Literature DB >> 35635342

Nurses and Midwives Human Resource for Health and Their Education in India: A Situational Analysis.

Manoja Kumar Das1, Deepak Singh1.   

Abstract

AIM: This study aimed to the status of the nurses and midwives human resource and training institutes in India and variations across states.
METHOD: This cross-sectional study collected information available from open sources (all data for the states) and supplemented with grey literature, as of 2019. The census population data were used for estimating the nurses and midwives dentistry. There was no sample selection. All the available information for the 30 states and six Union Territories were included.
RESULTS: The auxiliary nurses and midwives (ANMs) density varied from 0.7 (Bihar and Telangana) to 26.6 (Andhra Pradesh) in states and 6.6 per 10,000 population at a national level. The registered nurses and midwives (RN/RM) density varied from 0.8 (Bihar) and 0.9 (Jharkhand) to 78.7 (Kerala) in states and 16.1 per 10,000 population at a national level. In 2019, there were 1890 ANM training schools, 3155 general nurses and midwives (GNM) training colleges, and 1958 Bachelor of Science (BSc) nursing training colleges in India. These institutions had 54,948 ANM, 227,370 GNM/BSc and 40,795 postgraduate nursing seats. With the current capacity, the nurses and midwives deficit can only be met in a 6-12 years period.
CONCLUSION: India suffers from severe nurses and midwives shortage compared to the global norms with wide variations across the states. Increasing the training institution's number and seats are needed to meet the norms.

Entities:  

Year:  2022        PMID： 35635342      PMCID： PMC8958234          DOI： 10.5152/FNJN.2021.21013

Source DB:  PubMed          Journal:  Florence Nightingale J Nurs        ISSN： 2687-6442


Introduction

India has made significant progress in health indicators in recent times. In 2018, the crude birth and death rates were 20 (11% decline) and 6.2 (15% decline) per 1000 populations, respectively (Registrar General of India, 2020). Over the same period, the infant mortality rate (IMR) reached 32 per 1000 live births (decline by 36%) and the maternal mortality ratio (MMR) reached 113 per 100,000 live births (decline by 47%) (Registrar General of India, 2020). But this progress fell short to achieve the IMR and MMR goals of the National Rural Health Mission (NRHM) (IMR <30 per 1000 live births and MMR <100 per 10,000 live births by 2010) (Programme Evaluation Organization & Planning Commission, 2011) and the 12th five-year plan (IMR <25 per 1000 live births and MMR <100 per 10,000 live births by 2017) (Planning Commission, 2013). The human resource for health (HRH) has a significant contribution to these changes in health indicators, along with the infrastructural, systemic, and financial interventions (High Level Expert Group on Universal Health Coverage, 2010). Healthcare (curative and preventive) services in India are delivered by a wide range of professionals including doctors, nurses and midwives, paramedics, and support service providers. Additionally, there are dentists, Ayush doctors (under the indigenous Indian system of medicine including Ayurveda, Homeopathy, Unani, Siddha and Yoga), who provide clinical care. Nurses and midwives include the community level functionaries (auxiliary nurses and midwives, ANMs), general nurses and midwives (GNMs), graduate nurses, nurses with postgraduate and diploma in specialties. Additionally, physiotherapists, psychologists, paramedical technicians, other support functionaries contribute to India’s HRH. Additionally, there are community-level functionaries, accredited social health activists (ASHAs) who assist in health service delivery from 2005 to 2006 onwards. Usually, the Ayush doctors and ASHAs are not included in the World Health Organization’s (WHO) HRH index estimation (High Level Expert Group on Universal Health Coverage, 2010). WHO has revised the minimum HRH norms from 22.8 (2006) to 44.5 (2016) health workers per 10,000 population to achieve sustainable development goals (SDGs) and universal health coverage (UHC) (World Health Organization, 2017b). The revised norm is almost double of India’s current healthcare workforce status. The Global Health Workforce Alliance categorized India as one of the “most severe crisis” from the HRH aspect (Global Health Workforce Alliance & World Health Organization, 2013). India has a large network of 160,713 health sub-centers (HSCs), 34,705 primary health centers (PHCs), 5863 community health centers (CHCs), 438 sub-district hospitals (SDHs), and 756 district hospitals (DHs) (as of March 2020) (Ministry of Health and Family Welfare, 2020). Under the Ayushman Bharat scheme, over 50,000 health wellness centers (HWCs, up-gradation of some HSCs and PHCs) have been established till now at the HSCs and PHCs and target for 150,000 HCWs by December 2020, to facilitate comprehensive primary healthcare services delivery (Ministry of Health & Family Welfare, 2018). According to the government information, as of January 2019, the doctor: population ratio was 1:1457 for allopathic doctors and nurse: population ratio was 1:675, which was lower than the norms suggested by WHO (1:1000 for doctors and 3:1000 for nurses/midwives) (Ministry of Health and Family Welfare, 2019). Nurses and midwives (34.4%) and ANMs (14.1%) constitute the major share of the HRH in India (2016–2017) (Nair, 2019). In 2010, a high-level expert group (HLEG) on UHC in India recommended several strategies for addressing the HRH gaps to achieve the UHC including two ANMs and a nurse practitioner at HSCs, increasing the number of nursing and midwifery training institutions and career progression for nurses and midwives along with the allopathic and Ayush doctors and other allied health workforce (High Level Expert Group on Universal Health Coverage, 2010). Since then several efforts to augment the HRH production in India including nurses and midwives have been initiated by the Government of India (Ministry of Health and Family Welfare, 2019). There is a need to document the status of the nurses and midwives availability and the training capacity of the institutions in India for appropriate planning at national and state levels. The aim of the study was “what is the present status of the nurses and midwives HRH, the training capacity of the institutions in India and the trend since 2004?” This report presents the current status of the nurses and midwives HRH and their education opportunities in India and the changes over the last two decades. What is the status of the nurses and midwives HRH in India? What is the profile of the nurses and midwives educational institutions and their training capacity in India?

Methods

Study Design

This study is a descriptive and cross-sectional situational analysis.

Sample

There was no sample selection. This study collected all available data for the nurses and midwives HRH status for all the states, Union Territories and national level as of 2019 and their educational institutes and seats during 2004 and 2019. The study included data for the national and states level of India.

Data Collection

In this study, the health management and information system reports of the Ministry of Health and Family Welfare, Government of India for the period 2019-2020 (as of June 2020) were used. The list of nurse and midwife training institutions, courses and student intake capacity available from the Nursing Council of India (INC, website: https://www.indiannursingCouncil.org; last updated 15 December 2020) were manually compiled. The data for nurses and midwives for India and different states were extracted from other published literature and grey literature available in the open domain (the keywords used: nurses, nursing, midwife, midwives, nursing council, registration, education, courses, schools, workforce, human resources, shortage, migration, India, and states). The population of India and the states for 2019 were estimated using the Census 2011 data and decadal growth rate (Registrar General & Census Commissioner, India, 2013). Both authors participated in document search, data collection, and analysis.

Data Collection Tools

The data from various sources were abstracted and collated according to the types of courses, institutions, states, and years.

Statistical Analysis

Descriptive analysis was undertaken for the information extracted from different sources using excel and STATA 15.0 (Stata Corporation, Texas, USA). The data were presented as absolute numbers, percentages, average, standard deviation, minimum and maximum for the states, Union Territories and national level. The information for the year 2019–2020 was used for estimation of the nurses and midwives density per 10,000 population for the personnel in position and seats for training at state and national levels. Similarly, for different courses, the seat index per 10,000 population at state and national levels was also estimated.

Ethical Considerations

As data used for this study were obtained from publicly available sources and not linked to any identifiable individual, explicit individual consent was not required. The protocol was reviewed by INCLEN Independent Ethics Committee (Ref no-22, Date January 20, 2020) and exempted.

Results

Nurses and Midwives Density

According to the available information from the Government of India (2018), there were 872,693 ANMs, 56,602 lady health visitors (LHVs; supervisors of ANMs with 6 months additional training), and 2,108,919 RNs/RMs. As reflected in Table 1, at the national level, the population densities for ANM, RN/RM, LHV, and all nurses and midwives pooled were 6.6, 16.1, 0.4, and 23.2 per 10,000 population. The figures for some union territories (UTs) were not available. The ANM density per 10,000 population varied from 0.7 in Bihar and Telangana to 26.6 in Andhra Pradesh. From these figures, it appears that there were discrepancies in the available numbers for the states Andhra Pradesh and Telangana, which were separated in 2014. The RN/RS density per 10,000 population varied from 0.8 in Bihar and 0.9 in Jharkhand to 78.7 in Kerala. The LHV density per 10,000 population varied from zero in 10states to 2.4 in Kerala, and LHV is considered as a dying cadre. At pooled level, the nurses and midwives density per 10,000 population was lowest in Bihar (1.6) and highest in Kerala (89.9). Eleven states had the nurses and midwives density above three per 1000 population, meeting the WHO norm (Table 1, 2).
Table 1.

Nursing Professional Density in States and Union Territories of India

States and Union Territories Number of Nurses and midwivesa Population (in Millions)b Nurses and Midwives Density (per 10,000 Population)c
ANM (n)RN/RM (n)LHV (n)Total (n)ANMRN/RMLHVPooled
States
 Andhra Pradesh138,435232,6212480373,536 52.03226.6 44.7 0.5 71.8
 Arunachal Pradesh11581094352287 1.4937.8 7.3 0.2 15.3
 Assam27,92522,38835350,666 34.0438.2 6.6 0.1 14.9
 Bihar8624941351118,548 118.3330.7 0.8 0.0 1.6
 Chhattisgarh133,2913,048135227,729 28.4684.7 4.6 0.5 9.7
 Delhi451667,416071,932 19.5612.3 34.5 -36.8
 Goa----1.534
 Gujarat48,517123,1700171,687 67.3197.2 18.3 - 25.5
 Haryana26,60730,43069457,731 28.4019.4 10.7 0.2 20.3
 Himachal Pradesh11,67320,93450033,107 7.26816.1 28.8 0.7 45.6
 Jammu & Kashmir*----13.427----
 Jharkhand475533101428207 37.0471.3 0.9 0.0 2.2
 Karnataka54,039231,6436840292,522 65.4508.3 35.4 1.0 44.7
 Kerala30,706275,5448507314,757 35.0038.8 78.7 2.4 89.9
 Madhya Pradesh39,563118,7931731160,087 81.4714.9 14.6 0.2 19.6
 Maharashtra71,079139,247671210,997 121.3915.9 11.5 0.1 17.4
 Manipur387787980 12,675 3.08012.6 28.6 - 41.2
 Meghalaya18466637206 8,689 3.2005.8 20.7 0.6 27.2
 Mizoram2157363405791 1.18418.2 30.7 - 48.9
 Nagaland----2.134----
 Orissa62,159755752381,37,972 43.55014.3 17.4 0.1 31.7
 Punjab23,02976,6802584102,293 29.6997.8 25.8 0.9 34.4
 Rajasthan108,688200,1712732311,591 76.59214.2 26.1 0.4 40.7
 Sikkim216114401360 0.6593.3 17.4 - 20.6
 Tamil Nadu58,411293,105112,47362,763 75.4607.7 38.8 1.5 48.1
 Telangana27629397012,159 37.0300.7 2.5 - 3.3
 Tripura223241401486520 3.9635.6 10.4 0.4 16.5
 Uttar Pradesh60,25874,7772763137,798 223.0032.7 3.4 0.1 6.2
 Uttarakhand24012613145028 11.0552.2 2.4 0.0 4.5
 West Bengal63,73163,197128,541,39,78296.5006.6 6.5 1.3 14.5
Union Territories
 Andaman and Nicobar Island----0.396----
 Chandigarh----1.170----
 Dadra and Nagar Haveli----0.525----
 Daman and Diu----0.395----
 Lakshadweep----0.067----
 Puducherry----1.481----
Total183,785 198,143 17,989399,917 1323.3841.9 5.0 0.1 7.0

Note: *Recently divided into two Union Territories, Jammu and Kashmir and Ladakh.

aData source: Ministry of Health and Family Welfare, Government of India (July 2, 2019).

bEstimated population for 2019 using the Census 2011 and decadal growth rate.

cEstimated nurses and midwives density.

Table 2.

Nursing and Midwife Courses Seat Indexa at State and National Level for India (2019)

State/Union TerritoryANMa GNMa BSca MSca PBBSca Othersa Pooleda
States
 Andhra Pradesh0.191.331.500.140.190.033.38
 Arunachal Pradesh1.261.550.300.000.000.003.10
 Assam0.280.650.220.040.030.011.24
 Bihar0.330.100.040.000.010.000.48
 Chhattisgarh0.081.051.650.160.210.023.16
 Delhi0.140.300.290.050.040.090.92
 Goa0.470.240.850.120.050.191.91
 Gujarat0.600.970.690.060.080.022.41
 Haryana0.931.150.600.080.300.043.09
 Himachal Pradesh0.441.931.570.220.480.004.64
 Jammu & Kashmir0.360.500.620.060.090.001.63
 Jharkhand0.560.310.120.000.030.011.03
 Karnataka0.123.482.700.491.010.107.89
 Kerala0.141.502.000.310.360.134.45
 Madhya Pradesh0.361.871.010.130.260.013.64
 Maharashtra0.960.610.380.060.120.042.17
 Manipur0.751.910.970.060.070.003.76
 Meghalaya0.230.890.310.030.100.001.57
 Mizoram1.091.460.870.000.000.003.42
 Nagaland0.240.650.160.000.080.001.14
 Odisha0.900.690.350.060.070.012.09
 Punjab1.893.431.770.230.960.038.30
 Rajasthan0.101.070.950.060.150.012.33
 Sikkim0.300.602.550.370.000.003.82
 Tamil Nadu0.231.021.520.250.320.073.40
 Telangana0.131.031.190.120.120.052.63
 Tripura0.540.630.460.060.050.001.74
 Uttar Pradesh0.360.540.200.020.040.001.17
 Uttarakhand0.541.091.020.140.190.023.00
 West Bengal0.120.400.150.020.040.020.76
Union Territories
 Andaman & Nicobar  Island0.250.250.000.000.000.000.51
 Chandigarh0.100.000.590.100.200.071.06
 Dadra & Nagar Haveli 0.000.001.300.430.000.001.73
 Daman & Diu0.000.001.340.000.000.001.34
 Lakshadweep0.000.000.000.000.000.000.00
 Puducherry0.961.775.540.871.180.4010.72
India0.420.980.740.100.180.032.44

Note: aIndex estimated per 10,000 population using nursing and midwife course seats according to Indian Nursing Council (for the year 2019–20) and population estimated for 2019 using Census 2011 and decadal growth rate.

ANM = Auxiliary Nurse and Midwife; GNM = General Nursing and Midwifery; BSc = Bachelor of Science Nursing-Basic; MSc = Masters of Science Nursing; PBBSc = Post Basic BSc Nursing; Others: Included MPhil, PhD, certificate, and diploma courses.

Nurses and Midwives Education

According to the INC, there are several nurse and midwifery courses being offered in India including certificate, diploma, degree (graduate, postgraduate, and PhD) programs, some are awarded by the nursing boards and others by the universities (Table 3). The ANM, GNM, and BSc nursing courses are the major ones offered. According to the level of engagement and function in the public health system, the ANMs and LHVs primarily function at the HSC and PHCs. The GNMs usually function as staff nurses and midwives at the PHC, CHC, SDH, and DHs. The MSc, MPhil, and PhD degree holders are usually engaged in teaching institutes and medical or dental colleges. The private sector health institutions also engage the nurses usually with GNM and BSc degrees, while the super-specialty hospitals may engage the PBBSc and additional certificate course qualified nurses. The BSc, PBBSc, and postgraduate degree holders usually also migrate to other countries.
Table 3

The types of nursing academic courses in India

Type of courseEligibility Course durationType of examinationRegistration Work prospects
Auxiliary Nurse & Midwife (ANM)10th grade pass 2 yearsNursing Examination Board*RANMHSCs and PHCs
General Nursing & Midwifery (GNM)12th grade pass with minimum of 40% aggregate marksAge 17-35 yearsOR Registered ANM/LHV 3 and 1/2 years;3 years from 2015-2016Nursing Examination Board*RN/RMPHCs, CHCs, Public health hospitals
B. Sc (Basic)12th grade pass with PCBE subjects and minimum of 45% aggregate marks 4 yearsUniversityRN/RMDH, MCH and SSH
B.Sc (Post Basic)12th grade pass+ GNM passRegular: 2 yearsDistance: 3 yearsUniversityAdditionalDH, MCH and SSH
M. Sc.B.Sc. Nursing/ B.Sc. Honors Nursing/ Post Basic B.Sc. Nursing with minimum of 55% aggregate marksMinimum one year of work experience after Basic B.Sc. or Post-Basic B.Sc. Nursing2 yearsUniversityAdditionalANMS, NS/NC, MCH and SSH
MSc Nurse practitioner coursesB.Sc. Nursing with minimum of 55% aggregate marks Minimum of one year clinical experience2 years UniversityAdditionalMCH and SSH
M. PhilM.SC. Nursing1 year (Full time)2 years (part time)UniversityAdditionalNS/NC, MCH and SSH
PhDM.Sc./M.Phil.3-5 yearsUniversityAdditionalNS/NC, MCH and SSH
Post Basic Specialty Diploma/Nurse Practitioner CoursesB.Sc Nursing with 1-3 years of clinical experience1 year Nursing Examination Board*AdditionalMCH and SSHs
Lady Health Visitor (LHV)ANM6 months Nursing Examination Board*Additional PHCs and CHCs

Note: *Nursing Examination Board, non-university programmes

RANM and RN/RM: Registered with the State Nurses and Midwives Registration Council

Abbreviations: ANM: Auxiliary Nurse and Midwife; B.Sc: Bachelor in Science; DH: District Hospital; HSC: Health Sub-centres; LHV: Lady Health Visitor; MCH: Medical College Hospital; M.Sc: Masters in Science; NS/NC: Nursing School or Nursing College; PHC: Primary Health Centre; RANM: Registered Auxiliary Nurse & Midwife (ANM); RN/RM: Registered Nurse and Registered Midwife; SSH: Super specialty hospital.

The INC and the 29 state nursing councils (SNCs) oversee nursing education in the country and respective states. The SNCs register the students passing out from the institutions in their respective states. No SNC exists in the UTs and state of Nagaland. In 2019, there were 1890 ANM training schools, 3155 GNM training colleges, and 1958 BSc nursing training colleges in India. Additionally, 765, 217, and 650 colleges offered PBBSc certificate, PBBSc diploma in nursing, and MSc courses. Between 2004 and 2019, in India, the numbers of nursing institutions have increased by 8.8 times for ANM courses, 4.6 times for GNM courses, 10.6 times for BSc courses, 20.7 times for PBBSc courses, and 20.3 times for MSc courses (Figure 1). The rise in institutions has been higher from 2010 onwards. The rise in MPhil, PhD, and other specialty courses was very small compared to the others. The rise in the number of institutions was higher in some states (Assam, Bihar, Chhattisgarh, Delhi, Gujarat, Haryana, Jammu and Kashmir, Jharkhand, Karnataka, Madhya Pradesh, Maharashtra, Odisha, Punjab, Tamil Nadu, and Uttar Pradesh), especially for the ANM, GNM, and BSc courses (Supplementary Tables 1-6).
Figure 1.

The Trend of Nursing Institutions in India During 2004 and 2019.ANM = Auxiliary Nurse and Midwife; GNM = General Nursing and Midwifery; BSc = Bachelor of Science Nursing-Basic; MSc = Masters of Science Nursing; PBBSc = Post Basic BSc Nursing; PBDC = Post Basic certificate and diploma courses.

In 2019, the institutions had 54,948 ANM seats, 227,370 GNM or BSc nursing seats, and 40,795 post-BSc or postgraduate courses. While ten states had >10,000 GNM/BSc seats, only three states had >5000 ANM seats. Six states had >2000 seats in regular postgraduate or diploma or certificate nursing courses. Table 2 summarizes the nurses and midwifery course seat index at the state and national level for the year 2019.

Adequacy of the Institutions and Student Intake Capacity

According to the HLEG for UHC estimate, the ANM cadre requirement for 2022 was 832,178. According to the INC, the annual ANM intake capacity was 39,325 in 2019. Considering the availability of 80% of the registered ANMs in service, 80% of the newly trained ANMs join public health service and annual attrition of 3% due to various reasons, the estimated time needed to meet the estimates is 12 years. The HLEG estimated the nursing cadre requirement for 2022 as 1,616,227. According to the INC, the annual GNM and BSc nursing intake capacity was 177,368 in 2019. Considering the availability of the registered nurses as 60% (adjusting for the migration, joining private sector) and 60% of the newly trained nurses joining public health services and 3% annual attrition due to various reasons, the estimated time needed to meet the estimates is 5–6 years. With population growth, the public health infrastructure shall also need expansion. Additionally, the augmentation of public health infrastructure with HWCs has escalated the HRH demand. With these expansions, the HRH demands are expected to multiply by at least 125%. Considering the expansion of private sector health infrastructure, the HRH, especially the nursing cadre training shall need augmentation to meet the demand in coming years.

Nurses and Midwifery Journals from India

On searching, 21 nurses and midwifery journals published from India were retrieved (Table 4). None of these were indexed in PubMed. Six of these were published by Tamil Nadu Nurses and Midwives Council.

Discussion

This paper presents the status of the nurses and midwives cadre HRH and the training institutes for nurses and midwives in India as of 2019. This paper estimated the nurses and midwives density for the states in India and the national level. According to the estimated nurses and midwives density, eleven states met the WHO norm and six states had < 1 nurse/midwife per 1000 population. The status of union territories (except Delhi) and Jammu and Kashmir were not available. It was observed that considering the public health infrastructure, there is a gross deficit in the existing nursing cadre HRH in India. The available nurses and midwives density in India was 1:2000 (0.5 per 1000 population), which is low compared to the density in the lower middle (1.7 per 1000 population), upper-middle (2.7 per 1000 population), and high income (7.1 per 1000 population) countries in 2013 (World Health Organization, 2017a). The Indian nurses and midwives density is lower than the overall density in the WHO Southeast Asia region (1.5 per 1000 population) (World Health Organization, 2017a). According to the National Sample Survey Organization survey (India, 2016), about 78.7% of the nurses and midwives were registered. The HRH density per 10,000 population for the nurses and midwives was 12.7 and for the ANMs were 6.0 at the national level. The report also noted that 58% of the nurses and midwives had inadequate qualifications or training in India. After adjusting for the inadequate qualifications, the nurses and midwives density per 10,000 population dropped from 12.7 to 4.2. While 44.8% of the nurses and midwives were in the public sector, 55.3% were in the private sector (Karan ). This indicates the unavailability of adequately trained nurses in the public sector. The status may be more in the private sector. About two-thirds (67%) to of the nurses and midwives were working in the urban areas (Karan ). The density of nurses and midwives in the urban area in India was 7.2 compared to 1.3 per 10,000 population in rural areas. The share of inappropriately qualified nurses and midwives in rural areas was 68.2% compared to 56.2% in urban areas (Rao ). The existing courses and training capacity of the institutes appear inadequate to meet the nursing HRH demand in the coming decade. If the demand for the growing private healthcare sector is considered, the demand expands further. From 2010 onwards the number of nurses and midwives training institutions, especially for the ANM, GNM, and BSc nursing courses has increased significantly. The nurses and midwives training institutions are unevenly distributed across the states. In 2019, the pooled nursing course seat density was <1 per 10,000 population in three states. Some states like Maharashtra, Karnataka, Kerala, Punjab, Madhya Pradesh, Tamil Nadu, and Uttar Pradesh had more institutions and seats. While most of the states had more seats for GNM/BSc nursing training, ANMs, Bihar, and Jharkhand had more ANM seats. Despite the rise in the number of institutions, it is estimated that at this pace, the existing gaps shall be met in 5–12 years period for different nurses and midwives cadres according to the education levels. These numbers of seats don’t reflect the actual availability of nurses and midwives for service in India. Under the NRHM, efforts were made to expand the HRH base with the induction of new manpower through contractual arrangements. Due to the lower salary, no continuity assurance, no promotion plan, and lack of additional benefits, after few years, several of these workers have been agitating and going on strikes seeking regularization of services (Gill, 2016). In India, the nurses and midwives workforce are also challenged by the societal class, caste system, and family level decision-making dynamics (Gill, 2016). It is estimated that about 20% of the nursing workforce, especially those with qualifications BSc nursing and above, migrate to other countries (Hawkes ; Thompson & Walton-Roberts, 2019). Over the last few decades, mass migration and recruitment drives for high-income countries through agencies are being organized. India stands the second source of migrated nurses to the United Kingdom after Indonesia. It is reported that about 16,000–18,000 nurses migrate annually from India (Srinivasan, 2016). Job satisfaction, salary, working conditions, professional status, career prospects, and overall living conditions are the key drivers for migration to other countries (Garner ; Thomas, 2006). The education and practice of nursing and midwifery are clubbed in India. The graduates are expected to play a need-based dual role of nurse and midwife. The current Indian Nursing Council Act and some state nurses Acts don’t ask for regular updating of knowledge and skills through continued education or in-service training. The nurses and midwives face challenges from the trainee doctors and supervisors for practice with minimal continued practice of skills. Several of the nursing and midwifery institutions face challenges including infrastructure, availability of adequate teachers and quality teaching, and adequate supervision as per the INC’s guidelines (Mayra ). To push the infant and maternal mortality reduction agenda and achieve the targets under SDGs, there is a need to focus on nursing and midwifery training and skill sustenance. Simultaneously to support the advancements in medical services and provide world-class clinical services for patients from India and other developing countries, there is a need to focus on improving the quality of nursing education and creating opportunities for specialized nursing training and certification. Thus, the Indian nursing and midwifery academic sector is facing both quantity and quality challenges, which require strategic thinking and appropriate investments. Additionally, there is also a need for pushing the research agenda in nursing and midwifery and promote nurse-researchers to address the context-specific and socio-cultural appropriate issues to improve the quality of clinical care and patient satisfaction. Attention is also needed for the dedicated nursing and midwifery journals, promoting quality publications and indexing them.

Study Limitations

The study has some limitations. The data used for this study are secondary and taken from government data sources, which might suffer from completeness and validation challenges. The segregation for the public- and private sector was not available.

Conclusion and Recommendations

India suffers from a gross shortage of nurses and midwives HRH compared to the global norms with wide inter-state variations. The states with a lesser number of nursing and midwife training institutions have a severe deficit. With inadequate HRH status and sub-optimal skills, the national health policy and SDG goals cannot be achieved in the planned timeline. While the primary focus at present appears to be on the number of nurses and midwives, the efforts for improving the skills, specialized nursing services and research in nursing and midwifery must also be emphasized. Retention of qualified nurses and outmigration of nurses remain constant challenges for India. Although there is an encouraging rise in the number of institutions and seat availability for the training of nurses and midwives over the last decade, there is a need for a further increase over the next five years to meet the global norm in a shorter timeline. In parallel to the increase in the numbers of institutions and seats, there is a need to focus on the quality of training, skill retention and new competencies acquisition to support the advancements in clinical, nursing, and midwifery care. In international migration of nurses from India also must be factored in while planning the nursing training institutions and intake capacity for India and states. Additionally, there is a need to focus on creating opportunities for training and services in specialty nursing disciplines to appropriately support the advancement in clinical care.

Ethics Committee Approval

Ethics committee approval was received for this study from the ethics committee of INCLEN Independent Ethics Committee (Date: January 20, 2020, Ref no- IIEC-022).

Author Contributions

Concept – M.K.D.; Data Collection and/or Processing – M.K.D., D.S.; Analysis and/or Interpretation – M.K.D.; Writing Manuscript – M.K.D., D.S.; Critical Review – M.K.D., D.S.
Supplementary Table 1

Number of Auxiliary Nurse & Midwife (ANM) training institutions in the states during 2004 and 2019

Year2004200520062007200820092010201120122013201420152016201720182019
States
Andhra Pradesh22303033333334405867706945393932
Arunachal Pradesh0111122222245677
Assam976666791616171924253435
Bihar2325272721242729446770758197110108
Chhattisgarh00115683170889093917955
Delhi111113443667881010
Goa0111111111122222
Gujarat2233338136081899910487118131
Haryana9101013233940455568758289818785
Himachal Pradesh122444669109875910
Jammu & Kashmir0011122361013131515141414
Jharkhand013311214172733384958566765
Karnataka14444626384545424338282726
Kerala12151414141414152025191919202018
Madhya Pradesh 79131311747682141123126111101919590
Maharashtra161622474897180265390466554572561542552545
Manipur03344566811111110887
Meghalaya 0022222222222223
Mizoram1222223333333344
Nagaland0111111111111222
Orissa151616161622506786105119131133131131129
Punjab2733343535374990127158173176174171175170
Rajasthan881010101111114643332928292927
Sikkim0000000001111111
Tamil Nadu871112131313142037353744294145
Telangana00000000000018171717
Tripura0111122233333235
Uttar Pradesh3030303026272665120146166180182158239239
Uttarakhand000044691418192021142121
West Bengal16202025253755595862595451443128
Union Territories
Andaman & Nicobar Islands0111111111111111
Chandigarh0000000011111111
Dadra & Nagar Haveli0000000000000000
Daman & Diu0000000000000000
Lakshadweep0000000000000000
Pondicherry0111111214546577
Total20824727131232949167693514421707185319211927179819091890

Note: Data source- Indian Nursing Council

Supplementary Table 2

Number of General Nursing & Midwifery (GNM) training institutions in the states during 2004 and 2019

Year2004200520062007200820092010201120122013201420152016201720182019
States
Andhra Pradesh91119182222220233244261248258263253164156162155
Arunachal Pradesh0222222222355777
Assam12111113131516182425263032335254
Bihar13131515579111115151618172324
Chhattisgarh221251011263041465876728481
Delhi12161717171715151523181818162018
Goa0122222222111111
Gujarat182228343340496980979910210691143148
Haryana12192530323841455364697881718481
Himachal Pradesh56665625353334343538284139
Jammu & Kashmir00231335101213141616161616
Jharkhand002231315192122232424242829
Karnataka154274392458467509520560545556531519515489487480
Kerala7491137172190206218224219230210209206188186176
Madhya Pradesh 16222427192764135233271295313337297404392
Maharashtra475871999097101106137177221254263254268264
Manipur04476767812121313131516
Meghalaya 0558777777777778
Mizoram3445555555555566
Nagaland0111111122344555
Orissa4102020202840485258637679798078
Punjab558092115117132147168182204215214212207218214
Rajasthan385774106120141155176181184173173174174175168
Sikkim0100000111222222
Tamil Nadu5466102122115145164189196212205210212199210204
Telangana00000000000091889190
Tripura1333333355555556
Uttar Pradesh243450626680108146173197219228238197280276
Uttarakhand0002226101318181922162932
West Bengal22283840404146495461636467567575
Union territories
Andaman & Nicobar Island0111111111111011
Chandigarh0000000000000000
Dadra & Nagar Haveli0000011111111000
Daman & Diu0000000000000000
Lakshadweep0000000000000000
Pondicherry01111111455577109
Total65795113121597162018202028235125502803286529583040282032153155

Note: Data source- Indian Nursing Council

Supplementary Table 3

Number of BSc nursing training institutions in the states during 2004 and 2019

Year2004200520062007200820092010201120122013201420152016201720182019
States
Andhra Pradesh3968107167180187211255220224230225144135149144
Arunachal Pradesh0000000000011111
Assam223466697881010111217
Bihar00000000134455910
Chhattisgarh24910112531424760667181779495
Delhi5557788161013111111101114
Goa0023333333333333
Gujarat035861123343643465258498998
Haryana12311111616242328303232273837
Himachal Pradesh0000016111214161619122630
Jammu & Kashmir0002033444558151416
Jharkhand000021345667981010
Karnataka67149237285284303311354339343334334325314319314
Kerala5125983828897119122129128126131124131132
Madhya Pradesh 7192342487485101116119124133147126190186
Maharashtra211234348587286849395979990104105
Manipur0000001446666677
Meghalaya 0011111222222222
Mizoram1122222222222223
Nagaland0000000000111111
Orissa04812131313161414151820202133
Punjab1114193031607692849294101101100108108
Rajasthan23518365995149143143140152159165168150
Sikkim0111111222222223
Tamil Nadu3638498086114131166158169169172173166180181
Telangana00000000000084838584
Tripura0000111123444344
Uttar Pradesh2266612223739545658656094103
Uttarakhand0125555881091012132023
West Bengal2256691216160181820212325
Union territories
Andaman & Nicobar Islands0000000000000100
Chandigarh1111111111222222
Dadra & Nagar Haveli0000000000111111
Daman & Diu0000000000000011
Lakshadweep 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0
Pondicherry0556688121214141415121515
Total18534758083388310701244157015161602164116901752166719361958

Note: Data source- Indian Nursing Council

Supplementary Table 4

Number of Post Basic BSc nursing training institutions in the states during 2004 and 2019

Year2004200520062007200820092010201120122013201420152016201720182019
State
Andhra Pradesh111111112313640404229263233
Arunachal Pradesh0000000000000000
Assam0000211334444444
Bihar0000000011111122
Chhattisgarh000025891314141617161919
Delhi2222222111223344
Goa0111011111111111
Gujarat111111581217181818101620
Haryana0004088111321262728192829
Himachal Pradesh00000000222444814
Jammu & Kashmir0001023333334443
Jharkhand0000011113344455
Karnataka15202221272664131169186192194191181183177
Kerala12564819345054525251474641
Madhya Pradesh 344561029334747504955517273
Maharashtra556851021283750555656515552
Manipur0000000000000011
Meghalaya 0000000011111111
Mizoram0000000000000000
Nagaland0000000011111111
Orissa00121232223566610
Pondicherry
Punjab1561022649747687869290879190
Rajasthan000121431505959525248474642
Sikkim0000000111222100
Tamil Nadu55912371326486279807779707265
Telangana00000000000016161616
Tripura0000000111111111
Uttar Pradesh111102681220222629263435
Uttarakhand0001011425546377
West Bengal112426101011121198111110
Union territories
Andaman & Nicobar Islands0000000000000000
Chandigarh1111111111111111
Dadra & Nagar Haveli0000000000011111
Daman & Diu0000000000000000
Lakshadweep0000000000000000
Pondicherry0000016788777677
Total37496282105142307500626721735752762700775765

Note: Data source- Indian Nursing Council

Supplementary Table 5

Number of MSc nursing training institutions in the states during 2004 and 2019

Year2004200520062007200820092010201120122013201420152016201720182019
States
Andhra Pradesh022211929545358555532293336
Arunachal Pradesh0000000000000000
Assam0001123434455557
Bihar0000000000000000
Chhattisgarh0011341012912141615142021
Delhi1122233333344677
Goa0000100000011111
Gujarat00111124446913111520
Haryana00004113344485910
Himachal Pradesh0000000000111157
Jammu & Kashmir0000000022222234
Jharkhand0000100000001111
Karnataka152025282257120166174181181178176155157151
Kerala13336630445766676668606359
Madhya Pradesh 123541320262527292737415959
Maharashtra122581016222933333535343840
Manipur0000000000000002
Meghalaya 0000000000000111
Mizoram0000000000000000
Nagaland0000000000000000
Orissa000121456677891012
Punjab002210413262631363840403535
Rajasthan00015255815151822242625
Sikkim0000000000000111
Tamil Nadu12193342124144546279827983798279
Telangana00000000000025242423
Tripura0000000000022222
Uttar Pradesh00001046677912121717
Uttarakhand0000112313444488
West Bengal0222444768999121213
Union territories
Andaman & Nicobar Islands0000000000000000
Chandigarh1111111111111111
Dadra & Nagar Haveli0000000000000111
Daman & Diu0000000000000000
Lakshadweep0000000000000000
Pondicherry0000014557777677
Total3252779790171315450483551567577611581643650

Note: Data source- Indian Nursing Council

Supplementary Table 6

Number of Post Basic Diploma nursing training institutions in the states during 2004 and 2019

Year2004200520062007200820092010201120122013201420152016201720182019
States
Andhra Pradesh00000000021232215131413
Arunachal Pradesh0000000000000000
Assam0000000001223122
Bihar0000000000000033
Chhattisgarh000000000781010663
Delhi000000000118912101410
Goa0000000000000002
Gujarat00000000015151497106
Haryana0000000005577585
Himachal Pradesh0000000000000000
Jammu & Kashmir0000000000001000
Jharkhand0000000002222222
Karnataka00000000050555662445441
Kerala00000000035333335333928
Madhya Pradesh 0000000001110121110107
Maharashtra00000000025252638314029
Manipur0000000000000000
Meghalaya 0000000000000000
Mizoram0000000000001000
Nagaland0000000000000000
Orissa0000000002334333
Punjab0000000006989886
Rajasthan0000000004323220
Sikkim0000000000000000
Tamil Nadu00000000042363843253325
Telangana000000000000119139
Tripura0000000000000000
Uttar Pradesh0000000003435474
Uttarakhand00000000010000020
West Bengal00000000011152020171513
Union territories
Andaman & Nicobar Islands0000000000000000
Chandigarh0000000000000001
Dadra & Nagar Haveli0000000000000000
Daman & Diu0000000000000000
Lakshadweep0000000000000000
Pondicherry0000000007757775
Total000000000268263272308237292217

Note: Data source- Indian Nursing Council

Supplementary Table 7

Nursing and midwife course seat index in the states and national level according to population (per 10000 population) for the year 2019

State/ Union TerritoriesPopulation (year 2019) in millionsANMGNMB.Sc M.ScPBBScPBDC Pooled
nRatenRatenRatenRatenRatenRatenRate
States
Andhra Pradesh50.7769500.196,7701.337,6151.507260.149650.191600.0317,1863.38
Arunachal Pradesh1.3541701.262101.55400.3000.0000.0000.004203.10
Assam33.5169430.282,1640.657500.221210.041150.03500.014,1431.24
Bihar107.29334900.331,0960.104700.0400.00700.01400.005,1660.48
Chhattisgarh26.7822100.082,8051.054,4101.654240.165650.21600.028,4743.16
Delhi23.1643200.146950.306650.291230.051000.042200.092,1230.92
Goa2.1171000.47500.241800.85250.12100.05400.194051.91
Gujarat64.89138800.606,2650.974,4640.693840.065200.081350.0215,6482.41
Haryana28.63126700.933,2901.151,7150.602170.088450.301100.048,8473.09
Himachal Pradesh7.2593200.441,4001.931,1401.571610.223450.4800.003,3664.64
Jammu & Kashmir12.7804650.366350.507900.62780.061100.0900.002,0781.63
Jharkhand34.88719400.561,0850.314200.12170.001200.03210.013,6031.03
Karnataka6,3.9367550.1222,2473.4817,2502.703,1160.496,4301.016650.1050,4637.89
Kerala36.2415050.145,4451.507,2552.001,1370.311,3100.364670.1316,1194.45
Madhya Pradesh81.10129250.3615,1401.878,2251.011,0390.132,0800.26950.0129,5043.64
Maharashtra124.326119950.967,6040.614,6850.387130.061,4750.124690.0426,9412.17
Manipur2.6732000.755101.912600.97160.06200.0700.001,0063.76
Meghalaya2.860650.232550.89900.31100.03300.1000.004501.57
Mizoram1.0961201.091601.46950.8700.0000.0000.003753.42
Nagaland2.454600.241600.65400.1600.00200.0800.002801.14
Odisha43.45039200.903,0150.691,5300.352670.062950.07450.019,0722.09
Punjab29.86856551.8910,2333.435,3001.776770.232,8550.96830.0324,8038.30
Rajasthan75.8287500.108,0851.077,1950.954600.061,1050.15450.0117,6402.33
Sikkim0.667200.30400.601702.55250.3700.0000.002553.82
Tamil Nadu70.34416200.237,1751.0210,6601.521,7540.252,2400.324750.0723,9243.40
Telangana39.3624950.134,0521.034,6901.194630.124600.121900.0510,3502.63
Tripura3.9462150.542500.631800.46220.06200.0500.006871.74
Uttar Pradesh228.15282300.3612,3700.544,6500.204090.021,0200.041100.0026,7891.17
Uttarakhand11.0105950.541,2051.091,1201.021490.142100.19250.023,3043.00
West Bengal95.87511450.123,8600.401,4300.152200.024250.042050.027,2850.76
Union Territories
Andaman.& Nicobar Island0.785200.25200.2500.0000.0000.0000.00400.51
Chandigarh2.028200.1000.001200.59200.10400.20150.072151.06
Dadra & Nagar Haveli 0.46200.0000.00601.30200.4300.0000.00801.73
Daman & Diu0.37400.0000.00501.3400.0000.0000.00501.34
Lakshadweep0.084 0.00 0.00 0.00 0.00 0.0000.0000.00
Puducherry1.8681800.963301.771,0355.541620.872201.18750.402,00210.72
India1,312.240547280.421,28,2710.9897,4840.7412,7530.1023,7600.183,7100.033,20,7062.44

Note: Index estimated per 10000 population using nursing and midwife course seats according to Indian Nursing Council (for the year 2019-20) and population estimated for 2019 using Census 2011 and decadal growth rate.

Abbreviation: ANM: Auxiliary Nurse and Midwife; GNM: General Nursing and Midwifery; B.Sc: Bachelor of Science Nursing-Basic; M.Sc.: Masters of Science Nursing; PBBSc: Post Basic BSc Nursing; PBDC: Post Basic certificate and diploma courses.

Supplementary Table 8

Nursing and midwife course seat index in the states and national level according to population (per 10000 population) for the year 2011

State/ Union TerritoriesPopulation (year 2011) in millionsANMGNMB.Sc M.ScPBBScPBDC Pooled
nRatenRatenRatenRatenRatenRatenRate
States
Andhra Pradesh84.5811,2950.1510,8041.2811,4411.351,0090.121,1100.133300.0425,989.03.07
Arunachal Pradesh1.384400.29400.2900.0000.0000.0000.0080.00.58
Assam31.2063840.126080.193000.10470.02950.03600.021,494.00.48
Bihar104.0991,2380.124260.04400.0000.00300.0000.001,734.00.17
Chhattisgarh25.5452,3350.911,0850.422,2300.871660.063550.14700.036,241.02.44
Delhi16.7881200.076250.375050.30550.03200.012300.141,555.00.93
Goa1.459200.14700.481300.8900.00100.0700.00230.01.58
Gujarat60.4402,0400.343,1950.531,6650.28750.013500.063200.057,645.01.26
Haryana25.3511,8500.732,1400.841,0450.41500.023900.151150.055,590.02.21
Himachal Pradesh6.8651850.271,2501.825400.7900.00700.1000.002,045.02.98
Jammu & Kashmir12.2583550.294950.401800.15330.031100.09200.021,193.00.97
Jharkhand32.9886950.217350.222300.0700.00300.01260.011,716.00.52
Karnataka61.0951,3250.2225,3244.1417,7832.913,4080.566,1901.016400.1054,670.08.95
Kerala33.4063900.126,8052.046,5801.971,0910.331,7150.513670.1116,948.05.07
Madhya Pradesh72.6273,7250.518,1601.125,1200.703940.051,2950.181750.0218,869.02.60
Maharashtra112.3747,7330.693,7990.343,7500.334640.041,1050.103640.0317,215.01.53
Manipur2.8562150.752300.811600.5600.0000.0000.00605.02.12
Meghalaya2.967450.151950.66900.3000.00300.1000.00360.01.21
Mizoram1.097900.821301.18630.5700.0000.0000.00283.02.58
Nagaland1.979200.10500.2500.0000.00200.1000.0090.00.45
Odisha41.9742,2600.541,8600.446900.161150.03500.01600.015,035.01.20
Punjab27.7434,3501.578,9633.234,0901.474160.152,4300.881300.0520,379.07.35
Rajasthan68.5481,2000.188,4801.246,1960.901100.021,6000.23750.0117,661.02.58
Sikkim0.61100.00600.981602.6200.00500.8200.00270.04.42
Tamil Nadu72.1474550.065,5200.778,8901.231,4080.202,1950.307880.1119,256.02.67
Telangana35.004 0.00 0.00 0.00 0.00 0.00 0.000.00.00
Tripura3.6741100.302100.571100.3000.00300.0800.00460.01.25
Uttar Pradesh199.8123,8300.197,7400.391,7600.091050.013850.02650.0013,885.00.69
Uttarakhand10.0863650.364100.413600.36250.02700.0700.001,230.01.22
West Bengal91.2762,5550.282,0510.227050.081070.014250.052920.036,135.00.67
Union Territories
Andaman.& Nicobar Island0.381200.53200.5300.0000.0000.0000.0040.01.05
Chandigarh1.055400.3800.00600.57200.19400.3800.00160.01.52
Dadra & Nagar Haveli 0.34400.00200.5800.0000.0000.0000.0020.00.58
Daman & Diu0.24300.0000.0000.0000.0000.0000.000.00.00
Lakshadweep0.064 0.00 0.00 0.00 0.00 0.00 0.000.00.00
Puducherry1.248400.321200.968757.011020.822401.92750.601,452.011.64
India1,312.240547280.421,28,2710.9897,4840.7412,7530.1023,7600.183,7100.033,20,7062.44

Note: Index estimated per 10000 population using nursing and midwife course seats according to Indian Nursing Council (for the year 2011-12) and population from Census 2011

Table 4

List of Journals with nursing and midwifery focus published from India

S. No.Title of the JournalPublished by institute/associationPubmed Indexed
1Indian Journal of Continuing Nursing EducationCollege of Nursing, Christian Medical College, Vellore, Tamil Nadu No
2Journal of Pediatric NursingTamil Nadu Nurses and Midwives Council, Chennai, Tamil Nadu No
3Journal of Medical & Surgical NursingTamil Nadu Nurses and Midwives Council, Chennai, Tamil Nadu No
4Journal of Community Health NursingTamil Nadu Nurses and Midwives Council, Chennai, Tamil Nadu No
5Journal of Obstetrics and Gynaecological NursingTamil Nadu Nurses and Midwives Council, Chennai, Tamil Nadu No
6Journal of Mental Health NursingTamil Nadu Nurses and Midwives Council, Chennai, Tamil Nadu No
7Journal of Nursing Education and AdministrationTamil Nadu Nurses and Midwives Council, Chennai, Tamil Nadu No
8The Journal of Nursing TrendzMIOT College of Nursing, Chennai, Tamil NaduNo
8The Nurse The Nurse, Komarapalayam, Tamil Nadu
9Nurses of IndiaNurses of India, Bengaluru, KarnatakaNo
10Indian Journal of Psychiatric NursingIndian Society of Psychiatric Nurses, Bengaluru, KarnatakaNo
11Kerala Nursing ForumThe Philus College of Nursing, Kottayam, Kerala No
12The Journal of Nursing ResearchGovernment College of Nursing, Thiruvananthapuram, KeralaNo
13Journal of Nursing Research Society of IndiaCollege of Nursing, Bharati Vidyapeeth, Pune, Maharashtra No
14Nursing ImageNursing Image, Mumbai, Maharashtra No
15Trends in Nursing Administration and EducationCollege of Nursing, Bhopal, Madhya PradeshNo
16Indian Journal of Holistic NursingCollege of Nursing, Bhopal, Madhya PradeshNo
17Indian Journal of Nursing StudiesChoithram College of Nursing, IndoreNo
18The Nursing Journal of IndiaTrained Nurses Association of India, New DelhiNo
19Nightingale Nursing TimesNightingale Nursing Times, NOIDA, Uttar PradeshNo
20International Journal of Nursing EducationInstitute of Medico-Legal Publications, NOIDA, Uttar Pradesh No
21Nursing and Midwifery Research JournalNational Institute of Nursing Education, ChandigarhNo
  6 in total

Review 1.  Nurse migration from India: a literature review.

Authors:  Shelby L Garner; Shelley F Conroy; Susan Gerding Bader
Journal:  Int J Nurs Stud       Date:  2015-07-17       Impact factor: 5.837

2.  The international migration of Indian nurses.

Authors:  P Thomas
Journal:  Int Nurs Rev       Date:  2006-12       Impact factor: 2.871

3.  Composition and distribution of the health workforce in India: estimates based on data from the National Sample Survey.

Authors:  Krishna D Rao; Renu Shahrawat; Aarushi Bhatnagar
Journal:  WHO South East Asia J Public Health       Date:  2016-09

4.  Challenges and needed reforms in midwifery and nursing regulatory systems in India: Implications for education and practice.

Authors:  Kaveri Mayra; Sabu S Padmadas; Zoë Matthews
Journal:  PLoS One       Date:  2021-05-14       Impact factor: 3.240

5.  Size, composition and distribution of human resource for health in India: new estimates using National Sample Survey and Registry data.

Authors:  Anup Karan; Himanshu Negandhi; Rajesh Nair; Anjali Sharma; Ritika Tiwari; Sanjay Zodpey
Journal:  BMJ Open       Date:  2019-05-27       Impact factor: 2.692

6.  Nursing brain drain from India.

Authors:  Michael Hawkes; Mary Kolenko; Michelle Shockness; Krishna Diwaker
Journal:  Hum Resour Health       Date:  2009-02-02
  6 in total

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