Availability and inequality in the distribution of health workers in the public health system in rural India

  • Aditya Singh

Student thesis: Doctoral Thesis


After decades of effort, the health outcomes in India are still poor. In addition to the slow socioeconomic development and sluggish progress in poverty eradication, the ongoing poor health status of individuals living in rural India is often attributed to an inefficient and largely dysfunctional public healthcare system. Although India has developed a huge network of public health facilities, the utilization of services at these facilities still remains abysmal. One of the factors underlying this situation is thought to be the poor availability of human resources in healthcare. Recognising the need to overhaul the system, the government launched the National Rural Health Mission (NRHM), an initiative that aimed to increase health worker availability in public health facilities. It has been more than a decade since the launch of the NRHM, and the time is ripe to evaluate the extent to which health worker availability has improved in public health facilities, and how inequalities in the distribution of health workers in public facilities has changed. Related to this is an important question: What factors shape such distributional inequalities? The NRHM introduced new cadres to the public health system – a 2nd nurse midwife at the sub-centres and a traditional medical doctor at the primary health centres. Thus, this study also investigated the effects associated with the implementation of these workers on healthcare utilization.
This study largely uses quantitative tools and secondary data from the District Level Household Survey (DLHS) series. It finds that the overall health worker availability has improved slightly, but the availability of a few health worker cadres, such as male health workers, has deteriorated. The study also found that the distribution of health workers has become more unequal over the study period. While the inequality in the distribution of health workers within states remains considerably high, the inequality in the availability of health workers across states has increased. The study finds a mesh of complex factors affecting the availability and distribution of health workers across health facilities, which include the availability of basic amenities, physical infrastructure, work environments, family and personal choices, misuse of transfer, and deployment policies. It also finds that the utilization of health services is lower at those sub-centres run by a 2nd ANM compared to those run by permanent ANMs. Evidence about the impact of a 2nd ANM and AYUSH are inconclusive for most indicators. Thus, the findings of this study suggest that there is a need to further improve health worker availability at rural public health facilities. The emphasis should be on reducing the inequality not only across states, but also within states. Special efforts would be required for north and central Indian states that have struggled to improve their health worker availability during this period. The findings also call for policymakers to devise new strategies to retain health workers in rural and remote areas, while implementing transparent and apolitical transfer and deployment policies. The government should also look into issues as to why those sub-centres run by a 2nd ANM are not performing at par with those sub-centres run by permanent ANMs.
Date of AwardSept 2016
Original languageEnglish
Awarding Institution
  • University of Portsmouth
SupervisorSasee Pallikadavath (Supervisor)

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