Health Workforce in India Where To Invest How Much and Why

Health workforce
in India:
where to
invest,
how much
and why?
Health workforce in India: where to invest, how much and why? i

Health workforce in India: where to invest, how much and why?
ISBN: 978-92-9020-993-5
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Health workforce
in India:
where to
invest,
how much
and why?
Content
Abbreviations................................................................................................................. i
Project team and contributors..................................................................................... iii
Executive summary...................................................................................................... v
Chapter 1: Introduction 1
1.1 Investment in health and HRH at the global level................................................1
1.2 Investment in health and HRH in India................................................................4
1.3 HRH situation in India..........................................................................................4
1.4 Framework for education and labour dynamics in HRH......................................5
Chapter 2: Methods 8
2.1 Data sources........................................................................................................8
2.2 Methods of estimating the health workforce........................................................8
Chapter 3: Results 13
3.1 Current size and density of HRH.......................................................................13
3.2 Supply side estimates of HRH by the year 2030...............................................14
3.3 Health workers’ need at different WHO recommended thresholds
and estimated shortages by the year 2030........................................................16
3.4 Strategies and required volume of investment for overcoming
gaps in HRH by 2030.........................................................................................17
3.5 Estimated benefits of enhanced investment in HRH.........................................28
Chapter 4: Discussions and policy implications 30
References 34
Appendices 37
Abbreviations
ANM Auxiliary Nurse Midwife

AYUSH Ayurveda, Yoga & Naturopathy, Unani, Siddah and Homeopathy
CBHI Central Bureau of Health Intelligence
CHC community health centre
ComHEEG High-level Commission on Health Employment and Economic Growth
CSS centrally sponsored scheme
GoI Government of India
GNM General Nurse Midwife
HRH human resources for health
HLEG High-level Expert Group
INC Indian Nursing Council
ILO International Labour Organization
INR Indian National Rupee
INC Indian Nursing Council
LMIC low and low-middle income countries
MCI Medical Council of India
MoH Ministry of Health
MoHFW Ministry of Health and Family Welfare
NMC National Medical Commission
NHP National Health Policy
NGO nongovernmental organization
NHWA National Health Workforce Account
NITI Aayog National Institute for Transforming India
NMC National Medical Commission
NSSO National Sample Survey Office
OECD Organization for Economic Cooperation and Development
PHC primary health centre
PHFI Public Health Foundation of India
PLFS Periodic Labour Force Survey
SDG Sustainable Development Goal
SBA skilled birth attendant
SC sub-centre
WHO World Health Organization
WPR worker population ratio
Health workforce in India: where to invest, how much and why? i

Project team and
contributors
Public Health Foundation of India

• Professor Sanjay Zodpey
• Dr Anup Karan
• Dr Himanshu Negandhi
• Dr Mehnaz Kabeer
World Health Organization

• Dr Dilip Singh Mairembam
• Dr Tomas Zapata
• Professor James Buchan
• Dr Hilde De Graeve
Health workforce in India: where to invest, how much and why? iii
Executive summary
Investments in human resources for health (HRH) have multiple returns for population health and
also beyond the health sector in a country. The High-level Commission on Health and Employment
and Economic Growth (ComHEEG) highlighted the importance of investing in HRH. The High-level
Commission 2016 emphasized that investment in health systems, including investments in health
workers, in addition to improving health outcomes, has potential to generate employment, promote
equity and wellbeing and improve social cohesion, along with fostering economic growth (WHO, 2016a).
India, currently faces acute shortage of health workforce. It will therefore benefit from enhanced
investment in HRH in multiple ways. Such investments in India will not only generate employment within
the health sector but also positively affect employment in other sectors, increase women’s participation
in the labour force, increase formalization of employment, enhance labour productivity and economic
growth (NITI Aayog, 2018).
The present study aims to identify existing levels of shortage in health workforce in India, identify areas
of enhanced investment, required levels of such investments to meet the Sustainable Development
Goals (SDGs) by 2030 and reap potential benefits of such investments.
The present study uses an array of data sources to alternative estimates of existing and potential
shortages in health workforce and the required investment to bridge such gaps. The actual stock of
health professionals registered with different professional councils and active health workforce in the
country were estimated using data extracted from mainly two sources, namely the National Health
Workforce Account (NHWA) 2018 and the Periodic Labour Force Survey (PLFS) 2018–2019 conducted
by the National Sample Survey Office (NSSO), government of India.
Using the two sources of data, the study provides estimates of shortages in the health workforce and
required investments to achieve WHO-recommended health worker: population ratio thresholds by the
terminal year of the SDGs 2030. Since there is a difference in the actual stock available and the actively
participating qualified health workforce, the study estimated shortages in both actual stock and active
health workforce separately. It also provided estimates on the required investments to bridge the gaps
on using the two measures of the health workforce.
The NHWA 2018 data reported about 1.16 million doctors and 2.34 million nurses being produced in
the country as of 2018. Approximately, 0.79 million Ayurveda, Yoga & Naturopathy, Unani, Siddah and
Homeopathy (AYUSH) practitioners are also part of the health workforce. This translates into a health
workers stock: population ratio of 24.4 skilled health worker per 10 000 population. However, considering
the active health workforce (PLFS 2018–2019), the density drops to 11 skilled health workers per 10 000
population.
Some reasons for these differences between NHWA and NSSO estimates are explained by mortality,
retirement, migration from the total stock of health professionals (Karan et al., 2019, 2021; Rao et al.,
2016). However, one of the main reasons of the difference in the estimates across the two sources has
been attributed to labour market attrition.
Studies in the past highlighted that a large proportion of qualified health professionals are actually not
a part of the active health workforce (Karan et al. 2019, 2021). Studies estimated such attrition rate up
to 25–30% of qualified health professionals. This essentially highlights that the size of the active health
workforce in India is a little over 50% of the total stock of qualified health professionals. Also evidence
indicates that an overwhelming large proportion (70–75%) of these out of workforce health professionals
are women and the elderly (60+ years) persons. Given these estimates, the projected shortages by the
year 2030 in health workers in actual stock and active health workforce to meet the WHO recommended
health worker thresholds, were duly estimated .
The study results suggested that to meet the density threshold of 34.5 skilled health worker per 10 000
population, there will be a shortfall of 0.16 million doctors and 0.65 nurses/midwives in the total stock
Health workforce in India: where to invest, how much and why? v

by the year 2030. The shortages at the same threshold would be much higher (0.57 million doctors
and 2 million nurses/midwives) by the year 2030, in case an active health workforce is considered.
The shortages will be even higher when compared with a higher threshold of 44.5 health workers per
10 000 population (Fig. 1).
Fig. 1. Estimate of shortages (in million) of health workers by 2030

at different health worker-population density thresholds
Threshold 34.5 Threshold 44.5
Active workforce 2.96

1.05
Stock 1.63
0.64
Active workforce 1.98

0.57
Stock 0.65
0.16
0 0.5 1 1.5 2 2.5 3
Doctors Nurses/midwives
The present study provides investment scenarios and required investment for overcoming shortages of
doctors and nurses/midwives with an assumed doctor: nurse ratio 1:2. In this regard, the study estimated
three bounds (lower, medium and higher) of investment.
Fig. 2. presents the summary of investment required to overcome HRH shortages (doctors and nurses/
midwives and to meet recommended WHO thresholds. The lower and upper bounds investment
requirements are based on the aim of bridging the gaps in the stock of health professionals and active
health workforce respectively. The medium bound investment considers an alternative scenario of
bringing back at least 50% of the out of workforce qualified health professionals into the workforce,
combined without considering AYUSH practitioners as part of the health workforce. Further within
these bounds, each scenario differs based on different combinations of expansion of seat capacity
in existing educational institutions and opening up of new institutions for an enhanced production of
health professionals.
For the lower bound of investment, the estimated investment ranges from INR 536–745 billion for
overcoming doctors and nurses/midwives shoratges and to achieve the threshold of 34.5 health worker
per 10 000 population. For the upper bound of investment, the estimated investment required to achieve
34.5 health worker per 10 000 population threshold ranges between INR 3676 and 4274 billion for
doctors and nurses/midwives. As a medium bound scenario, the investment requirement after including
50% of not working (or out of labour) health professionals, the required investment ranges from
INR 2127–2724 billion.
If only AYSUH is included, then the required investment ranges from INR 637–1116. However, including
both AYSUH and 50% of the not working health professionals, there are no shortages of doctors while
to overcome nurses/midwives shortages, the investment cost lies in the range of INR 491–919 billion. To
achieve the health workforce: population ratio of 44.5, the investment requirement is approximately 2 to
3 times higher. A summary of investment requirements to meet the health workforce: population density
ratio is presented in Fig. 2.
vi Health workforce in India: where to invest, how much and why?

Fig. 2. Investment (in billion) needs to overcome HRH
(doctors and nurses/midwives shortages to meet WHO thresholds, by 2030*
8,000 7,178
Invetsment required (In INR billion)
7,000
6,000 5,627
5,000
4,000 3,648 3,676
3,000
2,127
2,000
1,000 536
‐
Threshold Threshold Threshold Threshold Threshold Threshold
34.5 44.5 34.5 44.5 34.5 44.5
Lower bound Medium bound Upper bound
Note:* Medium bound (including 50% not-working (out of labour force) health professionals
This study also presents a conservative estimate of benefits of such investments that are only limited
to the health sector. The benefits are presented in terms of new employment generation within the
health sector and contribution to gross valued added by 2030. The study proposes making a one-time
investment during a period of five years ( 2021 to 2025). It is estimated that a one-time investment of
INR 3676 billion during 2021–2025 will result in an employment generation within the health sector to
the tune of 2.45 million and will contribute to gross value added to the extent of INR 2693 billion annually.
Recommendations
Investment in HRH for health is a prime requisite in India to achieve universal health coverage (UHC) and
the SDG agenda by 2030. Such investments will not only improve health outcomes but also generate
employment, increase labour productivity and promote economic growth. Thus, India needs to invest
in the development of HRH infrastructure by enhancing the supply of new health professionals and
increasing the active health workforce in the country. In addition, it also recommends addressing the
shortage of nurses by attracting young people to join the nursing profession, along with improvising the
quality of nursing education and institutions in the country.
Health professionals should be encouraged to join the labour force by creating more attractive
employment opportunities. Improving the health stock and workforce database and linking with live
registries are some of the other recommendations that have emerged from the study.
Health workforce in India: where to invest, how much and why? vii
CHAPTER 1
Introduction
Human resources for health (HRH) is an important building block in health systems, fundamental for
attaining universal health coverage (UHC) and Sustainable Development Goals (SDGs) by 2030. The
High-level Commission on Health and Employment and Economic Growth (ComHEEG), established by
the United Nations in 2016 highlighted the global agenda for investment in health, including investment
for building a health workforce (WHO, 2016a). The Global Strategy report by WHO, also stated HRH
investment to have positive returns in health outcomes and potential to enhance global security and
economic growth. The report raised concerns related to the current low levels of investment in health
workforce globally, creating a global deficit of educated and trained health workers, in turn affecting the
health workers accessibility by population in need of health care (WHO, 2016b).
Inspite of well-recognized returns of investment in health and HRH, many challenges persist when
considering investment for HRH in the health systems of different countries. Thus, investment strategies
must consider these challenges, to have an efficient and adequate HRH investment for the population.
The present study is an attempt to highlight an investment case of HRH in India, identify crucial areas of
investment and estimate quantum of investment required to achieve different thresholds of population
health workforce ratio for meeting the SDGs by 2030.
1.1 Investment in health and HRH at the global level

The ComHEEG recognized the importance of global need of investment in health workforce and
highlighted that investment in health systems, including investments in health workers can improve
health outcomes, promote equity and wellbeing and improve social cohesion along with fostering
economic growth. For instance, in low and low-iddle income countries (LMICs), around one-quarter of
economic growth during a decade, can be attributed to the improvements in health and the investment
returns which are estimated to be around 9 to 1 (WHO, 2006a).
The commission also states the importance of changing health labour market in fostering education and
jobs, especially for women and young graduates. The commission provides policy recommendations
which countries must adopt, thereby leading them to create a sustainable and efficient HRH (Box 1).
HRH includes individuals working towards improving health wherein, “all people engaged in actions
whose primary intent is to enhance health” (WHO, 2006).
The Global Health Strategy re-emphasized health workforce on four parameters, namely the availability
of health workers with adequate skill-mix, accessibile with equitable distribution, acceptable by ensuring
trust and promoting demand and quality for providing effective health care services (WHO, 2016a,
2013). The investments in health care have the potential to create employment not only in the health
sector but also by inducing non-health sector jobs. The study on “health workforce and the employment
effects in 185 countries”, highlights that filling up existing health worker shortages has the potential to
create employment for 18.3 million health occupations and 31.8 million jobs for non-health occupations.
For instance, in a broader health economy, creating a job for one physician can create 2.3 jobs for
workers of non-health occupation (Scheil-Adlung, 2016).
Health workforce in India: where to invest, how much and why? 1

Box 1.
Recommendations and strategic actions by the High-level Commission
Ten recommendations and five strategic actions to transform the health workforce for SDGs were
recommended by the ComHEEG. Each of these focuses on quality care, strengthening of the
heath system and provisioning for social protection systems. The strategic actions are to be taken
at the national, regional and international level to start the implementation of the Commission’s
recommendation
Recommendations Strategic actions

1. Develop labour market policies to stimulate A. Emphasize political leadership, commitments
investment for creating decent jobs in the and intersectoral engagement to develop an
health sector. implementation plan for a five-year period at
2. Maximize women’s employment in the health the end of year 2016.
sector, empower them and reduce gender B. Establish a global framework to increase
bias. accountability, advocacy and commitment.
3. Scale-up high quality, transformative C. Invest and build individual and institutional
education and build health workers with highly skills to advance the health labour market
competent skills. data and analysis.
4. Shift focus on primary and preventive health D. Develop intersectoral plans and commit
services from hospital care and provide an budgetary resources for investment.
effective, high quality, affordable, people- E. Develop an international platform on health
centric, community-based and ambulatory worker mobility.
care to underserved areas.
5. Harness technology and digital
communication to improve access, service
delivery, enhance health education and health
information systems.
6. Invest in building international health core
capacities in health systems.
7. Strive for adequate fundraising and reform
health care financing.
8. Promote intersectoral cooperation and
collaboration to invest in health workforce
strategies and education.
9. Maximize mutuality of benefit among
countries in International migration, optimize
skills use and advance health workers’
qualification.
10. Adopt robust research and analysis of health
labour dynamics.
Source: WHO, 2016a
In order to understand the global scenario, a WHO report on “Health workforce requirements for UHC
and SDGs” stated an estimated increase of up to 67.3 million global health workforce by 2030 (WHO,
2016c). Thus, it is imperative to properly plan the availability and structure of HRH, in order to utilize
the maximum capacity of the available workforce. Estimating the future need and shortages based on
population growth, it is important to recognize the need for introduction of new policies and/or modulate
existing policies. Globally, the availability and requirement of HRH varies across countries.
The retention of nurses in the health workforce is an important factor for providing quality health care
services. However, their turnover rates which describe nurses leaving their current organization or
leaving the profession altogether, were reported to be around 44.3% in New Zealand and 26.8% in
the United States (Duffield et al., 2014). However, the loss from the nurses’ turnover not only affects
health care services but also impacts labour productivity, while incurring higher costs for replacements
(Buchan, 2018).
2 Health workforce in India: where to invest, how much and why?

This imbalance in skills-mix of doctors and nurses/midwives affects the availability and accessibility of
health services for health needs. The WHO study “Human resources for health observer” stated the
global nurse/midwife to physician ratio of 2:1 in 2013 (WHO, 2016c). However, the ratio of nurses to
physicians is 2.8:1 for the Organization for Economic Cooperation and Development (OECD) average.
Many countries are falling below the OECD average (WHO, 2013). A recent study conducted by the
Public Health Foundation of India (PHFI) and WHO stated although the total stock of nurse to doctor
ratio considering the National Health Workforce Accounts (NHWA) data is 2.02:1 at the all-India level.
However, at the all-India level, considering the NSSO estimates, the doctor to nurse/midwives ratio
dropped to 1.7:1 (Karan et al., 2021).
The NHWA provides a framework and acts as a tool guide for formulating health workforce policies
and planning. The framework covers major components of the health workforce for assessing the
educational sector requirements and labour market dynamics in health care services (WHO, 2017a).
In alignment with this, the Global strategy on HRH, WHO, recommends thresholds for understanding
the availability of HRH pattern in a global scenario. These thresholds are for estimating health workers’
density, especially for doctors and nurses/midwives (WHO, 2016b, 2013). Detailed indicators for each
threshold are given in Box 2.
Box 2.
WHO recommends different health worker thresholds and indicators
Thresholds Indicators
1.22.8 Skilled health: workers A. This threshold mainly focuses on maternal and
(physicians and nurses/ newborn health.
midwives) per 1000 population. B. Reflecting health services (assisted delivery) for
achieving 80% coverage by a skilled birth attendant
(SBA).
2.34.5 Skilled health: workers C. This threshold is based on social protection and its
(physicians and nurses/ outcomes which consider the “staff access deficit”
midwives) per 1000 population. indicator.
3.44.5 Skilled health: workers D. This threshold on 12 tracer health indicators, focuses
(physicians and nurses/ on reaching the estimated number of skilled health
midwives) per 1000 population. workers, in order to have a high achievement
coverage (80% or above) for the 12 tracer health
indicators.
The 12 tracer indicators reflect:
-Reproductive, maternal, newborn and child health
(RMNCH) including family planning; antenatal care
coverage; skilled birth attendance; anddiphtheria–
tetanus–pertussis (DPT3) immunization.
-Infectious diseases related to potable water;
sanitation; antiretroviral therapy; tuberculosis
treatment.
-Non-communicable diseases (NCD) such as cataract
surgery; tobacco smoking; diabetes; hypertension
treatment.
4. 59.5 Skilled health - workers E. This threshold mainly focuses on reducing global
(physicians and nurses/ maternal deaths due to preventable causes to 50 per
midwives) per 1000 population. 1 00 000 live births by 2035.
Source:WHO, 2016c, 2013
The investments in HRH largely involve funding for upgradation of institutions, creating new infrastructure,
training and upgradation of skills and expenses for stimulating new employment opportunities. The World
Health Report 2006, estimated that training would only cost US$ 136 million annually for an average
sized country. Meanwhile, for employing a new health workforce, it would cost an additional US $311
million (WHO, 2011). Another study (Sternberg et al, 2017), for LMICs, estimated an amount of US $371

billion for achieving health system targets and an additional cost requirement of US $274 billion per year
to progress towards SDG 3 targets by 2030. A larger component (75%) of these estimates relate to the
development of the health workforce and infrastructure (medical equipment) (Stenberg et al., 2017).
1.2 Investment in health and HRH in India

The requirement of an enhanced investment in the health workforce in India is brought out by the fact
that such investments will not only improve good health and wellbeing but also strengthen the health
system and generate employment. A WHO report stated the need for 1.8 million doctors, nurses and
midwives in India to achieve the recommended threshold of 44.5 skilled health professionals per 10 000
population (WHO, 2020). These estimates call for an urgent emphasis and need to invest in HRH. Such
investments in addition to strengthening the country’s health system and improving population health,
have the potential to improve overall labour productivity, formalize labour markets and create additional
employment opportunities.
Past studies highlight the higher participation of females in the global health workforce. A recent study
on gender equity in health workforce estimated 67% of health workers being female in 107 countries
with a much higher share in the nurses and midwifery workforce (Boniol et al., 2019). The Indian health
care sector is largely formalized (60%), compared to many other sectors (20%). In India, the female
labour force participation is higher in the health sector (~50%), in comparison to other sectors (~25%)
(Andres et al., 2017; Desai et al., 2018; Stephan and Pieters, 2015). Thus, such an investment can have
multiple returns that go beyond the health sector, such as formalization of labour market, and increasing
female labour force participation rate (NITI Aayog, 2018).
1.3 HRH situation in India

In India, health system and health care services consist of various categories of health professionals
such as doctors, nurses/midwives, AYUSH, allied health professionals, physiotherapists, pharmacists
and others. These health workers strive together to provide human health services and cater to the
health care needs of the population. However, studies have reflected a skill-mix imbalance and acute
shortage of doctors and nurses in the country. Notably, a lower number of qualified health workers,
presence of unqualified health workers (especially in rural areas) and imbalances in health worker
distribution in rural and urban areas are some of the challenges in the Indian health sector (Rao et al.,
2016). Migration of doctors and nurses to OECD countries is also a phenomenon in the Indian health
workforce (Walton-Roberts and Rajan, 2020).
A recent PHFI-WHO 2020 study highlighted the lower density of health workers and imbalances in
HRH distribution in India. The density of doctors and nurse/midwives in actual stock is around 8.3
and 17.4 respectively per 10 000 persons. However, if the number of qualified active health workforce
is considered, the health worker density drops to 4.8 and 5.7 respectively. The study also highlights
disparities in skill-mix and lopsided distribution among Indian states. While, bulk of the population resides
in rural areas (66%), only 33% health workers are available to deliver services (Karan et al., 2021).
Another study reflected a huge difference in the health professional availability in the workforce when
compared to the number of qualified practitioners registered with different councils. It was estimated
that 20% of adequately qualified health professionals are not working in the health workforce (Karan et
al., 2019).
At the same time, steps are being initiated to uplift the health sector to meet challenges. In this regard,
India’s health sector is expected to double by 2022, increasing the workforce demand from 35.9 lakh in
2013 to 74 lakh in 2022 (National Skill Development Corporation, 2015). For improving the quality, skill
upgradation of nurses/midwives and obstetricians was conducted under the initiative named “Daksh”
(MoHFW, 2020a).
The National Health Policy 2017 also emphasizes upgradation of sub-centres (SCs), primary health
centres (PHC) and district hospitals (DH) for the deployment of more workforce (MoHFW, 2017). At
the same time, to overcome shortage of doctors and nurses, the government is working towards HRH
development through Centrally Sponsored Schemes (CSS), such as upgradation of DHs to medical
colleges, increasing the uptake of seats and relaxing norms required for building new medical colleges,
improving quality of nursing education and so on.
Recently, the government started a centrally sponsored scheme to upgrade DHs to medical colleges and

allocated funds in the range of INR 189 crore to INR 325 crore for building new medical colleges in the
aspirational districts (MoHFW, 2020b). While, for increasing the intake capacity of MBBS seats in existing
medical colleges, an upper ceiling of 1.2 crore per MBBS seat was being allocated for strengthening and
upgrading State Government Medical Colleges (MoHFW, 2019a). Similarly, the budget document of the
state of Gujarat also states its 60% share allocation of INR 60 crore for MBBS seat upgradation from
150 to 250 seats (Government of Gujarat, 2017).
In the 11th five year plan (2007–2012), INR 6 crore was allocated to states, for CSS upgrading a school
of nursing attached to a medical college into a college of nursing (Government of India, 2014; Sharma,
2020). Also, a cost of INR 26.5 crore has been allocated for construction of nursing colleges in Bihar
(BMSICL, 2018). NITI Aayog’s strategy for “New India@75” also aims at creating 1.5 million jobs in
the public health sector, creating more employment opportunities, primarily for women by 2022–2023
(NITI Aayog, 2018). Similarly, NITI Aayog’s annual report 2019–2020, re-emphasizes the importance
of nursing sector reforms, providing quality education and structural reforms for maximizing their
productivity (NITI Aayog, 2019).
These prior estimates of future HRH shortages and additional need of health workers for health care
services, reflects the need for strategies and investment scenarios that can contribute to the strengthening
of planning, production and development of a sustainable and efficient health workforce.
Although past studies have documented various concerns related to HRH in India, the strategies and
magnitude of required investments to overcome these challenges have not been adequately discussed.
The main objectives of the present study are two-fold:
i. estimate the magnitude of HRH (doctors and nurses/midwives shortages currently and for the
year 2030, with respect to different thresholds of population/HRH ratio; and
ii. estimate quantum of investment required to bridge gaps.
In addition, the study presented different alternative strategies for meeting the current and potential HRH
gaps in India. It also estimated potential benefits of such investment within and beyond the health sector
at different levels of enhanced investments.
1.4 Framework for education and labour dynamics in HRH

The HRH and its services are highly influenced by education and labour markets dynamics in any
given country. There are several push-pull factors which play an important role in building the HRH
structure and distribution. The availability and accessibility of HRH by population, largely depends on
parameters like total number of health professionals produced, actual available stock (after adjusting for
attrition because of migration of health workforce) and number of medically qualified persons active in
the workforce and who are providing human health services. The variation in these parameters can alter
the HRH density and skill-mix and influence the human health services at the national level.
Understanding the dynamics at each level of these parameters is therefore essential to estimate the
size of investment required to achieve the recommended WHO thresholds and maintain an adequate
skill-mix ratio. Fig. 3. provides the framework for education and labour dynamics in HRH (WHO, 2016b).
The study adopted a framework to map the journey from production to active health workforce in India,
as suggested in the Global Strategy report of WHO (WHO, 2016b) and customized it for the Indian
scenario. The health worker shortages at each level of these parameters are context-specific and require
specific strategies to address these shortages. Moreover, these shortages can vary at production level,
in terms of actual available health professionals at stock level and in the active labour market level, for
providing human health services. Invariably, a significant portion of adequately qualified actual available
health professional stock remain inactive and unemployed (Fig. 3.), hence creating shortages in the
labour market for human health services.

Framework for education and labor dynamics of Human Resources in Health
Fig. 3. Framework for education and labour dynamics of HRH
Policies to increase production

Health professionals ‐Expanding / Creating new institutions
Medical Education ‐Increasing intake capacity
‐Doctors ‐Attracting students for enrollment in health sector
‐Nurses(/Midwives)
Policies to address inefficiencies and increase workforce participation

Total production of health ‐Retrain/ re‐skilling of unemployed health worker
professionals ‐Recruitments to absorb unemployed health workers
‐Regulations to improve skill‐mix competence
‐To bring medically qualified persons back into the healthcare sector
Policies to reduce attrition
Attrition
‐To increase retention of
(Migration +
health workers in the
Death + Active workforce
country Health workers
Retirement) (Human Health equipped to deliver
‐To increase retirement age
of health professionals. Services) quality services
Employed Active workforce

Health (Non‐ Human
Adequate HRH threshold
professionals Health Services)
Unemployed for population
(Actual stock) E.g. Administrative (22.8/34.5/44.5 per 10 000
Out of labour force & other jobs. population)
4
In order to address these concerns, policies should be initiated towards increasing the production
of health professionals, reducing attrition by encouraging professionals to be retained in the country
and increasing workforce participation through new recruitments. These can be done by opening
new institutions, increasing seat intake in medical colleges and attracting professionals to join the
health sector. Regulation of skill-mix and provisioning attractive vacancies can further improvise
workforce participation.
To address these shortages, there would be some identifiable cost centres at each level of these
parameters. Working at each of these cost centres would be crucial for formulating the strategies and
estimating the required investments for meeting the HRH gaps. Fig. 4. identifies areas for investment
that can then improve the HRH situation in India.
Framework for cost Centre in Human Resources in Health
Fig. 4. Framework for cost centres in HRH
Need‐based shortages in HRH
Increasing available Increasing active health

Creating new health professionals stock
(increasing production) workforce
(reducing attrition)
Cost of opening new

institution Cost of incentives for Capital cost and salaries
retention of health of new recruits
Cost of upgradation of workers in rural areas
district hospitals to medical
colleges and nursing schools Cost of attracting Indian Cost of Reskilling /
educated health workers training a health workers
Cost of increasing intake
from abroad and reducing
capacity in existing
outmigration
institutions
To overcome shortages in HRH, investments are needed in various activities at multiple levels of
investment (Fig. 4). These health worker shortages can be overcome by creating new health professionals,
enhancing the total available stock and increasing the active participation of health professionals in the
health workforce for providing human health services.

The cost centres for this involves the cost of increasing seat capacity in existing colleges, upgradation
of existing institutions and opening of new institutions. It also includes investments to counter the labour
market dynamics such as the provision of incentives for attracting professionals to work in rural areas.
Cost centres also include investment required for training and upgradating skills to meet the demand
side requirements.

Chapter 2
Methods
2.1 Data sources

The study uses data from a range of sources that include the NHWA, Global Health Workforce Statistics,
Geneva on India, 2018; National Sample Survey Office (NSSO), Government of India, Periodic Labour
Force Survey (PLFS) from July 2018–June 2019; annual supply of new graduates (doctors and nurses/
midwives) from the Medical Council of India (MCI) and Indian Nursing Council (INC) annual reports
and related websites; population projection from Census of India 2019 and (v) websites of different
government and private educational institutions involved in imparting education for doctors and
nurses/midwives.
In addition, the team undertook a detailed review of literature from government and private sources providing
information on unit costs of opening new institutions for education of doctors and nurses/midwives.
2.1.1 NHWA data

NHWA provides country-wise data on the stock of different categories of health workers. The latest data
of HRH stock for India is available for the year 2018. The present study uses all-India level data of two
health professional categories, doctors and nurses/midwives (WHO, 2021).
2.1.2 NSSO data

The second source of data has been taken from nationally represented “Periodic Labour Force Survey
(PLFS)” conducted by NSSO, government of India at regular intervals. The survey provides detailed
information on various socio-economic parameters in the country. In PLFS July 2018–June 2019, sample
size of the survey was 101 579 households (55 812 rural and 45 767 urban) and 420 757 persons (239
817 rural areas and 180 940 urban areas).
The survey provided information on the detailed activity status, employment situation, sector of
employment and occupation types of each worker, educational achievements of every individual (NSSO,
2020). The present study values were estimated after accounting for the right qualification.
Data was collected from different councils on annual seats available, number of institutions and yearly
data on the number of new health professional registrations. The National Medical Commission (NMC)
is an umbrella body that regulates medical education and professionals in India. Similarly, the INC
regulates nursing education and acts as a regulatory body for nurses/midwives. The study team used
NMC and INC annual reports and websites to collect various sources of information (INC, 2021; NMC,
2021). The population projection for the years 2019 to 2030 was extracted from the technical report
(MoHFW, 2019b) and additional education-related information from few other government websites.
2.2 Methods of estimating the health workforce

2.2.1 Estimating size and composition of health workforce and projections up to 2030
A distinction was made across total ‘production’ and total ‘stock’ of health professionals on the one
hand and ‘active health workforce’ on the other. While total production of health professionals was
defined as the numbers of health professional registered with NMC for doctors and with INC for nurses
and/midwives for a particular year, total existing stock was defined after accounting for net migration
(outmigration-in-migration), deaths and retirement of health professionals in total production for the
same year year (Box 3).
In contrast, active health workforce was defined as health professionals actually engaged in human

health service. The worker population ratio (WPR) was estimated for different categories of health
workers using PLFS 2018–2019 and applied on the projected population as of January 2019 to arrive
at a total magnitude of health workers categorized by doctors and nurses/midwives (Karan et al. 2021).
Box 3.
Parameters related to health professionals used in the study
1. Net migration. It refers to the difference between number of health professionals coming in a
country (out-migration) and number of health professionals leaving a country (in-migration).
Out-migration refers to total number of health professionals leaving the country for work. Thus,
after studying in the country of origin, they migrate to other countries.
Both the annual and total out-migration of health professionals was considered. In-migration
referred to total number of health professionals joining a country workforce annually. These
health professionals exclusively doctors, in-migrated to the country after receiving education
from foreign universities. Total out-migration of (-6%) and (-3.3%) was used from the actual
stock for doctors and nurses respectively. Annual net migration rate (+5%) in doctors and
annual outmigration of (-4.6%) in nurses/midwives was used.
2. Mortality: This referred to expected number of deaths of health professionals annually,

according to the national statistics. Mortality (for age 30–59 years at a declining rate was used
from 2.5% in 2019 to 2.1% in 2030.
3. Retirement: These refer to the number of health professionals retiring annually from the
workforce. Using existing evidence in literature, (-1.07% and -1.02% retirement rates were
used for those above 60 years of age for doctors and nurses/midwives respectively.
Baseline numbers and projection up to 2030

Baseline numbers were arrived at by linearly projecting the total production and stock numbers as of
2020. For an active health workforce, an estimated WPR was applied for doctors and nurses/midwives
separately on the projected population as of January 2020.
For projection of total production and stock of health professionals and active health workforce, a
standard method was discussed (Ridoutt et al., 2017). However, a range of indicators were used from
India to modify the method for the purpose of the present analysis.
The total production and stock of health professionals was projected annually from 2021 to 2030 by
cumulatively adding number of pass-outs (doctors and nurses/midwives) from five years ago. For the
period 2020–2025, number of pass-outs was estimated considering all potential new institutions likely
to be opened during the period (Appendix A-II for new institutions to be opened during and post 2020).
For estimating projection of stock numbers projected, net migration separately for doctors and nurses/
midwives), mortality (for age 30–59 years at a declining rate from 2.5% in 2019 to 2.1% in 2030) and a
constant retirement rate (age 60 years) were applied.
For projecting the size of an active health workforce by 2030, an additional factor was accounted for.
This was the proportion of qualified health professionals who were not part of the health workforce. It
included qualified health professionals representing those working in non-human health services; those
who were unemployed and those who were not part of the labour force. These estimates were arrived
at using PLFS 2018–2019 and were considered constant over the 2020–2030 period. Box 4 provides
estimation methods used to arrive at the baseline and health workers projections up to 2030.

Box 4.
Estimation of baseline and projection up to 2030
Baseline 2020
....................................................... (1)
Where ‘ ’ is total production of health professionals in year 2020. was estimated from
NHWA 2018 data. Subscript ‘h’ stands for types of health workers (doctors and nurses /midwives).
NHWA is the National Health Workforce Accounts data and ‘s’ is total annual admission of medical
students across all institutions in India.
................................................................................ (2)
Where, S is the total stock of health professionals, are total net migration,
deaths and retirement in the year 2020.
................................................................................................... (3)
Where HW is the active health workforce, WPR is worker population ratio estimated from PLFS
2018–2019 for respective categories of health workers, ‘popl2020’ is projected population as of
January 2020.
Projection up to 2030
Total production of health professionals was estimated for each of the years between 2020 and 2030
using the baseline number as presented in equation (1) and annual admission of students in all
medical institutions with a five years lag, i.e.
........................................................................................................................ (4)
Where subscript ‘t’ is year of estimation.
Accordingly, total stock of health professions and active health workers were estimated using
equations (5) and (6) respectively, as follows:
........................................................................................................ (5)
....................... (6)
Where OW is health professionals remaining out of workforce, U is unemployed and NW is health

professionals working in non-human health services.
2.2.2 Needs and shortages estimation in HRH for the period 2020–2030
In the present study, the medium range of the density threshold of 34.5 and 44.5 were used where
skilled health professionals per 10 000 population, for estimating actual need, shortages and quantum
of investments were required to overcome shortages in HRH. The density threshold of 22.8 skilled
health professionals per 10 000 population was not considered, as it only took into account one indicator
for attaining UHC. Considering doctor: nurse /midwife ratio of 1:2 and population projection, it was
estimated that the total need and gaps would be segregated by the required number of doctors and
nurses /midwives respectively. The gaps were estimated by considering the stock and active health
workforce estimates separately for each year during 2020 to 2030.
2.2.3 Strategies and required investments for overcoming projected shortages in HRH
by the year 2030
The strategies were proposed considering existing and proposed institutions for doctors and nurses.
They were based on increasing pass-outs (or utilization of capacities in existing institutions) and seat
intake (expansion) in existing colleges and opening of new medical colleges or nursing colleges.
Required investment for HRH would be arrived at by multiplying the unit cost of opening new institutions
and/or expanding the existing seat capacity of institutions by number of institutions/seats required. The

number of institutions/seats could be inferred using the two HRH : population ratios (34.5 and 44.5
doctors and nurses/midwives per 10 000 population). Three different scenarios are presented below for
investment:
a) Lower bound investment to meet HRH gaps. Lower bound investment was estimated considering
the required investment to overcome shortages in the projected stock of HRH. These investment
estimates were based on different strategies and scenarios of seat expansion and opening of new
institutions for doctors and nurses/midwives.
b) Upper bound investment to meet HRH gaps. The upper bound investment was estimated
considering the required investment to overcome shortages in active health workforce. These
investment estimates were also based on the different strategies and scenarios of seat expansion
and opening of new institutions for doctors and nurses/midwives. Additionaly, a moderate labour
market attrition rate of 20% and 30% in doctors and nurses/midwives respectively was used to
estimate the active health workforce size.
c) Middle bound investment to meet HRH gaps. In this scenario of investment, the required
investment was estimated with a view to encourage and create efforts to engage 50% of estimated
non-working (out of labour) health professionals in 2030, into the health workforce. At the same
time, these scenarios focused on the opening of new medical colleges and nursing institutions
and expanding seat capacity (or pass-outs) in existing institutions. The middle-bound investment
scenario also considered AYUSH health practitioners as part of the total health workforce.
2.2.4 Benefits of investment in HRH by 2030

Investments in HRH had a much broader impact on multiple sectors of the economy. The present study
attempted to estimate one limited benefit of such HRH investments, in terms of increased employment
in the health sector along with contribution of increased employment to national income. The study
estimated labour productivity in terms of gross value added (GVA) per worker in health sector for the
year 2019. Labour productivity in the health sector for the year 2019 was finally multiplied with the total
additional employment in the health sector in the year 2030 because of enhanced investment in health
workforce (Box 5). Total additional employment for the year 2030 was estimated by adding number
of ‘support staff’ and ‘health assistants’ to total number of additional doctors and nurses/midwives as
estimated for the year 2030.
The ratio of 3:1 was used for both total HRH: support staff and total HRH: health assistant based on
previous study estimates (Karan et al., 2019, 2021). Health assistants included dieticians and nutritionists,
optometrists and opticians, dental assistants, physiotherapy associates, pharmacist assistants,
occupational therapists and so on. The support staff includes ambulance drivers, professionals, garbage
collectors, cashiers, clerks, mechanics, finance personnel and so on.

Box 5.
Estimation of benefits of investment
Equation (7) and (8) were used to calculate employment generation and their contribution to national
income respectively.
Employment generation
.......................................................................................... (7)
is the total number of workers employed in the health sector for the year 2030. For the year
2030, the study team estimated the size of support staff and health assistants using the projected
increased employment of doctors and nurses/midwives. was the number of doctors and
nurses/midwives employed in the workforce due to enhanced investment, to overcome HRH
shortages. was the total number of support staff who acquired jobs due to employment
generation for doctors and nurses /midwives. was the number of health assistants employed
in the workforce with the engagement of doctors and nurses/midwives in the health sector.
Contribution to national income
The labour productivity in the health sector for the year 2019 was estimated as follows:
............................................................................................................ (8)
Where was labour productivity of health sector workers and was the gross value
added in the health sector in 2019 at current prices.
Finally, total benefits of enhanced investment in the health workforce was estimated as a total
contribution to gross value added by new employment because the enhanced investment was as
follows:
...................................................................................................... (9)
Where related to changes in gross value added in the health sector and
was the additional employment because of the enhanced investment.

Chapter 3
Results
3.1 Current size and density of HRH

Using NSSO and NHWA data, the estimates of HRH at the all-India level are presented in Table 1.
Mainly, three parameters are presented with total production of health professionals; actual stock of
health professionals (after adjusting for mortality, retirements and migration) from the accumulated
production by 2018; and active health workforce estimated from PLFS 2018–2019.
The NHWA data reported 1.16 million doctors, 2.34 million nurses/midwives as total production in the
country by 2018. NHWA data also recorded approximately 0.79 million traditional medicine professionals,
who were mainly AYUSH practitioners.
Table 1. Size and composition of HRH in India

Parameters NHWA Health professionals Active health Active health
(Total production), (actual stock) workforce 2019^ workforce as
2018 2018* (in million) % of actual
Absolute Density Absolute Density Absolute Density stock
number (In / 10 000 number / 10 000 number / 10 000
million) population (in population (in population
million) million)
Allopathic
1.16 8.8 1.05 7.9 0.66 5 63
doctors
Nurses /
2.34 17.7 2.18 16.5 0.79 6 36
midwives
HRH 1
(allopathic
doctors + 3.5 26.5 3.23 24.4 1.45 11 45
nurses/
midwives)
AYUSH
0.79 6 0.76 5.8 0.25 1.9 33
practitioners
HRH 2
(allopathic
doctors +
4.29 32.5 3.99 30.2 1.7 12.9 42.6
nurses/
midwives)+
AYUSH)
* Adjusted for attrition (out-migration): allopathic doctors: (- 6 %); nurses: (- 3.3 %), death rate (for both nurses and doctors:
(-2.5), retirement rate (doctors): (-1.07%), retirement rate (nurses): (-1.02%)
^ Estimated from PLFS:2018–2019
After accounting for net migration, mortality and retirement, total stock of health professionals as of
2018 was estimated to be 1.05 million doctors and 2.18 million nurses/midwives. However, the size of
the estimated active health workforce was considerably lower with 0.66 million doctors and 0.79 million
nurses/midwives. At the aggregate level, adding numbers of doctors and nurses/midwives together with
the size of active health workforce was around 45% of the total actual stock of health professionals.
Accordingly, the density, of health professionals available in stock stood at 24.4 per 10 000 population
when considering only allopathic doctors and nurses/midwives. However, including AYUSH professionals,

the density of health worker stock increased to 30.2 per 10 000 population. The density of active health
workforce was also estimated to be 11 health workers per 10 000 population, including doctors and
nurses/midwives. After including AYUSH, the density was 12.9 per 10 000 persons.
After accounting for migration, mortality and retirement of health professionals in the stock data, the
differences in the estimates of stock of health professionals and active health force was explained by
the extent of labour market attrition. A large proportion of qualified health professionals, as represented
in the stock data, were not part of the active health workforce. PLFS 2018–2019 data indicated
that approximately 4% medical graduates (doctors) and 11% diploma holders in medicine nurse/
midwives were unemployed. Further, a sizeable proportion of qualified professionals were employed in
non-health sectors. However, the most disquieting fact was that approximately 20% doctors and 30%
nurses reported themselves out of the labour force. A distribution of total stock of qualified health
professionals by working and not working as health workforce is presented in Appendix Fig. A-I.
3.2 Supply side estimates of HRH by the year 2030

Fig. 5. presents the estimated number of doctors in actual stock and active health workforce from the
year 2020 to 2030. Thus, there will be 1.25 million doctors in actual stock which will increase to about
1.51 million by 2030. Meanwhile, the doctors in the active health workforce will be about 0.87 million in
2025 to 1.1 million by the year 2030. The increase in actual stock would be much higher (0.26 million)
from 2025 to 2030 compared to only 0.17 million increase till 2025. Similarly, an increase in the active
health workforce was much higher from 2025 to 2030 compared to an increase from 2020 to 2025. This
increase was due to the opening of new medical colleges in the country. The projected estimates of total
production of doctors, actual stock available and doctors in the active health workforce for the year 2020
to 2025 is given in Appendix A-VI.
In nurses (Fig. 4.), there has been a steady increase from 2025 to 2030 in the actual stock and active
health workforce which was similar to the steady increase from 2020 to 2025. The projected estimates of
total production of nurses/midwives, actual stock of nurses/midwives and nurses/midwives in the active
health workforce for the year 2020 to 2025 is given in Appendix A-VII.
Figure
Fig. 3. Estimated
5. Estimated number number
of doctorsof(Indoctors (Inactual
million) in million) inand
stock actual
active
health workforce, from year 2020 to 2030
stock and active health workforce , from year 2020 to 2030
1.70
1.51
1.46
1.50 1.41
1.30 1.35
1.25
Doctors (In million)
1.30 1.17 1.21

1.11 1.14 1.10
1.08 1.05
1.10 0.96 1.01
0.87 0.91
0.79 0.83
0.90 0.73 0.76
0.70
0.70
0.50
0.30
2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Year
Doctors in actual stock Doctors in active workforce
Figure 4. Estimated number of nurses (/midwives) in actual stock and

active health workforce (In million), from year 2020 to 2030
3.00 2.65 2.70 2.74
2.50 2.55 2.60
(/midwives) in million
2.36 2.41 2.46

2.50 2.26 2.31
2.00
14 Health workforce in India: where to invest, how much and why? 1.36 1.41
1.50 1.21 1.26 1.31
1.06 1.11 1.16
0.89 0.95 1.00
1.00
Doctors in actual stock Doctors in active workforce
Fig. Figure 4. Estimated

6. Estimated numbernumber
of nursesof (/midwives)
nurses (/midwives)
in actual in actual
stock andstock and
active health
workforce (In million), from year 2020 to 2030
active health workforce (In million), from year 2020 to 2030
3.00 2.65 2.70 2.74
2.50 2.55 2.60
Nurses (/midwives) in million
2.36 2.41 2.46

2.50 2.26 2.31
2.00
1.31 1.36 1.41
1.50 1.16 1.21 1.26
1.00 1.06 1.11
0.89 0.95
1.00
0.50
0.00
2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030
Year
Nurses (/midwives) in actual stock Nurses (/midwives) in active health workforce
Table 2 presents projections, total cumulative production and stock of total qualified health professionals
and active health workforce, separately for doctors, nurses/midwives and AYUSH practitioners by the
year 2030. As of 2030, there would be a total cumulative production of 2.06 million doctors while only
a little over half of them will be working in human health services. While the actual available stock in
nurses/midwives will be 2.74 million by 2030, only half of this stock will be in the active health workforce.
Table 2. Projected estimates of HRH supply by 2030

Doctors Nurses / Doctors AYUSH Doctors
Parameters (density)# midwives +nurses / (density)# +nurses/
(density)# midwives midwives+AYUSH
(density)# (density)#
Total production of
2.06
health professionals 3.94 (26.9) 6 (41) 1.29 (8.8) 7.29 (49.8)
(14.1)
(in million)*
Total stock of health
1.51
professionals 2.74 (18.7) 4.25 (29) 0.93 (6.4) 5.18 (35.4)
(10.3)
(in million)**
Active health workforce
1.1 (7.5) 1.41 (9.6) 2.51 (17.1) 0.51 (3.5) 3.02 (20.6)
(in million)^
* NHWA estimates, # density per 10 000 persons
** NHWA estimates: Adjusted for attrition (mortality, retirement and migration) Doctors: Net migration rate (+5%),
death rate (-2.5 to -2.1%), retirement rate (-1.07%) Nurses /midwives: Annual migration (-4.6%), death rate (-2.5 to -2.1%),
retirement rate (-1.02%)
^ Estimated from NSSO, PLFS:2018-19, moderate labour market attrition of 20% doctors and 30% nurses and
attrition (mortality, retirement and migration) Doctors: Net migration rate (+5%), death rate (-2.5 to -2.1%), retirement
rate (-1.07%) Nurses /midwives: Annual migration (-4.6%), death rate (-2.5 to -2.1%), retirement rate (-1.02%).
Similarly, in the case of AYUSH professionals, 0.93 million is the actual stock available and only 0.51 million
AYUSH practitioners are available for providing health care. Moreover, the total stock of HRH including
doctors and nurses/midwives is about 4.25 million and including AYUSH available stock increases to
5.18 million by the year 2030. The projected estimates of HRH (doctors and nurses/midwives) for the
year 2020, 2025 and 2030 is given in Appendix A-V. However, there are only 2.51 million doctors and
nurses/midwives in the active health workforce to provide health care services. Including AYUSH in the
workforce, the number of active health workers is expected to increase to 3.02 million by the year 2030.
The density of health professionals is about 41 skilled health professionals per 10 000 persons when
considering the actual stock, after adjusting the active health workforce estimates which are reflecting
density of only 17.1 skilled doctors and nurses/midwives in the active health workforce. On including AYUSH
professionals, the density is around 20.6 skilled doctors and nurses/midwives in the active health workforce.

3.3 Health workers’ need at different WHO recommended thresholds and
estimated shortages by the year 2030
The desired number of doctors and nurses to meet the overall HRH: population ratio thresholds of 34.5
and 44.5 per 10 000 population were estimated assuming a doctors: nurses/midwives ratio of 1:2. Fig. 7.
provides a comparison of actual need and expected HRH supply in terms of total stock and active health
workforce. The supply side scenario has taken into account the opening of new institutions for doctors
and nurses during 2020–2025.
Figure 5. Comparison of HRH supply and need of health worker
(In million),
Fig. 7. Comparison of HRH supply and need byof2030
health worker (In million), by 2030
Supply Need by 4.37

Health professionals (In million)
by 2030 2030
3.39
2.74
2.15
1.51 1.67
1.41
1.10
Health workers in active Available stock of health Health worker need for Health worker need for
health workforce professionals threshold of 34.5 HWs per threshold of 44.5 HWs per
10,000 population 10,000 population
Doctors Nurses (/midwives)

Note: Supply of health professionals/workforce by 2030 has been estimated considering all the announced opening of new
institutions for doctors and nurse /midwives.
In Fig. 7. it is observed that the estimated HRH supply is not sufficient and reflects shortage of a large
number of health workers to meet 34.5 and 44.5 density of HWs per 10 000 population by the year 2030.
The shortage estimates reflect a shortfall of 0.16 million doctors in total stock by the year 2030 to meet
the density threshold of 34.5 skilled health worker per 10 000 population. The shortages at the same
threshold are much higher (0.57 million) if the active health workforce is considered. At the density of
44.5, both the stock and active health workforce report doctor shortage of 0.64 million and 1.05 million
respectively. Appendix A-VIII presents the projected shortage of doctors at different thresholds for the
years 2020, 2025 and 2030.

Figure 6. Estimates of health worker shortages (in million) by
2030 at WHO thresholds
Fig. 8. Estimates of health worker shortages (in million) by 2030 at WHO thresholds
0.64
Density of health worker per 10,000 population
At threshold density At threshold density Doctors
1.05
1.63
of 44.5
Nurses (/midwives)
2.96
Doctors 0.16
0.57
0.65
of 34.5
Nurses (/midwives)
1.98
0.00 0.50 1.00 1.50 2.00 2.50 3.00

Shortage of health worker (in million)
Stock of health professionals Active health workforce
Note: With an assumed, doctors: nurses /midwives ratio of 1:2
The nurse’s shortage in stock is estimated to reach up to 0.65 million by the year 2030 to meet the
threshold of 34.5 skilled health worker per 10 000 population. The shortages at the same threshold are
more than three-fold if the number of nurses/midwives who are actively working and providing health
care services is considered. Thus, the estimates of an active workforce reflect a shortage of 1.98 million
nurses/midwives in human health services by the year 2030.
For density of 44.5 skilled health worker per 10 000 population, both the stock and active health workforce
report a shortage of nurses of approximately 1.63 million and 2.96 million respectively. Appendix A-IX
presents the projected shortage of nurses/midwives at different thresholds for the years 2020, 2025
and 2030.
3.4 Strategies and required volume of investment for overcoming gaps in

HRH by 2030
3.4.1 Strategies
Given the shortages in HRH, it is crucial to develop strategies for enhancing the production of health
professionals, making efficient investments in development, strengthening HRH to address these
shortages and meeting the recommended WHO thresholds. To ensure all these objectives are met,
different strategies of investment for doctors and nurses/midwives are enumerated in Table 3.
It is estimated that the production would be completed within the next four years (up to 2025) to achieve
SDGs by 2030. This was done taking into account the duration of medical education (year of admission
and year of pass-out), which varies from 4 years for a nursing graduate to 5.5 years for a medical
graduate. For proposing the scenarios, the team estimated health professionals (doctors and nurses/
midwives intake and pass-outs per institution (Appendix A-III) and compared it with different countries
(Appendix A-IV).
In order to overcome the shortages, two-fold strategies may be used, namely expanding seats in existing
institutions; and increasing the number of educational institutions. The expansion of seats may need
relatively lower amount of investment as compared with opening of new institutions. Thus, priority could
be given to expand seats in the existing institutions. However, the expansion of seats in existing colleges
is not sufficient and opening of new institutions will be required to meet the referred two HRH: population
thresholds. Different alternative strategies for increased levels of production of doctors and nurses are
presented in Table 3.

Appendix A-X presents the required annual and total production of doctors and nurses/midwives for
overcoming shortages, by 2030.
Table 3. Strategies for production of doctors and nurses/midwives to overcome

HRH shortages by 2030
Strategy Doctors Nurses/midwives
scenarios
Scenario 1 1) Expanding current average 136 seats 1) Utilizing existing capacities in nursing
to 150 seats in existing medical col- institutions to increase average pass-
leges out up to 40 pass-out/nursing colleges
2) Opening new medical colleges for 2) Opening new nursing colleges for
overcoming the remaining doctors overcoming remaining nurses /mid-
shortages wives shortages
• Lower bound: 199 and 1005 new • Lower bound: 198 to 4288 new
medical colleges required to meet nursing institutions to meet 34.5
34.5 and 44.5 threshold respec- and 44.5 threshold respectively
tively • Upper bound: 5755 and 9845 new
• Upper bound: 885 and 1691 new nursing institutions to meet 34.5
medical colleges required to meet and 44.5 threshold respectively
34.5 and 44.5 threshold respec-
tively
Scenario 2 1) Expanding current average 136 seats 1) Utilizing existing capacities in nurs-
to 170 seats in existing medical col- ing institutions to increase average
leges pass-outs up to 40 pass-outs/nursing
2) Opening new medical colleges for college
overcoming remaining doctors short- 2) Expanding current average 40 seats
ages to 50 seats in existing nursing institu-
• Lower bound: 96 and 915 new tions
medical colleges required to meet 3) Opening new nursing colleges for
34.5 and 44.5 threshold respec- overcoming the remaining nurses/mid-
tively wives shortages
• Upper bound: 795 and 1601 new • Lower bound: 3103 new nursing
medical colleges required to meet institutions to meet 44.5 threshold
34.5 and 44.5 threshold respec- respectively
nursing institutions to meet 34.5
and 44.5 threshold respectively
Scenario 3 1) Expanding current average 136 seats 1) Utilizing capacities in existing nurs-
to 175 seats in existing medical col- ing institutions to increase average
leges pass-outs up to 40 pass-outs/nursing
2) Opening new medical colleges for college
overcoming remaining doctors short- 2) Expanding current average 40 seats
ages to 60 seats in existing nursing institu-
• Lower bound: 87 and 892 new tions
medical colleges required to meet 3) Opening new nursing colleges for
34.5 and 44.5 threshold respec- overcoming remaining nurses(/mid-
tively wives) shortages
• Upper bound: 772 and 1578 new • Lower bound: 1918 new nursing
medical colleges required to meet institutions to meet 44.5 threshold
34.5 and 44.5 threshold respec- respectively
nursing institutions to meet 34.5
and 44.5 threshold respectively
The average number of seats for doctors were estimated using the data on total number of medical
colleges and available seats. Similarly, for nurses the total number of nursing institutions and the total
available seats were extracted from the council reports. The average seats estimation was done after
including the proposed new medical colleges and nursing institutions, by the year 2025. The number of
annual supply (or pass-outs) will be less than the total seats available.

Based on the review, the study team estimated the current average number of seats using the total seats
taken up by students per annum based on available training capacity. In case of nurses, the number of
new registrations per annual training capacity was used to estimate the annual supply and for estimating
the average seats. Appendix A-III presents the supply side parameters of doctors and nurses/midwives.
For overcoming the shortage of doctors, the strategies used three different scenarios. Scenario 1
involved expansion of current average 136 seats per institution to 150 seats in existing colleges and
overcoming the remaining health worker shortages with opening of 200–1000 new medical colleges (150
seats/college) for overcoming 34.5 threshold shortages, depending on different investment scenarios.
Similarly, nurses’ shortages could be overcome using three scenarios.
The main strategy for overcoming nurses’ shortages was to utilize the existing seat capacity in existing
institutions by encouraging and attracting youth to join the nursing sector. This should be coupled with
expansion of seats and opening of new colleges (60 seats/college). In addition, alternative scenarios of
seat expansion in existing institutions was also considered in scenarios 2 and 3.
Strategy 1 used to overcome shortages in stock by the year 2030

Fig. 9. presents the strategy proposed for overcoming doctor’s shortage in actual stock and to meet
density thresholds of 34.5 and 44.5 health worker per 10 000 population. The scenarios 1, 2 and 3
were formulated to overcome doctor’s shortages by an annual additional production of 0.04 million and
0.16 million for four years (say, during 2021 to 2025) to meet threshold density of 34.5 and 44.5 per 10
000 population respectively. A strategy is also presented using the expansion of seats in existing and
proposed medical colleges, along with the required number of new colleges. The strategy to overcome
doctors shoratges in actual stock by 2030 is given in Appendix A-XI.
Furthermore, it is evident that the shortage in the stock of doctors at the 34.5 threshold of HRH: population
density can be overcome by an annual production of doctors to the tune of 10 000 by expanding the
seat capacity from current average of 136 to 150 seats per institution. This can be combined with 30 000
doctors to be produced from 199 new colleges of average seat capacity of 150. As an alternative, same
shortages can be overcome by seat expansion to produce 20 000 doctors and an additional 20 000 from
96 new institutions. Since the shortage is much larger at the 44.5 threshold, there is need to produce
more new doctors by opening a larger number of new institutions as in 1005 institutions under scenario
1; about 915 institutions under scenario 2; and 892 institutions under scenario 3.
Figure 7. Strategy to overcome actual stock shortages of doctors at
different
Fig. 9. Strategy WHO actual
to overcome thresholds,
stock by 2030 of doctors at
shortages
different WHO thresholds, by 2030
Required annual production of
doctors (in million) by 2025
0.14 0.13
0.15
0.02 0.01
0.03
0.02 0.03 0.02 0.03
0.01 0.01
Scenario 1‐ Scenario 2 ‐ Scenario 3 ‐ Scenario 1 ‐ Scenario 2 ‐ Scenario 3 ‐
199 new 96 new 87 new 1005 new 915 new 892 new
colleges colleges colleges colleges colleges colleges
At threshold 34.5 health worker per 10 000 population At threshold 44.5 health worker per 10 000
population
Addional seats required (Opening new medical colleges)

Expansion of seats in existing (/proposed) medical colleges

Similarly, for meeting the shortage in the stock of nurses at the 34.5 and 44.5, an alternate scenario is
presented in Fig. 10. For meeting the shortage in the stock of nurses, the most crucial point will be fuller
utilization of existing seat capacities of the institutions. Average seat to pass-out ratio in the existing
nursing institutions is estimated to be as low as 0.47.
In fact, shortage at the 34.5 threshold can be met easily only by 90–95% capacity utilization of seats in
existing institutions so that no new institutions will be needed. However, to meet the higher threshold of
44.5, opening new nursing institutions in the range of 2000 to 4000 will be required even after greater
utilization of the seat capacity of the existing institutions. The strategy to overcome nurses/midwives
shortages in actual stock is given in Appendix A-XII.
Figure 8. Strategy to overcome actual stock shortages of nurses/midwives at
Fig. 10. Strategy to overcome actual
different stock shortages
thresholds, by 2030 of nurses/midwives at
different thresholds, by 2030
Required annual production of nurses
0.12
/(midwives) (in million) by 2025
0.19
0.26
0.01 0.29
0.22
0.15 0.16 0.16 0.15
Scenario 1‐ Scenario 2 Scenario 3 Scenario 1 ‐ Scenario 2 ‐ Scenario 3 ‐

198 new 4288 new 3103 new 1918 new
colleges colleges colleges colleges
At threshold 34.5 health worker per 10 000 At threshold 44.5 health worker per 10 000
population population
Additional seats (Opening new nursing colleges)

Seats expansion in existing colleges (/increasing utilization rate)
Strategy 2 used to overcome shortages in active health workforce by the year 2030
Fig. 11. and Fig. 12. present the strategy proposed for overcoming doctors and nurses/midwives shortage
respectively in the active health workforce. Since the current estimates of active health workforce is
significantly lower than the current stock of health professionals, shortage of doctors and nurses to
meet referred thresholds of HRH: population density are much higher compared to the shortage in stock
situations.
Shortage of doctors at the 34.5 and 44.5 for the year 2030 is projected to be approximately 0.57 million
and 1.05 million respectively. The scenarios 1, 2 and 3 are formulated to overcome doctor’s shortage by
an annual additional production of 0.14 million and 0.26 million for four years (say, during 2021 to 2025)
to meet threshold density of 34.5 and 44.5 per 10 000 population respectively. To meet this gap, a large
number of institutions need to be opened to produce new graduates.

Figure 9. Strategy to overcome active health workforce shortages of
doctors at different WHO thresholds, by 2030
Figure 9. Strategy to overcome active health workforce shortages of

doctors at different WHO thresholds, by 2030
Fig. 11. Strategy to overcome active health workforce shortages
of
2025 by 2025
annual production
of doctors at different WHO thresholds, by 2030
of
bymillion)
0.25 0.24 0.24

production
0.13 0.12 0.12

million)(in
0.24 0.24
doctors (indoctors
Required
0.01 0.02 0.03 0.25

0.01 0.02 0.03
Required annual
Scenario
0.13 1‐ Scenario 0.12 3 ‐
0.12 2 ‐ Scenario Scenario 1 ‐ Scenario 2 ‐ Scenario 3 ‐
colleges
0.01 colleges
0.02 colleges
0.03 colleges
0.01 colleges
0.02 colleges
0.03
At threshold 34.5 health1‐worker
Scenario per 10
Scenario 2 ‐000Scenario
population
3 ‐ At threshold 44.5 health1worker
Scenario per 10
‐ Scenario 2 ‐000Scenario
population
3‐
Expansion colleges
of seats in existing colleges colleges Addional seats (Opening
colleges new medical
colleges colleges)colleges
colleges
At threshold 34.5 health worker per 10 000 population At threshold 44.5 health worker per 10 000 population
Expansion of seats in existing colleges Addional seats (Opening new medical colleges)
Figure 10.Strategy
Fig. 12. Strategyto
toovercome
overcomeactive
activehealth
healthworkforce
workforceshortages
shortages of
of nurses
nurses
(/midwives)at
(/midwives) atdifferent
different WHO
WHO thresholds,
thresholds, by
by2030
2030
Figure 10. Strategy to overcome active health workforce shortages of nurses

2025 by 2025
(/midwives) at different WHO thresholds, by 2030

of
0.45
annual production
0.59 0.52
(inbymillion)
0.20
0.35 0.27
of
0.45
annual production
0.29 0.59 0.52 0.29

(in million)
0.22 0.22
0.15 0.20 0.15
nurses(/midwives)
0.35 0.27
Scenario 1 : Scenario 2 : Scenario 3 : Scenario 1 : Scenario 2 : Scenario 3 :
Required Required
5755 new 4570 new 0.29

3385 new 9845 new 8660 new 0.29
7475 new
0.22 0.22
0.15 0.15
nurses(/midwives)

At threshold 34.5 health1worker
Scenario per 10
: Scenario 2 :000Scenario
populationAt
3: threshold 44.5 health1worker
Scenario per 10
: Scenario 2 :000Scenario
population
3:
Additionalcolleges
colleges seats (Opening new nursing colleges) colleges
colleges colleges colleges
Seatsworker
At threshold 34.5 health expansion in 000
per 10 existing colleges (/increasing
populationAt utilization
threshold 44.5 health rate)
worker per 10 000 population
The strategy to overcome Additional seats (Opening

the shortage new in
of doctors nursing colleges)
an active health workforce are given in Appendix
A-XIII. Approximately 0.12 to 0.13 million new graduates need to be producedrate)
Seats expansion in existing colleges (/increasing utilization by opening new institutions
for meeting the gap at 34.5 density and 0.24 to 0.25 million doctors produced by opening new institutions
for bridging gaps at 44.5 density by 2030. However, for increasing the production of nurses, the main
strategy still could be utilizing the capacities in the existing institutions coupled with opening of new
institutions. The strategy to overcome shortage of nurses in the active health workforce is given in
Appendix A-XIV.
3.4.2 Required investment

The study team proposed the required investment in two range bounds of investment 1) Lower bound of
investment which considered the shortages of HRH in projected stock and 2) Upper bound of investment
which considered the shortages of HRH in projected active health workforce.
A middle bound of scenario considering shortages of HRH in projected active health workforce after
adopting an alternative strategy was also considered. This was done by attracting and adding 50% of

currently non-working health professionals (or out of labour force) in the health workforce and including
traditional medical practitioners (AYUSH).
Lower bound of investment

a) Investment scenario for doctors: In the lower bound of investment, the investment scenarios
are structured on parameters such as increasing average number of seat intake in the existing
institutions by 14, 34 and 39 seats in existing colleges along with opening of the 199, 96 and 87
new medical colleges respectively to produce new medical graduates (doctors) during the period
of 2021–2025 to overcome shortages at the threshold of 34.5 skilled health workers per 10 000
population by the year 2030.
Similarly, three scenarios have been presented to meet the threshold of 44.5 skilled health worker
per 10 000 population, increasing the average number of seat intake in existing institutions by 14,
34 and 39 seats along with the opening of 1005, 915 and 892 new medical colleges respectively.
In a best case scenario to meet the shortage of doctors in stock, there will be a need to increase
the average number of seats by 34 seats in existing colleges and consider opening of 87 new
medical colleges, costing INR 523 billion to meet the threshold of 34.5 health workers density
per 10 000 population by the year 2030. At the same time, considering the other scenarios, the
estimated investment cost ranges from INR 523 billion to INR 692 billion to meet the threshold
density of 34.5. Meanwhile, the investment need escalates in the range of INR 2941 billion to
INR 3109 billion to overcome doctor’s shortages and to meet the threshold density of 44.5 skilled
health workers per 10 000 population (Table 4).
b) Investment scenario for nurses/midwives: Table 4 also includes estimates on the required
investment for producing nurses/midwives under the three scenarios for bridging the gaps at
the HRH: population density of 34.5 and 44.5. The results indicate that to overcome the nurse’s
shortage in the actual stock at the 34.5 threshold, only increasing the proportion of passing-out/
seat capacity in the existing nursing institutions will be sufficient and an investment of INR 17–58
billion will be needed for opening new nursing institutions. However, to meet the threshold of 44.5
skilled health workers per 10 000 population, the investment need escalates in the range of INR
707 billion to INR 1136 billion.

Table 4. New investment required for meeting the shortage of
nurses/midwives and doctors by 2030
Parameters WHO HRH Estimated cost of investment (in billion)
recommended shortage# Scenario 1 Scenario 2 Scenario 3
density (in million)
threshold Cost of Total Cost of Total Cost of Total
opening cost opening cost opening cost
new (in new (In new (in
colleges billion)^ colleges billion)^ colleges billion)^
(in billion) (in billion) (in billion)
Lower bound of investment – Actual stock shortages
Doctors* 34.5 skilled 0.04 598 692 289 519 260 523
health worker/
10 000
population
44.5 skilled 0.16 3015 3109 2745 2947 2677 2941
health worker/
10 000
population
Nurses/ 34.5 skilled 0.16 53 53 0 17 0 17
midwives ** health worker/
10 000
population
44.5 skilled 0.41 1136 1136 822 922 508 707
health worker/
10 000
population
Upper bound of investment – Active health workforce shortages
Doctors* 34.5 skilled 0.14 2654 2749 2384 2614 2317 2580
health worker/
10 000
population
44.5 skilled 0.26 5072 5166 4802 5031 4734 4998
health worker/
10 000
population
Nurses 34.5 skilled 0.49 1525 1525 1211 1310 897 1096
health worker/
/midwives** 10 000
population
44.5 skilled 0.74 2609 2609 2295 2394 1981 2180
health worker/
10 000
population
# Required production per annum for a duration of 4 years (Total required production/4)
^ The investment estimates include cost of seats expansion in existing/proposed colleges
* Doctors: Cost of increasing seats-1 crore/ seat; cost of opening new medical colleges-300 crore/college
** Nurses: Cost of increasing 1 seat-0.14 crore; cost of opening 1 nursing college-26.5 crore
Upper bound of investment

a) Investment scenario for doctors. The upper bound of investment required to meet the shortage
of doctors in the active health workforce by 2030 reflects that investment in the range of INR 2500
to 5000 billion is required. A large part of such investment is needed for opening new medical
colleges in the range of 770 to 1700 during 2021 to 2025 with an average intake capacity of 150.
Simultaneously there will be need to expand seat capacity in existing institutions by 14, 34 and 39
seats per institution.

b) Investment scenario for nurses/midwives. To meet the threshold of 34.5 skilled health workers
per 10 000 population, the average number of seat intake must be increased in existing colleges
by 0, 10 and 20 seats and opening of 5755, 4570 and 3385 new nursing institutions respectively.
Meanwhile, to meet the threshold of 44.5 skilled health workers per 10 000 population, similar
three scenarios have been presented based on increasing average pass-outs from existing
institutions, along with increasing the average number of seat intake in existing colleges by 0, 10
and 20 seats and opening of 9845, 8660 and 7475 new nursing institutions, respectively with an
average intake capacity of 60.
The estimated investment ranges from INR 1096 billion to INR 1525 billion to meet threshold density of
34.5 skilled health worker per 10 000 population. The investment costs further escalated in the range of
INR 2180 billion to INR 2609 billion to meet threshold density of 44.5 skilled health worker per 10 000
population. The required investment to meet nurses/midwives shortage in active health workforce to
meet the recommended WHO threshold by 2030 is given in Table 4.
Middle bound investment and strategy to overcome active health workforce shortages
by the year 2030
The engagement of even half the non-working (out of labour) health professionals in the health sector
is likely to reduce shortage of health workers at each level of threshold. Thus, in turn, creating a much
lower investment requirement than that needed to overcome actual active health workforce shortage.
As a middle level investment scenario, an alternative strategy to estimate the required investment
has been estimated to overcome HRH shortages in the active health workforce. This includes 50%
of estimated out of workforce (unemployed + out of labour force) health professionals into the health
workforce (Table 5 and 6).
Figure 11. Strategy

Fig. 13. Strategy to
to overcome
overcomedoctor’s
doctor’s shortage
shortage in
in active
activehealth
health
workforce shortages (Middle bound of investment), by
workforce shortages (Middle bound of investment), by 20302030
At threshold of 44.5 per 10 000 population

At threshold of 34.5 per
Required annual production of
Strategy A*
doctors (in million) by 2025
10,000 population^ 2.06 1.93 1.9
AYUSH
1.26 Strategy A +
Strategy A* 1.12 1.09 AYUSH*
0.85 0.8
AYUSH 0.72 0.69 0.65 0.62
0.009
0.005 0.23 0.26 0.23 0.26 0.23 0.26 0.23 0.26
0.015 0.015 0.09 0.09 0.09 0.09

Addional seats (Opening new nursing colleges)
Note: * Adopting strategy A of including 50% of out of labour force doctors (0.19 million) from actual stock to overcome active
health workforce; ^ After including both strategy A & AYUSH, there are no shortages to meet 34.5 threshold.

Figure 12. Strategy to overcome active health workforce shortages of nurses
Fig.(/midwives) at different
14. Strategy WHO active
to overcome threshold (Including
health 50% out
workforce of labourofforce
shortages nurses
(/midwives) at different WHO threshold nurses ) by 2030
(Including 50% out of labour force nurses) by 2030
of nurses (/midwives)(in million) by 2025

Required annual production
0.31
0.38
0.45
0.07
0.14
0.21
0.29 0.29
0.22 0.22
0.15 0.15
Scenario 1 : Scenario 2 : Scenario 3 : Scenario 1 : Scenario 2 : Scenario 3 :

At threshold 34.5 health worker per 10,000 At threshold 44.5 health worker per 10,000
population population
Additional seats (Opening new nursing colleges)

Note: *Adopting strategy of including 50% of out of labour force nurses/midwives (0.55 million) from actual stock to overcome
active health workforce.
Table 5 also presents health worker shortages after including AYUSH practitioners in the active health
workforce. Fig. 13. and Fig. 14. presents the proposed strategy to overcome shortages for doctors and
nurses/midwives respectively, after including 50% of estimated non-working health professionals and
AYUSH practitioners into the health labour market.
Table 5. Middle bound investment to

overcome shortage of doctors in active health workforce^.
Parameters Threshold Scenario 1 Scenario 2 Scenario 3
(shortages) Cost of Total cost Cost of Total cost Cost of Total
opening (in billion)^ opening (in billion)^ opening cost (in
new new new billion)^
institutions institutions institutions
(in billion) (in billion) (in billion)
Doctors 34.5 (0.015 103 197 0 146 0 146
shortage million)
(Including only 44.5 (0.14 2520 2615 2250 2480 2183 2446
AYUSH) million)
Doctors 34.5 (0.09 1710 1805 1440 1670 1373 1636
(strategy A**) million)
44.5 (0.22 4128 4222 3858 4087 3790 4053
million)
Doctors 34.5 No shortages
(strategy A + 44.5 (0.08 1576 1671 1306 1536 1239 1502
AYUSH) million)
** Strategy A including 50% medically qualified health professionals who are not part of the health workforce
^ Doctors: Cost of increasing seats-1 crore/ seat; cost of opening new medical colleges-300 crore/college
a) Investment scenario for doctors. Table 5 presents the middle bound investment required to meet
the shortage of doctors in the active health workforce after including half of out of workforce doctors
into the workforce by 2030. Adopting the alternate strategy, to meet the thresholds of 34.5 and 44.5
skilled health workers per 10 000 population. At both the thresholds, an increase in seat capacity in
existing institutions is proposed as 14, 34 and 39 seats per institution. If 50% of the current out of
workforce health professionals join the workforce, there will be a need to open 570, 480 and 458 new

medical colleges under the three scenarios respectively. However, at the higher thresholds of 44.5, the
requirement of opening new colleges will be 1376, 1286 and 1263 respectively.
Hence, the estimated investment cost ranges from INR 1636 billion to INR 1805 billion to meet threshold
density of 34.5 skilled health worker per 10 000 population. The required investment costs range from
INR 4053 billion to INR 4222 billion to meet the threshold density of 44.5 skilled health worker per
10 000 population.
The Indian health system also includes AYUSH practitioners. This would be around 0.51 million
adequately qualified practitioners who will be available in the active health workforce by 2030, catering
to health care needs of the population. The government also recognizes them to be a part of the
health workforce that is providing health care needs. Including AYUSH practitioners to supplement the
shortage of allopathic doctors can reduce the cost involved in creating new HRH in India. If only AYUSH
practitioners are included, the investment cost could range from INR 146 billion and INR 197 billion to
overcome shortage of doctors, to meet 34.5 health worker threshold per 10 000 population.
For these scenarios, the strategy of seats expansion by 10 and 20 seats are to be done only in 429 and
374 medical colleges respectively. However, the required investment ranges from INR 2446 billion to INR
2615 billion to meet the 44.5 health worker threshold per 10 000 population. If both 50% not working (out
of labour) allopathic doctors and AYUSH practitioners are included, the investment requirement drops to
INR 1502 billion to INR 1671 billion to overcome HRH shortages at 44.5 health worker threshold per 10
000 population. The cost of investment (middle bound investment) scenarios to overcome the shortage
of doctors in active health workforce is given in Appendix A-XV.
b) Investment scenario for nurses/midwives. Table 6 proposes the required investment to meet the
shortage of nurses/midwives in the active workforce. This would be done after including half of the out
of the workforce nurses/midwives into the workforce by the year 2030. To meet the threshold of 34.5
skilled health workers per 10 000 population, shortages can be overcome by increasing the average
number of seat intake in existing colleges by 0, 10 and 20 seats and opening of 3470, 2285 and 1100
new nursing colleges respectively.
Meanwhile, to meet the threshold of 44.5 skilled health workers per 10 000 population, three scenarios
are presented based on an increasing average pass-out from existing institutions, along with increasing
the average number of seat intake in existing colleges by 0, 10 and 20 seats and opening of 75 606 375
and 5190 new nursing colleges respectively.
The investment costs range from INR 491 billion to INR 919 billion to meet the threshold density of 34.5
skilled health worker per 10 000 population. The investment costs further escalate from INR 1574 billion
to INR 2003 billion to meet the threshold density of 44.5 skilled health worker per 10 000 population. The
investment scenarios to overcome nurse’s/midwives shortages in active health workforce using 50% of
not working (out of labour) nurses is given in Appendix A-XVI.
Table 6. Middle bound investment to overcome active health

workforce shortage of nurses by 2030
Parameters Investment cost ^
WHO Nurses Scenario Cost of Cost of opening Total cost (in
recommended /midwives expansion of new institutions billion)
density threshold shortages seats (in billion)
(in million) (in billion)
34.5 health Scenario 1 0 919 919
worker per 10 000 0.36 Scenario 2 100 605 705
population
Scenario 3 199 291 491
44.5 health Scenario 1 0 2003 2003
worker per 10 000 0.6 Scenario 2 100 1689 1789
population
199 1375 1574
^ Nurses: Cost of increasing 1 seat-0.14 crore; Cost of opening 1 nursing college-26.5 crore

Alternative scenario using government medical colleges for overcoming doctor’s
shortages by 2030
In Fig. 15. the magnitude of investment required to overcome shortage of doctors only using government
medical colleges for seat expansion is provided. In this scenario, an estimated additional capacity of
26 726 seats in government medical colleges has been estimated by increasing the intake of seats
up to 200 per college, exclusively in colleges with current uptake below 200. Thus, to overcome stock
shortages, the estimated cost of expansion and opening of new medical colleges is about INR 519 billion
and INR 2937 billion to overcome shortages and to meet the threshold of 34.5 and 44.5 respectively.
Similarly, the estimated middle bound investment after introducing 50% out of workforce health
professionals into the active workforce is INR 1632 billion to INR 4049 billion to overcome shortages
and to meet threshold of 34.5 and 44.5 respectively. Including only AYUSH, the investment cost is INR
146 billion to INR 2442 billion to overcome 34.5 and 44.5 health worker threshold per 10 000 population.
While including both AYUSH and 50% out of labour professionals, there are no shortages at 34.5 and to
overcome shortages at 44.5 threshold, the estimated cost is INR 1498 billion.
Meanwhile, to overcome active health workforce shortages, the estimated upper bound of investment
is INR 2576 billion and INR 4994 billion to meet threshold of 34.5 and 44.5 respectively. Detailed
investment scenario to overcome the shortage of doctors by the year 2030, using government medical
colleges, is given in Appendix A-XVII.
Thus, to meet the threshold density of 34.5 health worker per 10 000 population, the investment amount
to overcome shortage of doctors in actual stock ranges from INR 523 billion in scenario 3 to INR 692
billion in scenario 1. However, the investment amount escalates to INR 2941 billion to INR 3109 billion to
overcome threshold of 44.5 health worker shortages. Similarly, for nurses, the investment amount will be
in the range of INR 17–53 billion and INR 700–1200 billion for overcoming shortage of nurses/midwives
at 34.5 and 44.5 per 10 000 population.
In the upper bound, to overcome the active health workforce shortages, the investment cost is estimated
to be about INR 2580 billion in scenario 3 to overcome shortage of doctors at 34.5 threshold. However, the
investment cost escalates to around INR 5000 billion for overcoming shortage of doctors at 44.5 threshold.
Figure
Fig. 15. 13. Investment
Investment scenariototoovercome
scenario overcome doctors
doctors shortages
shortagesusing
using
government colleges (In billion), by 2030
government colleges (In billion), by 2030
Upper bound of
Middle bound of investment investment
Lower bound of
Cost of investment (In billion)
4,726
3,782
2,670
2,175 2,309
1,365 1,231
252 146
267 267 267 267 267 267 267 267
34.5 : 84 44.5: 890 34.5 44.5 : 725 34.5: 455 44.5: 1261 34.5 : 410 34.5 : 770 44.5 : 1575
new colleges new colleges new colleges new colleges new colleges new colleges new colleges new colleges
AYUSH STRATEGY A STRATEGY A +

AYUSH
WHO recommended threshold per 10 000 population (Required opening of new colleges)
Cost of seats expansion Cost of opening new colleges

For overcoming shortage of nurses at 34.5 threshold, the required investment is about INR 1096 billion
in scenario 3 to around INR 1525 billion in scenario 1. However, to meet 44.5 threshold, the required
investment is about INR 2180 billion in scenario 3 to around INR 2609 billion in scenario 1. The middle
bound of investment after including AYUSH practitioners drops to about INR 146 billion in scenario 3 to
overcome 34.5 threshold shortages. The required investment is around INR 2446 billion to overcome
shortages to meet 44.5 threshold.
Meanwhile, after applying the strategy to include 50% non-working (out of labour) health professionals,
the investment cost of about INR 1636 billion and INR 4053 billion in scenario 3 are needed to meet the
34.5 and 44.5 health worker per 10 000 population respectively, by the year 2030. Summary of three
bounds of investment scenarios to overcome shortages of doctors and nurses/midwives is given in
Appendix A-XVIII.
3.5. Estimated benefits of enhanced investment in HRH

The estimates of HRH shortages, reflect the requirement of 0.57 million doctors and 1.98 million nurses/
midwives to overcome HRH shortages in the active health workforce. Notably, there are differences in
the actual available HRH stock and HRH actively participating in health workforce. However, it is the
actively working health workers who mainly provide human health services and cater to population
needs. Thus, for estimating benefits, the quantum of investment required for overcoming HRH shortages
in the active health workforce have been used to meet the threshold of 34.5 health worker per 10 000
population by the year 2030. Thus, the estimated upper bound of investment of INR 3676 billion will
create an employment for 2.55 million health workers in the workforce. Meanwhile, the health sector
also employs support staff which includes sanitarians, clerks, motorists, cashiers and so on.
In addition, enhanced employment of doctors and nurses/midwives will need employment of health
associate personnel such as nutritionists, dieticians, optometrists, sanitarians, diagnostic assistants etc.
The team estimated the proportion of support staff and health associate personnel separately to the
number of doctors and nurses/midwives from the baseline data on active health workforce for the period
2018–2019. This ratio was applied on the projected number of doctors and nurses/midwives for the year
2030 to generate the number of support staff and health associate personnel for the same year. Finally,
they estimated marginal gross value added (GVA) because of the increased employment in the health
sector as a whole. Table 7 provides estimates of employment generation and gross value added to the
economy.
Table 7. Estimates of benefits of investment by 2030

Parameters HRH Employment generation (in million) Total gross value
investment health Support Health Total added annually (in
(in billion) professionals staff* associate** billion)
Active health workforce

34.5 skilled
health
worker per 3,676 2.55 0.85 0.85 4.25 2,693
10 000
population
^ HRH: Supportive staff-3:1, HRH:Health associate-3:1
* Supportive staff includes other support workers such as clerks, motor drivers, garbage collectors.
** Includes health assistants such as nutritionists, dieticians, optometrists and so on.
Table 7 reflects that the additional employment of 2.55 million consisting of doctors and nurses/midwives
with the investment scenario of INR 3676 billion will generate new 0.85 employment of support staff and
health associate personnel separately. This implies an investment of INR 3676 billion that will generate
a total employment of 4.25 million each year. For the present study, the team accounted for investment
to be made once during 2021 to 2025 to generate employment of 4.25 million by the year 2030.
They applied labour productivity (GVA/employment) in the health sector from the baseline of 2018–2019
and applied to the additional employment for the year 2030 to arrive at the marginal GVA because of the
increased employment. The GAV in the health sector in 2019–2020 was estimated at about INR 3275
billion at current prices. The total workers in the health sector (including support staff) was around 5.17

million. Thus, the labour productivity (GVA/employment) per worker stood at 6.33 lakhs. The marginal
GVA was estimated to be INR 2693 for the year 2030. Here it was important to note that the estimated
investment was a one-time requirement to be completed during the period 2021–2025 but contribution
to GVA because of increased employment was for each year for a longer period of time.

Chapter 4
Discussions and policy

implications
The returns of investment in health and HRH have been widely discussed in literature. These investments
have a multitude of effect beyond the health sector (WHO, 2016a). Moreover, it is estimated that the
creation of one health occupation in the health sector creates 1.5 new jobs for workers in non-health
occupations (Scheil-Adlung, 2016). Thus, these investments have the potential not only to improve
population health but also augment initiatives taken for achieving UHC. These steps can directly or
indirectly affect many other domains of improving sustainable standards of living through employment
generation and increased earnings. In the Indian context, such investments not only reduce the burden of
disease but also empower women through employment generation. Also, the labour market productivity
and formalization of labour increases with such investments as the majority of health sector comprises
of formal employment.
Past studies have noted acute shortages and lopsided distribution of health workforce in the country and
the needed investment to meet the health workforce/population ratio as recommended by WHO (Karan
et al., 2021, 2019; Rao et al., 2016). However previous studies do not estimate the volume of investment
required to meet the needed health workforce/population ratios.
In the present study, updated information is provided on shortages in HRH (doctors and nurse/
midwives) in India as compared with recommended different thresholds of HRH/population ratio before
projecting the situation up to 2030. Two sources of data have been used, namely NHWA and nationally
representative labour force survey (PLFS 2018–2019). The NHWA, which is mainly based on information
on registration of health professionals with different councils, reflects the total production and stock of
health professionals in the country. The NHWA data as of 2018 and projections for 2030 do not reflect
major shortages to meet the HRH/population ratio of 34.5. Even the higher thresholds of 44.5 can be
achieved with an annual investment of approximately INR 4000–5000 billion during the four year period
between 2021–2025.
However, the current estimates on actual active health workforce reflect major shortage of doctors
and nurses/midwives, even to meet the lowest health workforce/population ratio of 34.5. The shortage
declines marginally by 2030 mainly because of a likely increase in the number of institutions imparting
education to doctors and nurses/midwives during the period 2021 to 2025. To meet the gap at 34.5,
the investment need must be in the range of INR 3000 billion for doctors and INR 1100–1500 billion for
nurses. To meet the higher threshold of 44.5 HRH: population ratio by 2030, the required investment is
in the range of INR 8000 billion. These estimated required investments are actually a one-time capital
investment for four to five years during the period 2021–2025.
AYUSH practitioners are an integral part of the Indian health system and they play an important role in
delivering health services to the country’s population. If the active health workforce is added with AYUSH
qualifications, the shortage of an active health workforce in 2030 will be to the tune of 0.015 million and
0.14 million to meet the threshold of 34.5 and 44.5 HRH: population ratio respectively. The required
investment to bridge the gap will be in the range of INR 200 billion and INR 2615 billion respectively.
One of the main reasons of a large difference between the stock of health professionals and active
health workforce has been the large-scale labour market attrition. It is estimated that approximately 30%
individuals with a medical degree in medicine and more than 60% individuals with a diploma in medicine
are part of the current health workforce (Karan et al., 2021). Most qualified health professionals are

registered with their respective councils such as NMC and INC. Such labour market attrition is not
unique for India. Past studies have noted that voluntary attrition rates in nurses has been around 9.3%,
especially for several European countries (Lopes et al., 2017).
If efforts are made to bring back even 50% of the out of workforce health professionals into the workforce
by providing them improved wok environment, increase in retirement rates, posting to a place of their
choice, flexible work hours etc., there will be no shortage of active health workforce at the threshold of
34.5 HRH: population ratio. To meet the higher threshold of 44.5, the required investment may come
down to the level of INR 3000–3500 billion, especially if AYUSH is also considered as part of the health
workforce.
These investments are required on two fronts, namely opening of new institutions of education for
doctors and nurses; and expanding the existing intake capacities of existing institutions. There could
be a combination of these two strategies. For instance, expansion of existing intake capacity of 136
student per medical college to 150 students and 175 students per medical college on an average will
need opening of approximately 200–1000 new medical colleges. For nurses, better utilization of existing
capacities in different institutions is important.
Currently the average intake capacity of nursing institutions is approximately 41 students per institution.
However, the pass-out/training capacity from these institutions is estimated to be only 19 per institution.
Nurses’ availability in the workforce can be significantly improved if quality of education in nursing
institutions is enhanced and a higher pass-out rate achieved. In India, gaining employment in the public
sector is considered the main reason for opting for nursing education.
Low demand for trained nurses, mismatch between skills acquired during education and skills needed
by an employer are some of the reasons that affect employment opportunities (Seth, 2016). The decision
to join the public or private sector or opting for higher education are influenced by a range of socio-
economic factors and non-technical skills knowledge.
Students stated poor communication skills affecting their job prospects and those who had training in
non-technical skills by saying that they were much more likely to opt for higher education and private
jobs. Students suggested improvement in training facilities and placement services (Seth, 2016). Also,
low retention rate of nurses in the system has been one of the most important reasons of the shortage of
nurses in the active workforce. Effective commitment also influences the turnover of nurses. (Dasgupta,
2015). Only a few studies are conducted to understand the turnover of nurses in India. However, past
studies reported 28–35% attrition rates among nurses (Lakshman, 2016). Past studies also highlight the
poor quality of nursing faculties and inequitable distribution of nurses and unfilled/vacant positions of
sanctioned health workers posts in public health settings (Rao et al., 2011). Thus, it is highly important
to recognize the challenges and concerns in the nursing sector to maintain an adequate skill-mix and
quality of health care services.
Embedded in these estimates, are numerous factors and concerns which are present in medical
education. These invariably affect the supply of new graduates which in turn affects the total available
stock in the country. One of such factors is out-migration of qualified health professionals. Although out-
migration has slightly reduced in recent years, a major proportion of the workforce, say about 6.6% and
3% of doctors and nurses respectively are registered within Indian councils and are working in OECD
countries (Walton-Roberts and Rajan, 2020). Attracting these health professionals back to India can
reduce some shortages in the active health workforce.
While the government is planning to open several new medical colleges in the country, these initiatives
to increase the supply are not sufficient to meet WHO recommended thresholds and SDGs. So far,
government has announced establishing of 157 new medical colleges and eight All India Institutes
of Medical Sciences (AIIMS) in different parts of the country. However, the requirement of such new
institutions could be in the range of 750–1000 in order to bridge the gap of shortages on the active health
workforce. The underutilization of nursing schools is a major concern for developing HRH. Government
has initiated upgradation of nursing schools to colleges along with improving the quality of nursing
education in the country. It is also being considered to convert all GNM courses to graduate courses
(INC, 2019; Nagarajan, 2019).
The present study also reflects the acute shortage of nurses in the country. Moreover, the strategies to
overcome shortages, not only recommends the opening of new nursing colleges but also highlights the

need to attract young talent to join the nursing profession. This requires higher commitment and political
will to improve the quality of teaching faculty in the nursing institution, incentivizing nursing education
and provisioning attractive job opportunities for nurses.
Thus, the strategies presented in this study recommend the opening of a larger number of new
medical institutions and nursing colleges, along with expanding existing capacities. Given the gaps, it
is emphasized that there must be an increase in current public health spending, especially focusing on
creating a strong and much better health workforce. This will also help prepare and invest in health care
settings in order to absorb them, meet WHO recommended thresholds and fulfil the vision of equity and
UHC (MoHFW, 2017; Reddy et al., 2011).
The distribution of institutions for health professionals are lopsided in the country. On the supply-side
scenario for doctors, almost half the new graduates have passed out from public sector institutions.
However, amongst nurses/midwives, a majority (90%) of them are in the private sector (INC, 2021;
NMC, 2021). Thus, the estimated volume of investment can be distributed in similar proportion in both
sectors. In addition to this, higher contribution and commitment of the public sector towards enhancing
HRH density in the country is recommended.
The present study estimated employment generation at 4.25 million new workers in the health sector.
Such increased employment has the potential to contribute substantially to the national income. The
estimated marginal gross value addition because of increased employment is to the tune of annual INR
2696 billion at constant 2019–2020 prices. The estimated quantum of investment is the total volume
required for one time during the period 2021–2025. However, once shortages are met with these
investments, the returns will be perpetual. For instance, if the estimated investment is made during the
next one to two years, the return on the investment will be five times higher of the estimated annual
marginal value added of INR 2696 (for the period 2026–2030) as of 2030. Thus, these investments not
only help to achieve UHC and SDGs but also contribute to the national income.
This study has a few obvious limitations while estimating the much-needed investments and benefits of
such investments. First of all, the study only estimated a one-time capital investment need for producing
more number of doctors and nurses. These investments will be needed for the expansion of seating
capacities in existing educational institutions and the opening of new institutions. However, the study
did not estimate the required annual recurring expenditure likely to be made on faculty recruitment,
consumables, maintenance etc. Similarly, the size of benefits estimated in the study remain limited to
only employment generation and labour productivity in the health sector and more for only one year.
However, the benefit of such investments are expected to flow beyond the health sector and over many
years. The study recommends that a more detailed study for estimating total costs of investments and
benefits be conducted.
Second, for estimating the size of the active health force, the methods in this study assume a constant
labour market attrition rate, i.e. proportion of qualified health professionals who are not part of the health
workforce. However, the labour force survey in the future may reflect a varied attrition rate. This has
the portential to affect the projected size of the estimated active health workforce in the current study.
To address this issue in a limited way, the study only considers a moderate labour market attrition of
qualified health professionals.
The study has come up with the following recommendations to improve the HRH to meet the WHO
recommended thresholds and to attain a better health status in the global scenario:
1) Investing in opening new medical colleges. In general, production of new graduates in India
is considerably lower to that in OECD and BRICS countries. India needs to significantly increase
the supply of new graduates by increasing the number of institutions from the present level of 675
medical colleges and 7110 nursing institutions. The increase in the number of medical colleges
and nursing institutions may be to the tune of 1000 and 5000 respectively.
2) Investing in the development of HRH infrastructure and improving the quality of nursing
education. The infrastructure for creating the required health workforce should be developed
in the existing institutions or by creating newer ones to develop health professionals to meet
future shortages in HRH. The quality of nursing education and institutions should be upgraded to
address the poor quality and low pass-out rates in nursing institutions.

3) Increasing enrollment and attracting of students to the nursing profession. There is urgent
need to increase enrollment of students in existing institutions and motivating students to join the
nursing profession. Greater emphasis must be given to improvising the nursing faculty and the
infrastructure of nursing institutions along with providing good employment opportunities. This will
help create quality nurses and encourage them to join the workforce.
4) Regulation of an adequate skill-mix in India. The government must regulate the public
and private sector by setting a required benchmark of skill-mix ratio. This step can increase
the recruitment rates of doctors and nurses in both the private and public sector. Adopting an
adequate skill-mix can also improve the quality of care in the sectors.
5) Harnessing technology. Telemedicine and mHealth are used in the country to enhance health
care delivery and provide health care services in hard-to-reach areas. Greater emphasis can be
given to use technology in medical education training, along with offline sessions to grasp the
hands-on skills through practical sessions. The use of telemedicine to engage more females in
the workforce and to create employer-friendly working shifts can encourage many women to join
the workforce.
6) Improving health stock and health workforce database. There is urgent need to improve the
health professionals stock and health workforce database, linking the live registration of doctors
and nurses. These databases will provide valuable data on new graduates from different councils.
For better availability of data, a special active health workforce survey should be conducted using
the NSSO platform.

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Appendices
Appendix A-I: Graphical presentation of health professionals as of 2018^
Doctors (1.05 million) Nurses (2.18 million)

Working in non‐
Working in Active #
human health
non‐human health
services, 0.15
health services, workforce,
0.55 0.79
Active#
health
workforce,
0.66
Unemploy
ed, 0.04
Not in any
labour
force, 0.20
Unemployed
, 0.21 Not in any
labour force,
0.63
Active health workforce Active health workforce

Not in any labor force Not in any labor force
Unemployed Unemployed
Working in non human health services Working in non human health services
^ NHWA 2018 & # Estimated from PLFS:2018–2019

Appendix A-II. Cumulative supply of new health graduates, India for the
period 2019 to 2030
Cumulative supply of new health graduates, India, 2019 to 2030^
Year Cumulative Cumulative Cumulative
(2019 to 2020) (2021 to 2025) (2026 to 2030)
(2 years) (5 years) (5 years)
Doctor
Total institutions 554 675 675
Total seats available$ (in million) 0.11 0.36 0.46
Actual new supply$*(in million) 0.11 0.35 0.45
Nurses and midwives
Total institutions 7073 7110 7110
Total seats available (ANM)# (in million) 0.11 0.28 0.28
Actual new supply (ANM)** (in million) 0.06 0.15 0.15
Total seats available (GNM+B. Sc) (in
0.41 1.13 1.17
million)
Actual new supply (GNM+ BSc)##** (in
0.19 0.52 0.54
million)
Total seats available (in million) 0.52 1.41 1.44
Actual new supply** (in million) 0.25 0.67 0.68
$ with 5 year lag; # with 2 year lag; ## with 3 year lag (GNM) and with 4 year lag (B.Sc)
^ Includes new 121 institutions (doctors) and 37 institutions (nurses)
*Doctors-seat occupancy rate + vacant seat - 96.5%
** Nurses- total new registrations/training capacity-ANM (53%) and GNM & B.Sc Nurses (46%), based on latest 3 years data
Appendix A-III. Supply side parameters of doctors and nurses/midwives

Supply parameters Doctors Nurses
2030 2030
# of institutions 675 7110
Annual seats available (000) 95 289
Annual seats available/# of institutions 141 41
Annual pass-out (000)* 92 137
Annual pass-out/# of institutions 136 19
* Existing pass-out rate of 96.5% for doctors and new registrations/ training capacity is ANM (53%) and GNM & BSc nurses
(46%) were applied annually for the following years

Appendix A-IV. Comparison of new graduates per 100 000 population in India and
select countries
Comparison of new graduates per 1 00 000 population, India and

selected countries, latest available data^
70.0 63.0
New graduates per 100000 population
60.0
50.0 44.0
40.0
31.0
30.0 23.7
20.0 15.9 14.9
13.1 13.1
8.0 8.3 6.7 9.2 9.3
10.0 4.6 3.8 6.3
0.0
OECD United United Thailand Brazil Sri Lanka India India
Kingdom states (2018) (2030)
Nurses Doctors
Appendix A-V. Projected estimates of HRH (doctors and nurses/midwives)

Projected estimates of HRH (doctors and nurses/midwives)
Parameters 2020 2025 2030
NHWA data Total production of health professionals (in million) 3.85 4.87 6.00
NHWA data Total stock of health professionals (in million)* 3.34 3.76 4.25
PLFS 2018-19 Active health workforce (in million)^ 1.60 2.03 2.51
* Adjusted for attrition (mortality, retirement and migration)
Doctors- Net migration rate (+5%), death rate (-2.5 to -2.1%), retirement rate (-1.07%)
Nurses- Annual migration (-4.6%), death rate (-2.5 to -2.1%), retirement rate (-1.02%)
^ Estimated from PLFS: 2018–2019, moderate labour market attrition of 20% doctors and 30% nurses and attrition (mortality,
retirement and migration): doctors- net migration rate: (+5%), death rate (-2.5 to -2.1%), retirement rate (-1.07%)
Nurses- Annual migration (-4.6%), death rate (-2.5 to -2.1%), retirement rate: (-1.02%)
Appendix A-VI . Projected estimates of doctors for 2020, 2025 and 2030
Projected estimate of doctors
NHWA data
1.27 1.62 2.07
Total production of health professionals (in million)
NHWA data
1.08 1.26 1.51
Total stock of health professionals (in million)*
PLFS 2018–2019
0.70 0.87 1.10
Active health workforce (in million)^
* Adjusted for attrition (mortality, retirement and migration):-
Doctors- Net migration rate (+5%), death rate (-2.5 to -2.1%), retirement rate (-1.07%)
^ Estimated from PLFS:2018–2019, moderate labour market attrition of 20% doctors and and attrition (mortality, retirement and
migration): Doctors- net migration rate (+5%), death rate (-2.5 to -2.1%), retirement rate (-1.07%)

Appendix A-VII. Projected estimates of nurses for 2020, 2025 and 2030
Projected estimate of nurses
NHWA data
2.58 3.25 3.94
Total production of health professionals (in million)
NHWA data
2.26 2.50 2.74
Total stock of health professionals (in million)*
PLFS 2018-19
0.89 1.16 1.41
Active health workforce (in million)^
*Adjusted for attrition (mortality, retirement and migration):-
Nurses /midwives- Annual migration (-4.6%), death rate (-2.5 to -2.1%), retirement rate (-1.02%)
^ Estimated from PLFS:2018–2019, moderate labour market attrition of 30% Nurses/midwives and attrition (mortality, retirement
and migration):Nurses /midwives- Annual migration (-4.6%), death rate (-2.5 to -2.1%), retirement rate (-1.02%)
Appendix A-VIII. Projected shortage of doctors at different recommended thresholds

Projected shortage of doctors at different recommended thresholds
Desired density NHWA data total stock of health
0.45 0.35 0.16
of 34.5 /10000 professionals (in million)*
population PLFS 2018–2019 active health
0.83 0.74 0.57
workforce (in million)^
Desired density NHWA data total stock of health
0.90 0.82 0.64
of 44.5 /10000 professionals (in million)*
population PLFS 2018–2019 active health
1.28 1.20 1.05
workforce (in million)^
Doctors- Net migration rate: (+5%), death rate: (-2.5 to -2.1%), retirement rate: (-1.07%)
^ Estimated from PLFS:2018-19, moderate labour market attrition of 20% doctors and 30% Nurses and attrition (mortality,
retirement and migration): Doctors- net migration rate (+5%), death rate (-2.5 to -2.1%), retirement rate (-1.07%)
Appendix A-IX. Projected shortage of nurses /midwives at different recommended

thresholds
Projected shortage of nurses /midwives at different recommended thresholds
Desired density of NHWA data total stock of health profes-
0.85 0.76 0.65
34.5 /10 000 popu- sionals (in million)*
lation PLFS 2018–2019 active health workforce
2.22 2.10 1.98
(in million)^
Desired density of NHWA data total stock of health profes-
1.75 1.70 1.63
44.5 /10 000 popu- sionals (in million)*
lation PLFS 2018–2019 active health workforce
3.12 3.04 2.96
(in million)^
Nurses/midwives - Annual migration (-4.6%), death rate (-2.5 to -2.1%), retirement rate (-1.02%)
^ Estimated from PLFS: 2018–2019, moderate labour market attrition of 30% nurses and attrition (mortality, retirement
and migration) Nurses /midwives- Annual migration (-4.6%), death rate (-2.5 to -2.1%), retirement rate (-1.02%)

Appendix A-X. Required annual and total production of doctors and nurses/midwives
for overcoming stock HRH shortages by the year 2030
Estimated shortage of doctors and nurses/midwives in stock and active health workforce, by 2030
Actual stock shortage
Total required production by 2030
Recommended threshold 34.5 44.5
Nurses /midwives (in million) 0.65 1.63
Doctors (in million) 0.16 0.64
Required annual production with duration of course- 4 years (required production / 4)
Active workforce shortage*
Total required production by 2030
Recommended threshold 34.5 44.5
Required annual production with duration of course for4 years (required production / 4)
* Adjusted for labour market attrition: Doctors (20%), Nurses (30%)
Appendix A-XI. Detailed strategy to overcome actual stock shortage of doctors

by 2030
Detailed strategy to overcome actual stock shortage of doctors by 2030
Parameters (shortages) 34.5 ( 0.04 million) 44.5 (0.16 million)
Scenario 1
Increasing seats in existing colleges per 136 to 150
0.01 0.01
annum (By 2025) (in million)
Additional seats required(in million) 0.03 0.15
New colleges required (by 2025) 199 1005
Scenario 2
0.02 0.02
annum (by 2025) (in million)
Additional seats required (in million) 0.02 0.14
Scenario 3
0.03 0.03
annum (by 2025) (in million)

Appendix A-XII. Detailed strategy to overcome actual stock shortage of nurses/
midwives by 2030 (in million)
Strategy to overcome actual stock shortages, nurses/midwives
34.5 44.5
Parameters (shortages)
(0.16 million) (0.41 million)
Scenario 1
Utilising existing capacity
Increasing average nurses/midwives pass-out in
19 to 40 0.15 0.15
existing colleges (in million)
New infrastructure
Additional pass-outs needed (in million) 0.01 0.26
New colleges required (60 seats/ college) 198 4288
Scenario 2
Utilising existing capacity
Increasing average nurses /midwives pass-out
19 to 40 0.15 0.15
in existing colleges (in million)
Additional pass-outs needed 0.01 0.26
Number of seats after increasing intake capacity
10 seats 0.01^ 0.07
(in million)
New infrastructure
Additional seats required after increasing intake
0.186
capacity seats (in million)
New colleges required (60 seats/ college) 3103
Scenario 3
Utilizing existing capacity
Increasing average nurses/midwives pass-outs
19 to 40 0.15 0.15
Number of seats after increasing intake capacity 20 seats 0.01^^ 0.14
New infrastructure
Additional seats required after increasing intake
0.12
capacity seats (in million)
New colleges required (60 seats/ college) 1918
* Number of seats- On increasing average nurses /midwives pass-out in existing colleges;
^ Seat expansion in 1190 institutions;
^^ Seats expansion in 595 institutions.

Appendix A-XIII. Detailed strategy to overcome active health workforce shortage of
doctors by 2030
Strategy to overcome active health workforce shortages of doctors
Parameters (shortage) 34.5 44.5
(0.14 million) (0.26 million) (0.26 million)
Scenario 1
Seats on increasing intake capacity in existing 136 to 150
0.01 0.01
colleges per annum (by 2025) (14 seats/college)
Additional seats required 0.13 0.25
New colleges required (by 2025) 150 seats/college 885 1691
Scenario 2
0.02 0.02
Scenario 3
0.03 0.03
Appendix A-XIV. Detailed strategy to overcome active health workforce shortage of

nurses/midwives by 2030
Strategy to overcome active workforce shortage of nurses/midwives
Parameters (shortage)* 34.5 44.5

(0.49 million) (0.74 million) (0.74 million)
Scenario 1
Increasing average nurses /midwives pass-outs
19 to 40 0.15 0.15
Scenario 2
19 to 40 0.15 0.15
Number of seats after increasing seats in
10 seats 0.07 0.07
New infrastructure

Scenario 3
19 to 40 0.15 0.15
Number of seats after increasing seats in
20 seats 0.14 0.14
New infrastructure
* Number of seats- On Increasing average nurses/midwives pass-outd in existing colleges (in million)
Appendix A-XV. Detailed strategy and middle bound investment to overcome doctor’s
shortage in active health workforce shortages by 2030
Recommended 34.5 44.5
threshold
Parameters Seats on Additional New Seats on Additional New
increasing seats institutions increasing seats institutions
intake required required intake required (in required
capacity (in million)* capacity million)*
in existing in existing
colleges colleges
(in million) (in million)
Shortages in active health workforce (middle bound of investment)
Including AYUSH (0.52 million AYUSH practitioners); 0.01 million shortages
(at threshold of 34.5); 0.14 million shortages (at threshold of 44.5)
Scenario 1 0.009 0.005 34 0.01 0.13 840
Scenario 2 0.015 0.02 0.11 750
Scenario 3 0.015 0.03 0.11 728
Strategy A (including 0.18 million doctors), 0.09 million shortages (at threshold of 34.5); 0.22
million shortages (at threshold of 44.5)
Scenario 1 0.01 0.09 570 0.01 0.21 1376
Scenario 2 0.02 0.07 480 0.02 0.19 1286
Scenario 3 0.03 0.07 458 0.03 0.19 1263
Strategy A + AYUSH (Total :0.7 million) 0.08 million shortages (at threshold of 44.5)
Scenario 1 - - - 0.01 0.08 525
Scenario 2 - - - 0.02 0.07 435
Scenario 3 - - - 0.03 0.06 413

Appendix A-XVI. Detailed strategy and middle bound investment to overcome shortage
of nurses in active health workforce by 2030
Strategy to overcome shortage of nurses/midwives in active workforce shortages, including 50% of out
of labour nurses in active health workforce
Parameters (shortage)* 34.5 44.5

(0.36 million) (0.6 million)
Scenario 1
Increasing average nurses/midwives pass-outs in
19 to 40 0.15 0.15
Scenario 2
19 to 40 0.15 0.15
existing colleges In million
Number of seats after increasing seats in existing
10 seats 0.07 0.07
colleges (in million)
New infrastructure
Scenario 3
19 to 40 0.15 0.15
Number of seats after increasing seats in existing
20 seats 1.42 1.42
colleges (in million)
New infrastructure
* Number of seats- On increasing average nurses /midwives pass-out in existing colleges (in million)
Appendix A-XVII. Investment scenario to overcome shortage of doctors using

government colleges by 2030^
WHO recommended 34.5, investment cost 44.5 investment
34.5 44.5
threshold (in billion) cost (in billion)
Lower bound of investment- 34.5 (0.04 million), 44.5 (0.16 million)
Number of seats after
0.03 267 0.03 267
expansion (in million)
Required new colleges 84 252 890 2670
Total cost 519 2937
Middle bound of investment
a) Including 50% OOLF into active workforce -34.5 (0.09 million), 44.5 (0.22 million)
0.01 267 0.03 267

Total cost 1632 4049
b) Including AYUSH-34.5 (0.01 million), 44.5 (0.14 million)
0.01 146 0.03 267
Required new colleges 725 2175
Total cost 146 2442
c) Introducing 50% OOLF into active workforce + AYUSH – 44.5 (0.09 million shortage)
0.03 267
expansion(in million)
Required new colleges 410 1231
Total cost 1498
Upper bound of investment: Threshold (shortages)-34.5 (0.14 million), 44.5 (0.26 million)
0.03 267 0.03 267
Total cost 2576 4994
^ Doctors: Cost of increasing seats-1 crore/ seat; cost of opening new medical colleges 300 crore/college
Appendix A-XVIII. Summary of three bound of investment scenario to overcome

shortage of doctors and nurses/midwives by 2030^
Parameters
Scenario 1 Scenario 2 Scenario 3
(Density per 10 000 persons)
Lower bound investment (in billion)
Threshold density of 34.5 745 536 540
Middle bound investment
Including AYUSH (in billion)
Including 50% of not working health professionals
AYUSH + including 50% of not working health professionals
Upper bound investment (in billion)
^ Doctors: Cost of increasing seats-INR 1 crore/ seat; cost of opening new medical colleges- INR300 crore/college & Nurses:
Cost of increasing 1 seat- INR 0.14 crore; cost of opening 1 nursing college-INR26.5 crore

List of Tables
Table 1. Size and composition of HRH in India....................................................................................13
Table 2. Projected estimates of HRH supply by 2030..........................................................................15
Table 3. Strategies for production of doctors and nurses/midwives to overcome
HRH shortages by 2030.........................................................................................................18
Table 4. New investment required for meeting the shortage of
nurses/midwives and doctors by 2030...................................................................................23
Table 5. Middle bound investment to overcome shortage of doctors in active
health workforce^...................................................................................................................25
Table 6. Middle bound investment to overcome active health
workforce shortage of nurses by 2030...................................................................................26
Table 7. Estimates of benefits of investment by 2030..........................................................................28
List of Figures
Fig. 1. Estimate of shortages (in million) of health workers by 2030
at different health worker-population density thresholds ........................................................ vi
Fig. 2. Investment (in billion) needs to overcome HRH

(doctors and nurses/midwives shortages to meet WHO thresholds, by 2030*...................... vii
Fig. 3. Framework for education and labour dynamics of HRH..........................................................6
Fig. 4. Framework for cost centres in HRH.........................................................................................6
Fig. 5. Estimated number of doctors (In million) in actual stock and active
health workforce, from year 2020 to 2030..............................................................................14
Fig. 6. Estimated number of nurses (/midwives) in actual stock and active health
workforce (In million), from year 2020 to 2030.......................................................................15
Fig. 7. Comparison of HRH supply and need of health worker (In million), by 2030.........................16
Fig. 8. Estimates of health worker shortages (in million) by 2030 at WHO thresholds ....................17
Fig. 9. Strategy to overcome actual stock shortages of doctors at

different WHO thresholds, by 2030 .......................................................................................19
Fig. 10. Strategy to overcome actual stock shortages of nurses/midwives at

different thresholds, by 2030 .................................................................................................20
Fig. 11. Strategy to overcome active health workforce shortages

of doctors at different WHO thresholds, by 2030 ..................................................................21
Fig. 12. Strategy to overcome active health workforce shortages of nurses

(/midwives) at different WHO thresholds, by 2030 ................................................................21
Fig. 13. Strategy to overcome doctor’s shortage in active health

workforce shortages (Middle bound of investment), by 2030.................................................24
Fig. 14. Strategy to overcome active health workforce shortages of nurses

(/midwives) at different WHO threshold (Including 50% out of
labour force nurses) by 2030 ................................................................................................25
Fig. 15. Investment scenario to overcome doctors shortages using

government colleges (In billion), by 2030...............................................................................27

List of Appendices
Appendix A-I: Graphical presentation of health professionals as of 2018^...................................37
Appendix A-II. Cumulative supply of new health graduates, India for the
period 2019 to 2030................................................................................................38
Appendix A-III. Supply side parameters of doctors and nurses/midwives.......................................38
Appendix A-IV. Comparison of new graduates per 100 000 population in India and
select countries.......................................................................................................39
Appendix A-V. Projected estimates of HRH (doctors and nurses/midwives)..................................39
Appendix A-VI. Projected estimates of doctors for 2020, 2025 and 2030.......................................39
Appendix A-VII. Projected estimates of nurses for 2020, 2025 and 2030........................................40
Appendix A-VIII. Projected shortage of doctors at different recommended thresholds.....................40
Appendix A-IX. Projected shortage of nurses /midwives at different recommended thresholds......40
Appendix A-X. Required annual and total production of doctors and nurses/midwives
for overcoming stock HRH shortages by the year 2030.........................................41
Appendix A-XI. Detailed strategy to overcome actual stock shortage of doctors by 2030 .............41
Appendix A-XIII. Detailed strategy to overcome active health workforce shortage of

doctors by 2030 .....................................................................................................43
Appendix A-XIV. Detailed strategy to overcome active health workforce shortage of

nurses/midwives by 2030.......................................................................................43
Appendix A-XV. Detailed strategy and middle bound investment to overcome doctor’s
shortage in active health workforce shortages by 2030..........................................44
Appendix A-XVI. Detailed strategy and middle bound investment to overcome shortage
of nurses in active health workforce by 2030..........................................................45
Appendix A-XVII. Investment scenario to overcome shortage of doctors using

government colleges by 2030^...............................................................................45
Appendix A-XVIII. Summary of three bound of investment scenario to overcome shortage of doctors
and nurses/midwives by 2030^...............................................................................46

It is of crucial importance and significant policy
interests to understand where and how much
efficient investment to make in the HWF to
achieve the highest possible benefits with a
short- to medium-term perspective. Building
on the existing studies and taking lead from
the PHFI-WHO (2020) study, the present
study aims to further explore and identify the
areas of investment, estimate the required
magnitude of investment, and identify channel/
forms of investments.

Health Workforce in India Where To Invest How Much and Why

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Health workforce

Health workforce in India: where to invest, how much and why? i

© World Health Organization 2022

Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.

Chapter 4: Discussions and policy implications 30

ANM Auxiliary Nurse Midwife

Health workforce in India: where to invest, how much and why? i

Public Health Foundation of India

World Health Organization

Health workforce in India: where to invest, how much and why? v

Fig. 1. Estimate of shortages (in million) of health workers by 2030

Active workforce 2.96

Active workforce 1.98

0 0.5 1 1.5 2 2.5 3

vi Health workforce in India: where to invest, how much and why?

1.1 Investment in health and HRH at the global level

Health workforce in India: where to invest, how much and why? 1

Recommendations Strategic actions

2 Health workforce in India: where to invest, how much and why?

Health workforce in India: where to invest, how much and why? 3

1.2 Investment in health and HRH in India

1.3 HRH situation in India

4 Health workforce in India: where to invest, how much and why?

1.4 Framework for education and labour dynamics in HRH

Health workforce in India: where to invest, how much and why? 5

Policies to increase production

Policies to address inefficiencies and increase workforce participation

Employed Active workforce

Need‐based shortages in HRH

Increasing available Increasing active health

Cost of opening new

6 Health workforce in India: where to invest, how much and why?

Health workforce in India: where to invest, how much and why? 7

2.1 Data sources

2.1.1 NHWA data

2.1.2 NSSO data

2.2 Methods of estimating the health workforce

8 Health workforce in India: where to invest, how much and why?

Parameters related to health professionals used in the study

2. Mortality: This referred to expected number of deaths of health professionals annually,

Baseline numbers and projection up to 2030

Health workforce in India: where to invest, how much and why? 9

Estimation of baseline and projection up to 2030

Where subscript ‘t’ is year of estimation.

Where OW is health professionals remaining out of workforce, U is unemployed and NW is health

10 Health workforce in India: where to invest, how much and why?

2.2.4 Benefits of investment in HRH by 2030

Health workforce in India: where to invest, how much and why? 11

Estimation of benefits of investment

Contribution to national income

was the additional employment because of the enhanced investment.

12 Health workforce in India: where to invest, how much and why?

3.1 Current size and density of HRH

Table 1. Size and composition of HRH in India

Health workforce in India: where to invest, how much and why? 13

3.2 Supply side estimates of HRH by the year 2030

1.30 1.17 1.21

Doctors in actual stock Doctors in active workforce

Figure 4. Estimated number of nurses (/midwives) in actual stock and

2.36 2.41 2.46

Fig. Figure 4. Estimated

2.36 2.41 2.46

Nurses (/midwives) in actual stock Nurses (/midwives) in active health workforce