The Growing Demand for Healthcare and Opportunities for Job Creation in India  

The Indian healthcare system is a complex network of public and private institutions that provide a wide range of services. According to the NITI Aayog, it is the fifth largest employer in the country, and enagages about 4.7 million workers.

India has a rising population alongside an increasing old-age dependency ratio. Despite its sizeable middle class, a larger share of the population remains impoverished, or just a step away from it. The country is also experiencing a rising incidence of lifestyle-related diseases, in addition to the pervasive health issues stemming from poverty, poor sanitation, and nutrition.

Against this diverse backdrop, the demand for healthcare is projected to grow significantly. The expansion of healthcare to meet this demand has the potential to create more employment, especially for women.

The JustJobs Network (JJN) and the World Bank, India hosted a discussion to explore the opportunities and challenges to expand India’s healthcare sector to meet growing demand.

This invite-only event convened a small group of participants ranging from researchers and non-governmental practitioners to private-sector players to discuss the unfolding future of India’s healthcare sector and women’s access to well-remunerated “good jobs” in it.

Summary 

India’s Healthcare Sector: Role of Public and Private Sector  

• Indian healthcare system includes both the public and private sectors. They need not be contradictory but can be complementary. However, considering the size and diversity of the Indian population, it is the public system that needs to play the dominant role to ensure equitable access.
• Preventive healthcare is a public good and plays an essential role in improving the health of individuals and communities, reducing the burden of diseases on society. In India, optimising preventive healthcare is essential. However, it has not received adequate attention from either the public or the private sector.  
• Some efforts have been made in recent years to rectify this. The government, under Ayushman Bharat, has started upgrading PHC Sub-centres to Health and Wellness Centres to cover maternal and child health services, non-communicable disease, free drugs, and diagnostic services. Private companies such as iKure are also entering the sector. There may be scope for Public Private Investment (PPP) in this sector. 
• The private sector is dominant in the training space, especially for nursing and allied health services. However, it remains unregulated, and the quality of the institutions that impart the training varies widely. 
• There is also a wide geographical divide in terms of educational institutions. Over 42 percent of nursing colleges are concentrated in the southern states ¹, and most are in the private sector and located in urban areas. There is a need to build capacity in various parts of the country.  
• India’s healthcare system is highly fragmented, with a mixture of public and private healthcare providers. These include a substantial number of solo practitioners and small independent medical clinics and nursing homes. ² It is extremely challenging to regulate these practitioners and clinics effectively.   
• Sectors such as medical devices and pharmaceuticals are regulated not only by Indian regulatory bodies but also by international agencies such as Central Drugs Standard Control Organisation (CDSCO) and National Health Service (NHS). At times, there are discrepancies in regulations between the U.S. and India. During the COVID-19 pandemic, there was very little quality control of devices that were being imported. 

Human Resource Needs and Potential for Formalisation

• The Indian health sector has its challenges. It faces an acute shortage of trained healthcare professionals (doctors and nurses) and inequitable distribution of skilled health workers (urban vs. rural, public vs. private and inter-state).  
• Physicians in India tend to be concentrated in urban areas and tend to be relatively better off socio-economically. A large majority are disconnected from rural India, with many not wishing to practice in these areas. There is also a lack socio-economic diversity among doctors.  
• The shortage of nurses is also because of the lack of institutions offering training in nursing. In addition, many nurses migrate to other countries due to poor remuneration and inadequate facilities within India.  
• India has a large cadre of community health workers (CHW) ³, which include Accredited Social Health Activists (ASHA), Auxiliary Nurse Midwives (ANM) and Anganwadi Workers (AWW). Currently, many of these CHW cadres are treated as volunteers or contract workers without any job security, adequate pay, avenues of promotion, or dignity.  
• One of the solutions proposed to tackle the shortage of trained health workers was to utilise CHWs more effectively. Frontline and community level workers could be skilled further to enable them to provide more services to communities that are currently underserved by other public and private providers. Ethiopia presents an example where such grassroots workers have improved access to healthcare among certain rural populations.  
• If CHWs are upskilled through certification programmes which have market value, they could either be recruited as a government employee with benefits like health insurance and pension or gain employment in the private sector. An example of this is the Swasthya Swaraj model in Odisha. Under this model, educated tribal girls are trained and given a diploma in Community Health Practice, which has a market value. Thailand and India started with ASHA type grassroots workers. Thailand has provided them with certification which has even enabled them to become oncology nurses. 

Potential for Job Creation 

• The care economy has the potential to create jobs since the jobs are likely to remain human-centric. This includes childcare, elderly care, care for disabled and sick people. 
• The healthcare workforce in India has many women. Almost 80 percent of nursing staff are women. ¹ However, they are neither respected nor receive adequate pay, insurance, and job security. This was cited among the reasons for which nurses from India migrate to other countries.  
• To encourage people to join the cadre of CHWs, the government needs to invest more in their training, upgrade their remuneration, and provide professional and personal dignity.
• In urban areas, there is also a demand for General Nurse and Midwives (GNMs) for elder care. However, there is lack of institutional training mechanisms for those charged with delivering the services. Trained in-house by companies, they are classified as domestic workers rather than health workers.
• To enable more women to join the workforce, better provisioning of early childhood care is essential. Currently, under Integrated Child Development Services (ICDS), 0–3-year-old infants are not included within the Anganwadis (though ICDS does provide for their nutrition), which take care of 3–6-year-olds.  In the private sector, high end creches are available, but there are no provisions for childcare among lower-income communities. Civil society organisations provide some solutions, but these constitute a minuscule fraction of what is necessary.  
• One of the biggest barriers to care work is that it is not something that people aspire to, and it is not considered a career of respect and dignity. This affects the supply of personnel. These perceptions are reinforced by the government that does not recognise or regulate several care-related occupations adequately. 
• Some state governments such as Karnataka (Koosina Mane), Haryana (budget provision for creches) and Odisha are pro-active about providing childcare but other states still need to take concrete action. However, it is too early to say how effective some of these initiatives will be.  
• Care work entails a degree of ethical commitment, which becomes a challenge when public systems dehumanise workers.  
• Better Human Resource management in the public sector is critical. Some of the experts pointed out that rules that govern the recruitment, conduct and termination of public sector healthcare personnel have not been updated for years. Furthermore, there is hesitation in hiring for specialist posts or even in regular employment because they need to be paid higher salaries. Many posts remain vacant for a variety of reasons. ⁵

Financing of Healthcare 

• The financing of the healthcare sector needs to go beyond tertiary care toward building an integrated system with an emphasis on preventive care.   
• India spent just 2.1 percent of its Gross Domestic Product on healthcare in 2022-23. ⁶ Arguably, what India does spend is neither spend efficiently nor effectively. Even three years after the COVID-19 pandemic, there has not been adequate provisioning for the sector.  
• Health insurance is inadequate since it does not work for chronic illnesses, does not cover Outpatient Department (OPD) and does cover the lack of availability of healthcare facilities.  
• Insurance only helps in the margins and creates perverse incentive to bypass primary and secondary care. To rectify this, insurance needs to cover primary care and OPD. Although the budget allocation for Central Government Health Scheme (CGHS) has increased, it is unclear if this is an efficient use of resources. Overall significant public investment is required in community and primary health, and in secondary health.  
• The recent budget has announced insurance for ASHA workers. 
• Pradhan Mantri Jan Arogya Yojana (PMJAY) provides a health cover of Rs. 5 lakhs per family per year for secondary and tertiary care hospitalisation. Households covered are based on the deprivation and occupational criteria of Socio-Economic Caste Census 2011 (SECC 2011) for rural and urban areas respectively. It provides data about what kind of diseases require insurance. 
• Evidence from NCAER suggests that there is a gap among the urban poor in their knowledge about government schemes that provide insurance.  
• The first JJN-World Bank Roundtable on “Understanding the Impact of COVID through Data: Methods and Means,” held on June 21, 2022, discussed the key issues related to availability, access, and quality of data in India. In this roundtable, the various sources of data on healthcare such as surveys, census and Programme Management Information Systems were pointed out. However, issues related to quality, accessibility and standardisation need to be addressed to strengthen India’s healthcare system. ⁷