The challenge of providing health workers in rural and remote areas spans nations across the globe. World Health Organization in its 2006 report ‘Working together for health’ highlighted the stark nature of the problem. India, along with sub-Saharan African nations, fell within the group of countries estimated to have a ‘critical’ shortage, making it highly challenging for them to provide essential healthcare to their populations. Not much has changed since then. Even as the number of health workers has increased substantially, their ratio to the population is still far short of the required. The shortfall in doctors remains especially daunting. As against the recommended doctor to population ratio of 1.1:1000, Indian figures for actively practising allopathic doctors, based on NSSO data, stand at less than half that. 80% of these are estimated to practice in the private sector and only 33% in rural areas where they serve 65% of the country’s population (Karan et al 2019). Difficulties due to this geographical mal-distribution are severely accentuated by the dis-balance in the types of doctors available in rural areas; the deficit in specialists far outweighs that of generalists. RHS statistics for 2020-21 from the central Ministry of Health show that only 62% of required posts of specialists have been sanctioned by states and only 20% filled, leaving 4 out of every 5 positions vacant. The situation in Meghalaya is even worse. A mere 3 positions out of the required 112 have specialists in place. A slight surplus of doctors at the Primary Health Centre generalist positions where 162 doctors are in position against 121 required, may mitigate the shortages in numbers to some extent but does little to address the unfulfilled medical needs of the people. As evidenced by the recent HRH Situational Analysis in the state by NHSRC, burden of NCDs has more than doubled in the last three decades, raising the need for specialist care. Even by IPHS standards, the study found a shortage of over 33% doctors in the public sector. The report also finds severe geographical inequities in the distribution with large surpluses in three districts but severe shortfalls in all others. This geographical mal-distribution has worsened since 2005 when 4% of Medical Officer positions were vacant while there was a 21% surplus overall; today 11% are vacant with a 33% surplus.

It is important that any attempt to address these challenges be evidence based and empirically driven. Starting with the correct estimates of the numbers required is therefore essential. WHO estimates of health worker needs, developed in 2006 and placed at 2.25 doctors and nurses per 1000 population, were based on the subjective adoption of a single target of 80% coverage of assisted births. The organization has since acknowledged the need to expand beyond this single parameter to better represent population health needs while assessing health worker requirements. In 2016 therefore it adopted an index based on 12 indicators for such assessment. These indicators represent services for maternal and child health, communicable and non-communicable diseases, preventive services and those aimed at proximal health determinants, reflecting the current global focus on Universal Healthcare (UHC) and Sustainable Development Goals (SDGs). Based on this SDG index, it suggests a combined desired ratio of doctor, nurse and midwives to the population of 4.45 to 1000 (WHO 2016). NHSRC recommends viewing this combination as 1 doctor for every 3 nurses and midwives, giving a doctor: population required ratio of 1.1:1000 (NHSRC 2019).

If it is assumed that all rural CHCs and PHCs in India adhere to the strictest (best) IPHS 2022 criteria ie. every rural CHC is a fully functional FRU, serves only 120,000 population and oversees four 24x7 PHCs, with each PHC covering 30,000 population, it provides us an IPHS recommended figure of 20 doctors for the entire CHC population. This gives us a ratio of 1 doctor for a population of 6000, or 0.16 to every 1000. The latest IPHS standard is thus less than a sixth of the WHO recommendation. When figures of the actual numbers present on the ground suggest that a third of even these positions are vacant, as the Meghalaya study by NHSRC does, it gives us a sense of the enormity of the challenge facing the public sector.