|Year : 2019 | Volume
| Issue : 2 | Page : 38-42
Health workforce availability and competency to manage noncommunicable diseases at secondary care level hospitals of Delhi
Shalli Bavoria, Baridalyne Nongkynrih, Anand Krishnan
Centre for Community Medicine, AIIMS, New Delhi, India
|Date of Web Publication||10-Jul-2019|
Dr. Shalli Bavoria
Demonstrator Room, Post Graduate Department of Preventive and Social Medicine, Government Medical College, Jammu, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Context: Health system strengthening is a major component of the national strategy to address noncommunicable diseases (NCDs). Human resource (HR) is an important building block of health system, and its capacity to address NCDs needs to be assessed.
Aims: We assessed the availability, training, and self-rated competencies of available staff in secondary-level health facilities under the Government of Delhi for NCD services.
Settings and Design: This study was conducted in a secondary care hospital in Delhi; this was a cross-sectional study.
Subjects and Methods: Fifteen hospitals listed by the Directorate of Health Services, Delhi, were assessed through personal visits. Medical superintendents provided information regarding the availability of workforce and their training. Self-rated competency was assessed among doctors, nurses, and laboratory workers using a self-administered questionnaire.
Results: A total of 85 doctors, 66 nurses and 52 laboratory technicians were interviewed. Shortage of staff ranged from 7.2% for staff nurse to 42.5% for medicine specialist. None of the staff had undergone special training for providing NCD-related services. 96.5% of doctors and 83.3% of nurses reported being aware of standard treatment guidelines for diabetes and hypertension. Key reported deficiencies were seen in doctors and nurses in managing diabetes complications. Cancer was not being managed in any hospital. Proficiency in cardiovascular disease management was reported by 24.7% and COPD management by 83.5% of doctors. There was major gap in competencies related to stroke management.
Conclusions: Availability of trained and competent workforce was a limiting step in delivering NCD care in secondary-level public health facilities of Delhi, indicating the need for strengthening the HR capacity.
Keywords: Management, noncommunicable diseases, secondary care hospitals, training
|How to cite this article:|
Bavoria S, Nongkynrih B, Krishnan A. Health workforce availability and competency to manage noncommunicable diseases at secondary care level hospitals of Delhi. Int J Non-Commun Dis 2019;4:38-42
|How to cite this URL:|
Bavoria S, Nongkynrih B, Krishnan A. Health workforce availability and competency to manage noncommunicable diseases at secondary care level hospitals of Delhi. Int J Non-Commun Dis [serial online] 2019 [cited 2019 Sep 20];4:38-42. Available from: http://www.ijncd.org/text.asp?2019/4/2/38/262464
| Introduction|| |
Noncommunicable diseases (NCDs), mainly cardiovascular diseases (CVDs), cancers, diabetes, obesity, and chronic respiratory diseases, represent a leading threat to human health and human development in today's world. As the prevalence of NCDs rises, there will be greater demand for NCD-related health-care services, including diagnosis and treatment. The high burden of NCDs aggravates the already overloaded public health-care system, which will require reorientation to address these newer challenges through referrals, follow-up systems, and clinical guidelines for NCD treatment.
One of the strategies for addressing NCDs is strengthening health system response to NCDs. It is defined as the process of identifying and implementing the changes in policy and practice in a country's health system and any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency. Currently, in India, the focus is on strengthening secondary care facilities for the provision of NCD-related services. However, strengthening health system response to NCDs in India poses significant challenges. In a situation where the ratio of health workers per 10,000 population is low, the human resource (HR) challenge for effectively addressing NCDs is immense. Focus on governance, capacity building of existing staff, additional staff for NCD programs, provision of essential drugs, and technology and well-functioning information system is required as building blocks of health system.
In response to the NCD burden, India launched the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke (NPCDCS) in 2010 and in 2013 in Delhi. NPCDCS aims at integration of NCD interventions in the National Health Mission framework for optimization of scarce resources and provision of seamless services to the end customer patients as also for ensuring long-term sustainability of interventions. Essential contractual staff such as doctors and nurses are also provided under the program for management of NCD clinics. It also aims to train the health professionals and care providers at various levels for health promotion, NCD prevention, and early detection and management of cancer, diabetes, CVDs, and stroke.
Our objective was to assess the availability, training, and self-rated competencies of HRs (doctors, nurses, and laboratory technicians) for provision of NCD services in secondary care health facilities in Delhi.
| Subjects and Methods|| |
A survey was conducted among 15 secondary care hospitals under the Government of National Capital Territory of Delhi from May 2016 to June 2016. The list of hospitals was provided by the Directorate of Health Services, Delhi. Three domains of HR availability were studied which included availability, training of workforce, and self-rated competency. Medical superintendent and statistical officer of the hospital provided information regarding the availability of the workforce and their training.
All the nurses, doctors, and laboratory technicians available at the time of the visit were interviewed. A health facility assessment tool was developed based on IPHS standards and NPCDCS guidelines. It had two components. The first was details of training undergone by them and the second was self-rated competency assessment of different skills and procedures for NCD which includes diabetes mellitus, stroke, cancer, CVD, and COPD management. The skills were identified based on the procedures mentioned in specific disease management guidelines. Staff were considered trained if they had received any training for NCD services within the past 2 years. Separate questionnaires were prepared for each set of participants. The answers could be given as proficient, comfortable performing, limited experience, and never performed. These were operationally defined as:
- Proficient – can do complicated case as well
- Comfortable performing – can perform but not in complicated cases
- Limited experience – have just little experience in doing that procedure
- Never performed – never done the particular procedure.
Ethical clearance was taken from the AIIMS Ethical Committee. Permissions were taken from the medical superintendent of the hospitals under study. Written informed consent was taken from all health-care providers who were interviewed.
Capacity building was measured under three domains including availability and shortage of staff, knowledge of guidelines, and self-rated competency in disease management. All the data were presented as proportions and 95% confidence intervals were not estimated.
| Results|| |
Availability of human resource
The sanctioned and filled posts of different categories of HR in the hospital are shown in [Table 1]. It shows that most of the health facilities had shortage of staff with gap ranging from 7.2% among staff nurses to 42.5% of medicine specialists. Dentists were also in short supply as 46% vacancies were reported. It was also seen that 54.4% shortage was reported in physiotherapy staff who have a very important role in rehabilitation.
|Table 1: Availability of human resources in secondary care hospitals of the Government of Delhi|
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Doctors (71.9%), nurses (92.8%), and laboratory technicians (68%) who were available at the time of survey were interviewed. The mean age was similar for all the three levels of respondents. Most of the health-care providers had work experience of >5 years. However, none of them had received any specific training for NCD management.
Most of the doctors and nurses reported that they were aware of standard treatment guidelines for HT and DM management. They reported little knowledge with respect to stroke and CVD management guidelines, which was especially poor among nurses [Table 2].
Self-rated competency of nurses and doctors on disease management
The competencies were measured under three domains including screening and diagnosis, treatment, and complication identification and management. Each domain included a set of questions to measure the competency of the health-care providers.
Most of the doctors rated themselves as competent in the management of various NCDs except for cancer (1.2%), which was not being managed in any of the hospitals. They could perform all the basic activities, but when it came to complication identification and management, the competency varied from 32.9% in COPD to nil in cancer [Table 3].
|Table 3: Self-rated competency of doctors and nurses in different domains of noncommunicable disease management|
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Nurses rated their competency as good in the diagnosis of diabetes and hypertension but reported had little experience in cancer management. They also reported poor competencies in treatment (ranging from 42.8% in diabetes to nil in cancer) aspects and identification and management of complications [Table 3].
Self-rated competency of laboratory technicians
Laboratory technicians rated themselves as proficient in basic investigations. Ten percent of the laboratory workers had never performed HbA1c analysis. They had not received any special training for NCD management, and little experience was seen in other investigations such as preparing slides for Pap smear More Details [Figure 1].
|Figure 1: Self-rated competency of laboratory technicians to perform tests related to noncommunicable diseases|
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| Discussion|| |
This study attempted to measure the readiness of secondary care hospitals of Delhi for managing NCDs which included CVDs, diabetes, COPD, and cancers (oral, breast, and cervical) as there is an increasing burden of NCDs worldwide including in India. A total of 15 general secondary hospitals run by the Government of Delhi were assessed along with 85 doctors, 66 nurses, and 52 laboratory technicians, who worked in them.
Under NPCDCS, there should be an “NCD clinic” at community health centre and district hospitals for cancer, diabetes, hypertension, CVDs, and strokes, where comprehensive management of patients referred by lower health facilities would be done. Patients who report directly would also be screened for common NCDs. Screening, confirmation of diagnosis, and management (including diet counseling and lifestyle management) would be the key functions of the clinic [Figure 2].
|Figure 2: Facilities recommended for noncommunicable disease clinic at CHC and district hospital under the National Programme for Prevention and Control of Cancer, Diabetes, Cardiovascular Disease and Stroke|
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In our study, it was found that there was shortage of staff. Many of the sanctioned posts were lying vacant. Medical officer's posts were mostly filled by MBBS doctors who had less experience of managing NCDs. Furthermore, none of the staff had been provided any special training for NCD management. Most patient load was related to hypertension and diabetes with much lower load due to CVD and cancer patients. In cancer, only follow-up patients were seen with no day-care chemotherapy facilities. In a study done in India by Rao, it was seen that that 10% primary health centers were running without a doctor, 34% did not have nursing staff, and 16% were running without a pharmacist. These findings are similar to that of our study, where vacant posts varied from 7.5% for nurses to 42.5% for doctors. Studies done in Madhya Pradesh and Nepal also reported shortage of laboratory staff, health educators, and nurses.
Training of the staff was a major concern. Despite the rolling out of a national program for NCDs, the training component has not yet taken off. All the basic management and services provided by doctors were based on their skills during their education which was around 10 years back. A similar study done in Pakistan also had findings which suggest the importance of training for the management of chronic diseases. They found that physicians tell their participants about their diagnosis, prescribed them medications, but did not teach them self-monitoring and management of their illness which is a skill acquired only by training. A study in Cambodia also had reported that health-care providers reported limited experience in the management of complicated cases and inadequate counseling of patients. Another study in Uganda reported that doctors have little experience for the management of hypertension and diabetes as compared to HIV.
The limitation of the study was that the survey was conducted in a small sample of 15 secondary care hospitals in Delhi. However, it did not cover hospitals run by municipal corporations, central government, or those in private and NGO sector. Thus, results may not be taken as representative of the whole state of Delhi. Our study used self-rated competency rather than an objective measure of competency and it is possible that health-care providers overestimated their competencies. Only staff available at the time of visit were assessed for competencies, and this might have introduced a bias.
| Conclusion|| |
The study revealed both quantitative and qualitative gaps in HRs. This study was done 3 years back and matters could have improved as many new initiatives have been taken in this regard. This study highlights the need for regular health facility audit and measurement of quality of services being provided so that quality improvement measures can be instituted.
We would like to thank Dr. Deveshish Bhattacharya, Addl. Director (Public Health Wing-II), NCD Issue Related To Cancer Control and Disaster Management, State Nodal Officer (Trauma and Burns) Control Room DGEHS, for providing the guidance in identifying the health facilities and granting permission from the facilities to conduct the dissertation.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Duran A, Khot A. Strengthening the health system to better confront noncommunicable diseases in India. Indian J Community Med 2011;36:S32-7.
Beaglehole R, Yach D. Globalisation and the prevention and control of non-communicable disease: The neglected chronic diseases of adults. Lancet 2003;362:903-8.
Thakur J, Pala S, Sharma Y, Jain S, Kumari S, Kumar R. Integrated non-communicable disease control program in a Northern part of India: Lessons from a demonstration project in low resource settings of a developing country. CVD Prev Control 2009;4:193-9.
Director General of Health Services, Ministry of Health and Family Welfare, Goverment of India. Indian Public Health Standards (IPHS) for District Hospitals; 2017.
Gosain M, Goel AD, Kharya P, Agarwal R, Amarchand R, Rai SK, et al.
Reduction of neonatal mortality requires strengthening of the health system: A situational analysis of neonatal care services in Ballabgarh. J Trop Pediatr 2017;63:365-73.
Rao K, Bhatnagar A, Berman P. India's health workforce: size, composition and distribution. In: La Forgia J, Rao K, eds. India Health Beat. New Delhi: World Bank, New Delhi and Public Health Foundation of India, 2009.
Pakhare A, Kumar S, Goyal S, Joshi R. Assessment of primary care facilities for cardiovascular disease preparedness in Madhya Pradesh, India. BMC Health Serv Res 2015;15:408.
Baral B, Prajapati R, Karki KB, Bhandari K. Distribution and skill mix of health workforce in Nepal. J Nepal Health Res Counc 2013;11:126-32.
Jafar TH, Haaland BA, Rahman A, Razzak JA, Bilger M, Naghavi M, et al.
Non-communicable diseases and injuries in Pakistan: Strategic priorities. Lancet 2013;381:2281-90.
Jacobs B, Hill P, Bigdeli M, Men C. Managing non-communicable diseases at health district level in Cambodia: A systems analysis and suggestions for improvement. BMC Health Serv Res 2016;16:32.
Katende D, Mutungi G, Baisley K, Biraro S, Ikoona E, Peck R, et al.
Readiness of Ugandan health services for the management of outpatients with chronic diseases. Trop Med Int Health 2015;20:1385-95.
[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3]