Health
Care in Haryana
Although there
has been considerable improvement in the health status as measured by the
increase in life span
(Life
Expectancy) from 33 to 66 years, fall in infant mortality rate and crude death
rate, statistics also show that such achievements have fallen far short of the
nation’s expectations. India
• It
has the largest number of medical colleges in the world
• It
produces among largest numbers of doctors in the developing world. These
doctors are exported to many other countries, and are considered among the best
in the world.
•
This country gets 'Medical tourists' from many developed countries reflecting
the high standard of medical skill and expertise here. They seek care in its
state-of-the-art, high-tech hospitals which compare with the best in the world.
•
Turning to medicines, we find that this country is the fourth largest producer
of drugs by volume in the world and is among the largest exporter of drugs in
the world. Of course, all these resources require finances. We find that people
here do not lag behind in paying and spend a lot on healthcare -
more
than many other developing countries. Despite the existence of such impressive
healthcare
resources,
as we begin to move around and talk to some people in the villages and towns of
this country we are surprised to find that -
•
Despite all these resources, the majority of citizens has very limited access
to quality Healthcare, and has poor health indicators.
The report of the National Commission on Microeconomics and health
(NCMH), Equitable Development Health
Future ,states that “ the probability of the poor falling sick is 2.3 times
more than the rich and there is an 18 years difference in the life expectancy
at birth between 72 years in Kerala and 58 years in Madhya Pradesh”India’s
performance is worse than Bangladesh and Sri Lanka . Against India’s infant
mortality rate of 68 per 1000 live births , Sri Lanka has only 8. Bangladesh
also has under 5 mortality rate at 69 per 1000 births below India’s 87 in the
same age group. McKinsey estimates that the health care spending in India will
increase from Rs. 86,000 crore in 2000-2001 to over 200,000 crore by 2012.
•
There are low levels of immunization - in fact less than half of the children
are completely immunized (added to this, complete immunization coverage has
declined in recent years!).
•
Similarly, the minimum of three checkups during pregnancy remains unavailable
for half of all pregnant women.
•
There are massive inequities in access to healthcare - while the rich avail of
most modern and expensive health services, the poor, especially in rural areas
do not get even rudimentary healthcare.
• Hospitalization
rates among the well off are six times higher than rates among the poor!
•
Despite such a large drug industry which exports medicines across the globe,
about two-thirds of the population lack access to essential drugs.
•
This is a country of paradoxes where women from well off families suffer due to
unnecessary cesarean operations - in some urban centers close to half of
deliveries are done by operation- while their poorer rural sisters frequently
die during childbirth due to lack of access to the same cesarean operation at
time of genuine need.
•
Although people spend a lot on healthcare (the poorest spend one-eighth of
their total income on healthcare), the government spends much less. Of the
total health spending in the country, all levels of government make less than
one-fifth, while the remaining major portion is shelled out by ordinary
citizens from their pockets. This makes the healthcare system in this country
one of the most
privatised
systems in the world.
•
Taking loans or selling assets pays for two out of five hospitalization
episodes. The proportion of people who are unable to access any form of
treatment due to inability to pay is quite large and increasing.
A
large private sector leads to high profit motives of private providers. It has
been estimated that almost two-thirds of the medicines prescribed here by
doctors are irrational or unnecessary. Nearly half of all outpatients receive
mostly unnecessary injections. Hence we say that this is a country of
tremendous paradoxes. And you
must have of course guessed it by now - this is the country where all of us live.
This paradoxical
country is India
How Much Does
Our Government Spend on Healthcare? How Much Do We Spend on Healthcare from Our
Personal Resources?
The total value
of the health sector in India
The tragedy is
that in India, as in most other countries, those who have the capacity to buy
healthcare from the market may often get this care without having to pay for it
directly, and those who are below the poverty line are forced to make direct
payments to access healthcare from the market.
National data
reveals that half of the people in the poorest 20% of population sold assets or
took loans to access hospital care. Hence loans and sale of assets are
estimated to contribute substantially to financing healthcare. This makes the
need for social security even more imminent.
The health services have been dismally poor
and inaccessible for a large majority of the population in
There
are three streams of health providers that have emerged in post independent India-
With less than one percent of the GDP invested in
public health provision, India is home to one fifth of the world diseases,
where the regular level of malnourished
children is higher than that of Sub Saharan Africa and with high rates of anaemia and maternal
undernourishment
Health
is an indicator of well -being that has direct implications not only for the
quality of life but also indirect implications for the production of economic
goods and services. “ Health for all by the year 2000” was a national goal set
by the Indian Govt in 1978.Since then a lot has been done in improving health
both in rural and urban India. Despite all concerted efforts, however, India
Haryana
The growth of Haryana state provides new opportunities. The Government of the state of Haryana is
engaged in the process of re-assessing the public health care system to arrive
at policy options developing and harnessing the available human resources to
make greater impact on the health status of the people. As part of this effort, one should attempt to
address the following 3 questions:
1.
How adequate are the existing human and
material resources at various levels of care (namely from Sub Centre level to
district hospital level) in the state; and how optimally have they been
deployed?
- What
factors contribute to or hinder the performance of the personnel in
position at various levels of care?
- What
structural features of the health care system as it has evolved affect its
utilization and its effectiveness?
From the analysis of the situation in its totality,
one may proceed to make recommendations
towards a policy on workforce management, with emphasis on organizational,
motivational and capability building aspects.
One has to see how existing resources of manpower and materials can be
optimally utilized and critical gaps identified and addressed . The question is that how the facilities at
different levels can be structured and reorganized.
A study was conducted- a questionnaire based survey of
facilities that was applied on a sample of 128 Sub centres, 64 PHCs and 32
CHCs, also 356 employees of 8 cadres were interviewed in Chhatisgarh.and
analysis was done
There are certain similarities of situation and a lot
can be gathered from their experience. There are four types of stake holders in
health service system in the state:
- The
employees and their associations
- The
officers at the national, state and district level
- The
Medical profession and professional bodies.
- Civil
society
It is noted that in the last decade the department of
health in Haryana has seen a lot of new developments:
Annexure-I and Annexure-II
However the constraints that the system has inherited
are considerable. A larger plan to reach
a basic set of services for each level of the three tier health care system is
needed. It has been tried to chart out
the contours of such a plan and project an approach to reaching it. In the larger interests of improving the system
the aim is to set out all the lacunae in workforce management and rationalization
of services, explore its causes and set down the possibilities for immediate
and long term action to improve and strengthen it.
Situational Analysis
Adequacy of “Sanctioned
Facilities”
As per existing norms one sub centre is planned for
every 5000 population, one PHC for every 30,000 and one CHC for every 1,00,000 population. For tribal areas the norm is one sub centre
per 3000 population, one PHC per 20,000 population and one CHC per 80,000
population. We have 16,531,493 Rural Population
Annexure –III
Ø We
need 929 Sub Centre more . 131 more PHCs are needed along with the staff and
other infrastructure required. We need 75 more
CHCs.
Location of Facilities
with relation to access
Amongst existing facilities there is considerable loss
of utilization due to improper location and improper distribution. In many of the cases, there is considerable mal distribution. And this is compounded by improper choice of
village within the section or sector and the choice of venue within the
village.
Adequacy of staff and
their Utilization with Relation to Functionality of Centers:
Even the female para medical staff is not adequate in
numbers. There are serious shortfalls in
all other staff. Female worker has to
share the greater part of the work load.
Many categories of staff at sub centre and PHC level are characterized
by poorly designed work schedules and are poorly utilized with high degree of
redundant work time. Rationalization of
paramedical work time offers therefore, the most effective route to addressing
staff adequacy.
The current work description of Multi Purpose Health
Worker(MPPW) female is unrealistic and is being coped with developing a focus on
just one or two tasks and informal local arrangements. As a result a number of essential services
are completely left out (eg. early recognition of child hood pneumonia or
proper treatment of diarrhea or adolescent health care etc.) and a quality of a
number of other services, like antenatal care are seriously compromised (very
few pregnant women get their BP taken and blood and urine tested).
Rationalisation of Drugs and
Consumables supply:
The essential drug list is not being implemented. The main deficits are a failure to procure
the entire items of the list, a failure to send samples for quality control and
a failure to exclude drugs not on the list.
Other element of the drug policy
are also not in place. Thus procurement is problematic and sporadic, occurring once or
twice a year with quotas to peripheral facilities to distribute the drugs.
There are numerous breaks in supply and the
distribution system appears to be unresponsive to changing needs. Restriction of drugs to a narrow spectrum and
breaks in supply are not even perceived as serious within the system reflecting
poor perception of quality of care issues.
The problem with consumables is even more serious than
with drugs. Laboratory chemicals seem
the worst affected but even gauze and bandages, needles and needle holders
could be in short supply repeatedly.
Rationalization of Equipment:
Low investment minor equipment like Sahil’s Haemoglobinometer or material
required to test Haemoglobin or Blood Pressure apparatus and infant weighing
machines, which, if used, will need replacement frequently. Another group is ‘major equipment’ like ECG,
USG(Ultrasound) and X-rays which require less replacement but require trained
manpower to operate. In minor category,
there may be considerable under utilization.
Due to quality of care issues many of these instruments/equipment are
not utilized. If utilized then they
require replacement for which ready system of purchases and restocking is
required.
In major equipment, the main problem is mismatches between
equipment supply and man power to use it. (e.g. ECG machines without any one
who operate it), between equipment supply and level of services currently
provided at that level (e.g. Halothane-a drug used for anesthesia, was sent at
CHC levels where there was no anesthetist,
neonatal care units where there are no caesarean operations done, Color
Doppler equipments supplied where there is no vascular, cardiologist or cardio
thoracic surgeon available), between equipment supply and consumables available
to use ( e.g. X-ray machines running out of X-ray film) and between equipment
purchase and maintenance.
At one level all such mismatches are attributable to
failures of concerned officials/officers.
But at another level it points to a governance/administrative failure,
with one committee maximizing purchases, and another set of persons looking at
distribution and no one looking at training and maintenance or eventual
utilization of equipment.
Infrastructure Adequacy:
The short falls in basic availability of its own
buildings is well known. Toilet
construction and maintenance too are major infrastructural inadequacies. Maintenance of buildings is also poor and
many buildings are old and need extensive renovation or replacement.
No Light at Sub Centre: Problems with electricity supply are also there. Generator back up is not available at many
places. Inverter at CHC level .is
available – but are not .of sufficient
time capacity.
Problems with water supply are however considerable. Most of these
facilities have a bore well and hand pump so that they are functional. However any hospital with in patient
facilities, even if it were for only conducting normal delivery, would require
running tap water, bathing facilities and toilets separately for staff and for
patients.. How many of CHCs and PHCs
have such a water supply arrangement?
Waste management based on segregation of wastes with proper disposal of
each category of biological waste is a relatively untouched area of
intervention.
Service Conditions
(Transfer; promotion;
financial burdens; personal security, accommodation for staff)
The lack of a fair
transparent system of
transfer is easily one of the greatest causes of workforce dissatisfaction and
demoralization. Some staff spend their
lifetimes working in remote areas seeking and never getting a transfer whereas
others perceived to be able to personally and unfairly influence decision
making to get priority postings through out their career. This makes less staff willing to serve in
rural areas and when they are so posted, do their work with such a deep rooted
sense of frustration and anger that the quality of the work suffers. The problems of doctors not willing to serve
in rural areas should be seen only in this context and should not even be held
out against the medical profession unless a basic transfer policy has been put
in place.
Promotions need to be regular
and timely and fair. Otherwise it leads to a situation of deep
dissatisfaction that runs through the entire department. It has also been observed that many times the positions of authority
starting from the top most and proceeding through the CMOs up to BMOs are held
in an adhoc and arbitrary manner.
Further the opportunities for
an active career plan for
a talented doctor or one who is able to work hard and perform more are
absent. For paramedical staff too the
lack of any possibility of promotion let alone a career plan acts as a great
demotivation from taking any initiative.
These are all remediable aspects that need to be urgently attended to.
Another major problem is
personal security, again a
problem maximal with MPHW females.
Violence and sexual harassment, covert and overt affects about 10% but
creates a sense of insecurity in all. In
Delivery Huts these type of problems have come to light recently.
No definite pattern of
venue: Another basic
service issue is accommodation. At no level is there adequate housing for all
staff. Available housing facility many times is not worth living. The focus has
been on developing government housing for doctors first. At the CHC level there is accommodation
available, especially for doctors . But
it is seldom adequate to house even half the staff or even half the number of
doctors. Available accommodation is also
underutilized because of many factors.
Laboratory Services:
Laboratory services at the sub centre are almost
absent. By laid down norms four basic tests
– Blood pressure checking , weighing of pregnant women and children, blood
haemoglobin estimation and urine testing for sugar and albumen (also E. S. R)
are expected to take place here.
These above tests like BP check however do take place
in PHCs but even here they are not regular.
The lab technicians are not available at many places. Slide test is being done routinely. The PHC,
as per norms, has a basic laboratory which can do about 20 basic diagnostic
tests, has almost been forgotten within the system. Microscope availability is there but
underutilized.
In CHCs the laboratory is active to some extent but
perform most of the time two tests, the blood smear examination for malarial
parasites and the sputum examination for Acid Fast bacillus(AFB). The list of desirable diagnostics at the CHC
level is over 40 tests. At most of the
CHCs the workload of these two tests is
heavy. Also as a consequence, reaching back time, gets lengthened
considerably (on an average 10 days to 20 days). The blood smear examination has increasingly
taken the form of a “modern” ritual denoting medical care devoid of content .
Target of slide making is also a cause for it.
There is no major perception of the lack of laboratory services as a serious
lacunae – again reflecting on the weaknesses in under standing and lack of
emphasis of quality issues in medical care.
Referral Services:
The current referral services have two forms. Firstly there is a fund placed at the
disposal of the Panchayat for use to hire/pay for transport to shift needy
patients to a hospital. There is an
understanding that this must be used for high risk and complication of child
birth. Funds flow and even awareness of
this provision in Panchayats is low and because of other structural constraints
(lack of vehicle; inability to call vehicle in time etc) its utilization is
very low even as the need for referral goes unanswered.
The other referral is the patient being asked orally
or with a slip to go and seek treatment at a higher centre. This brings no advantage to patient or to the
system and is perceived by the patient as the referral facility having
deliberately or otherwise failed to deliver its services. There are no clear norms for what is to be
referred and when and there are no mechanisms to monitor referral to reduce
unnecessary referral and insist on necessary ones. There is no feedback of any sort. In short there is no referral system.
The third system is that there is no need of referral
system for going to corporate hospitals for treatment. The rates are fixed. You go directly, get the treatment, pay the bills
and get the money reimbursed. It has
created more problems. Those who can not
pay from their pocket in advance are at loss in such an arrangement.
Integration with Indian
System of Medicines:
There is large manpower in (Indian System of Medicine)
ISMs available in the state level and more pertinent in the districts. Then utilization for public health goals is
minimal. The utilization of their indigenous
curative care services is also minimal.
Their integration with the public health system is yet to be perceived.
The bottle neck is not their willingness.
The members individually and as a department welcomes such role allocation. However the administrative unification at the
district level and the programmatic synergy at the level of programme design
have not been planned for.
Training:
Training programmes are few and are driven exclusively
by the vertical health programmes of the day, largely funded from external
donors or the central government. As a
result whatever trainings are taking place are arbitrary in choice of trainees
and fragmented as strategy. Most
training programmes are of one or two days and relate to a single disease and
an immediate campaign for example a one day leprosy training or two days on HIV
family counseling or one day on blindness control and so on. Some persons have received many such training
programmes in diverse area while some have received none. Then again the MPHW (F) had a special round
of training in Reproductive and Child Health(RCH). The vertical orientation of
training leads to closely associated work of other diseases not being taught
even in much longer capability building trainings. Thus e.g. the supervisors are trained on
blood smear examination for malarial parasites but doing a differential count
on the same slide would not be emphasized.
Almost no training is based on building competencies
to attain a level of clinical service in a given facility. We therefore, have a situation where there is
a perception with senior officials that the system is being flooded with
training programmes Yet the system can
not guarantee that in such centres or PHCs or CHCs of a given district, the
level of knowledge and skills needed is now available. It may not even be able to state, faculty
wise what level of skill building has been achieved and what are the gaps. All these problems can be said to be true of Information
Education Communication(IEC )also.
Structural Issues:
Governance:
It is not adequate to locate all problems only at the
administrative level. Some of the key
administrative decisions are often taken at the political level. Of these,
transfers, promotions and purchases, which are purely administrative activities
have in practice become central areas of political decision making.
The policy frame works for the state remain weak. Most current practices in administration are
inherited, having been handed down as traditional practices, rather than having
been shaped by active policy frameworks that guide decision making. What policy initiatives have been taken
remain weak in implementation. For
example, the essential drug list is adopted but purchases have not been guided
by it. Patients are facing great problem because of high cost of drugs which
they are compelled to purchase
Another illustration relates to senior appointments
and tenure. If a policy has to be
implemented then a capable person or team must be put in place, monitored,
allowed the time frame for that person to show results and the person must be
changed if he/she fails to deliver. This
requires a clear transparent system of senior appointments, a secure tenure, a
clear set of goals and mandate for the person to achieve and periodic review of
the same. We note that in contrast to
this ideal all incumbent officers many of them are holding their posts in an
officiating capacity. Appointments
become a prerogative of power and influence.
There is no surety of tenure.
Administrative arbitrariness in such areas are to be recognized as
indicators of poor performance.
Significantly even recruitments that are to take place
on regular bnasis are not taking place.
Fesh recruitments have been, therefore, only contractual, even where
there are vacant posts. This is again an
issue of governance. The problem is that there is a cynicism about policy
making itself. There is a feeling, often
justified by experience as with essential drugs list that any thing can be passed as policy
statement without any binding on its implementation.
Normally the ministry would lay down policy and the
directorate would be answerable for its implementation. The ministry would be the main vehicle of
ensuring accountability and transparency of the directorate and be answerable
to the legislature for it. The creation
of a state health society is meant to facilitate not weaken this
relationship. However, when the
separation between governance and implementation is lost and the ministry
itself is responsible for implementation, as in the current nature of the state
health society, or when the ministry is unable to ensure policy based
implementation in core administrative areas, then health sector reform
goes beyond the administrative realm to
that of the reform of governance. One
would then have to look to the legislature, the judiciary and institutions of
civil society to ensure accountability.
The question we pose is that in the core administrative areas – tenure,
transfers, promotions, purchases and transparaency is it a technical and
managerial failure or a failure of governance?
If it is an inability to formulate a transfer and promotion policy or
organize a system of purchases then is it a technical and managerial questions?. If not, then,it is a failure of governance.
State Level Work
Organisation:
Annexure--IV
The inability to de-concentrate powers and
responsibilities at this level is a key problem and may be the main reason for
being unable to keep to project schedules.
The experiences of other states may be helpful in this regard. A related
diversion is the need or professionalization at the state leadership
level. Though they have very relevant
practical experience, professional training in public health management, health
policy and in hospital administration has been weak. Epidemiology is seen as a separate specialty
area – not as something basic to health planning and few are conversant with
its methods. Administration would be
perceived as nothing more than knowing the rules and common sense. There have been serious efforts in improving
this situation by training inputs, but these are minimal and for this level of
leadership rather too late. A medical
administrative state cadre may be suggested.
Even in relative areas of pure management and administration like
infrastructure development and purchases and logistics, the system has not made
use of qualified management skills, which are easily available on the market.
Decentralization:
Yet another major issue of decentralization of powers
to districts. Currently all district
officers perceive districts as having very limited powers – in all of the above
aspects of administration as well as in training and programme planning. Indeed for the main post they are only
implementing agencies for national health programmes and medico- legal
work. Their own terms of selection,
transfer and monitoring have all the same organizational and motivational
problems common to other sections and it seriously compromises their work out
put. Thus while decentralization of powers
and finances is essential, it needs to be born in the context of these key
administrative reforms being carried out.
Currently elected panchayats have a negligible role in
the health secor and even in this the support and programme design needed for them
to be effective is not available.
Financing of Health Care:
Financing of health care is an important issue and
that budgetary allocation on each facility and workforce relate to out
comes. Also that what is adequate
utilization or wasteful relates to amount of investment that has gone into
it. These financial matters should also
become the agenda.
Mapping the private sector and exploring its
possibility of synergy with the public health system and developing a policy
framework for its growth and regulation are yet issues that need to be addressed.
Regulating Private Hospitals
Mapping the private sector
and exploring its possibility of synergy with the public health system and
developing a policy framework for its growth and regulation are yet issues that need to be addressed .Owing to
the poor health delivery system in the state , the public sector in the
state,there is a mushroom growth of private hospitals and nursing homes. Some
of them indulge into a variety of malpractices. There is an urgent need for
regulating private services,both to protect the consumers and contain costs. A
system of accredition can be thought of as a mechanism to regulate the private
health providers.
It is recommended that a
committee with Health Minister as the Chairperson and some senior medical
officers of the state and representatives of the private health providers be
constituted to evolve this mechanism.
Urban Health is another major area which needs more
attention. There is already a
realization that health care for the urban poor and public health programmes in
the urban context is grossly inadequate and there is an urgent need to develop
viable cost effective models of health care delivery.
Functional states and design of specific health programmes
needs to be examined. These are closely
related to workforce issues and allow considerable scope for
rationalization. Such programmes include
the various national disease control programmes, the reproductive and child
health programmes and the strategies of epidemic management.
Current Information,Education
Communication (IEC) strategy
needs to be examined; one of the most important dimensions of public health
strategy. This area needs to be
developed in a more creative way.
The services which are supposed to be delivered by Health Sub Centers, PHCs and CHCs are to
be as per the latest laid down norms.
Recommendations
I.
Adequacy of facilities:
Ø Increasing Numbers of Peripheral Health
Facilities.
Ø Increasing Health Sub Centers to ensure sub
centers as per population norms i.e. one sub centre for every 5000 population
Rural population of Haryana is
1,50,29,989. So 3005 centers are
required.
We have only 2433 Sub Centers. We need 572 Sub Centre more. One male and one female health workers are
required for each Health Sub Centre. So
we need 3005 male MHW and 3005 Female MHW. We have 425 Male MHW and 1909 Female
MHW. The gap is very disturbing For 2433
Sub Centers even we need 2008 Male MHW and 524 Female MHW workers.
According to latest norms one Female MPHW
is added for each Health Sub Centre.
Hence we need 2433 Female MHW in
addition to earlier requirements.
Ø Increasing PHCs to ensure that there is a
PHC on every 30,000 population as per the norms. There are 411 PHCs. We need 509 PHCs. Hence 98 more PHCs are needed along with the
staff and other infrastructure required.
Ø Increase peripheral health facilities in
urban centers i.e. create a comprehensive urban health plan which includes a
network of urban health centers.
Ø Increase number of CHCs so as to confirm to
the population norms: One CHC for 80,000 population because density of
population is higher in Haryana or at the most for 1,00,000 population. Rural population is 1,50,29,989. So we need 150 CHCs in total. We have 87 CHCs at present. We need 63 more CHC salon with the
infrastructure and human resource
Ø
Adoption
of minimum norms of service delivery and provisioning for it: One of the most important recommendations of
the HARC is the adaptation of recommended norms on service delivery for each
facility- the health Sub Centre, the PHC, the CHC and the civil and district
hospitals. These norms may be widely
disseminated and health sector planners must be informed about the same. (Annexure V).
II.
Problem of Location of these Facilities:
1. Block level mapping (GIS
based): It is required to prepare block level maps
showing all villages with existing Health Sub Centers and PHCs in all blocks as
well as demarcating various sections and sectors according to population norms
Based on this to search out ideal locations for Health Sub Centres and PHCs and
compare this to where they are currently located. This may be most efficiently done on GIS
based software created for this purpose.
2. Optimum Location of These Facilities: This would consider geographical optimum as also take into account
economic activity, like the village weekly market and common bus stand for 5-6
villages , locate the centre in coherence with such activity so as to make it
easier and more likely for people to access the Sub Centre or PHC or CHC . This may be included as a parameter in the
GIS data base. This data base may also
reflect location preferences with a quick stakeholder analysis.
3. Reallocation
Possibilities: Based on the above inputs decision is to be taken on location
at first for all facilities where Government constructions are needed like in
Health Sub Centres without buildings, sectors without PHCs, v/s sectors with
PHCs operating from rented buildings.
Where necessary infrastructure has already been constructed these
facilities may be classified into those that are by location completely
unusable; those that may be continue to be used unless there are alternate uses
for the current building and funds to build one at ideal location, and a third
category where current location of facilities is acceptable. Based on this a plan of construction priority
for each block may be drawn up.
4. Constructions Only According to Plans:
Once such a plan is drawn up for each block funds may be sought from
internal budgetary mechanisms and from external agencies, insisting all the
while that all constructions must be in accordance with the plan. The approval of designs of the buildings and
the construction would be done at the district level under approval from the
empowered body which is made at the state level to look at purchases,
maintenance, and infrastructure development.
5. No 100 Bed Hospitals: in any block or district should be built
till all district hospitals and all CHCs staffed and functional as envisaged.
III. Restructuring
Staffing Patterns, Redefining Jobs and Adequacy of Manpower
Recalculating Manpower Gaps: Gaps in staffing should be re-calculated
after planning for multi-skilling and redistribution of existing staff such
that there are no redundant manpower.
Two Female MPWs in each Sub
Centre: Sub Centers may plan for two female MPHWs and
one male MPHW. The job description and
work load of the MPHW (F) needs to be lessened and made realistic except for
institutional delivery and 1U CD insertion, every task done by women can be
done by men also. When there will be two
female MPW, the number of population for female will become half which will
help in quality service.
Multi skilling all PHC Para medicals:
The PHC staffing pattern needs restructuring to ensure utilization of
man power and better functioning of the facility. PHCs may plan for having three or four male
multi skilled employees with a male multi skilled supervisor and three or four
female multi skilled workers and a female multi skilled supervisor. There would also be two medical officers one
male ( and one female – MBBS or Ayush
MO
Rationalization
of Deployment of Medical Doctors at the PHC level:
Ø Differentiated
strategy according to difficulty levels: The ideal
would be two medical officers at every PHC (as in Tamil Nadu), preferably one
lady doctor. The number of posts need to be increased as per the requirement.
The vacant jobs should be advertised immediately and filled. However, this may
not immediately be realized due to shortage of potential recruits and the
difficulty in finding even one medical officer per remote area. Therefore, it can be suggested that PHCs be
categorized into most difficult, difficult and easy and a different strategy be
adopted for each.The incentives in form of- i) increase in rural health allowance
to Rs 2500 per month and special pay package for categorized PHCs ranging from
5000-8000 per month or the doctors be allowed private practice after duty hours
as in Rajasthan.
Ø 24
hour Multi skilled Paramedical Based Services in all PHCs: It
can be recommended that in all PHCs irrespective of category, 24 hour service
with emphasis on institutional delivery be insisted on by multi-skilling and
deploying para medicals. The multi
skilled paramedical worker should also be trained in emergency care management
at Primary level. It can be emphasized
that by paramedical worker we mean the current MPWs or Pharmacists or staff
nurses currently in service with further training inputs and not the
legitimization of under qualified allopathic practice that also goes by the
name of paramedical course. The role of
doctor in the PHC would be to provide leadership and on the job training and a
referral back up for this team. Where a
doctor is resident, the doctor is available on call 24 hrs to back up this
team.
Ø Daily
Visits by CHC Based Doctors for Most Difficult PHCs:
Where no medical doctors are available
currently, where access is a problem and accommodation facilities are low
(category C), even as efforts are made to fill these posts, the backing up is
done by daily visits and in a few distant PHCs two or three visits per week of
a medical doctor from the respective CHCs.
The doctor would be required to be available during working hours and
his stay at PHC would be insisted on only if adequate accommodation and security
arrangements, governmental or rental are available. Even in this, exemption may be given for
special reasons as long as stay in nearby block town as part of the CHC team
and daily attendance is regular. Family
accommodation at the CHC would be easier to organize. In other words we should not insist on
medical doctors staying in PHCs designated category C – most difficult (one
considers that the above approach with mobile doctors but fixed facilities may
be more cost effective than mobile hospitals when combined with the use of
multi skilled para medicals.
Ø Strengthening
BAMS Doctors Role While Keeping Medical
Officers Option Open:
The use of medical officers with BAMS (Ayurvedic
Scheme) to fill up vacancies where no medical officers are currently available
is welcome. However all the service
issues discussed earlier about MBBS doctors equally affect functionality. More over currently they would be unable to deliver
the notified services at the PHC level and special training would be needed to
close the gaps. The post of the
allopathic doctor should be retained and the search to fill this post should continues
with offer of better incentives. Also if training, transfer and promotion
policies are put in place, these vacancies would certainly be much less. By integrating ISM sector with the allopathic
sector we may also approximate the ideal of two medical officers per PHC much
faster and have less underutilized manpower in our hands.
The CHCs be Strengthened By:
Ø Appointment
of six Medical Officers at least.
Four of these
at least should be specialist (physician, pediatrician, surgeon,
gynecologist) mix.. If there are a
number of PHCs not having doctors to be looked after with visits, the number
posted here may increase further? One Anesthetist
must also be posted in every CHC otherwise the other specialists will become
defunct. The four medical officers norm
is sub critical.
Ø Adequate
Multi Skilled Male and Female Paramedical Staff:
Who can manage the necessary support work and multi
skilled imaging technicians who can also manage X-rays, USG and ECG too? In addition there would be a unskilled worker
category of undifferentiated, inter changeable class IV functioneries-
chaukidar, peon, sweeper, waterman – all rolled into one.
Six qualified staff nurses, two qualified laboratory technicians and an
optometrist are also a must at this level.
Ø Redesignating
the Block Extension Educator:
The block level extension educator may be renamed the
block senior paramedical supervisor and be responsible for capability building,
IEC and supervision of sector supervisors.
Adequate Clerical and
Accounting Staff, at least two, be provided to every CHC
along with computer and printers.
IV. Rationalisation
of Work Allocation and Approaches to Improve Outreach:
In Addition to
the above measures, Improving Outreach Requires:
Ø Reorganisation
of MPW Work Schedule:
MPWs may be required to tour for three days a week,
instead of the present one or two days a week.
One day a week should be devoted to review and drawing supplies from
PHCs. The remaining two days a week
should be devoted to clinical work and other services provided at Sub
Centre. These two days are fixed and her
clienteles should know that he/she is available there in her headquarters on
these two days. In each field visit day,
he/she would visit a specified number of houses and hold meetings with one of
the four identified local groups. Once a
month he/she should attend a Block Level Review and Training. If there are two MPWs posted their two days
at the headquarters may be fixed in such a way that the Sub-Centre is open on four previously
specified days every week, which is better than the current one day a week or
so.
Revised MPHW Job Description:
An MPHW’s job description for both male and
female worker should be
·
Immunization
– children and pregnant women largely at the village visit and camps but
supplemented by immunization at the sub centre.
·
Antenatal
care and post partum care at sub centre, with visits to these pregnant women
(unable/unwilling to come).
·
Motivation
and facilitation for all methods of contraception
·
Training
and support to local women health committees and Mahila Saksharta Samooh
activists.
·
Regular
house visits, such that every house hold is visited once every 15 days or one
month) for a set of “case detection, follow up and counseling activities” along
with first contact curative care where required. (this include all national
programmes related activities).
·
Focal
group discussions/health education sessions/health camps during village visits.
·
Curative
care during field visits on three days and at Sub Centre on two days.
·
Response
to epidemic using a graded epidemic response protocol. In
addition to the above male worker would have the following tasks:
·
Addressing
male youth on adolescent problems and STDs control.
·
Interaction
with Panchayats, SKS, and with local leaders for facilitation of health
programmes.
·
In addition to the above female MPHWs shall
have the following tasks:
·
Assistance
at childbirth
·
1UCD
insertion
·
Addressing
adolescent girls on health problems.
Out Reach Camps:
As a rule health camps are beset with problems. They are wasteful of resources, they disturb
routine activity. They alter priorities
of the persons and problems attended to and they create a high visibility for low
priority and inadequate activities mostly symptomatic or even irrational
curative care for trivial illness.
However in villages or clusters of villages where one or other service
has less than 50% coverage or there is a large number of persons to be reached,
a health camp which reduces and brings down to a manageable level the burden of
unfinished service delivery would be welcome.
Health camps therefore, should be preceded and driven by health needs
identified by MPHWs (Panchayats or Mahila Saksharta Samooh or SKS) rather than
programme targets to be met above. Thus
a blindness treatment camp preceded by a careful identification of those needy
and driven by such needs with a carefully planned follow up, or an immunization
camp for measles where a survey shows that over half the children have not
received it, is much more useful than declaring a series of camps first and
then trying to mobilize the clientele for it.
V.
Rationalisation of Drugs and Consumables
Supply:
·
The essential Drug List:
The essential drug list needs to be
implemented. In particular the expanded
list of drugs adopted for Health Sub Centre and PHCs has to become available to
them at once. This is to be accompanied
by training on standard treatment guidelines and drug formulary for the
expanded list. The essential drug list may also incorporate all consumables and
minor equipment (frequently replaceable).
A quick process of appeal can be built in where a CMO or programme
director appeals for being permitted to purchase a drug outside the list, but
this must be done with prior permission and with due process. Up to 10% of the
budget may go to such outside the list purchases. Any violation of the drug list should invite
disciplinary action or else it would be difficult to get a meaningful drug
policy into place.
Distribution:
Systems where pharmaceuticals,
consumables and equipment will reach from district level warehouses to peripheral
facilities in a routine manner are essential.
A number of equipment that MPWs use requires frequent replacements like
BP apparatus and thermometer and they should also be therefore, a part of
consumables management. The drug and
supplies policy should reflect this. It
can be recommended that a distribution system based on the “PASS Book” like in
Tamil Nadu is urgently needed so that distribution can be all year around and
responsive to patterns of usages. In
this system each facility has a passbook, which reflects the amount of drugs in
stock. When the stock falls to below
three months usage, a level fixed at the district level for each drug then the
facility immediately indents for the drug to the district warehouse which in
turn supplies the drug to the PHC in the same week. When the district stock falls below a three
months supply an order is sent off the next day and within a month the item
would reach the concerned district warehouse.
·
Procurement
We recommend that the pre-qualification of suppliers
and the price negotiation be done at the state level by an empowered body in a
a transparent and open manner. When the
district warehouse stock falls below its three-month figure then the same drug
is immediately procured at approved rates.
Therefore, all subsequent districts orders are through this empowered
body and supplies would be sent directly to the districts. This body would arrange for quality testing
of drugs also.
·
Drug Policy
All of the above should be incorporated in
a separate drug and consumables policy.
The adoption of such a drugs and consumables policy for the state is
another urgently required policy measure.
VI. RATIONALISATION
OF EQUIPMENT-PROCUREMENT AND UTILISATION
- Smaller
low cost equipment that is frequently replaceable must be dealt with as for
consumables.
- Larger
equipment, which is costlier and requires training to make operational,
needs to be purchased and deployed only as part of block and district
level plans linked to service quality deliverables. This would ensure that there is no
mismatch between equipment purchase and infrastructure, between equipment
and skilled manpower available, between equipment and related consumables
supply and that the purchase of equipment is linked to quality improvements in the package of services
offered at this level.
- Purchase
can have the same policy of pre-qualification and price negotiation at the
state level with districts while placing orders. The same empowered body which implements
drug and supplies procurement and distribution may undertake all equipment
purchase. Further such a body would
ensure that adequate arrangements are made for maintenance and such
arrangements are renewed.
VII.
INFRASTRUCTURE ARRANGEMENTS
- There is
an ongoing effort to build 30 bedded hospitals with a modern operation
theatre in every designated CHC.
This is a welcome effort and deserves to be strengthened. At the level of the block ensuring bed
occupancy of these 30 beds is itself a challenge. Therefore, the attempt to take on 100
bed rural hospitals is ill advised and would be diverting funds away from
this basic goal which is far from complete.
- Given the
large gap in infrastructure our recommendation is that a plan be drawn up
for closing the gaps prioritizing sector PHCs and CHCs and completely
integrating with ISM infrastructure. Sub-centres would be only next in
priority and institutional delivery in sub-centres and need not be
insisted on at this stage. Once the
plan is drawn up one set of blocks be prioritized and the gap closed in
that set of blocks along with closing equipment and manpower gaps before
moving to the next set of blocks.
Thereby the entire infrastructure requirements for the state would
be met over a five year period
without having to face the gross under utilization of
infrastructure as is currently faced.
If there are financial constraints to infrastructure development the
evidence of good utilisation would help to overcome them. Currently utilization is so poor that
both state finance departments and external donors feel justified in
shying away from infrastructure investments. This coordinated development of infrastructure
is the heart of the Enhance Quality In Primary Health Centres(EQUIP)
programme’s rationale.
- Attention
may be given to closing the gaps regarding water supply and power supply
and to ensuring that separate toilets for staff as well as bathing
facilities for men and women are also in place in each of the PHC and CHC
structures. Inadequately recognized
priority areas are waste disposal systems, drainage and sewerage all of
which needs to be put into place in all PHCs and CHCs.
- Telephones
are one of the most immediately remediable problems and same urgency needs
to be given to this issue.
- There is
much effort at computerization at state level and providing computers and
web-access with training to use this would enhance monitoring and support
capabilities tremendously. It
should be possible to prioritise this and within a finite time frame
achieve this capability at least for PHCs and CHCs and later for Health
Sub Centre(HSCs) as well. Computerisation
in the present day is also a culture that may be encouraged.
VIII.
SERVICE CONDITIONS
Transfer; Promotion; Financial burdens;
Personal Security, Accommodation for Staff
- Transfer Policy
A clear policy on transfer is well-perceived
and long overdue reform measure. This is
needed for all categories of staff but particularly for the male and female
multipurpose workers and their supervisors and the medical staff. A committee composed of some senior
officials, some motivated workers identified by the department and some
representatives of the workers service associations should evolve such a policy
that is considered fair, transparent and easy to implement at the earliest.
The following principles should be considered
while developing the transfer policy:
ü Pressure for transfers would be reduced by
making MPW selection into a block level cadre and other category selection
including medical officers, other than Class-I officers into a district level
cadre.
ü The authority for the transfer shall be a
district and state level transfer tribunals.
The tribunal may be made up of a three-person board chaired by the Chief
Medical and Health Officer of the district, with one of the board members
appointed by the District Collector and another by the Employees Association.
ü A roster of request for transfer should be
maintained. Transfer shall be considered
in that seniority. Within the same
transfer seniority shall prevail.
ü All cadres may apply for transfer stating
their preferred choices.
ü All postings in the district shall be
classified into very difficult (C) and medium difficult (B) and choice
postings(A). Every staff shall be
required to serve roughly equal time in all these levels of difficulty.
ü After ten years in one area transfer is
mandatory as also a matter of right, but can be according to choice if the
chosen post is vacant. Transfer out of a
difficult area would not be mandatory but would be an employee’s right if the
required period of service has been given.
ü Mutual transfers shall be allowed but
without contradicting any of the above clauses.
ü Persons in the last ten years of service
may be exempted from mandatory transfer.
ü All promotions may be considered only after
five years in difficult posting or ten years in medium posting is completed.
- Promotion Policy for
ü Regular
Prompt Promotion with Six
Months Pre-Promotion Training: Prompt promotion of MPHWs to sector supervisors
may be ensured. Before they take up the
task as sector supervisors both MPHWs male and female may undertake a six-month
training programme (?Currently male supervisors do not have to undergo this training
though women supervisors have to). There
is a large backlog and urgency needs to be given to prompt implementation of
these promotions.
ü Fast-Track
Promotion: We also
recommend an additional system in which a portion of total Lady Health Visitor(LHV)
and male sector supervisor posts (25%) may be reserved for promoting MPHWs on
the basis of their willingness to serve in difficult areas if they had not done
so in the past, and an examination of their skills and knowledge after a
minimum period of service eg seven years of service.
We expect that this will
motivate some enthusiastic functionaries to volunteer to serve in more
difficult areas. If those promoted are
not able to fulfil their commitment and get transferred to non-difficult areas
before fulfilling their 5 year commitment, their appointment as LHV/Sector
supervisor will be revoked and they will be reinstated as MPHWs.
For those MPHWs already in difficult areas, a
promotion in this channel may induce them to continue their services in these
areas.
We understand that in difficult areas multiskilled
sector supervisors would have to play a major role in running 24 hour services
at sector level (see along with recommendation on multi-skilling in next
sections). In such a context such a
parallel channel where some younger more dynamic persons become available at
the supervisor grade would be useful to initiate this process.
ü Redesignation
of the Block Extension Educator(BEE); The Block extension educator does not do block
extension education and may be renamed block senior paramedical
supervisor. He would have a special
responsibility in training, capability building, IEC and supervision. This promotion should be seniority cum merit
promotion based on adequate testing of training capability from within the
cadre of all sector supervisors who have completed a certain number of years.
ü One
Time Bound Seniority Based Promotion for All: For all other service categories promotions and
benefits there shall be one time-bound seniority based promotion from selection
cadre to senior cadre.
Promotion
Policy and Career Plan For Medical Officers
Negative
attitudes to the service and to their work amongst medical officers must be
recognized to be as a failure to understand and care for this cadre and due to
poor structuring of health systems – not “lazily” blamed on the medical
officers. The lack of transfer policy
and frank discrimination in transfers is one important reason for
demoralization. The lack of promotion
avenues is another. For doctors other
than promotions the ability to enhance their skills, their prestige within the
profession, their prestige in society and their contribution to science are all
important motivational aspects that need to be provided for. Their inability to make a career plan where
they can enhance clinical skills or get other promotional or career
opportunities later is a problem. The
system would reap rich benefits if it saw the desire for career advancement of
the doctors as an opportunity instead of as a problem.
The key recommendation on
promotions for doctors are:
ü Contractual appointments must be seen as
adhoc arrangements. Regular appointments
may remain the mainstay of the workforce.
ü Timely,
time bound promotions to senior grades and specialist grades needs to be
ensured.
ü Skill
retention for specialists.
The feeling of professional dissatisfaction may be higher especially in
postgraduates serving as medical officers and needs to be addressed through
better professional opportunities. Every
postgraduate could be linked to CHCs, which they attend on periodic occasions
for providing specialist services. Thus
a surgeon should be able to perform operations on certain days and so on. And they should be able to send for
investigations at higher centres directly and have access to drugs related to
their field of specialization, which normally we would not expect a PHC doctor
to handle and so on.
ü Choice
of stream for Class-I Officers. After ten years of service
when they enter class – I officer status the doctors may be given a choice
between a clinical stream (if necessary of a district cadre) or a state level
administrative cadre with opportunities for advancement professionally in both
these streams.
ü Financial
Burdens of MPHWs : The
department should provide for adequate allowance to MPHWs to carry out routine
paper work. Payments should be prompt
and be made on half-yearly or annual basis.
Also, unfair reductions and false statements on
expenses made on travel and other programme purposes should be eliminated. The assistance cell (discussed later) should
be available for confidential complaints in this regard.
ü Personal
security: Creating a Women
Employees Assistance Cell at District Level
This must be recognized as an issue for MPW
females. The Supreme Court has already
laid down the procedures under the VISAKA guidelines and these may be
publicized and implemented.
We also recommend a Women Employees Assistance Cell in
all districts that will provide legal aid, counseling and protection and some
degree of grievance redressal particularly to the MPHW female workers. The WEAC should meet every quarter and have a
confidential postal access. It should
take up all issues confidentially and in non-confrontational manner. It should not hesitate to recommends firm
administrative or legal action where necessary, with adequate publicity for it
to act as a deterrent. The WEAC should
be headed by a woman outside the health department – with some experience of
work on women’s issues. The WEAC should
be nominated by the District Collector in consultation with the Chief Medical
Officer.
ü Accommodation
Block Level-Government Housing Plan: All
accommodation for medical staff at CHC level should be part of a government
housing development plan common to all government departments so that adequate
supporting infrastructure and facilities can be developed. This can be done with private partnerships,
not only to speed implementation, but also to bring in investment. The accommodation so provided should be
adequate for all staff. Work could start
with prioritization of more difficult blocks so as to speed up development
there.
Sector Level-Category-wise Priorities: All PHCs in
medium category difficulty should be prioritized for building government
accommodation, for all the staff in a cost effective manner. This would act as an incentive for staff to
work there. In “most difficult” category
areas accommodation may be planned for para medical staff as a priority at this
stage.
Sub-Centre Buildings: Sub-centre buildings may not be
seen as a priority except where the complete block level planning is completed. It is best to prioritise those Sub-centres
where there are no rooms available on rent or alternate building available for
developing infrastructure then only move to other centres. Since institutional delivery is not being
insisted on at HSC level, rented accommodation with a store and a
consultation/immunization room available and paid for by the government should
be adequate for most HSCs in the immediate period. When a new building is undertaken, the
current design of MPW accommodation cum HSC facility may be continued even
though institutional delivery is not insisted on as this space has other uses
to merit its retention. Where needed and
when the systems of referral have developed it may be easily be designated for
institutional deliveries.
IX. LABORATORY
SERVICES
- Multi skilled Cadre for PHCs: Since the current number of
laboratory technicians is adequate only to man the CHCs, a greater effort
should be made on multi-skilling other cadre to undertake this work at the
sector level. Over a few years
every support staff should have these basic skills.
- Basic Set of Tests for PHC:
The basic laboratory set of tests provided at the PHC must include
blood haemoglobin estimation, total count, differential counts, bleeding
time and clotting time, blood smear examination for parasites, urine
examination for albumin, sugar, ketones, bile salts and pigments,
microscopy of urine, sputum acid fast microscopy, grams staining of
sputum, csf, stool microscopic examination for ova and cysts and hanging
drop examination of stools. The
sickling test may also be considered.
All these tests require very basic skills and are easily taught. The most difficult of these is the BSE
(blood smear examination) for malarial parasite and sputum for AFB but given that multi-skilling in this is
already accepted, ability to train in this wider range of tests should not
be considered a problem.
- Training Approach:
This set of tests can be taught to a team member – primarily by the
medical officer. Training
programmes at the district level would only supplement this. The medical officer would only need a
one week package to be refreshed on this if there is a good text to follow
along with proper teaching materials organized well. Charts and guidebooks that both doctors
and multi-skilled staff can refer to along with pictures of microscopic
appearances should also be available in every centre and their absence is
a serious remediable problem.
- CHC tests as Per Standard Treatment
Guidelines: The set of tests to be available in a
CHC have been described as part of the state’s standard treatment
guidelines and service delivery norms should be able to conduct the
following diagnostics:. Broadly the CHC should be able to conduct the
following diagnostics:
ü Basic blood biochemistry, and microscopic
studies with grams stain, cerebrospinal, pleural, peritoneal fluid
examination. Immunological testing esp.
for hepatitis, typhoid, AIDS, and syphilis
ü Basic imaging: X-ray, ECG and ultrasound be
the norm for all CHCs.
ü Every CHC should also have the capability
to take and send samples for microbiological cultures and histo-pathological
studies at the district level where relevant.
- Upgraded Laboratory Technicians at CHC: The qualified laboratory technician
at the CHC level should be upgraded to provide this much larger package of
tests then what is currently available.
Where still gaps remain public private partnerships to close these
gaps may be prioritized. The
laboratory technicians and the X-ray technicians should work under the
supervision and guidance and quality control of a suitable district level
officer in addition to the block medical officer.
- Health Sub-Centre Level Tests: At the HSC level urine testing for
albumen and sugar and blood testing for hemoglobin should be
implemented. In addition it should
be possible to train a cadre of NGOs and “trainers of ASHA programmes” and
male MPHWs to do Blood smear examination (BSEs) and sputum AFB testing
along with the above. Thus reducing reporting time of blood smears to less
than 24 hours, for all habitations.
This would require investment by the government in a microscope and
a basic kit and a piece rate payment arrangement by which these essentially
private service providers can be remunerated for diagnostics done for the public system.
X.
REFERRAL SYSTEM
§ Defining Referral Needs
The importance of a referral system can not
be over emphasized. Broadly, between the
PHC and the CHC, or between the CHC and the district hospital, the following
reasons necessitate the need for a good referral system:
a. For establishing the diagnosis for which
laboratory investigation not available at the PHC/CHC are needed.
b. For establishing the diagnosis for which a
second opinion or an expert opinion not available in the PHC/CHC is needed.
c. For management of case whose diagnosis is
known and infrastructure, staff, equipment is adequate but for whom drugs are
available only at the next level e.g. epilepsy.
d. For management of a case whose diagnosis is
known but where a quality of equipment or infrastructure or staff is needed
which is not available in the PHC – e.g. all in-hospital care or surgical care
etc.
Ø Under condition a & b, referral is a
one time event and with a good quality, prompt feedback the case can be further
managed at the PHC level. This referral
therefore, enhances he quantity and quality of services provided by the
PHC. Condition c is avoidable and
requires that the drugs be available at the PHC. The new essential drug list has a number of
drugs included in the primary health centre list so as to avoid such referrals
altogether and if needed this may be supplemented by allowing special indents.
Ø Condition “d” may occur as an emergency or
in routine out patient circumstances.
Some of these cases would need to be followed up at the higher level for
all time to come. But many would be able
to be sent back for follow up to the primary level once the acute crisis is
over. Availability of this referral
enhances the credibility of the PHC.
§ Designing Effective Feedback in a Referral
System
We can thus see that most of the above referral
purposes need a referral system, the heart of which is the feedback arrangement
to the primary level. If such a system
is well in place the capabilities of the PHC and the medical officer there are
dramatically increased. In our situation
of illiteracy and low schooling and mystification of medial practice sending a
note back with the patient is not a reliable, accountable or effective referral
system. In addition to sending the note
back with the patient the feedback data on referred patients, whether it be
expert opinion, or laboratory investigation, or instructions for follow up
should be transmitted in writing through the health system and available for
verification. Eventually this feedback
should be electronically transferred through Web and Will systems.
§ Block
Level Ambulance Services
A good transporatation system is essential
for any referral system to function properly.
It is suggested that in addition to the ambulance with the CHC a block
level ambulance service be developed in partnership with local community
organizations to transport patients and this be tied to the referral
systems. It is also essential to
construct a referral system between HSC and PHC and between ASHA and PHC based
on similar principles of specifying situations that need referral and arranging
for a strong feedback mechanism. Good
communication between different tiers is needed as well and this should be
linked to the ambulance service.
§ Referral
Fund with Panchayats: The referral fund currently placed at the
disposal of panchayats may be operationalised through ASHA and with links to
the above mentioned ambulance system.
The ASHA should be authorized to arrange the required funds for referring
needy patients and even accompanying
patients to PHC and CHC especially for certain categories of illness like high
risk pregnancy or life threatening emergencies and so on.
XI. INTEGRATION
WITH INDIGENOUS SYSTEMS OF MEDICINE
- Need to
Integrate at Level of Public Health System: Integration of the ISM structure with
the mainstream public health services is desirable for a number of
reasons. There is a substantial
investment entailed in these systems.
Utilisation is however extremely low both in terms of utilization
ISM services and in terms of it sub-serving public health goals. By integrating the ISM network with the
public health programmes a substantial income in outcomes can be expected
of little extra cost.
- Defining
ISM Package of Services at Each Level
Integration requires as a first step the definition of what package
of services each category of personnel and facility in the ISMs would
provide.
- Multi skilling
ISM Personnel for Public Health Functions:
Integration requires, based on the above, a multi-skilling of
personnel to serve new roles, new job descriptions and administrative
changes to facilitate such synergy.
It also requires adequate policies of transfers and promotions and
skill up gradation so that they too do not face the de motivational
factors that the mainstream is already seized with.
- Sharing
Infrastructure: If either the ISM facility or the mainstream sector PHC
does not have adequate infrastructure, a PHC building or the existing
infrastructure may be shared. Thus
in working out areas of coverage priority be given to closing the gap
between number of sectors and the number of PHCs. We note that if there is a synergistic
deployment of the two, the current gap between number of sectors and the
number of PHCs, largest gap in the system as would be adequately closed
- Making a
Common District and Block Public Health Plan: At the district level the district
Ayurvedic officer serve as part of the health planning committee and this
plan is integrated as a subset under the district health plan of the
CHMO’s office and the district health society. At the block level coordination is by
the BMO. At the sector level ISM
facilities may be asked to perform public health tasks in a section
allotted to them also.
XII.
TRAINING :The goal of the training policy shall be to ensure
that all the requisite skills to attain a specific quality of care for a given
facility becomes available at that level.
This is true for para-medicals as well as for medical officers.
To achieve this goal we recommend an in-service
training package with following features:
- For Para medicals : Multi skilling
Ø Minimum
Periodic Re-training: The
training policy must specify that evry two years at least 15 days of training
per MPW and health supervisor (male and female) must be received
Ø Training
Roster: A roster of all
MPWs and health supervisors should be maintained at the block and district level just for this
purpose denoting last training attended, topics and number of days of training
in each. The block medical officers may
coordinate with district training centre to see that all their health workers
have received the mandatory training.
Ø Syllabus: The syllabus for it should be built up to
include:
Ø Changes in heath programme guidelines of
national health programmes – best addressed through two day sensitization
programmes, whenever such a change is made.
Ø Renewal of care area of their work – RCH
programme for MPHWs (at least 15 days) and national programmes for male
workers.
Ø Multi
skilling training in which
female workers learn more about national programmes and about basic laboratory
skills and male workers learn about RCH and adequate levels of basic laboratory
skills.
Ø Adequate
training for first contact curative care.
Ø A
modified IEC programme
capability with focus on interpersonal and community mobilization skills along
with better understanding of a multicultural and ethnically diverse society.
§ On-the
Job Training: The supervisors should be held responsible
for on the job training of the health workers and periodic evaluation of
knowledge and skills of health workers be used to ensure that they perform this
task adequately, as they should be accountable for this in their juniors. The medical officers must be equipped to
evaluate the supervisors on training in most areas and in some areas like basic
laboratory services they should be capable of providing the training on the
job.
- Integrate Training Funds: All training funds from various
programmes are deployed in such a way that even as the objective of that
grant is realized, the training goals the state has set itself is also
advanced within that same space.
- Training Cell to Precede and Prepare
for SIHFW: A training cell for in-service MPWs and
supervisors training needs to be constituted in the SIHFW that is
constantly doing training needs assessment, training material development,
master trainer training of district training centers, supervision of
training rosters and training evaluation.
- For Medical Officers
Continuing Medical Education: We recommend a Continuing Medical Education
scheme for medical doctors to upgrade their knowledge and skills. This should replace the current practice of
upgrading their knowledge through sporadic camps of national disease
programmes. The envisaged CME scheme
should also be useful for promotion purpose.
A CME should be pursued as a very useful intervention strategy in health
care delivery system.
Minimum
Skill-Mix for CHC: Having defined a minimum package of services
at the CHC as essential to meet public health goals one needs to a put in place
a road map by which the desirable skill mix needed for delivering such a
package of services would become a reality. We make the following suggestions
in this regard:
ü Decide on what skill mix is needed in each
CHC and what the gaps are. The focus is
on emergency obstetric care but the skill mix approach need not be confined to
this alone.
ü Draw up a schedule of providing short term
trainings so that existing medical officers and specialists fill up the gaps
with acquired basic skill sets other than in areas which their primary
specialization. Thus a surgeon may also
learn to do Caesarean section or ENT and ophthalmic work, or a physician may
learn pediatric functions and so on.
ü Where gaps still remain one may use public
private partnerships to fill up the gaps.
XIII.
STATE AND DISTRICT LEVEL ORGANISATION
- Promotions and Tenure at the State
Level
ü Prompt and Regular Appointments: All vacancies must be filled up at the
directorate (directors, joint directors, deputy directors, chief medical
officers and programme officers at the state level) must be filled up within a
period of six months on a regular basis from eligible staff at that level or by
promotion, (except those posts that are to be recruited from the outside on a
consultancy/contract basis where it could take up to an year). For programme officers at the district level
and block medical officers must be filled up within the same timeframe but in
the event of creating a separate administrative cadre where these are entry
points they could take longer, up to a year.
ü Officiating Officers: In the period between the next regular
appointment and the relinquishment of the earlier appointee if an officer must
be given temporary charge, then only the senior most officer may qualify for
the same.
ü Security of Tenure: All posts of CMOs, Directors and BMOs would
have a security of three year tenure.
Unless there is gross failure of function certified by a panel they
would not be transferred. They would be
set a three year goal for development in their area when they take charge and
be reviewed against these goals.
- Work Allocation and Job descriptions
at the state level
ü Distribution of Work: The four directors may have work allocations
reordered so that the burden on the director of health services is reduced. This could be partly by passing same of the
work to the other three directors.
ü A separate Director or Separate Body for
Purchases: Another area of devolution of
powers is purchases. This devolution
could be by creating a separate autonomous para-state body to be headed by a
non clinical management expert or even outsourced to a management firm to take
charge of all purchases and distribution of drugs, consumables, equipment and
infrastructural development.
ü Another Director for Training, Policy and Planning
and IEC: Yet another area of devolution is for capability development and
planning this person would also head the state institute of health and family
welfare. Given the nature of the task,
this director is best recruited on contract or on deputation from the open
market with in house candidates also eligible to apply.
ü Specific Work Allocation and Powers for
Joint Directors: Even after such devolution the director of health services
would have a very large but now potentially manageable portfolio, if there is
adequate delegation of work to joint directors.
The joint directors, assisted by deputy directors, would be also given a
clear charter of work with adequate powers for planning and independent action
and placed in charge of specific programmes and sectors where they would have
to show results. Deputy Directors would
be the programme officers at the state level as well as three who assist in
core administrative issues of the directors.
Their numbers may be decided accordingly.
ü SHRC and External Inputs for Planning: We
feel that this above mix of four promotes internal to the department and two
recruits (on contractual/deputation basis or by the para -statal route) from
the open market and the mix of skill proposed would give the much needed dynamism
that a vibrant public health system needs.
In addition to this or as part of this (integrated with or in conjunction
with the SIHFW) formal state civil society partnership institutions need to be worked up .Planning
and innovation requires fresh inputs and insights brought in from the larger
academic, professional and activist circles.
Contracting in directors is one avenue of such recruitment. Building state-civil society partnership
institutions like the State Health Resource Centre(SHRC) where motivated
persons with their own commitment and initiative can contribute to the state
government is another major avenue.
- Systems for purchases and
Infrastructure Development:
The essential drug list and the norms for
health services provision adopted by the state would define the minimum drugs,
the minimum set of equipment and the minimum infrastructure development needed
for that level of care. The need and
challenge of developing a system of purchases is to ensure that the drug and
equipment purchase of this matches and parallels the human power and
infrastructure available and developing in that facility. This is not incompatible with
decentralization. On the other hand it
is almost a precondition for it. The
human power and expertise needed to select and finalize purchases of a
bewildering range of drugs and equipment would just not be available in all
districts and cannot be built up without costly redundancies. But the
current centralized system is inefficient with high degree of mismatches and
bottlenecks and sub-optimal in use of scarce financial resources.
The state role is to provide for a separate
office if not an institution headed by a management person with experience in
procurement and supplies.(ONLY FOR HEALTH DEPARTMENT) Delegating a clinician to this is
inappropriate, though close coordination with clinicians would be
essential. Such an office can complete
pre-qualification of companies, issues tender documents and negotiate prices
and place orders on behalf of chief medical officers for all supplies-drugs,
consumable and equipment. Such
collective bargaining can give better prices than if each district head
bargained on his own, but the requirement would be of the district. The further advantage is that by monitoring
stock positions on a daily basis and linked with a distribution system the
supplies of drugs can be flexible and streamlined to meet the needs of the
system. The key recommendation in this
is outsourcing to a management firm or a management head or a para-statal body created
for this purpose headed by such a person taken on contract. This firm has to display its final rates it
has secured and show comparisons with other states and public sector units to
show that it has been able to get quality at rates comparable to the best deals
in the nation. Quality testing of drugs
and Maintenance of equipment both of which have very poor or non-existent
arrangement would be taken care of by this.
It should further display the entire process on a website so that it is
part of the public domain.
In infrastructure development again this
office would provide assistance to the CMO in design specifications, tendering
and issueing contracts. Payments could
be made from the CMO0s office under such decentralization.
This is not a new idea. Broadly this is what the Tamilnadu Medical
Supplies Corporation has achieved and it provides consultancy for this. One may go further and seek with TNMSC or a
private management firm a BOT (Build Operate Transfer) agreement building into
this agreement indicators not only for building the system but also a planned
capability building in the department and eventually transfer of this to a
state body.
- Decentralization and Delegation of
Powers to Districts
ü The Role of Panchayati Raj
Institutions: The study group sees
decentralization as a major goal. Decentralization
is necessary to have a health plan that is flexible and responds to local
needs. It is needed as a better system
of administration. It allows for
creativity and innovation. It allows for
different rates of growth responsive to human resources available and the
quality of leadership provided. Decentralization
is however essentially a political process implying decentralization of
governance – as distinct from the mere increase in delegation of powers to CMOs. Decentralization of health department
functions to panchayats is therefore best done as part of a process of
political decentralization which includes increasing powers and financial
resources of panchayats as well as with capability building. In the absence of such political initiative,
involvement of panchayats in decision making, planning and programme
implementation by placing them in district and block level committees can at
best achieve capability building. This
should be pursued as an interim measure.
ü Moily Commission –Panchayats
Moily Administrative Reforms Commission
observes:” Provision of health care facilities through PHCs ,CHCs and hospitals
and prevention of diseases through health education are the two major components
of the health care system in rural areas”. It recommends that primary health
care “ could be entrusted to local governments under the Eleventh Schedule of
the Constitution in order to give a special thrust to this sector”
The idea of entrusting primary health care
to local government i.e. Panchayati raj Institutions(PRI’s), deserves serious
consideration. Keeping in view the fact that PRIs in Haryana are not as
developed as in some other states and are in a state of evolution, a broad
based local committee can be thought of which should comprise some members of
the Panchayat, some primary health officials, representatives pf weaker
sections, women etc.
ü Delegation of Powers to CMOs: This is a desirable goal for increasing the
efficiency of the system and for responsiveness to local needs. We however need to view decentralization in
the current context – where there is little innovation, where there are serious
mismatches, where officers are officiating and accountability is non
enforceable, where management skill are low and where administrative powers and
financial resources are limited.
Our recommendation is
therefore, to make decentralization:
Ø The Chief Medical Officer must be a regular
appointee, not officiating.
Ø The Chief Medical Officer must have a
minimum tenure of three years.
Ø The Chief Medical Officer must have served
as block medical officer or programme officer
Ø Be part of the health management cadre if
this is created and officer must have had public health management training
(for ensuring capability).
Ø Purchases and infrastructure development
must have the state level managerial arrangements as indicated above.
Ø A state level body on capability building
and technical advice on planning must be accessible to him/her.
If all the above conditions are satisfied then the
Chief Medical Officers powers must be enhanced to a level where it includes
modifying and creating his own health programmes based on the district health
plan and seeking budgetary support for it.
The administrative powers of the CMO must be at least tht of the joint
director. All purchases required to
reach recommended norms of service delivery, district level recruitment of
staff, promotions and training to reach service delivery norms should be
incrementally bought under the district powers along with technical support
arrangements from the state level.In the absence of the above five criteria
being realized the existing powers are perhaps what is optimal, along with
rigorous supervision.
- The Development of a Health Administrative
Cadre
ü Need for Two Cadre Streams: Some clinicians are not
interested in or resent administrative work but can not refuse the offer for it
is related to seniority and status.
There are some who would want to undertake administrative work, would
prefer this for their career and would be happy to get themselves qualified in
this area. But to give up clinical work
especially in the private practice domain is a loss of both professional status
and income. These contradictions need to
be resolved pragmatically by charting two career streams – one clinical and one
administrative.
ü The Health Administrative Stream: A health
administrative cadre may be created of all the persons working as BMOs, CMOs,
District and State Programme Officers, and officers in the training
institutions. All would be class I
officers. These persons are paid 25% or
such of salary as non practicing allowance and forbidden from practice. They are further given a travel allowance for
supervision work if not provided with a vehicle. Their opportunities of promotion are easier
and they may even become class I earlier, but they would have more transfers
and would have to serve in difficult areas first. They would get one year training over two or
three spells – in management, in public health and epidemiology and health
planning. They could be eligible for a
one year sabbatical once in six years.
They would be part of a state cadre.
ü The Clinical Stream: Those who opt for the
clinical stream get no allowance and face less transfers. They have little promotion avenues though
specialized training can enhance their clinical skills. They can however rise to head district and
sub-district civil hospitals as civil
surgeons and with hospital administration training go onto being medical superintendents
of tertiary care hospitals. The civil
surgeon would serve under the CHMO so that there is a clear chain of command
especially as the specialists posted there are needed for public health
functions in other facilities. However
they would have considerable autonomy over hospital management. Alternatively the post of civil surgeon can
be abolished. Those in the clinical
stream can opt to be part of a district cadre.
ü First Ten Years-Common Cadre: The details have to be worked out by a
committee. The general principle is that
for the first ten years everyone is of a common cadre and then they choose one
of two career plans, both with their own attractions.
The
Post of the BMO
ü The BMO should be Made a Designated
Post. It should be the mandatory
entrance point into the administrative cadre.
It should require a minimum of 10 years of service to become a BMO.
ü Since the creation of a medical
administrative stream within is a difficult decision to make, a number of
immediate steps are also suggested.
These include:
ü A three-day induction orientation conducted
at state level, every quarter, for all BMOs who are appointed in that
quarter. This orientation helps them
learn all the basic programmes and the administrative issues that they have to
handle.
ü The development of annual block level plan
with guidance where they identify their goals and plan their activities and
mark out the constraints in equipment, drugs and infrastructures etc. for
action by the district.
ü A provision of a block medical officer
honorarium/allowance if we are able to ensure:
Ø Tenure of at least three years.
Ø That this is not seen as an opportunity for
generating private earnings – for themselves of for sleaze within the system.
Ø That the BMO assignment is linked to
developing and implementing a measured and monitored block level health plan.
Ø If tenure is assured to also insist on
every BMO completing a three month distance education programme on management
aspects arranged by the state government in collaboration with some institution
with expertise in health management.
Ø Empowering BMO with powers and support from
the CMO and state office required to affect their block level plans including
the provision of an adequate imprest fund and basic modern office support.
District
Programme Officers as Deputy CMOs
The post of programme officers should be
seen as assistants to the CMO and be part of the administration cadre. Instead of designating them in an adhoc
manner each district may have four officers to assist the CMO who would hold
largely administrative “Deputy CMO” function.
These could be a programme officer for RCH programmes including
immunization and family welfare, another for all other national programmes, a
third for training and IEC functions who is in charge of the district training
centre, and a fourth for purchases, distribution, logistics of all supplies and
infrastructure. Along with the CMO and
with adequate administrative and office support this would be available
district leadership team. If needs to be
emphasized that all the five are trained in public health and ideally form part
of an administrative cadre.
District
Chief Health and Medical Officer
The Chief Medical Officer should
necessarily be a regular appointment on promotion,l with adequate training and
experience working as both programme officer and a block medical officer and
assured of three-year tenure at least.
In such a context more powers can be delegated to this post.
- Development of management skills &
The development of planning capability
If mandatory training is introduced for all
district programme officers and Chief Medical Officers and Deputy Directors we
would get eventually get more planning capable staff in the directorate. A three-month health management course by a
national institute done by correspondence would be the basic minimum
qualification needed.
It is also important to ensure that all
those who become joint directors and directors have served as district Chief
Medical Officers and that all deputy directors nd CMOs have worked as BMOs or
district programme officers.
Development of planning
capability in the
directorate also requires further inputs from operational research and from
epidemiological work. Understanding the
rigour of this by participating in this or at least using such reports
consciously needs to be built in.
Without such experience planning is arbitrary, unscientific and becomes
an expression of power relationships with dependence on externally made and
poorly adapted programme designs. Further, in the current context,
opportunities for interaction with that section of NGOs who are active in
health advocacy or community action at both national and state level is
essential to develop a critical insight into ones own mindset and to critically
evaluate programme designs.
4 comments:
very well and reasoned study!
great
very well and reasoned study!
great
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