Workforce problems at rural public health-centres in India: A WISN retrospective analysis and national-level modelling study

BACKGROUND Rural India has a severe shortage of human resources for health (HRH). The National Rural Health Mission (NRHM) deploys HRH in the rural public health system to tackle shortages. Sanctioning under NRHM does not account for workload resulting in inadequate and inequitable HRH allocation. The Workforce Indicators of Staffing Needs (WISN) approach can identify shortages and inform appropriate sanctioning norms. India currently lacks nationally-relevant WISN estimates. We used existing data and modelling techniques to synthesize such estimates. METHODS We conducted a retrospective analysis of existing survey data for 93 facilities from 5 states over 8 years to create WISN calculations for HRH cadres at primary and community health centres (PHCs and CHCs) in rural areas. We modelled nationally-representative average WISN-based requirements for specialist doctors at CHCs, general doctors and nurses at PHCs and CHCs. For 2019, we calculated national and state-level overall and per-centre WISN differences and ratios to depict shortage and workload pressure. We checked correlations between WISN ratios for cadres at a given centre-type to assess joint workload pressure. We evaluated the gaps between WISN-based requirements and sanctioned posts to investigate suboptimal sanctioning through concordance analysis and difference comparisons. RESULTS In 2019, at the national-level, WISN differences depicted workforce shortages for all considered HRH cadres. WISN ratios showed that nurses at PHCs and CHCs, and all specialist doctors at CHCs had very high workload pressure. States with more workload on PHC-doctors also had more workload on PHC-nurses depicting an augmenting or compounding effect on workload pressure across cadres. A similar result was seen for CHC-specialist pairs - physicians and surgeons, physicians and paediatricians, and paediatricians and obstetricians-gynaecologists. We found poor concordance between current sanctioning norms and WISN-based requirements with all cadres facing under-sanctioning. We also present across-state variations in workforce problems, workload pressure and sanctioning problems. CONCLUSION We demonstrate the use of WISN calculations based on available data and modelling techniques for national-level estimation. Our findings suggest prioritising nurses and specialists in the rural public health system and updating the existing sanctioning norms based on workload assessments. Workload-based rural HRH deployment can ensure adequate availability and optimal distribution.

Research on efficiency measurement and spatiotemporal disparity of rural public health services in China

Objective Based on the rural public health services of 29 regions in China, a service efficiency evaluation index system consisting of input and output dimensions was constructed, and the coupling, coordination and disparity efficiencies of rural public health services in China were studied, providing information to redress the imbalance in the interregional coordinated development. Methods The efficiency, spatiotemporal disparity pattern, spatial correlation and evolutionary trend of the coordinated development of rural public health services of 29 regions in China from 2004 to 2018 were analyzed using efficiency and spatial analysis methods such as Data Envelopment Analysis (DEA), kernel density estimation and Moran’s Ⅰ analysis. Result Nowadays, there are problems of unbalanced and insufficient development between the fields and regions in the development of rural public health services in China. The development level of rural public health services in various regions shows a distribution pattern that the service efficiency is “high in the middle”, “middle in the east” and “low in the west”, indicating a spatial cluster effect.

A Century Later: Rural Public Health’s Enduring Challenges and Opportunities

The US public health community has demonstrated increasing awareness of rural health disparities in the past several years. Although current interest is high, the topic is not new, and some of the earliest public health literature includes reports on infectious disease and sanitation in rural places. Continuing through the first third of the 20th century, dozens of articles documented rural disparities in infant and maternal mortality, sanitation and water safety, health care access, and among Black, Indigenous, and People of Color communities. Current rural research reveals similar challenges, and strategies suggested for addressing rural–urban health disparities 100 years ago resonate today. This article examines rural public health literature from a century ago and its connections to contemporary rural health disparities. We describe parallels between current and historical rural public health challenges and discuss how strategies proposed in the early 20th century may inform current policy and practice. As we explore the new frontier of rural public health, it is critical to consider enduring rural challenges and how to ensure that proposed solutions translate into actual health improvements. (Am J Public Health. 2020;110:1678–1686. https://doi.org/10.2105/AJPH.2020.305868 )

The State of Rural Public Health: Enduring Needs in a New Decade

Public health in the rural United States is a complex and underfunded enterprise. While urban–rural disparities have been a focus for researchers and policymakers alike for decades, inequalities continue to grow. Life expectancy at birth is now 1 to 2 years greater between wealthier urban and rural counties, and is as much as 5 years, on average, between wealthy and poor counties. This article explores the growth in these disparities over the past 40 years, with roots in structural, economic, and social spending differentials that have emerged or persisted over the same time period. Importantly, a focus on place-based disparities recognizes that the rural United States is not a monolith, with important geographic and cultural differences present regionally. We also focus on the challenges the rural governmental public health enterprise faces, the so-called “double disparity” of worse health outcomes and behaviors alongside modest investment in health departments compared with their nonrural peers. Finally, we offer 5 population-based “prescriptions” for supporting rural public health in the United States. These relate to greater investment and supporting rural advocacy to better address the needs of the rural United States in this new decade.

Regional Differences and Influencing Factors of Allocation Efficiency of Rural Public Health Resources in China

In the face of increasingly growing health demands and the impact of various public health emergencies, it is of great significance to study the regional differences in the allocation efficiency of the rural public health resources and its improvement mechanism. In this paper, the game competition relationship is included in the evaluation model, and the game cross-efficiency model is used to measure the allocation efficiency of the rural public health resources in 31 provinces of China from 2008 to 2017. Then, the Theil index model and the Gini index model are applied in exploring the regional differences in the allocation efficiency of rural public health resources and its sources. Finally, the bootstrap truncated regression model is used to analyze the influencing factors of the allocation efficiency of the rural public health resources in China. The results show that, first, the total allocation efficiency level of the rural public health resources in China from 2008 to 2017 is relatively low, and it presents a U-shaped trend, first falling and then rising. Second, the changing trend of the allocation efficiency of the rural public health resources in the eastern, central, and western regions of China is similar to that in the nationwide region, and it shows a gradient trend that “the allocation efficiency in the eastern region is high, the allocation efficiency in the western region is low, and the allocation efficiency in the Central region is at the medium level”. However, the gap among the three regions is continually narrowing. Third, the calculation results of the Theil index and the Gini index show that intra-regional differences are the major source of the regional differences in the allocation efficiency of the rural public health resources in China, and the inter-regional differences demonstrate an expansion trend. Finally, the improvement of the education level and the social support level will generally improve the allocation efficiency of the rural public health resources in China and its three regions. The increased governmental financial support and urbanization level will reduce the allocation efficiency of the rural public health resources in China and its three regions. The economic development level, the living conditions and the population density are the important influencing factors of the allocation efficiency differences of the rural public health resources in the three regions. Therefore, on the basis of ensuring the increase of the total supply of the rural public health resources, more attention should be paid to the improvement of the allocation efficiency. Moreover, on the basis of continually narrowing the inter-regional differences among the eastern, central, and western regions, more attention should be paid to the intra-regional differences of the allocation efficiency of the rural public health resources among the different provinces. The various economic and social policies should be constantly optimized to jointly improve the allocation efficiency of the rural public health resources.