Haryana

ThegrowthofHaryanastateprovidesnewopportunities.TheGovernmentofthe
state of Haryana is engaged in the process of reassessing the public health care
systemtoarriveatpolicyoptionsdevelopingandharnessingtheavailablehuman
resources to make greater impact on the health status of the people. As part of
thiseffort,oneshouldattempttoaddressthefollowing3questions.
1.Howadequatearetheexistinghumanandmaterialresourcesatvariouslevels
of care (namely from Sub Centre level to district hospital level) in the state; and
howoptimallyhavetheybeendeployed?
2. What factors contribute to or hinder the performance of the personnel in
positionatvariouslevelsofcare?
3. What structural features of the health care system as it has evolved affect its
utilizationanditseffectiveness?
Fromthe analysisofthesituationinitstotality,onemayproceedto
make recommendations towards a policy on workforce management, with
emphasisonorganizational,motivationalandcapabilitybuildingaspects.Onehas
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 to provide health
caretoallthepeoplewithoutanydiscrimination.
Astudywasconductedaquestionnairebasedsurveyoffacilitiesthatwasapplied
on a sample of 128 Sub centres, 64 PHCs and 32 CHCs, also 356 employees of 8
cadreswereinterviewedinChhatisgarhandanalysiswasdone.Therearecertain
similaritiesofsituationandalotcanbegatheredfromtheirexperience.Thereare
fourtypesofstakeholdersinhealthservicesysteminthestate.
1.Theemployeesandtheirassociations.
2.Theofficersatthenational,stateanddistrictlevel.
3.TheMedicalprofessionandprofessionalbodies.
4.Civilsociety.
ItisnotedthatinthelastdecadethedepartmentofhealthinHaryanahasseena
lotofnewdevelopments:

Howevertheconstraintsthatthesystemhasinheritedareconsiderable.Alarger
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
projectanapproachtoreachingit.Inthelargerinterestsofimprovingthesystem
theaimistosetoutallthelacunaeinworkforcemanagementandrationalization
of services, explore its causes and set down the possibilities for immediate and
longtermactiontoimproveandstrengthenit.
SituationalAnalysis
AdequacyofSanctionedFacilities
As per existing norms one sub centre is planned for every 5000 population, one
PHC for every 30,000 and one CHC for every 80,0001,20,000 population. For
tribalareasthenormisonesubcentreper3000population,onePHCper20,000
populationandoneCHCper80,000population.

SNO FACILITY ATPRESENTSHOULDBE

1 SUBCENTRE
2 PHC
3 CHC
4 SPECIALISTSINCHC
SURGEON
PHYSICIAN
PAEDIATRICIAN
GYNECOLOGIST
ANAESTHETIST

Weneed572SubCentremore.98morePHCsareneededalongwiththestaff
andotherinfrastructurerequired.Weneed63moreCHCs.
LocationofFacilitieswithrelationtoaccess:
Amongstexistingfacilitiesthereisconsiderablelossofutilizationduetoimproper
location and improper distribution. In many of the cases, there is considerable
maldistribution.Andthisiscompoundedbyimproperchoiceofvillagewithinthe
sectionorsectorandthechoiceofvenuewithinthevillage.
AdequacyofstaffandtheirUtilizationwithRelationtoFunctionalityofCentres:
Eventhefemaleparamedicalstaffisnotadequateinnumbers.Thereareserious
shortfalls in all other staff. Female worker has to share the greater part of the
workload.ManycategoriesofstaffatsubcentreandPHClevelarecharacterized
by poorly designed work schedules and are poorly utilized with high degree of
redundant work time. Rationalisation of paramedical work time offers therefore,
themosteffectiveroutetoaddressingstaffadequacy.
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
treatmentordiarrheaoradolescenthealthcareetc.)andaqualityofanumberof
otherservices,likeantenatalcareareseriouslycompromised(veryfewpregnant
womengettheirBPtakenandbloodandurinetested).
RationalisationofDrugsandConsumablessupply:
Theessentialdruglistisnotbeingimplemented.Themaindeficitsareafailureto
procure the entire items of the list, a failure to send samples for quality control
andafailuretoexcludedrugsnotonthelist.Otherelementofthedrugpolicyare
also not in place. Thus procurement is problematic and sporadic, occurring once
ortwiceayearwithquotastoperipheralfacilitiestodistributethedrugs.
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
poorperceptionofqualityofcareissues.
The problem with consumable is even more serious than with drugs. Laboratory
chemicals seem the worst affected but even gauze and bandages, needles and
needleholderscouldbeinshortsupplyrepeatedly.
RationalizationofEquipment:
Low investment minor equipment like Sahils 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 Xrays which require less
replacement but require trained manpower to operate. In minor category, there
maybeconsiderableunderutilization.Duetoqualityofcareissuesmanyofthese
instruments/equipmentarenotutilized.Ifutilizedthentheyrequirereplacement
forwhichreadysystemofpurchasesandrestockingisrequired.
Inmajorequipment,themainproblemismismatchesbetweenequipmentsupply
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.Halothaneadrugusedforanaesthesia,wassentat
CHC levels where there was no anesthetist, neonatal care units where there are
nocaesareanoperationsdone,ColourDopplerequipmentssuppliedwherethere
is no vascular, cardiologist or cardio thoracic surgeon available), between
equipmentsupplyandconsumablesavailabletouse(e.g.Xraymachinesrunning
outofXrayfilm)andbetweenequipmentpurchaseandmaintenance.
Atonelevelallsuchmismatchesareattributabletofailuresofconcernedofficials/
officers. But at another level it points to a governance/ administrative failure,
withonecommitteemaximizingpurchases,andanothersetofpersonslookingat
distribution and no one looking at training and maintenance or eventual
utilizationofequipment.
InfrastructureAdequacy:
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. Now after SKS formation repairs could be
possible.
NoLightatSubCentre:Problemswithelectricitysupplyarealsothere.Generator
backupisnotavailableatmanyplaces.InverteratCHClevelisavailablebutare
notofsufficienttimecapacity.
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,wouldrequirerunningtapwater,bathingfacilitiesandtoiletsseparately
forstaffandforpatients.HowmanyofCHCsandPHCshavesuchawatersupply
arrangement? Waste management based on segregation of wastes with proper
disposal of each category of biological waste is a relatively untouched area of
intervention.
ServiceConditions
(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
serveinruralareasandwhentheyaresoposted,dotheirworkwithsuchadeep
rooted sense of frustration and anger that the quality of the work suffers. The
problemsofdoctorsnotwillingtoserveinruralareasshouldbeseenonlyinthis
contextandshould noteven beheldoutagainstthemedical professionunlessa
basictransferpolicyhasbeenputinplace.
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
alsobeenobservedthatmanytimes
the position of authority starting from the top most and proceeding through the
Civil Surgeon upto Senior Medical Officer are held in an adhoc and arbitrary
manner.
Further the opportunities for an active career plan for a talented doctor or one
whoisabletoworkhardandperformmoreareabsent.Forparamedicalstafftoo
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
needtobeurgentlyattendedto.
Another major problem is personal security, again a problem maximal with
MPHWfemales.
Violenceandsexualharassment,covertandovertaffectsabout10%butcreatesa
sense of insecurity in all. In Delivery Huts these type of problems have come to
lightrecently.
Nodefinitepatternofvenue:Anotherbasicserviceissueisaccommodation.Atno
levelisthereadequatehousingforallstaff.Availablehousingfacilitymanytimes
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
numberofdoctors.Availableaccommodationisalsounderutilizedbecause
ofmanyfactors.
LaboratoryServices:
Laboratoryservicesatthesubcentrearealmostabsent.Bylaiddownnormsfour
basictests
Blood pressure checking, weighing of pregnant women and children, blood
haemoglobin estimation and urine testing for sugar and albumen (also E.S.R) are
expectedtotakeplacehere.
TheseabovetestslikeBPcheckhoweverdotakeplaceinPHCsbutevenherethey
arenotregular.
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
basicdiagnostictests,hasalmostbeen
forgottenwithinthesystem.Microscopeavailabilityistherebutunderutilized.
InCHCsthelaboratoryisactivetosomeextentbutperformmostofthetimetwo
tests, the blood smear examination for malarial parasites and the sputum
examinationforAcidFastbacillus
(AFB).ThelistofdesirablediagnosticsattheCHClevelisover40tests.Atmostof
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
modernritualdenotingmedicalcaredevoidofcontent.Targetofslidemakingis
alsoacauseforit.Thereisnomajorperceptionofthelackoflaboratoryservices
as a serious lacunae again reflecting on the weaknesses in under standing and
lackofemphasisofqualityissuesinmedicalcare.
ReferralServices:
Thecurrentreferralserviceshavetwoforms.Firstlythereisafundplacedatthe
disposalofthePanchayatforusetohire/payfortransporttoshiftneedypatients
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;
inabilitytocallvehicleintimeetc.)itsutilizationisverylowevenastheneedfor
referralgoesunanswered.
The other referral is the patient being asked orally or with a slip to go and seek
treatmentatahighercentre.Thisbringsnoadvantagetopatientortothesystem
and is perceived by the patient as the referral facility having deliberately or
otherwisefailedtodeliveritsservices.Therearenoclearnormsforwhatistobe
referred and when and there are no mechanism to monitor referral to reduce
unnecessary referral and insist on necessary ones. There is no feedback of any
sort.Inshortthereisnoreferralsystem(Nowthisalsodonotexist).
Thethirdsystemisthatthereisnoneedofreferralsystemforgoingtocorporate
hospitals for treatment. The rates are fixed. You go directly, get the treatment,
paythebillsandgetthemoneyreimbursed.Ithascreatedmoreproblems.Those
whocannotpayfromtheirpocketinadvanceareatlossinsuchanarrangement.
Fewgetadvancefortreatmentalso.
IntegrationwithIndianSystemofMedicines:
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
departmentwelcomesuchroleallocation.Howevertheadministrativeunification
at the district level and the programmatic synergy at the level of programme
designhavenotbeenplannedfor.
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.Asaresultwhatevertrainingsaretakingplacearearbitraryinchoice
of trainees and fragmented as strategy. Most training programmes are of one or
twodaysandrelatetoasinglediseaseandanimmediatecampaignforexamplea
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)hadaspecialroundoftrainingin
ReproductiveandChildHealth(RCH).Theverticalorientationoftrainingleadsto
closely associated work of other diseases not being taught even in much longer
capabilitybuildingtrainings.Thuse.g.thesupervisorsaretrainedonbloodsmear
examinationformalarialparasitesbutdoingadifferentialcountonthesameslide
wouldnotbeemphasized.
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 of PHCs or
CHCsofagivendistrict,thelevelofknowledgeandskillsneededisnowavailable.
Itmaynotevenbeabletostate,facultywisewhatlevelofskillbuildinghasbeen
achieved and what are the gaps. All these problems can be said to be true of
Information
EducationCommunication(IEC)also.
StructuralIssues:
Governance:
Itisnotadequatetolocateallproblemsonlyattheadministrativelevel.Someof
the key administrative decisions are often taken at the political level. Of these,
transfers, promotions and purchases, which are purely administrative activities
haveinpracticebecomecentralareasofpoliticaldecisionmaking.
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.Whatpolicyinitiativeshavebeentakenremainweakinimplementation.
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
whichtheyarecompelledtopurchase.
Another illustration relates to senior appointments and tenure. If a policy has to
beimplementedthenacapablepersonorteammustbeputinplace,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
officiatingcapacity.Appointmentsbecomeaprerogativeofpowerandinfluence.
There is no surety of tenure. Administrative arbitrariness in such areas are to be
recognizedasindicatorsofpoorperformance.
Significantly even recruitments that are to take place on regular basis are not
taking place. Fresh recruitments have been therefore, only contractual, even
wheretherearevacantposts.Thisisagainanissueofgovernance.Theproblemis
thatthereisacynicismaboutpolicymakingitself.
There is a feeling, often justified by experience as with essential drugs list that
anything can be passed as policy statement without any binding on its
implementation.Normallytheministrywouldlaydownpolicyandthedirectorate
would be answerable for its implementation. The ministry would be the main
vehicle of ensuring accountability and transparency of the directorate and be
answerabletothelegislatureforit.Thecreationofastatehealthsocietyismeant
tofacilitatenotweakenthisrelationship.However,whentheseparationbetween
governance and implementation is lost and the ministry itself is responsible for
implementation, as in the current nature 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
realmtothatofthereformofgovernance.Onewouldthenhavetolooktothe
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,purchasesandtransparencyisitatechnicalandmanagerialfailureor
afailureofgovernance?Ifitisaninabilitytoformulateatransferandpromotion
policy or organize a system of purchases then is it a technical and managerial
questions?Ifnot,then,itisafailureofgovernance.
StateLevelWorkOrganisation:
AnnexureIV??????

The inability to deconcentrate powers and responsibilities at this level is a key

problem and may be the main reason for being unable to keep to project
schedules.Theexperiencesofotherstatesmaybehelpfulinthisregard.Arelated
diversion is the need or professionalization at the state leadership level. Though
theyhaveveryrelevantpracticalexperience,professionaltraininginpublichealth
management,healthpolicyandinhospitaladministrationhasbeenweak.
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
havebeenseriouseffortsinimprovingthissituationbytraininginputs,butthese
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
andlogistics,thesystemhasnotmadeuseofqualifiedmanagementskills,which
areeasilyavailableonthemarket.
Decentralization:
Yet another major issue of decentralization of powers to districts. Currently all
districtofficersperceivedistrictsashavingverylimitedpowersinalloftheabove
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 medicolegal work. Their own terms of selection, transfer and
monitoringhaveallthesameorganizationalandmotivationalproblemscommon
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
contextofthesekeyadministrativereformsbeingcarriedout.
Currentlyelectedpanchayatshaveanegligibleroleinthehealthsectorandeven
inthisthesupportandprogrammedesignneededforthemtobeeffectiveisnot
available.
FinancingofHealthCare:
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.
Thesefinancialmattersshouldalsobecometheagenda.
Mappingtheprivatesectorandexploringitspossibilityofsynergywiththepublic
health system and developing a policy framework for its growth and regulation
areyetissuesthatneedtobeaddressed.
RegulatingPrivateHospitalsandNursingHomes:
Mappingtheprivatesectorandexploringitspossibilityofsynergywiththepublic
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
systeminthestate,thepublicsectorinthestate,thereisamushroomgrowthof
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
protecttheconsumersandcontaincosts.Asystemofaccreditioncanbethought
ofasamechanismtoregulatetheprivatehealthproviders.
ItisrecommendedthatacommitteewithHealthMinisterastheChairpersonand
someseniormedicalofficersofthestateandrepresentativesoftheprivatehealth
providersbeconstitutedtoevolvethismechanism.
UrbanHealthisanothermajorareawhichneedsmoreattention.Thereisalready
arealizationthathealthcarefortheurbanpoorandpublichealthprogrammesin
the urban context is grossly inadequate and there is an urgent need to develop
viablecosteffectivemodelsofhealthcaredelivery.
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
strategiesofepidemicmanagement.
Current Information, Education Communication (IEC) strategy needs to be
examined;
one ofthe most important dimensions of public health strategy. This area needs
tobedevelopedinamorecreativeway.
Theserviceswhicharesupposedtobedelivered bySubCentres, PHCsandCHCs
aretobeasperthelatestlaiddownnorms.
Recommendations
1.Adequacyoffacilities:
IncreasingNumbersofPeripheralHealthFacilities.
Increasing Sub Centres to ensure sub centres as per population norms i.e. one
subcentreforevery5000population
Rural population of Haryana is 1,50,29,989. So 3005 centres are required. We
have only 2433 Sub Centres. We need 572 Sub Centre more. One male and one
femalehealthworkersarerequiredforeachHealthSubCentre.Soweneed3005
maleMPHWand3005FemaleMHW.Wehave425MaleMHWand1909Female
MPHW.Thegapisverydisturbingfor2433Subcentresevenweneed2008Male
MPHWand524FemaleMPHWworkers.
According to latest norms one Female MPHW is added for each Health Sub
Centre.Henceweneed2433FemaleMPHWinadditiontoearlierrequirements.
IncreasingPHCstoensurethatthereisaPHConevery30,000populationasper
the norms. There are 411 PHCs. We need 509 PHCs. Hence 98 more PHCs are
neededalongwiththestaffandotherinfrastructurerequired.
Increaseperipheralhealthfacilitiesinurbancentresi.e.createacomprehensive
urbanhealthplanwhichincludesanetworkofurbanhealthcentres.
IncreasenumberofCHCssoastoconfirmtothepopulationnorms:OneCHCfor
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
CHCsintotal.EvenifoneCHCfor1,20,000populationisfollowed,weshouldhave
125CHCs.Wehave87CHCsatpresent.Weneed63or38moreCHCsalongwith
theinfrastructureandhumanresource.AtpresentthereisoneCHCfor3PHCs.
Adoptionofminimumnormsofservicedeliveryandprovisioningforit.Oneofthe
most important recommendations of the HARC is the adaptation of
recommended norms on service delivery for each facility the Sub Centre, the
PHC, the CHC and the civil and district hospitals. These norms may be widely
disseminatedandhealthsectorplannersmustbeinformedaboutthesame.
(AnnexureIV)
II.ProblemofLocationoftheseFacilities:
1. Block level mapping (GIS based): It is required to prepare block level maps
showing all villages with existing Sub Centres and PHCs in all blocks as well as
demarcatingvarioussectionsandsectorsaccordingtopopulationnormsBasedon
this to search out ideal location for Sub Centres and PHCs and compare this to
wheretheyarecurrentlylocated.ThismaybemostefficientlydoneonGISbased
softwarecreatedforthispurpose.
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 56villages, locate the centre in coherence
withsuchactivitysoastomakeiteasierandmorelikelyforpeopletoaccessthe
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
stakeholderanalysis.
3. Reallocation Possibilities: Based on the above inputs decision is to betaken on
locationatfirst forallfacilities where Government constructionsare neededlike
in. Sub Centres without buildings, sectors without PHCs, v/s sectors with PHCs
operatingfromrentedbuildings.Wherenecessaryinfrastructurehasalreadybeen
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
thisaplanofconstructionpriorityforeachblockmaybedrawnup.
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,andinfrastructuredevelopment.
5. No 100 Bed Hospitals: in any block or district should be built till all district
hospitalsandallCHCsstaffedandfunctionalasenvisaged.
III.RestructuringStaffingPatterns,RedefiningJobsandAdequacyofManpower
Recalculating Manpower Gaps: Gaps in staffing should be recalculated after
planning for multiskilling and redistribution of existing staff such that there are
noredundantmanpower.
Two Female MPWs in each Sub Centre: Sub Centres may plan for two female
MPHWsandonemaleMPHW.ThejobdescriptionandworkloadoftheMPHW(F)
needstobelessenedandmaderealisticexceptforinstitutionaldeliveryandIUCD
insertion, every task done by women can be done by men also. When there will
betwofemaleMPW,thenumberofpopulationforfemalewillbecomehalfwhich
willhelpinqualityservice.
MultiskillingallPHCParamedicals:ThePHCstaffingpatternneedsrestructuringto
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 femaleMBBS or Ayush MO) in every PHC. These multi skilled workers must
be skilled in dressing, drug dispensation (pharmacists task) and first contact
curative care and in basic laboratory package as well as in RCH. Between them
they should be able to keep the PHC functional for 24 hrs., should provide
institutional delivery and the other services as proposed in the service delivery
norms.Afterthismultiskillingandrevisionofjobdescriptions,cadrerestructuring
mayfollowthis.Nooneistobedroppedunlessoneisnotwillingformultiskilling.
New recruitments should be into the multi skilled category and many existing
cadreswoulddieaway.Somelikestaffnursewouldfunctionasmultiskilledstaff
whenpostedinPHCbutcanplaytheroleofstaffnursewhenpostedinCHCand
district hospitals. It can be said that such retraining and re deployment would
solve a substantial part of the manpower vacancy problem. Each PHC may also
havetwostaffpersonnelatclassIVqualifications.
RationalizationofDevelopmentofMedicalDoctorsatthePHClevel:
Differentiated strategy according to difficulty levels: The ideal would be two
medicalofficersateveryPHC(asinTamilNadu),preferablyoneladydoctor.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
berealizedduetoshortageofpotentialrecruitsandthedifficultyinfindingeven
onemedicalofficerperremotearea.
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
formofi)increaseinruralhealthallowancetoRs.2500permonth.AtpresentRs.
250 is being given for the last 20 years (ii). The rural health service prerequisite
for applying for MD/MS is 2 years, it can be one year if one serves in category C
PHCforoneyear.(iii)DuringPGcourseoneisgivensalaryfortwoyearsandonly
honorarium for the 3rd year. One should get the salary for third year also. (IV)
After completing the course he should be allowed to work for one more year as
senior resident with full pay so that he/she can have practical confidence. (V)
Special pay package for categorized PHCs ranging from 50008000 per month
alongwithNPA25%orthedoctorsbeallowedprivatepracticeafterdutyhoursas
inRajasthan.
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 multiskilling and deploying
paramedicals. The multi skilled paramedical worker should also be trained in
emergency care management at Primary level. It can be emphasized that by
paramedicalworker wemean thecurrentMPHWs orPharmacistsor staffnurses
currentlyinservicewithfurthertraininginputsandnotthelegitimizationofunder
qualified allopathic practice that also goes by the name of paramedical course.
TheroleofdoctorinPHCwouldbetoprovideleadershipandonthejobtraining
and a referral back up for this team. Where a doctor is resident, the doctor is
availableoncall24hrs.tobackupthisteam.
DailyVisitsbyCHCBasedDoctorsforMostDifficultPHCs:
Wherenomedicaldoctorsareavailablecurrently,whereaccessisaproblemand
accommodation facilities are low (category C), even as efforts are made to fill
theseposts,thebackingupisdonebydailyvisitsandinafewdistantPHCstwoor
three visits per week of a medical doctor from the respective CHCs. The doctor
would be required to be available during working hours from 9 am to 5 pm at
headquarters and his stay at PHC would be insisted on only if adequate
accommodation governmental or rental are and proper security arrangements
areavailable.Eveninthis,exemptionmaybegivenforspecialreasonsaslongas
stayinnearbyblocktownaspartoftheCHCteamanddailyattendanceisregular.
FamilyaccommodationattheCHCwouldbeeasiertoorganize.Inotherwordswe
shouldnotinsistonmedicaldoctorsstayinginPHCsdesignatedcategoryCmost
difficult (one considers that the above approach with mobile doctors but fixed
facilities may be more cost effective than mobile hospitals when combined with
theuseofmultiskilledparamedicals.
Strengthening BAMS Doctors Role While Keeping Medical Officers Options
Open:
The use of medical officers with BAMS (Ayurvedic System) 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
PHClevelandspecialtrainingwouldbeneededtoclosethegaps.Thepostofthe
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
manpowerinourhands.
TheCHCsbeStrengthenedby:
AppointmentofsixMedicalOfficersatleast.
Four of these at least should be specialist (physician, pediatrician, surgeon,
gynecologist)mix.IfthereareanumberofPHCsnothavingdoctorstobelooked
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. SMO can call specialist on
paymentperhourifneedbe.
AdequateMultiSkilledMaleandFemaleParamedicalStaff:
Who can manage the necessary support work and multi skilled imaging
technicians who can also manage Xrays, USG and ECG too? In addition there
would be a unskilled worker category of undifferentiated, inter changeable class
IV functionaries chaukidar, peon, sweeper, waterman all rolled into one. Six
qualified staff nurses, two qualified laboratory technicians and an ophthalmic
assistantarealsoamustatthislevel.
RedesignatingtheBlockExtensionEducator:
Theblocklevelextensioneducatormayberenamedtheblockseniorparamedical
supervisorandberesponsibleforcapabilitybuilding.IECandsupervisionofsector
supervisors.
AdequateClericalandAccountingStaffatleasttwo,beprovidedtoeveryCHC
alongwithcomputerandprinter.
IVRationalisationofWorkAllocationandApproachestoImproveOutreach:In
Additiontotheabovemeasures,ImprovingOutreachRequires:
ReorganisationofMPHWWorkSchedule:
MPHWs 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
drawingsuppliesfrom
PHCs. The remaining two days a week should be devoted to clinical work and
otherservicesprovidedatSubCentre.Thesetwodaysarefixedandherclienteles
shouldknowthathe/sheisavailablethereinherheadquartersonthesetwodays.
Ineachfieldvisitdays,he/shewouldvisitaspecifiednumberofhousesandhold
meetings with one of the four indentified local groups. Once a month he/she
shouldattendaBlockLevelReviewandTraining.IftherearetwoMPHWsposted
theirtwodaysattheheadquartersmaybefixedinsuchawaythattheSubcentre
is open on four previously specified days every week, which is better than the
current,onedayaweekorso.
RevisedMPHWJobDescription:
Immunisation children and pregnant women largely at the village visit and
campsbutsupplementedbyimmunizationatthesubcentre.
Antenatal care and post partum care at sub centre, with visits to these
pregnantwomen(unable/unwillingtocome).
Motivationandfacilitationforallmethodsofcontraception
TrainingandsupporttolocalwomenhealthcommitteesandMahilaSaksharta
Samoohactivists.
Regularhousevisits,suchthatevery householdisvisitedonceevery15days
or
onemonth)forasetofcasedetection,followupandcounselingactivitiesalong
withfirstcontactcurativecarewhererequired.(thisincludeallnational
programmesrelatedactivities).
Focal group discussions/ health education sessions/ health camps during
village
visits.
CurativecareduringfieldvisitsonthreedaysandatSubCentreontwodays.
Responsetoepidemicusingagradedepidemicresponseprotocol.Inaddition
to
theabovemaleworkerwouldhavethefollowingtasks:
AddressingmakeyouthonadolescentproblemsandSTDcontrol
InteractionwithPanchayats,SKSandwithlocalleadersforfacilitationofhealth
programmes.
InadditiontotheabovefemaleMPHWsshallhavethefollowingtasks:
Assistanceatchildbirth
IUCDinsertion
Addressingadolescentgirlsonhealthproblems.
OutReachCamps:
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.
Howeverinvillagesorclustersofvillageswhereoneorotherservicehaslessthan
50%coverageorthereisalargenumberofpersonstobereached,ahealthcamp
which reduces and brings down to a manageable level the burden of unfinished
servicedeliverywouldbewelcome.Healthcampstherefore,shouldbepreceded
anddrivenbyhealthneedsidentifiedbyMPHWs(PanchayatsorMahilaSaksharta
SamoohorSKS)ratherthanprogrammetargetstobemetabove.Thusablindness
treatmentcampprecededbyacarefulidentificationofthoseneedyanddrivenby
such needs with a carefully planned follow up, or an immunization camp for
measleswhereasurveyshowsthatoverhalfthechildrenhavenotreceivedit,is
much more useful than declaring a series of camps first and then trying to
mobilizetheclienteleforit.
V.RationalisationofDrugsandConsumableSupply:
TheessentialDrugList:
Theessentialdruglistneedstobeimplemented.Inparticulartheexpandedlistof
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
quickprocessofappealcanbebuiltinwherea
Civil Surgeon or programme officer appeals for being permitted to purchase a
drug outside the list, but this must be done with prior permission and with due
process. Upto 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
difficulttogetameaningfuldrugpolicyintoplace.
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 MPHWs use requires frequent
replacements like BP apparatus and thermometer and they should also be
therefore,apartofconsumablesmanagement.
Thedrugandsuppliespolicyshouldreflectthis.Itcanberecommendedthata
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
drugsinstock.Whenthestockfallstobelowthreemonthsusage,alevelfixedat
the district level for each drug then the facility immediately indents for the drug
tothedistrictwarehousewhichinturnsuppliesthedrugtothePHCinthesame
week.Whenthedistrictstock falls belowathree monthssupplyanorder issent
offthenextdayandwithinamonththeitemwouldreachtheconcerneddistrict
warehouse.
Procurement
Werecommendthattheprequalificationofsuppliersandthepricesnegotiation
be done at the state level by an empowered body in 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
subsequentdistrictsordersarethroughthisempoweredbodyandsupplieswould
be sent directly to the districts. This body would arrange for quality testing of
drugsalso.
DrugPolicy
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
anotherurgentlyrequiredpolicymeasure.
VI.RATIONALISATIONOFEQUIPMENTPROCUREMENTANDUTILISATION
Smallerlowcostequipmentthatisfrequentlyreplaceablemust bedealtwith
asforconsumables.
Largerequipment,whichiscostlierandrequirestrainingtomakeoperational,
needstobepurchasedanddeployedonlyaspartofblockanddistrictlevelplans
linkedtoservicequalitydeliverables.Thiswouldensurethatthereisnomismatch
betweenequipmentpurchaseandinfrastructure,betweenequipmentandskilled
manpower available, between equipment and related consumables supply and
thatthepurchaseofequipmentislinkedtoqualityimprovementsinthepackage
ofservicesofferedatthislevel.
Purchasecanhavethesamepolicyofprequalificationandpricenegotiationat
the state level with districts while placing orders. The same empowered body
which implements drug and supplies procurement and distribution may
undertakeallequipmentpurchase.
Further such a body would ensure that adequate arrangements are made for
maintenanceandsucharrangementsarerenewed.
VII.INFRASTRUCTUREARRANGEMENTS
There is an ongoing effort to build 30 bedded hospitals with a modern
operationtheatreineverydesignatedCHC.Thisisawelcomeeffortanddeserves
tobestrengthened.Attheleveloftheblockensuringbedoccupancyofthese30
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
whichisfarfromcomplete.
Given the large gap in infrastructure our recommendation is that a plan be
drawn up for closing the gaps prioritizing sector PHC and CHCs and completely
integratingwithISMinfrastructure.Subcentreswouldbeonlynextinpriorityand
institutional delivery in subcentres 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
movingtothenextsetofblocks.
Therebytheentireinfrastructurerequirementsforthestatewouldbemetovera
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 utilization would help to
overcome them. Currently utilization is so poor that both state finance
departmentsandexternaldonorsfeeljustifiedinshyingawayfrominfrastructure
investments. This coordinated development of infrastructure is the heart of the
EnhanceQualityinPrimaryHealthCentres(EQUIP)programmes
rationale.
Attentionmaybegiventoclosingthegapsregardingwatersupplyandpower
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 system, drainage and
sewerageallofwhichneedstobeputintoplaceinallPHCsandCHCs.
Telephones are one of the most immediately remediable problems and same
urgencyneedstobegiventothisissue.
Thereismucheffortatcomputerizationatstatelevelandprovidingcomputers
andwebaccess with training to use this would enhance monitoring and support
capabilities tremendously. It should be possible to priorities this and within a
finite time frame achieve this capability at least for PHCs and CHCs and later for
SubCentre(SCs)aswell.Computerisationinthepresentdayisalsoaculturethat
maybeencouraged.
VIII.SERVICECONDITIONS
Transfer; Promotion; Financial burdens; Personal Security, Accommodation for
Staff
TransferPolicy
A clear policy on transfer is wellperceived and long overdue reform measure.
Thisisneededforallcategoriesofstaffbutparticularlyforthemaleandfemale
multipurposeworkersandtheirsupervisorsandthemedicalstaff.Acommittee
composedofsomeseniorofficials,somemotivatedworkersidentifiedbythe
departmentandsomerepresentativesoftheworkersserviceassociationsshould
evolvesuchapolicythatisconsideredfair,transparentandeasytoimplementat
theearliest.
The following principles should be considered while developing the transfer
policy:
Pressure for transfers would be reduced by making MPHW selection into a
block level cadre and other category selection including medical officers, other
than
ClassIofficersintoadistrictlevelcadre.
The authority for the transfer shall be a district and state level transfer
tribunals.
ThetribunalmaybemadeupofathreepersonboardchairedbytheCivilSurgeon
andProgrammeOfficerofthedistrict,withoneoftheboardmembersappointed
bytheDeputyCommissionerandanotherbytheEmployeesAssociation.
A roster of request for transfer should be maintained. Transfer shall be
consideredinthatseniority.Withinthesametransferseniorityshallprevail.
Allcadresmayapplyfortransferstatingtheirthreepreferredchoices.
Allpostingsinthedistrictshallbeclassifiedintoverydifficult(C)andmedium
difficult(B)andchoicepostings(A).Everystaffshallberequiredtoserveroughly
equaltimeinalltheselevelsofdifficulty.
Aftertenyearsinoneareatransferismandatoryasalsoamatterofright,but
canbeaccordingtochoiceifthechosenpostisvacant.Transferoutofadifficult
area would not be mandatory but would be an employees right if the required
periodofservicehasbeengiven.
Mutualtransfersshallbeallowedbutwithoutcontradictinganyoftheabove
clauses.
Persons in the last ten years of service may be exempted from mandatory
transfer.
All promotions may be considered only after five years in difficult posting or
tenyearsinmediumpostingiscompleted.
PromotionPolicyforParamedicals
RegularPromptPromotionwithSixMonthsPrePromotionTraining:
PromptpromotionofMPHWstosectorsupervisorsmaybeensured.Beforethey
take up the task as sector supervisors both MPHWs male and female may
undertake a sixmonth training programme (Currentlly male supervisors do not
havetoundergothistrainingthoughwomensupervisorshaveto).Thereisalarge
backlog and urgency needs to be given to prompt implementation of these
promotions.
FastTrack Promotion: We also recommend an additional system in which a
portionoftotalLadyHealthVisitors(LHV)andmalesectorsupervisorposts(25%)
maybereservedforpromotingMPHWsonthebasisoftheirwillingnesstoserve
in difficultareasifthey had notdone sointhepast,andanexaminationoftheir
skillsandknowledgeafteraminimumperiodofserviceeg.sevenyearsofservice.
Weexpectthatthiswillmotivatesomeenthusiasticfunctionariestovolunteerto
serve in more difficult areas. If those promoted are not able to fulfil their
commitment and get transferred to nondifficult areas before fulfilling their five
year commitment, their appointment as LHV/Sector supervisor will be revoked
andtheywillbereinstatedasMPHWs.
For those MPHWs already in difficult areas, a promotion in this channel may
inducethemtocontinuetheirservicesintheseareas.
We understand that in difficult areas multiskilled sector supervisors would have
to play a major role in running 24 hr.services at sector level (See alongwith
recommendation on multiskilling in next sections). In such a contexts such a
parallelchannelwheresomeyoungermoredynamicpersonsbecomeavailableat
thesupervisorsgradewouldtheusefultoinitiatethis
process.
Redesignation of the Block Extension Educator (BEE): T h e B l o c k 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
meritpromotionbasedonadequatetestingoftrainingcapabilityfromwithinthe
cadreofallsectorsupervisorswhohavecompletedacertainnumberofyears.
One Time Bound Seniority Based Promotion for All:For all other service
categories promotions and benefits there shall be one time bound seniority
basedpromotionfromselectioncadretoseniorcadre.
PromotionPolicyandCareerPlanForMedicalOfficers
Negativeattitudestotheserviceandtotheirworkamongstmedicalofficersmust
berecognizedtobeasafailuretounderstandandcareforthiscadreanddueto
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
reasonsfordemoralization.Thelackofpromotionavenuesisanother.Fordoctors
otherthanpromotionstheabilitytoenhancetheirskills,theirprestigewithinthe
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
opportunityinsteadofasaproblem.
Thekeyrecommendationonpromotionsfordoctorsare:
Contractual appointments must be seen as adhoc arrangements made so far
had to be stopped because of legal reasons. Regular appointments may remain
themainstayoftheworkforce.Thevacantpostsshouldbefilledupattheearliest.
Timely,timeboundpromotionstoseniorgradesandspecialistgradesneedsto
beensured.
ThereshouldbeascalelikethisStarting8000,after4years10000,after9years
12000,after14years14300forall.
Ranking in reference to other Govt. Officials at District level: Earlier Civil
Surgeonusedtobeat3.Itshouldberestored.
Skillretentionforspecialists.Thefeelingofprofessionaldissatisfactionmaybe
higherespeciallyinpostgraduatesservingasmedicalofficersandneedstobe
addressed through better professional opportunities. Every postgraduates could
belinkedtoCHCs,whichtheyattendonperiodicoccasionsforprovidingspecialist
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
normallywewouldnotexpectaPHCdoctortohandleandsoon.
ChoiceofstreamforClassIOfficers.Aftertenyearsofservicewhentheyenter
classIofficerstatusthedoctorsmaybegivenachoicebetweenaclinicalstream
(If necessary of a district cadre) or a state level administrative cadre with
opportunitiesforadvancementprofessionallyinboththesestreams.
FinancialBurdensofMPHWs.:Thedepartmentshouldprovideforadequate
allowance to MPHWs to carry out routine paper work. Payments should be
promptandbemadeonhalfyearlyorannualbasis.
Also, unfair reductions and false statements on expenses made on travel and
other programme purposes should be eliminated. The assistance cell (discussed
later)shouldbeavailableforconfidentialcomplaintsinthisregard.
Personalsecurity:CreatingaWomenEmployeesAssistanceCellatDistrict
Level.
ThismustberecognizedasanissueforMPWfemales.TheSupremeCourt
hasalreadylaiddowntheproceduresundertheVISAKAguidelinesandthese
maybepublicizedandimplemented.
We also recommend a Women Employees Assistance Cell in all districts that will
provide legal aid, counseling and protection and some degree of grievance
redressalparticularlytotheMPHWfemaleworkers.TheWEACshouldmeetevery
quarter and have a confidential postal access. It should take up all issues
confidentially and in nonconfrontational 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
outsidethehealthdepartmentwithsomeexperienceofworkonwomensissues.
TheWEACshouldbenominatedbythe
DistrictCollectorinconsultationwiththeCivilSurgeon.
Accommodation
Block LevelGovernment Housing Plan: All accommodation for medical staff at
CHClevelshouldbepartofagovernmenthousingdevelopmentplancommonto
all government departments so that adequate supporting infrastructure and
facilities can be developed. This can be done with private partnerships, not only
tospeedimplementation,butalsotobringininvestment.Theaccommodationso
provided should be adequate for all staff. Work could start with prioritization of
moredifficultblockssoastospeedupdevelopmentthere.
Sector LevelCategorywise Priorities: All PHCs in medium category difficulty
shouldbeprioritizedforbuildinggovernmentaccommodation,forallthestaffin
acosteffectivemanner.
Thiswouldactasanincentiveforstafftoworkthere.Inmostdifficultcategory
areas accommodation may be planned for para medical staff as a priority at this
stage.
SubCentre Buildings: Subcentre buildings may not be seen as a priority except
wherethecompleteblocklevelplanningiscompleted.Itisbesttoprioritisethose
Subcentres where there are no rooms available on rent or alternate building
availablefordevelopinginfrastructurethen
onlymovetoothercentres.Someinstitutionaldeliveryisnotbeinginsistedonat
HSClevel,
rented accommodation with a store and a consultation/ immunization room
availableandpaidforbythegovernmentshouldbeadequateformostSCsinthe
immediate period. When a new building is undertaken, the current design of
MPWaccommodationcumSCfacilitymaybecontinuedeventhoughinstitutional
delivery is not insisted on as this space has other uses to merit its retention.
Whereneededandwhenthesystemsofreferralhavedevelopeditmaybeeasily
bedesignatedforinstitutionaldeliveries.
IX..LABORATORYSERVICES
Multi skilled Cadre for PHCs: Since the current number of laboratory
techniciansisadequateonlytomantheCHCs,agreatereffortshouldbemadeon
multiskilling other cadre to undertake this work at the sector level. Over a few
yearseverysupportstaffshouldhavethesebasicskills.
BasicSetofTestsforPHC:ThebasiclaboratorysetoftestsprovidedatthePHC
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.Thesicklingtestmayalsobeconsidered.Allthesetestsrequireverybasic
skills and are easily taught. The most difficult of these is the BSE (Blood smear
examination)formalarialparasiteandsputumforAFBbutgiventhatmultiskilling
inthisisalreadyaccepted,abilitytotraininthiswiderrangeoftestsshouldnot
beconsideredaproblem.
TrainingApproach:Thissetoftestscanbetaughttoateammemberprimarily
by the medical officer. Training programmes at the district level would only
supplementthis.
Themedicalofficerwouldonlyneedaoneweekpackagetoberefreshedonthis
if there is a good text to follow along with proper teaching materials organized
well.Chartsandguidebooksthatbothdoctorsandmultiskilledstaffcanreferto
along with pictures of microscopic appearances should also be available in every
centreandtheirabsenceisaseriousremediableproblem.
CHC tests as Per Standard Treatment Guidelines: The set of tests to be
availableinaCHChavebeendescribedaspartofthestatesstandardtreatment
guidelines and service delivery norms should be able to conduct the following
diagnostics:.BroadlytheCHCshouldbeabletoconductthefollowingdiagnostics:
Basic blood biochemistry, and microscopic studies with grams stain,
cerebrospinal, pleural, peritoneal fluid examination. Immunological testing esp.
forhepatitis,typhoid,
AIDSandsyphilis.
BasicImaging:Xray,ECGandultrasoundbethenormforallCHCs.
Every CHC should also have the capability to take and send samples for
microbiological cultures and histopathological studies at the district level where
relevant.
Upgraded Laboratory Technicians at CHC: The qualified laboratory technician
attheCHClevelshouldbeupgradedtoprovidethismuchlargerpackageoftests
then what is currently available. Where still gaps remain public private
partnerships to close these gaps may be prioritized. The laboratory technicians
and the Xray technicians should work under the supervision and guidance and
quality control of a suitable district level officer in addition to the block medical
officer.
SubCentreLevelTests:AttheSClevelurinetestingforalbumenandsugarand
bloodtestingforhaemoglobinshouldbeimplemented.Inadditionitshouldbe
possibletotrainacadreofNGOsandtrainersofASHAprogrammesandmale
MPHWstodoBloodsmearexamination(BSEs)andsputumAFBtestingalongwith
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
microscopeandabasickitandapieceratepaymentarrangementbywhichthese
essentiallyprivateserviceproviderscanberemuneratedfordiagnosticsdonefor
thepublicsystem.
X.REFERRALSYSTEM
DefiningReferralNeeds
The importance of a referral system can not be over emphasized. Broadly,
betweenthePHCandtheCHC,orbetweentheCHCandthedistricthospital,the
followingreasonsnecessitatetheneedforagoodreferralsystem:
a.Forestablishingthediagnosisforwhichlaboratoryinvestigationnotavailableat
thePHC/CHCareneeded.
b.Forestablishingthediagnosisforwhichasecondopinionoranexpertopinion
notavailableinthePHC/CHCisneeded.
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.allinhospitalcareorsurgicalcareetc.
Under condition a & b, referral is a one time event and with a good quality,
promptfeedbackthecasecanbefurthermanagedatthePHClevel.Thisreferral
therefore,enhancesthequantityandqualityofservicesprovidedbythePHC.
ConditionCisavoidableandrequiresthatthedrugsbeavailableatthePHC.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
supplementedbyallowingspecialindents.
Condition d may occur as an emergency or in routine out patient
circumstances.
Someofthesecaseswouldneedtobefollowedupatthehigherlevelforalltime
tocome.Butmanywouldbeabletobesentbackforfollowuptotheprimary
level once the acute crisis is over. Availability of this referral enhances the
credibilityofthePHC.
DesigningEffectiveFeedbackinaReferralSystem
Wecanthusseethatmostoftheabovereferralpurposesneedareferralsystem,
theheartofwhichisthefeedbackarrangementtotheprimarylevel.Ifsucha
systemiswellinplacethecapabilitiesofthePHCandthemedicalofficerthere
aredramaticallyincreased.Inoursituationofilliteracyandlowschoolingand
mystificationofmedicalpracticesendinganotebackwiththepatientisnota
reliable,accountableoreffectivereferralsystem.Inadditiontosendingthenote
back with the patient the feedback data on referred patients, whether it be
expertopinion,orlaboratoryinvestigation,orinstructionsforfollowupshouldbe
transmittedinwritingthroughthehealthsystemandavailableforverification.
EventuallythisfeedbackshouldbeelectronicallytransferredthroughWeband
Willsystems.
BlockLevelAmbulanceServices
Agoodtransportationsystemisessentialforanyreferralsystemtofunction
properly.ItissuggestedthatinadditiontotheambulancewiththeCHCablock
levelambulanceservicebedevelopedinpartnershipwithlocalcommunity
organizationstotransportpatientsandthisbetiedtothereferralsystems.Itis
alsoessentialtoconstructareferralsystembetweenSCandPHCandbetween
femaleAccreditedASHAandPHCbasedonsimilarprinciplesofspecifying
situationsthatneedreferralandarrangingforastrongfeedbackmechanism.
Goodcommunicationbetweendifferenttiersisneededaswellandthisshould
belinkedtotheambulanceservice.
ReferralFundwithPanchayats:Thereferralfundcurrentlyplacedatthe
disposalofpanchayatsmaybeoperationalisedthroughASHAandwithlinksto
theabovementionedambulancesystem.TheASHAshouldbeauthorizedto
arrangetherequiredfundsforreferringneedypatientsandevenaccompanying
patientstoPHCandCHCespeciallyforcertaincategoriesofillnesslikehigh
riskpregnancyorlifethreateningemergenciesandsoon.
XI.INTEGRATIONWITHINDIGENOUSSYSTEMOFMEDICINE
NeedtoIntegrateatLevelofPublicHealthSystem:IntegrationoftheISM
structurewiththemainstreampublichealthservicesisdesirableforanumberof
reasons.Thereisasubstantialinvestmententailedinthesesystems.Utilisation
ishoweverextremelylowbothintermsofutilizationISMservicesandinterms
ofitsubservingpublichealthgoals.ByintegratingtheISMnetworkwiththe
publichealthprogrammesasubstantialincomeinoutcomescanbeexpectedof
littleextracost.
DefiningISMPackageofServicesatEachLevel:Integrationrequiresasa
firststepthedefinitionofwhatpackageofserviceseachcategoryofpersonnel
andfacilityintheISMswouldprovide.
MultiskillingISMPersonnelforPublicHealthFunctions:Integration
requires,basedontheabove,amultiskillingofpersonneltoservenewroles,
newjobdescriptionsandadministrativechangestofacilitatesuchsynergy.It
alsorequiresadequatepoliciesoftransfersandpromotionsandskillup
gradationsothattheytoodonotfacethedemotivationalfactorsthatthe
mainstreamisalreadyseizedwith.
SharingInfrastructure:IfeithertheISMfacilityorthemainstreamsector
PHCdoesnothaveadequateinfrastructure,aPHCbuildingortheexisting
infrastructuremaybeshared.Thusinworkingoutareasofcoverageprioritybe
giventoclosingthegapbetweennumberofsectorsandthenumberofPHCs.
Wenotethatifthereisasynergisticdeploymentofthetwo,thecurrentgap
betweennumberofsectorsandthenumberofPHCs,largestgapinthesystemas
wouldbeadequatelyclosed.
MakingaCommonDistrictandBlockPublicHealthPlan:Atthedistrict
levelthedistrictAyurvedicofficerserveaspartofthehealthplanningcommittee
andthisplanisintegratedasasubsetunderthedistricthealthplanoftheCivil
Surgeonsofficeandthedistricthealthsociety.Attheblocklevelcoordination
isbytheSMO.AtthesectorlevelISMfacilitiesmaybeaskedtoperform
publichealthtasksinasectionallottedtothemalso.
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
availableatthatlevel.Thisistruefor
paramedicalsaswellasformedicalofficers.
Toachievethisgoalwerecommendaninservicetrainingpackagewithfollowing
features:
ForParamedicals:Multiskilling
MinimumPeriodicRetraining:Thetrainingpolicymustspecifythateverytwo
years at least 15 days of training per MPW and health supervisor (male and
female)mustbereceived.
Training Roster: A roster of all MPHWs 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
healthworkershavereceivedthemandatorytraining.
Syllabus:Thesyllabusforitshouldbebuiltuptoinclude.
Changesinhealthprogrammeguidelinesofnationalhealthprogrammesbest
addressedthroughtwodaysensitizationprogrammes,wheneversuchachangeis
made.
Renewal of care area of their workRCH programme for MPHWs (at least 15
days)andnationalprogrammesformaleworkers.
Multiskilling training in which female workers learn more about national
programmesandaboutbasiclaboratoryskillsandmaleworkerslearnaboutRCH
andadequatelevelsofbasiclaboratoryskills.
Adequatetrainingforfirstcontactcurativecare.
A modified IEC programme capability with focus on interpersonal and
community mobilization skills along with better understanding of a multicultural
andethnically
diversesociety.
OntheJobTraining:Thesupervisorsshouldbeheldresponsibleforonthejob
trainingofthehealthworkersandperiodicevaluationofknowledgeandskillsof
healthworkersbeusedtoensurethattheyperformthistaskadequately,asthey
shouldbeaccountableforthisintheirjuniors.Themedicalofficersmustbe
equippedtoevaluatethesupervisorsontraininginmostareasandinsomeareas
likebasiclaboratoryservicestheyshouldbecapableofprovidingthetrainingon
thejobs.
IntegrateTrainingFunds:Alltrainingfundsfromvariousprogrammesare
deployedinsuchawaythatevenastheobjectivesofthatgrantisrealized,the
traininggoalsthestatehassetitselfisalsoadvancedwithinthesamespace.
TrainingCelltoPrecedeandPrepareforSIHFW:Atrainingcellforinservice
MPHWsandsupervisorstrainingneedstobeconstitutedintheSIHFWthatis
constantly doing training needs assessment, training material development,
master trainer training of district centres, supervision of training rosters and
trainingevaluation.
ForMedicalOfficers
ContinuingMedicalEducation:WerecommendaContinuingMedicalEducation
schemeformedicaldoctorstoupgradetheirknowledgeandskills.Thisshould
replace the current practice of upgrading their knowledge through sporadic
camps of national disease programmes. The envisaged CME scheme should also
beusefulforpromotionpurpose.ACMEshouldbepursuedasaveryuseful
interventionstrategyinhealthcaredeliverysystem.
MinimumSkillMixforCHC:Havingdefinedaminimumpackageofservicesat
the CHC as essential to meet public health goals one needs to a put in place a
roadmapbywhichthedesirableskillmixneededfordeliveringsuchapackageof
services would become a reality. We make the following suggestions in this
regard:
DecideonwhatskillmixisneededineachCHCandwhatthegapsare.Thefocus
isonemergencyobstetriccarebuttheskillmixapproachneednotbeconfinedto
thisalone.
Drawupascheduleofprovidingshorttermtrainingssothatexistingmedical
officersandspecialistsfillupthegapswithacquiredbasicskillsetsotherthanin
areaswhichtheirprimaryspecialization.Thusasurgeonmayalsolearntodo
Caesarean section or ENT and ophthalmic work, or a physician may learn
paediatricfunctionsandsoon.
Where gaps still remain one may use public private partnership to fill up the
gaps.
XIII.STATEANDDISTRICTLEVELORGANISATION
PromotionsandTenureattheStateLevel
Prompt and Regular Appointments: All vacancies must be filled up at the
directorate(directors,deputydirectors,CivilSurgeonsandprogrammeofficersat
thestatelevel)mustbefilledupwithinaperiodofsixmonthsonaregularbasis
fromeligiblestaffatthatlevelorbypromotion,(exceptthosepoststhataretobe
recruitedfromtheoutsideona
consultancy/ contract basis where it could take up to an year). For programme
officersatthedistrictlevelandblockmedicalofficersmustbefilledupwithinthe
same timeframe but in the event of creating a separate administrative cadre
wheretheseareentrypointstheycouldtakelonger,uptoayear.