A/HRC/14/20/Add.2 solutions”. Emphasizing the shortage of anaesthetists, the report recommends that the “state needs to seriously carry out the rationalization exercise to post specialists, especially anaesthetists, wherever required”.12 24. When applying the right-to-health lens to India’s health workforce, numerous issues are brought into sharp focus, including the terms and conditions of health workers, the degree to which health workers respect (and reflect) cultural difference, and how important it is that they always treat patients with politeness and dignity. Because of space constraints, the main focus in the present report is on the enormous problems of availability (i.e. the national shortage of some categories of health workers) and accessibility (i.e. the fact that available health workers are not accessible on an equitable basis). The conclusion in subsection 4 of the present section emphasizes another important right to health issue: health workforce strategies and plans of action. 2. Availability 25. In India, are there a sufficient number of maternal health workers available with the necessary competencies? By way of illustration, this question is considered in relation to skilled birth attendants and technical senior managers. Skilled birth attendants13 26. The provision of access to skilled birth attendants is one of the four cornerstone interventions to reduce maternal mortality. At first sight, India’s auxiliary nurse midwives (ANMs) play a decisive role in the delivery of this vital intervention. Of course, other health professionals, such as general practitioners, also contribute. Nonetheless, the Indian health system depends heavily upon ANMs making a major contribution to the provision of skilled and safe deliveries. 27. ANMs are multi-purpose health workers at the interface between the community and public health system. An ANM manages the lowest tier of the health system, the sub-centre, responsible for a population of 3,000–5,000 in rural areas. They are expected to perform a large, diverse range of preventive and curative functions, such as motivation for family planning, immunization, deliveries and treatment of childhood illnesses. They are also expected to reside in the sub-centre village and remain available around the clock. In recent years, their numbers nationwide have increased to more than 130,000. For the most part, there is not a significant shortfall of ANMs, for example, a recent report on Rajasthan concluded that in 2007 “there was no acute shortage of ANMs”.14 28. However, there are several major problems with ANMs. For example, they are often absent from the communities they are supposed to serve. In the present context, an especially grave problem is that ANMs do not have the competencies of a skilled birth attendant. As health programmes have evolved, the role and capacity of ANMs have changed substantially. In the 1960s, their main job was to deliver babies, as well as provide maternal and child health care. Today, their duties are mainly family planning, immunization and antenatal care. Their training has also changed. The new syllabus has less emphasis on midwifery; also, the training has been shortened from 24 to 18 months. As one study concludes, “ANM training today does not prepare [an ANM] for working in rural 12 13 14 8 India, “Common Review Mission II: Report of Maharashtra under NRHM” (Ministry of Health and Family Welfare, 2008). Here the focus is on the health workforce, so the narrower word “attendants” is used rather than “attendance”. Iyengar, Iyengar and Gupta, “Maternal health”, pp. 278 and 279. GE.10-12866