A longitudinal WISN analysis in Ajmer District, Rajasthan (2021-2024) examines systematic deficiencies in the human resource norms of Indian Public Health Standards (IPHS) at 24x7 primary and secondary health centres as part of a critical evaluation

In the vast network of public health care across India, the government has established a set of rules called the Indian Public Health Standards. These standards act as a blueprint for how clinics and hospitals should be built and staffed. For decades, the rule for how many doctors, nurses, and pharmacists a facility needs has been based almost entirely on the number of people living nearby. It is a simple calculation: if a village has a certain population, it gets a certain number of health workers. However, this approach assumes that every community is the same and that the demand for care is steady. In reality, the needs of a rural population can shift dramatically. A clinic might face a sudden surge in patients needing emergency care, or the local geography might make it hard for staff to arrive on time. When the rules for staffing do not match the actual, daily reality of the work, the system can become strained, leaving patients waiting and health workers overwhelmed.

To understand how well these rules are working in the real world, a team of researchers looked closely at the health system in Ajmer District, Rajasthan, over a three-year period from 2021 to 2024. They wanted to see if the current staffing levels were enough to handle the actual workload. Instead of just counting heads based on population, they used a method developed by the World Health Organization that measures the time it takes to do specific medical tasks. This approach calculates exactly how many hours of work are required to see every patient, deliver every baby, and dispense every medicine, and then compares that total time against the hours the available staff can actually work. It is a way of asking whether the people on the ground have enough time to do the job they are hired to do.

The researchers gathered data from 108 public health facilities, ranging from small primary health centers to larger district hospitals. They tracked how many people visited these clinics for outpatient care and how many were admitted to stay overnight. The numbers told a clear story of changing demand. Over the three years, the number of people walking into clinics for treatment rose by about 10 percent. The pressure was even more intense for patients needing to stay in the hospital, where admissions jumped by more than 50 percent. Yet, while the need for curative care grew, the number of pregnant women registering for care and the number of babies born in these facilities actually went down. This suggested that while people were coming for treatment, they were not necessarily seeking out the full range of preventive services, or perhaps they were being referred elsewhere.

Despite this growing demand for hospital care, the number of health workers available did not keep pace. The study found that the clinics were already missing a significant portion of their staff. In the most recent year of the study, the district had only about 42 percent of the required doctors and 45 percent of the required nurses. The shortage was even more severe for the support staff who keep the facility running. The clinics had only 12 percent of the pharmacists they needed and 31 percent of the laboratory technicians. Because the staff was so thin, the few workers who were present faced a crushing amount of work. The researchers calculated that for every doctor or nurse who should be there, only about 40 to 45 percent of the required person was actually present. This meant that the existing staff was carrying a load that was more than double what a single person could reasonably handle.

The situation was not just a snapshot of one bad year; it was getting worse over time. As the number of patients increased, the gap between the work that needed to be done and the people available to do it widened. The study showed that the staffing levels were deteriorating steadily from 2021 to 2024. This decline was felt most acutely in remote areas, where the difficulty of finding and keeping staff made the shortages even deeper. The researchers noted that the current rules, which rely on population counts, were failing to capture the intensity of the work happening in these rural centers. The system was designed for a static world, but the health needs of the community were dynamic and growing.

The findings suggest that the current way of planning for health workers in India is out of step with reality. By sticking to population-based numbers, the system is underestimating the true need for staff, especially in facilities that must operate around the clock. The study indicates that to fix these gaps, health officials need to switch to a method that looks at the actual work being done. If they can measure the time required for every task and plan the workforce based on that, they can ensure that the right number of people are in the right places. This shift would not just be about filling empty chairs; it would be about making sure that the doctors and nurses who are there have enough time to provide safe, effective care to the people who depend on them.