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Addressing health needs through human resource

Jun 05, 2009

Leveraging human capital to reduce maternal mortality in India, a research paper explores contrasting approaches employed by two Indian states to improve health outcomes in resource-constrained settings. Using case studies of Tamil Nadu and Gujarat, the paper examines the use of public private partnership to deal with staff shortage.

Leveraging human capital to reduce maternal mortality in India: enhanced public health system or public-private partnership?

Authors: Karl Krupp, Purnima Madhivanan

Publisher: Human Resources for Health, 2009

Achieving Millennium Development Goal 5 – reducing maternal deaths and providing universal access to reproductive health – will require substantial health system reform in many developing countries. Most, like India, face acute human resource shortages – particularly in rural areas where the needs are often greatest.


The World Health Organization estimates a current deficit of almost 2.4 million doctors, nurses and midwives. Complicating matters further, health workforces are typically concentrated in large cities, while maternal mortality is generally higher in rural areas.

There is growing evidence that human resource inputs are an important determinant of broader population-based outcomes such as maternal mortality. The issue is of crucial importance to developing countries facing the triple threat of rising demand, escalating costs and human resource shortages in public health care systems.

This paper focuses on how two large health systems in India – Gujarat and Tamil Nadu – have successfully applied human resources strategies in uniquely different contexts to the challenges of achieving MDG 5.

In 2005, Gujarat had an MMR of 172 per 100 000 live births. With those grim statistics in mind, the government developed a Public Private Partnership (PPP) called "Chiranjeevi Yojana" which realigned health system human resources by relocating obstetric gynaecology services from the public sector to the private sector. The scheme distributed vouchers to all pregnant women living below the poverty line who could choose a local OB/GYN and exchange the voucher for delivery services, free medicines and transport reimbursement.

In contrast to Gujarat's almost exclusive reliance on PPP, Tamil Nadu has continued to champion a public primary health care model. In order to deal with staff shortages, the state has successfully used a variety of HR strategies, including enhancement of the non-specialist physician and nursing.

While the state continues to provide most medical care, it is experimenting with private sector collaborations for ambulance services, facility maintenance, medical equipment, sanitation and construction. In addition, Tamil Nadu is establishing PPPs to provide health care access in tribal areas. Presently it has collaborations with the private companies and NGOs for mobile outreach clinical services, blood banks and provision of training and support for community health workers in remote areas.

With the current acute shortage of health care workers in developing countries, it has never been more urgent to assess how different human resource levers might be used to improve population-based health outcomes. It is telling that Gujarat and Tamil Nadu – the states which are among the most aggressive in experimenting with HR strategies – are also among the top performers in reducing maternal and neonatal mortality in India.

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