Nexus of Good: A holistic intervention

Over the period 2017-2023, credit to Uttar Pradesh government’s investment and focus, medical education infrastructure has witnessed phenomenal growth. The number of government medical colleges has doubled. The number of BSc. nursing colleges has quadrupled. An expansion of this magnitude would require matching human resources. To its credit, the UP government has sanctioned over 72,000 new positions in the last few months. Those who have worked in the government, know what a stupendous feat this is. However, this problem of plenty is accompanied by the challenge of an acute shortage of qualified healthcare professionals. Nurses are one such example. As of 2020, the state merely had 0.61 nurses per 1,000 population, compared to 4.79 in Tamil Nadu and 8.96 in Kerala. While the numbers are a problem, the quality of nurses in the workforce is an even greater bottleneck. The State Public Service Commission, during a recent recruitment drive for nurses, had advertised 4,500 vacancies. Out of 1,03,200 applicants, only 3,012 positions could be filled. Less than 3 per cent of the applicants (all of whom possess valid diplomas/degrees) managed to exhibit the minimum knowledge benchmark. There is, thus, a serious issue regarding the quality of training that is being imparted to them.

What began as an enquiry into the causes of unfilled staff nurse positions, gradually evolved over time to become a full-fledged mission. ‘Niramaya’ was launched by the Chief Minister and aims to improve the regulation and quality of nursing education in the state. Given that 96 per cent of the nursing seats in the state are in private nursing colleges, the task before the government was to institutionalise reforms by overhauling the regulatory mechanism at the State Medical Faculty (SMF) — the nursing education regulator. The nursing ecosystem in Uttar Pradesh is riddled with several challenges — an institutional affiliation process that gives no premium to quality, an admission process riddled with information asymmetry, indifferent enforcement of regulations governing the quality of training imparted in colleges, a decentralised and discretionary admissions process, and an examination and certification process for professional nurses which lacked integrity. Hence, Mission Niramaya took a comprehensive approach to solving the issues:

✼ Affiliation process: To reduce the discretion-based pick and choose regime, first-in-first out (FIFO) was adopted, and a backlog of 1,097 pending affiliation applications were processed in just two months in 2022. Utilising affordable technological solutions, such as Google Forms with institute affiliation inspection reports being uploaded on the day of the visit, a double-blind system in the appointment of inspectors, use of body cameras with live central monitoring, and a clear decision tree based on the Nursing Council requirements, were put in place. This ensured a rigorous and fool-proof methodology and a transparent affiliation process. 275 applications were granted, 577 were denied, while 195 institutions refused to have their premises inspected. Speaking orders, specifying the grounds of rejection, were issued wherever the applications were found unsuitable.

✼ Accreditation of institutes: This emerged as a solution to bridge the disparity in quality among educational establishments. A total of 702 institutions across the state underwent evaluations conducted by the Quality Council of India on the basis of infrastructure, pedagogical processes, and learning outcomes.

✼ Supportive supervision: This entailed pairing of nursing institutions. The mentor institutions assist the mentee institutions assigned to them in drawing up a quality improvement roadmap. The activities include faculty development, fostering collaboration, and sharing of best practices. So far, 12 mentor institutes have been paired with 110 mentee institutes under this programme.

✼ Reforming admissions: In pursuit of fostering equal opportunities for all applicants and attracting the best available talent to pursue nursing as a profession, UP introduced Common Nursing Entrance Test (CNET) in the academic year (AY) 21-22 for all degree programmes — BSc, Post-Basic BSc & MSc. For academic session 2023-24, an innovative online centralised admissions process for admission to Diploma Courses (ANM & GNM) is being introduced. This will create a centralised merit list based on the performance of the students in their 12th Board Exams, and the students would be able to opt for the colleges of their choice based on their rank in the overall merit list. This will completely eliminate discretion.

✼ Ensuring quality in teaching-learning process: The Indian Nursing Council requires a 1:10 faculty-student ratio in nursing-training centers. To ensure compliance and maintain high-quality training, biometric attendance was mandated for both faculty and students. Telephonic checks in April 2022 revealed that 161 out of 246 centers had less than 50 per cent mandated faculty. 42 centers were randomly selected for scrutiny. Given the limited staff availability at the SMF and the wide geographical expanse of the nursing colleges, electronic verification of faculty members was carried out through surprise video inspections. Consequently, 20 centers which were found to be serious defaulters were penalised, thereby sending a strong message to all nursing institutions.

✼ Outcome-based regulation: Given the limitations of SMF in enforcing input-based regulation (ensuring faculty and student attendance; ensuring that skill labs are well-endowed; SoPs on clinical exposure are being followed etc.), it was realised that unless a robust and fool-proof mechanism was evolved to ensure that only those professionals would be licensed who meet the minimum norms of knowledge, it would be impossible to align incentives of the private management of these nursing colleges with the quality goal that were sought to be achieved. Hence, a great deal of emphasis was placed on ensuring integrity in examinations — both theoretical and practical — conducted by SMF. Over 73,000 students across 550 exam centers were monitored live via 800+ CCTV cameras. As a result, pass rates in diploma courses [ANM and GNM] declined from 90 per cent to 61 per cent, and more drastically, in the BSc courses, the success rate was as low as 42 per cent.

✼ Digital platform underpinning reforms: A cutting-edge tech platform serves as the centrepiece for these transformative reforms. The application captures the entire workflow and business processes of the regulator. Incorporating the building blocks developed by the Government of India, such as the competency-based management of personnel of Mission Karmayogi; the learning management system of DIKSHA; and the Unique Identification of Health Professionals of Ayushman Bharat Digital Mission, this digital system provides for the life cycle management of a nurse — from the time when she is admitted as a student to her registration as a nurse, and continuance of education as a nursing professional. Uttar Pradesh has pioneered this ‘for-the-world’ platform, designed to function as a Digital Public Good (DPG). It is a state-of-the-art product that can be adopted with slight customisation by any higher education regulator.

Mission Niramaya, under the inspired leadership of Alok Kumar, Principal Secretary, Medical Education, has adopted an ecosystem approach by addressing all challenges simultaneously and holistically, since anything less would not create the disruption that was aimed at. They have been solving a critical issue that afflicts the healthcare system, and present a wonderful example of Nexus of Good. Other states can replicate the approach adopted in Uttar Pradesh.

Views expressed are personal