 1

33

State / Districts Population

(2011)

Districts

(Nos.)

Available Proposed

Medical

Colleges

B.Sc.

Nursing GNM Nursing

ANM Schools

Medical

Colleges 2012-15 2015-17 2017-22 Total

Nursing ANM Schools BSc GNM BSc GNM BSc GNM

XII Nagaland 1980602 11 0 0 1 1 1 - 1 - 1 1 1 4 1 1 Dimapur 379769 - - - - 1 - - - - 1 - 1 - 2 Tuensang 196801 - - - - - - 1 - - - - 1 - 3 Phek 163294 - - - - - - - - - - 1 1 - 4 Zunheboto 141014 - - - - - - - - 1 - - 1 -

XIII Orissa 41947358 30 6 14 47 67 10 2 4 2 3 3 8 22 0 1 Mayurbhanj 2513895 - - 2 4 1 1 - - - - - 1 - 2 Baleshwar 2317419 - - 1 3 1 1 - - - - - 1 - 3 Sundargarh 2080664 - - 3 1 1 - - 1 - - - 1 - 4 Jajapur 1826275 - - - 1 1 - 1 - - 1 - 2 - 5 Kendujhar 1802777 - - 1 3 1 - - 1 - - - 1 - 6 Kalahandi 1573054

- - 2 - 1 - - - - - 1 1 -

7 Bhadrak 1506522

- - 1 1 - - - - - 1 - 1 - 8 Bargarh 1478833

- - - 1 1 - 1 - - 1 - 2 -

9 Kendrapara 1439891

- - 2 4 1 - - - - - 1 1 - 10 Koraput 1376934

- - - 2 1 - 1 - - - 1 2 -

11 Nabarangapur 1218762

- - - - 1 - 1 - - - 1 2 - 12 Dhenkanal 1192948

- - - 1 - - - - 1 - 1 2 -

13 Subarnapur 652107

- - - - - - - - 1 - - 1 - 14 Malkangiri 612727

- - - 1 - - - - 1 - - 1 -

15 Nuapada 606490

- - 2 2 - - - - - - 1 1 -

16 Jharsuguda 579499

- - 1 1 - - - - - - 1 1 -

17 Gajapati 575880

- 1 - 1 - - - - - - 1 1 - XIV Rajasthan 68621012 33 10 132 157 17 17 - - - - - - 0 28

1 Jaipur 6663971

3 39 34 - - - - - - - - - 1

2 Jodhpur 3685681

1 8 16 - - - - - - - - - 1

3 Alwar 3671999

- 7 6 1 1 - - - - - - - -

4 Nagaur 3309234

- 5 5 - 1 - - - - - - - 1

5 Udaipur 3067549

2 11 14 1 - - - - - - - - 1

6 Barmer 2604453

- - 2 - 1 - - - - - - - 2

7 Bharatpur 2549121

- 2 3 1 1 - - - - - - - -

8 Bhilwara 2410459

- 5 5 - 1 - - - - - - - 1

9 Jhunjhunun 2139658

- 4 7 - 1 - - - - - - - 1

10 Churu 2041172

- 1 7 - 1 - - - - - - - 1

11 Pali 2038533

- 2 3 1 1 - - - - - - - -

12 Ganganagar 1969520

- 3 6 - 1 - - - - - - - 1

13 Jalor 1830151

- - - - 1 - - - - - - - 3

14 Banswara 1798194

- 1 3 - 1 - - - - - - - 1

15 Hanumangarh 1779650

- 3 3 - 1 - - - - - - - 1

16 Dausa 1637226

- 2 3 - 1 - - - - - - - 1

17 Chittaurgarh 1544392

- 2 1 - 1 - - - - - - - 1

18 Karauli 1458459

- - 2 - 1 - - - - - - - 1

19 Tonk 1421711

- 1 2 - 1 - - - - - - - 1

20 Jhalawar 1411327

1 3 - - 1 - - - - - - - 1

21 Dungarpur 1388906

- 1 3 - - - - - - - - - 1

22 Baran 1223921

- 1 - - - - - - - - - - 1

23 Rajsamand 1158283

- 1 2 - - - - - - - - - 1

24 Bundi 1113725

- 1 2 - - - - - - - - - 1

25 Pratapgarh 868231

- - - - - - - - - - - - 2

26 Jaisalmer 672008

- - - - - - - - - - - - 2

XV Sikkim 607688 4 1 2 1 - 0 - - - - - - 0 1

XVI Tripura 3671032 4 2 1 3 2 0 - 1 - 1 - - 2 2

1 South Tripura 875144

- - - 1 - - 1 - - - - 1 1

2 North Tripura 693281

- - - - - - - - 1 - - 1 1

34

State / Districts Population

(2011)

Districts

(Nos.)

Available Proposed

Medical

Colleges

B.Sc.

Nursing

GNM

Nursing ANM Schools

Medical

Colleges 2012-15 2015-17 2017-22 Total

Nursing ANM Schools BSc GNM BSc GNM BSc GNM

XVII Uttarakhand 10116752 13 4 10 11 14 0 - 1 - 1 2 2 6 0

1 Garhwal 686527

1 - - 1 - - - - 1 - - 1 -

2 Almora 621927

- - - 1 - - - - - 1 - 1 -

3 Pithoragarh 485993

- - - 1 - - 1 - - - - 1 -

4 Uttarkashi 329686

- - - - - - - - - 1 - 1 -

5 Bageshwar 259840

- - - - - - - - - - 1 1 -

6 Champawat 259315

- - - - - - - - - - 1 1 - XVIII Uttar Pradesh 199581477 71 21 33 141 73 49 3 40 2 40 5 82 172 99

1 Allahabad 5959798

1 9 3 - 1 - - 1 - 2 4 2

2 Moradabad 4773138

1 2 4 1 - - - - 1 - 2 3 3

3 Ghaziabad 4661452

2 2 4 - - - - 1 - 2 3 3

4 Azamgarh 4616509

- 1 2 2 1 1 - - 2 - 2 5 2

5 Jaunpur 4476072

- 4 2 1 1 - - 2 - 2 5 2

6 Sitapur 4474446

- 1 3 1 - - - 2 - 2 4 3

7 Bareilly 4465344

2 1 6 3 - - - 1 1 - - 2 -

8 Gorakhpur 4436275

1 6 3 - - - 1 1 - 1 3 -

9 Agra 4380793

2 1 6 5 - - - - 1 - - 1 -

10 Muzaffarnagar 4138605

1 1 1 - - 1 - 2 1 2 6 2

11 Hardoi 4091380

- 1 - 1 - 2 1 2 6 3

12 Kheri 4013634

- 2 1 - 1 - 2 1 2 6 1

13 Sultanpur 3790922

- 3 2 1 - 1 - 2 1 1 5 1

14 Budaun 3712738

- 1 - 1 - 2 1 2 6 3

15 Bijnor 3683896

- 1 1 1 - 1 - 1 - 2 4 2

16 Aligarh 3673849

1 1 5 - - - - 1 - 1 2 3

17 Ghazipur 3622727

- 1 - 1 - 1 - 2 4 3

18 Kushinagar 3560830

- 1 - 1 - 1 - 2 4 3

19 Bulandshahr 3498507

- 1 - 1 - 1 - 2 4 2

20 Bahraich 3478257

- 1 1 - 1 - 1 - 2 4 2

21 Saharanpur 3464228

- 2 1 1 - 1 - 1 - 2 4 2

22 Meerut 3447405

2 3 6 1 - - - - 1 - - 1 2

23 Gonda 3431386

- 3 3 1 - - - 1 - - 1 -

24 Rae Bareli 3404004

- 1 2 1 - - - 1 - 2 3 1

25 Bara Banki 3257983

1 1 1 1 - - - - 1 - 2 3 2

26 Gonda 3431386

- 3 3 1 - - - 1 - 1 2 -

27 Rae Bareli 3404004

- 1 2 1 - - - 1 - 1 2 2

28 Bara Banki 3257983

1 1 1 1 - - - - 1 - 1 2 2

29 Ballia 3223642

- 1 - 1 - 1 - 1 3 3

30 Pratapgarh 3173752

- 1 1 1 - 1 - 1 - 1 3 2

31 Unnao 3110595

- - - 1 - 1 - 1 3 2 32 Deoria 3098637

- 1 1 1 - - - 1 - 1 2 1

33 Shahjahanpur 3002376

- 1 1 1 - - - - - 1 1 1 34 Mahrajganj 2665292

- 1 - 1 - - - 1 2 2

35 Fatehpur 2632684

- 1 - 1 - - - 1 2 2 36 Siddharthnagar 2553526

- 3 1 - - - - - 1 1 2

37 Mathura 2541894

- 1 1 - - - - - 1 1 1 38 Firozabad 2496761

- 1 1 - - - - - 1 1 1

39 Mirzapur 2494533

- 1 2 1 - - - - - 1 1 1 40 Faizabad 2468371

- 1 1 - 1 - - - 1 2 1

41 Basti 2461056

- 1 1 - 1 - - - 1 2 1 42 Ambedkarnagar 2398709

- 1 1 1 - - - - - 1 1 1

43 Rampur 2335398

- 1 1 1 - - - - - 1 1 1 44 Mau 2205170

- 1 1 - - - - - 1 1 1

45 Balrampur 2149066

- 1 - 1 - - - 1 2 1

35

State / Districts Population

(2011)

Districts

(Nos.)

Available Proposed

Medical

Colleges

B.Sc.

Nursing

GNM

Nursing ANM Schools

Medical

Colleges

2012-15 2015-17 2017-22 Total

Nursing ANM Schools

BSc GNM BSc GNM BSc GNM

46 Pilibhit 2037225

- 3 1 1 - - - - - 1 1 1

47 Jhansi 2000755

1 4 3 - - - - - - 1 1 -

48 Chandauli 1952713

-

1 - 1 - - - 1 2 1

49 Farrukhabad 1887577

-

1 - 1 - - - 1 2 1

50 Sonbhadra 1862612

-

1 - 1 - - - 1 2 1

51 Mainpuri 1847194

-

1 1 - 1 - - - 1 2 -

52 Jyotibaphulenagar 1838771

-

1 - 1 - - - 1 2 1

53 Banda 1799541

-

1 - 1 - - - 1 2 1

54 Kanpur Dehat 1795092

-

1 - 1 - - - 1 2 1

55 Etah 1761152

- 2 1 - - - - - 1 1 1 56 SantKabir Nagar 1714300

-

1 - 1 - - - 1 2 1

57 Gautam Buddha 1674714

1 4 6 1 - - - - - 1 1 1 58 Jalaun 1670718

-

1 - 1 - - - 1 2 1

59 Kannauj 1658005

-

1 - 1 - - - 1 2 1 60 Kaushambi 1596909

-

1 - 1 - - - 1 2 1

61 Etawah 1579160

1 1 1 - - - - - 1 1 1 62 Mahamayanagar 1565678 - 1 - 1 - - - 1 2 1 63 S Ravidasnagar 1554203

-

- - 1 - - - 1 2 1

64 Kanshiramnagar 1438156

-

- - 1 - - - 1 2 1 65 Auraiya 1372287

- - - 1 - - - 1 2 1

66 Baghpat 1302156

- 1 2 - - 1 - - - - 1 1 67 Lalitpur 1218002

- - - 1 - - - 1 2 1

68 Shrawasti 1114615

- - - 1 - - - 1 2 1 69 Hamirpur 1104021

- - - 1 - - - 1 2 1

70 Chitrakoot 990626

- - - 1 - - - - 1 1 71 Mahoba 876055

- - - 1 - - - - 1 1

XIX West Bengal 91347736 19 11 15 50 59 20 1 2 2 2 3 28 38 25 1 North 24Parganas 10082852

- 1 4 4 1 - - 1 - 3 5 1

2 South 24Parganas 8153176

- 1 3 3 - - 1 1 - 3 5 2 3 Barddhaman 7723663

1 1 3 1 1 - - - - - 1 1 3

4 Murshidabad 7102430

- 1 3 2 - - 1 - - 3 4 1 5 PaschimMedinipur 5943300

1 1 1 4 - - - - - - 2 2 -

6 Hugli 5520389

- 2 7 1 - - - - - 1 1 - 7 Nadia 5168488

1 1 2 4 - - - - - - 1 1 -

8 PurbaMedinipur 5094238

- 1 2 1 - - - - 1 2 3 2 9 Haora 4841638

- 1 1 1 - - - - - 2 2 3

10 Kolkata 4486679

6 11 26 14 - - - - - - 1 1 - 11 Maldah 3997970

- 1 1 1 - - - - 1 1 2 3

12 Jalpaiguri 3869675

- 2 1 1 - - - - 1 1 2 3 13 Bankura 3596292

1 1 1 2 - - - - - - 1 1 2

14 Birbhum 3502387

-

3 1 - 1 - - - 1 2 - 15 Uttar Dinajpur 3000849

-

1 1 - 1 - - - 1 2 2

16 Puruliya 2927965

- 1 1 1 - - - - - 1 1 2 17 Koch Bihar 2822780

- 1 2 1 - - - - - 1 1 1

18 Darjiling 1842034

1 4 3 - - - - - - 1 1 - 19 DakshinDinajpur 1670931

- 1 2 1 - - - - - 1 1 -

36

Abbreviations

ANM Auxiliary Nurse Midwife

AYUSH Ayurvedha, Yoga, Naturopathy, Unani, Siddha and Homeopathy

BMT Bachelor of Medical Technology

BRHC Bachelor of Rural Health Care

CHC Community Health Centre

CHW Community Health Worker

DH District Hospital

DHq District Head Quarter

DHKI District Knowledge Health Institute

DMT Diploma in Medical Technology

EAG Empowered Action Group

GNM General Nursing and Midwifery

HRH Human Resources for Health

HRMIS Human Resources Management Information Systems

HW-Male Health Worker - Male

IMR Infant Mortality Rate

INC Indian Nursing Council

IPHS Indian Public Health Standards – Revised 2010 (draft)

JLI Joint learning Initiative

LHV Lady Health Visitor

MBBS Bachelor of Medicine and Bachelor of Surgery

MCH Medical College Hospital

MCI Medical Council of India

MMR Maternal Mortality Ratio

NCMH National Commission on Macroeconomics and Health

NHSRC National Health Systems Resource Centre

NRHM National Rural Health Mission

NSSO National Sample Survey Organisation

OECD Organisation for Economic Co-operation and Development

PHC Primary Health Centre

PHFI Public Health Foundation of India

PHN Public Health Nurse

RHS Rural Health Statistics of India

SDH Sub-District Hospital

SHC Sub-Health Centre

SIHFW State Institute of Health and Family Welfare

TB Tuberculosis

UT Union Territory

WHO World Health Organisation

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