International nurse recruitment in India

Health Services Research, June, 2007 by Binod Khadria

India is an overpopulated large country with the potential to supply English-speaking workers in many different fields to developed countries (GCIM 2005; Khadria 1999, 2005; NCAER 2005). As the demand for nurses rises worldwide, commercial recruiters have become increasingly interested in the potential for exporting nurses from India to these countries. While India does have a large potential labor pool that could be trained as nurses, at present India does not have enough professional nurses to meet its own domestic health services needs (Khadria 2004). This paper provides an overview of nursing education and migration in India, as well as a description of the current environment for international recruitment of nurses in India.

GENERAL DATA ON INDIA

The U.S. Population Reference Bureau (PRB 2004) estimates India's population to have been 1.086 billion in 2004, with a per capita income estimate for India at US$2,650. Life expectancy is 61 for males and 63 for females. The crude birth rate was 25 per 1,000 population in 2002, down from 40 in 1951 (UNDP 2005; Government of India 2001).

The number of hospitals (private and public) was over 38,000 in 2004, although these aggregate figures do not reflect the regional variations that are usually large within the country. The total number of hospital beds was reported to be 915,000 in 2004.

Data on health care workforce vary across sources though not by wide margins. Whereas the recommended international norm for nurse-physician ratio is between 2:1 and 3:1 (i.e., between 2.0 and 3.0), according to World Health Statistics 2005, for India, in 2003, it was a lower ratio--of 1.3--derived from the index of health care workforce per 10,000 population: 7.9 nurses and midwives, and 5.9 physicians (WHO 2005). Assuming that these may not have been radically different in the immediately preceding or succeeding year, any one number in a particular year would provide a rough approximation of the other figure, if one were to attempt constructing limited time-series data. For example, the Government of India stock figure of 625,000 modern allopathic doctors in 2002 would provide an approximate estimate of 812,500 nurses and midwives in that year, and similarly, a stock figure of over 1.3 million of registered nursing personnel (GNM, ANM, and HV and HS together) in 2004. It may, however, remain questionable whether there were actual increases of 50 percent each in the number of these health care worker categories over a short span of just 2 years (2002-2004), or these were due to nonstandardized problems of underestimation in the first year or a double counting in the second year. What is also important to note in this context is that the Indian data for doctors and nurses are net of attrition due to retirement, migration, and death, but one could not be sure if the practices of data collection have been consistent from year to year.

NURSING EDUCATION

There are a range of nurse categories in India. Entry-level eligibility for nursing education is a pass in the Senior Secondary School Leaving Certificate Examination or equivalent 12-year schooling, preferably with physics, chemistry, and biology as chosen subjects, and a minimum age of 17 years. Postsecondary programs include both a 4-year Bachelor of Science in Nursing degree (B.Sc.(N)) and 3-year General Nursing and Midwifery (GNM) diploma, the latter being the minimum requirement for an entry-level job of a staff nurse. Auxiliary Nurse Midwife (ANM), and Health Visitor (HV) and Health Supervisor (HS) are assisting nurses at a lower level of expertise.

Table 1 shows the stocks of registered nursing personnel in India. As of 2004, there were 865,135 GNMs, the 3-year diploma holders, and 506,924 ANMs, and 50,393 HV and HS. No complete or reliable data are available on the B.Sc.(N) degree holders.

Table 1 also shows the number of institutes that provide training and education in the field of nursing, by qualification types and levels of diplomas and degrees. There are more than 1,000 recognized nurse training centers in India, mostly attached to teaching hospitals, which together admit nearly 10,000 students every year. Many nurses receive training through military hospitals, although to qualify, the women trainees must be unmarried, divorced, legally separated, or widows. Those selected to the 4year B.Sc. and 3-year Probationary Nursing courses execute a bond to serve in the Military Nursing Services (MNS) for 5 and 4 years, respectively, as they are fully sponsored by the government. Recently some private institutions have launched 4-year programs, but most B.Sc.-level nurses are still graduates of government schools.

Amongst higher level courses in nursing that have been started in the country in more recent times are Master of Philosophy (M.Phil.) in Nursing--1 year for full time and 2 years duration for part time; a Diploma course in Nursing Education and Administration--of 10-month duration; Ph.D. in Nursing; Clinical Specialization in Master of Nursing; Clinical Specialization in Community Health Nursing, etc. No data are available on the numbers of these advanced graduates, although given the recent launch of such programs, they are likely to be still quite low.