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Health systems in a crisis – learnings from Covid-19 and how to build a stronger and more resilient health workforce

As Covid-19 continues to disrupt health services globally, this World Health Worker Week, our experts explore the effect of the pandemic on the health workers and recommend measures for policies to build a strong and resilient workforce.

The Covid-19 pandemic has shone a light on the poor standards of health systems in low- and middle-income countries. Many were under resourced, fragmented and largely unregulated, Covid-19 placed already strained resources and workforces under further stress. Our experts explore the effect of Covid-19 on the health workers in India. They reviewed the gaps in the health system and the challenges the workforce had to face. From this, they recommend measures for policies to build a strong and resilient workforce in India.

Cracks in the health system

Covid-19 has shed light on the various cracks in the Indian public health system. With respect to the health workforce, it highlighted weaknesses in the availability and distribution of the workforce. These factors were mainly attributed to lack of adequate funding and lack of adequate pandemic preparedness and planning. Initially, there were gaps in protecting the health workforce in some poorer states from the disease due to an insufficient supply of the personal protective gear (PPE) and violence/stigma against the community health workers.

However, the government later attempted to address these challenges by introducing various policies. It was also not easy for the government to manage people’s wavering trust in public hospitals and contain misinformation. The closure of private hospitals, which deliver most health services, led to an added burden of the already strained public facilities.

Facing a staff deficit

India spends only about 1.3% of GDP on health by the public system. The health workforce’s capacity in the Indian states directly reflects the priority given to health systems by the individual states. Hence, variations across the states on the number of human resources for health (HRH) exist. Although India has enough HRH, they are largely recruited by the private sector due to better job satisfaction and higher pay than public facilities, creating a large deficit in public hospitals, more so in the rural areas.

The staff shortage leads to the increased burden on the existing staff as presently, on an average, one government doctor deals with almost 11,000 persons at the primary care. The deficiency is further worsened in the number of specialists such as surgeons, obstetricians, paediatrician and physicians, and laboratory technicians in some states at the secondary care.

Stretched to capacity

In India, the preventive measures against Covid-19 were initially primarily undertaken by the public health system. However, the shortage of HRH in the public sector stretched the already burdened health workers to their limits in terms of overtime and fatigue. Consequently, the government had to recruit more health workers, in some instances from different Indian states, to manage the rapidly rising in-patient cases.

The challenge was compounded in the poorer Indian states such as Uttar Pradesh, Madhya Pradesh, and Bihar due to lack of adequate financing structures leading to difficulty retaining HRH, and a high proportion of elderly doctors were vulnerable to Covid-19. Such circumstances negatively affected case-detection and management in poorer states. Although the governments attempted engaging in active surveillance and management of Covid-19, other services were significantly hampered, leading to a complete closure during the lockdown. Hence, the strength of surveillance and management was proportional to the state’s health system capacity.

Sustaining quality of care during an emergency

India, like many other countries, lack formal and comprehensive policies for health workforce augmentation, mobilisation, motivation and support during times of health emergencies, such as pandemics. This is why policy frameworks are urgently needed to address these gaps. We suggest developing a health workforce resilience policy, which would provide the ‘capacity to respond, adapt, and strengthen’ to ensure sustained quality of care by improving the existing capacity of the HRH to mitigate the adverse outcomes of the health emergency.

Emergency preparedness and readiness

Based on our rapid review, we identified critical areas of HRH development. These components could be strengthened to maintain HRH resilience in the event of any future widespread health emergencies. The key recommendations include building emergency preparedness and readiness in the health facility and estimating the number of total qualified HRH, and building their technical capacity. We also suggest redeployment of the HRH and task-sharing with informal health providers and non-health community workers on a need-basis.

These components although would remain fundamentally the same everywhere, it would still need further deliberation and specification based on the local context. Additionally, we believe building and maintaining HRH’s motivation is key. Hence, providing incentives or ‘risk allowance’, psycho-social support, adequate personal protective gears, and protection from disease and stigma would be beneficial. Effective early engagement with stakeholders can also mitigate the disease burden.

Gaining public trust

Integration of the above components in the HRH resilience policy could help in improving disease surveillance and treatment without overburdening the health workforce at times of crisis. Furthermore, strengthening the HRH resilience can also aid in providing better quality care through continued services which can assist in reducing the morbidity and mortality. Consequently, this can help in gaining the trust of the public and the HRH.


Dr Rakesh Parashar is India Health Lead and a Senior Consultant at Oxford Policy Management

Ankita Mukherjee is a Research Assistant at Oxford Policy Management

This blog was originally published on March 9, 2021 on Gates Open Research