Haryana Health

8/12/2019 Haryana Health

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Haryana

ThegrowthofHaryanastateprovidesnewopportunities.TheGovernmentofthe

stateofHaryana isengaged intheprocessofreassessingthepublichealthcare

systemto

arrive

at

policy

options

developing

and

harnessing

the

available

human

resourcestomakegreater impactonthehealthstatusofthepeople.Aspartof

thiseffort,oneshouldattempttoaddressthefollowing3questions.

1.Howadequatearetheexistinghumanandmaterialresourcesatvariouslevels

ofcare(namelyfromSubCentre leveltodistricthospital level) inthestate;and

howoptimallyhavetheybeendeployed?

2. What factors contribute to or hinder the performance of the personnel in

positionat

various

levels

of

care?

3.Whatstructuralfeaturesofthehealthcaresystemas ithasevolvedaffect its

utilizationanditseffectiveness?

Fromtheanalysisofthesituationinitstotality,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

utilizedand

critical

gaps

identified

and

addressed.

The

question

is

that

how

the

facilitiesatdifferent levelscanbestructuredand reorganized toprovidehealth

caretoallthepeoplewithoutanydiscrimination.

Astudywasconducted aquestionnairebasedsurveyoffacilitiesthatwasapplied

onasampleof128Subcentres,64PHCsand32CHCs,also356employeesof8

cadreswereinterviewedinChhatisgarhandanalysiswasdone.Therearecertain

similaritiesofsituationandalotcanbegatheredfromtheirexperience.Thereare

fourtypes

of

stake

holders

in

health

service

system

in

the

state.

1.Theemployeesandtheirassociations.

2.Theofficersatthenational,stateanddistrictlevel.

3.TheMedicalprofessionandprofessionalbodies.


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4.Civilsociety.

ItisnotedthatinthelastdecadethedepartmentofhealthinHaryanahasseena

lotofnewdevelopments:


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Howevertheconstraintsthatthesystemhasinheritedareconsiderable.Alarger

plan to reachabasic setofservices foreach levelof the three tierhealthcare

system isneeded.Ithasbeentriedtochartoutthecontoursofsuchaplanand

projectanapproachtoreachingit.Inthelargerinterestsofimprovingthesystem

theaim

is

to

set

out

all

the

lacunae

in

workforce

management

and

rationalization

of services,explore itscausesand setdown thepossibilities for immediateand

longtermactiontoimproveandstrengthenit.

SituationalAnalysis

AdequacyofSanctionedFacilities

Asperexistingnormsonesubcentre isplanned forevery5000population,one

PHCfor

every

30,000

and

one

CHC

for

every

80,000

1,20,000

population.

For

tribalareasthenormisonesubcentreper3000population,onePHCper20,000

populationandoneCHCper80,000population.


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SNO FACILITY ATPRESENTSHOULDBE

1 SUBCENTRE

2 PHC

3 CHC

4 SPECIALISTSINCHC

SURGEON

PHYSICIAN

PAEDIATRICIAN

GYNECOLOGIST

ANAESTHETIST

Weneed572SubCentremore.98morePHCsareneededalongwiththestaff

andotherinfrastructurerequired.Weneed63moreCHCs.

LocationofFacilitieswithrelationtoaccess:

Amongstexistingfacilitiesthereisconsiderablelossofutilizationduetoimproper

location and improperdistribution. Inmanyof the cases, there is considerable

maldistribution.Andthisiscompoundedbyimproperchoiceofvillagewithinthe

sectionorsectorandthechoiceofvenuewithinthevillage.


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AdequacyofstaffandtheirUtilizationwithRelationtoFunctionalityofCentres:

Eventhefemaleparamedicalstaffisnotadequateinnumbers.Thereareserious

shortfalls inallother staff.Femaleworkerhas to share thegreaterpartof the

workload.

Many

categories

of

staff

at

sub

centre

and

PHC

level

are

characterized

bypoorlydesignedwork schedulesand arepoorlyutilizedwithhighdegreeof

redundantworktime.Rationalisationofparamedicalworktimeofferstherefore,

themosteffectiveroutetoaddressingstaffadequacy.

ThecurrentworkdescriptionofMultiPurposeHealthWorker(MPPW)female is

unrealisticand isbeingcopedwithdevelopinga focuson justoneor two tasks

and informal localarrangements.Asa resultanumberofessential servicesare

completely left out (eg. Early recognition of child hood pneumonia or proper

treatmentordiarrheaoradolescenthealthcareetc.)andaqualityofanumberof

otherservices,likeantenatalcareareseriouslycompromised(veryfewpregnant

womengettheirBPtakenandbloodandurinetested).

RationalisationofDrugsandConsumablessupply:

Theessentialdruglistisnotbeingimplemented.Themaindeficitsareafailureto

procure theentire itemsofthe list,a failuretosendsamples forqualitycontrol

andafailure

to

exclude

drugs

not

on

the

list.

Other

element

of

the

drug

policy

are

alsonot inplace.Thusprocurement isproblematicandsporadic,occurringonce

ortwiceayearwithquotastoperipheralfacilitiestodistributethedrugs.

Therearenumerousbreaks insupplyandthedistributionsystemappearstobe

unresponsive tochangingneeds.Restrictionofdrugs toanarrowspectrumand

breaks in supplyarenotevenperceivedas seriouswithin the system reflecting

poorperceptionofqualityofcareissues.

Theproblemwithconsumable isevenmoreseriousthanwithdrugs.Laboratory

chemicals seem theworst affectedbut evengauzeandbandages,needles and

needleholderscouldbeinshortsupplyrepeatedly.

RationalizationofEquipment:


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Low investment minor equipment like Sahils Haemoglobinometer or material

required to testHaemoglobinorBloodPressureapparatusand infantweighing

machines, which, if used, will need replacement frequently. Another group is

major equipment like ECG, USG(Ultrasound) and Xrays which require less

replacementbut

require

trained

manpower

to

operate.

In

minor

category,

there

maybeconsiderableunderutilization.Duetoqualityofcareissuesmanyofthese

instruments/equipmentarenotutilized.Ifutilizedthentheyrequirereplacement

forwhichreadysystemofpurchasesandrestockingisrequired.

Inmajorequipment,themainproblemismismatchesbetweenequipmentsupply

andmanpower to use it (e.g ECGmachineswithout anyonewhooperate it),

betweenequipmentsupplyand levelofservicescurrentlyprovidedat that level

(e.g.Halothane adrugusedforanaesthesia,wassentat

CHC levelswheretherewasnoanesthetist,neonatalcareunitswherethereare

nocaesareanoperationsdone,ColourDopplerequipmentssuppliedwherethere

is no vascular, cardiologist or cardio thoracic surgeon available), between

equipmentsupplyandconsumablesavailabletouse(e.g.Xraymachinesrunning

outofXrayfilm)andbetweenequipmentpurchaseandmaintenance.

Atone

level

all

such

mismatches

are

attributable

to

failures

of

concerned

officials/

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

constructionand

maintenance

too

are

major

infrastructural

inadequacies.

Maintenance of buildings is also poor and many buildings are old and need

extensive renovationor replacement.NowafterSKS formation repairscouldbe

possible.


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NoLightatSubCentre:Problemswithelectricitysupplyarealsothere.Generator

backupisnotavailableatmanyplaces.InverteratCHClevelisavailable butare

notofsufficienttimecapacity.

Problemswith

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?Wastemanagementbasedon segregationofwasteswithproper

disposal of each category of biologicalwaste 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 ofworkforce dissatisfaction and demoralization. Some staff spend their

lifetimesworking in remoteareasseekingandnevergettinga transferwhereas

othersperceived

to

be

able

to

personally

and

unfairly

influence

decision

making

togetprioritypostings throughout theircareer.Thismakes lessstaffwilling to

serveinruralareasandwhentheyaresoposted,dotheirworkwithsuchadeep

rooted senseof frustrationandanger that thequalityof thework suffers.The

problemsofdoctorsnotwillingtoserveinruralareasshouldbeseenonlyinthis

contextandshouldnotevenbeheldoutagainstthemedicalprofessionunlessa

basictransferpolicyhasbeenputinplace.

Promotions need to be regular and timely and fair. Otherwise it leads to a

situationofdeepdissatisfaction thatruns throughtheentiredepartment. Ithas

alsobeenobservedthatmanytimes

thepositionofauthoritystartingfromthetopmostandproceedingthroughthe

Civil Surgeon upto Senior Medical Officer are held in an adhoc and arbitrary

manner.


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Further theopportunities foranactivecareerplan fora talenteddoctororone

whoisabletoworkhardandperformmoreareabsent.Forparamedicalstafftoo

the lackof any possibilityofpromotion let alone a careerplan acts as a great

demotivation from taking any initiative. These are all remediable aspects that

needto

be

urgently

attended

to.

Another major problem is personal security, again a problem maximal with

MPHWfemales.

Violenceandsexualharassment,covertandovertaffectsabout10%butcreatesa

senseof insecurity inall. InDeliveryHuts these typeofproblemshavecome to

lightrecently.

Nodefinite

pattern

of

venue:

Another

basic

service

issue

is

accommodation.

At

no

levelisthereadequatehousingforallstaff.Availablehousingfacilitymanytimes

isnotworth living. The focushasbeenon developing government housing for

doctors first.At theCHC level there is accommodation available, especially for

doctors.But it isseldomadequatetohouseevenhalfthestafforevenhalf the

numberofdoctors.Availableaccommodationisalsounderutilizedbecause

ofmanyfactors.

LaboratoryServices:

Laboratoryservicesatthesubcentrearealmostabsent.Bylaiddownnormsfour

basictests

Blood pressure checking, weighing of pregnant women and children, blood

haemoglobinestimationandurinetestingforsugarandalbumen(alsoE.S.R)are

expectedtotakeplacehere.

Theseabove

tests

like

BP

check

however

do

take

place

in

PHCs

but

even

here

they

arenotregular.

The lab technicians are not available atmany places. Slide test is being done

routinely.ThePHC,aspernorms,hasabasic laboratorywhichcandoabout20

basicdiagnostictests,hasalmostbeen


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forgottenwithinthesystem.Microscopeavailabilityistherebutunderutilized.

InCHCsthelaboratoryisactivetosomeextentbutperformmostofthetimetwo

tests, the blood smear examination for malarial parasites and the sputum

examinationfor

Acid

Fast

bacillus

(AFB).ThelistofdesirablediagnosticsattheCHClevelisover40tests.Atmostof

the CHCs the workload of these two tests is heavy. Also as a consequence,

reachingback time,gets lengthenedconsiderably (onanaverage10days to20

days). The blood smear examination has increasingly taken the form of a

modernritualdenotingmedicalcaredevoidofcontent.Targetofslidemakingis

alsoacauseforit.Thereisnomajorperceptionofthelackoflaboratoryservices

asa serious lacunae again reflectingon theweaknesses inunder standingand

lackofemphasisofqualityissuesinmedicalcare.

ReferralServices:

Thecurrentreferralserviceshavetwoforms.Firstlythereisafundplacedatthe

disposalofthePanchayatforusetohire/payfortransporttoshiftneedypatients

toahospital.There isanunderstandingthatthismustbeusedforhighriskand

complicationof childbirth.Funds flowandevenawarenessof thisprovision in

Panchayatsis

low

and

because

of

other

structural

constraints

(lack

of

vehicle;

inabilitytocallvehicleintimeetc.)itsutilizationisverylowevenastheneedfor

referralgoesunanswered.

Theotherreferral isthepatientbeingaskedorallyorwithasliptogoandseek

treatmentatahighercentre.Thisbringsnoadvantagetopatientortothesystem

and is perceived by the patient as the referral facility having deliberately or

otherwisefailedtodeliveritsservices.Therearenoclearnormsforwhatistobe

referredand

when

and

there

are

no

mechanism

to

monitor

referral

to

reduce

unnecessary referraland insistonnecessaryones. There isno feedbackof any

sort.Inshortthereisnoreferralsystem(Nowthisalsodonotexist).

Thethirdsystemisthatthereisnoneedofreferralsystemforgoingtocorporate

hospitals for treatment.The ratesare fixed.Yougodirectly,get the treatment,


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paythebillsandgetthemoneyreimbursed.Ithascreatedmoreproblems.Those

whocannotpayfromtheirpocketinadvanceareatlossinsuchanarrangement.

Fewgetadvancefortreatmentalso.

Integrationwith

Indian

System

of

Medicines:

There is largemanpower in (Indian System ofMedicine) ISMs available in the

state levelandmorepertinent in thedistricts.Thenutilization forpublichealth

goals isminimal.Theutilizationoftheir indigenouscurativecareservices isalso

minimal.Their integrationwith thepublichealth system isyet tobeperceived.

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

oftraineesandfragmentedasstrategy.Mosttrainingprogrammesareofoneor

twodays

and

relate

to

asingle

disease

and

an

immediate

campaign

for

example

a

one day leprosy training or two days onHIV 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

closelyassociatedworkofotherdiseasesnotbeing taughteven inmuch longer

capabilitybuildingtrainings.Thuse.g.thesupervisorsaretrainedonbloodsmear

examinationformalarialparasitesbutdoingadifferentialcountonthesameslide

wouldnotbeemphasized.

Almostnotraining isbasedonbuildingcompetenciestoattaina levelofclinical

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


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programmes.Yet thesystemcannotguarantee that insuchcentresofPHCsor

CHCsofagivendistrict,thelevelofknowledgeandskillsneededisnowavailable.

Itmaynotevenbeabletostate,facultywisewhatlevelofskillbuildinghasbeen

achievedand

what

are

the

gaps.

All

these

problems

can

be

said

to

be

true

of

Information

EducationCommunication(IEC)also.

StructuralIssues:

Governance:

Itisnotadequatetolocateallproblemsonlyattheadministrativelevel.Someof

thekey

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

administrationare inherited,havingbeenhandeddownas traditionalpractices,

ratherthanhavingbeenshapedbyactivepolicyframeworksthatguidedecision

making.Whatpolicyinitiativeshavebeentakenremainweakinimplementation.

Forexample,

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 illustrationrelatestoseniorappointmentsandtenure. Ifapolicyhasto

beimplementedthenacapablepersonorteammustbeputinplace,monitored,

allowedthetimeframeforthatpersontoshowresultsandthepersonmustbe

changed if he/she fails to deliver. This requires a clear transparent system of

seniorappointments,a secure tenure,aclear setofgoalsandmandate for the

person toachieveandperiodicreviewof thesame.Wenote that incontrastto

this ideal all incumbent officers many of them are holding their posts in an

officiatingcapacity.Appointmentsbecomeaprerogativeofpowerandinfluence.

There isnosuretyoftenure.Administrativearbitrariness insuchareasaretobe

recognizedasindicatorsofpoorperformance.


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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 isa feeling,often justifiedbyexperienceaswithessentialdrugs list that

anything can be passed as policy statement without any binding on its

implementation.Normallytheministrywouldlaydownpolicyandthedirectorate

would be answerable for its implementation. Theministrywould be themain

vehicle of ensuring accountability and transparency of the directorate and be

answerabletothelegislatureforit.Thecreationofastatehealthsocietyismeant

tofacilitatenotweakenthisrelationship.However,whentheseparationbetween

governanceand

implementation

is

lost

and

the

ministry

itself

is

responsible

for

implementation, as in the currentnaturenatureof the statehealth society,or

when the ministry is unable to ensure policy based implementation in core

administrativeareas, thenhealth sector reformgoesbeyond theadministrative

realmtothatofthereformofgovernance.Onewouldthenhavetolooktothe

legislature,the judiciaryand institutionsofcivilsocietytoensureaccountability.

Thequestionwepose isthat inthecoreadministrativeareas tenure,transfers,

promotions,purchases

and

transparency

is

it

atechnical

and

managerial

failure

or

afailureofgovernance?Ifitisaninabilitytoformulateatransferandpromotion

policy or organize a system of purchases then is it a technical andmanagerial

questions?Ifnot,then,itisafailureofgovernance.

StateLevelWorkOrganisation:

AnnexureIV??????

The inability todeconcentratepowersand responsibilitiesat this level isakey

problem and may be the main reason for being unable to keep to project

schedules.Theexperiencesofotherstatesmaybehelpfulinthisregard.Arelated

diversion istheneedorprofessionalizationatthestate leadership level.Though


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theyhaveveryrelevantpracticalexperience,professionaltraininginpublichealth

management,healthpolicyandinhospitaladministrationhasbeenweak.

Epidemiology is seen as a separate specialty area not as something basic to

healthplanning

and

few

are

conversant

with

its

methods.

Administration

would

beperceivedasnothingmorethanknowingtherulesandcommonsense.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

managementandadministration like infrastructuredevelopmentandpurchases

andlogistics,thesystemhasnotmadeuseofqualifiedmanagementskills,which

areeasilyavailableonthemarket.

Decentralization:

Yet anothermajor issueofdecentralizationofpowers todistricts.Currently all

districtofficersperceivedistrictsashavingverylimitedpowers inalloftheabove

aspectsofadministrationaswellas intrainingandprogrammeplanning. Indeed

for the main post they are only implementing agencies for national health

programmesandmedicolegalwork.Theirown termsof selection, transferand

monitoringhaveallthesameorganizationalandmotivationalproblemscommon

toother

sections

and

it

seriously

compromises

their

work

out

put.

Thus

while

decentralizationofpowersand finances isessential, itneeds tobeborn in the

contextofthesekeyadministrativereformsbeingcarriedout.

Currentlyelectedpanchayatshaveanegligibleroleinthehealthsectorandeven

inthisthesupportandprogrammedesignneededforthemtobeeffectiveisnot

available.

FinancingofHealthCare:

Financingofhealth care isan important issueand thatbudgetaryallocationon

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.


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Mappingtheprivatesectorandexploringitspossibilityofsynergywiththepublic

health systemanddevelopingapolicy framework for itsgrowthand regulation

areyetissuesthatneedtobeaddressed.

RegulatingPrivate

Hospitals

and

Nursing

Homes:

Mappingtheprivatesectorandexploringitspossibilityofsynergywiththepublic

health systemanddevelopingapolicy framework for itsgrowthand 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

theurban

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.Theseareclosely related toworkforce issuesandallowconsiderable

scope for rationalization.Suchprogrammes include thevariousnationaldisease

control programmes, the reproductive and child health programmes and the

strategiesofepidemicmanagement.

CurrentInformation,

Education

Communication

(IEC)

strategy

needs

to

be

examined;

oneofthemost importantdimensionsofpublichealthstrategy.Thisareaneeds

tobedevelopedinamorecreativeway.


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TheserviceswhicharesupposedtobedeliveredbySubCentres,PHCsandCHCs

aretobeasperthelatestlaiddownnorms.

Recommendations

1.Adequacy

of

facilities:

IncreasingNumbersofPeripheralHealthFacilities.

IncreasingSubCentrestoensuresubcentresasperpopulationnorms i.e.one

subcentreforevery5000population

Rural population ofHaryana is 1,50,29,989. So 3005 centres are required.We

haveonly2433SubCentres.Weneed572SubCentremore.Onemaleandone

femalehealth

workers

are

required

for

each

Health

Sub

Centre.

So

we

need

3005

maleMPHWand3005FemaleMHW.Wehave425MaleMHWand1909Female

MPHW.Thegapisverydisturbingfor2433Subcentresevenweneed2008Male

MPHWand524FemaleMPHWworkers.

According to latest norms one Female MPHW is added for each Health Sub

Centre.Henceweneed2433FemaleMPHWinadditiontoearlierrequirements.

IncreasingPHCstoensurethatthereisaPHConevery30,000populationasper

thenorms.

There

are

411

PHCs.

We

need

509

PHCs.

Hence

98

more

PHCs

are

neededalongwiththestaffandotherinfrastructurerequired.

Increaseperipheralhealthfacilitiesinurbancentresi.e.createacomprehensive

urbanhealthplanwhichincludesanetworkofurbanhealthcentres.

IncreasenumberofCHCssoastoconfirmtothepopulationnorms:OneCHCfor

80,000populationbecausedensityofpopulation ishigher inHaryanaorat the

most for1,00,000population.Ruralpopulation is1,50,29,989,.Soweneed150

CHCsintotal.EvenifoneCHCfor1,20,000populationisfollowed,weshouldhave

125CHCs.Wehave87CHCsatpresent.Weneed63or38moreCHCsalongwith

theinfrastructureandhumanresource.AtpresentthereisoneCHCfor3PHCs.


17/42

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 levelmapping (GIS based): It is required to prepare block levelmaps

showing all villageswith existing SubCentres andPHCs in allblocks aswell as

demarcatingvarioussectionsandsectorsaccordingtopopulationnormsBasedon

this to searchout ideal location forSubCentresandPHCsandcompare 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 commonbus stand for56villages, locate the centre in coherence

withsuchactivitysoastomakeiteasierandmorelikelyforpeopletoaccessthe

SubCentre

or

PHC

or

CHC.

This

may

be

included

as

aparameter

in

the

GIS

data

base. This data base may also reflect location preferences with a quick

stakeholderanalysis.

3.ReallocationPossibilities:Basedontheabove inputsdecision istobetakenon

locationatfirstforallfacilitieswhereGovernmentconstructionsareneededlike

in. SubCentreswithout buildings, sectorswithout PHCs, v/s sectorswith PHCs

operatingfromrentedbuildings.Wherenecessaryinfrastructurehasalreadybeen

constructedthese

facilities

may

be

classified

into

those

that

are

by

location

completely unusable; those thatmay be continue to be used unless there are

alternateuses for thecurrentbuildingand funds tobuildoneat ideal location,

anda thirdcategorywherecurrent locationof facilities isacceptable.Basedon

thisaplanofconstructionpriorityforeachblockmaybedrawnup.


18/42

4.ConstructionsOnlyAccordingtoPlans:Oncesuchaplan isdrawnupforeach

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

constructionwould

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 BedHospitals: in any block or district should be built till all district

hospitalsandallCHCsstaffedandfunctionalasenvisaged.

III.RestructuringStaffingPatterns,RedefiningJobsandAdequacyofManpower

RecalculatingManpower

Gaps:

Gaps

in

staffing

should

be

re

calculated

after

planning formultiskillingandredistributionofexistingstaffsuch that thereare

noredundantmanpower.

Two FemaleMPWs in each Sub Centre: Sub Centresmay plan for two female

MPHWsandonemaleMPHW.ThejobdescriptionandworkloadoftheMPHW(F)

needstobelessenedandmaderealisticexceptforinstitutionaldeliveryandIUCD

insertion,everytaskdonebywomencanbedonebymenalso.Whentherewill

betwo

female

MPW,

the

number

of

population

for

female

will

become

half

which

willhelpinqualityservice.

MultiskillingallPHCParamedicals:ThePHCstaffingpatternneedsrestructuringto

ensureutilizationofmanpowerandbetter functioningofthefacility.PHCsmay

plan for having three or four male multi skilled employees with amale multi

skilled supervisor and three or four femalemulti skilledworkers and a female

multiskilledsupervisor.Therewouldalsobetwomedicalofficersonemale(and

one femaleMBBSorAyushMO) ineveryPHC.Thesemultiskilledworkersmust

be skilled in dressing, drug dispensation (pharmacists task) and first contact

curativecareand inbasic laboratorypackageaswellas inRCH.Between them

they should be able to keep the PHC functional for 24 hrs., should provide

institutionaldeliveryand theother servicesasproposed in the servicedelivery


19/42

norms.Afterthismultiskillingandrevisionofjobdescriptions,cadrerestructuring

mayfollowthis.Nooneistobedroppedunlessoneisnotwillingformultiskilling.

New recruitments should be into themulti skilled category andmany existing

cadreswould

die

away.

Some

like

staff

nurse

would

function

as

multi

skilled

staff

whenpostedinPHCbutcanplaytheroleofstaffnursewhenpostedinCHCand

district hospitals. It can be said that such retraining and re deploymentwould

solvea substantialpartof themanpowervacancyproblem.EachPHCmayalso

havetwostaffpersonnelatclassIVqualifications.

RationalizationofDevelopmentofMedicalDoctorsatthePHClevel:

Differentiated strategy according to difficulty levels: The idealwould be two

medicalofficers

at

every

PHC

(as

in

Tamil

Nadu),

preferably

one

lady

doctor.

The

numberofpostsneed tobe increasedasper the requirement.Thevacant jobs

shouldbeadvertised immediatelyandfilled.However,thismaynotimmediately

berealizedduetoshortageofpotentialrecruitsandthedifficultyinfindingeven

onemedicalofficerperremotearea.

Therefore, it can be suggested that PHCs be categorized into most difficult,

difficultandeasyandadifferentstrategybeadoptedforeach.The incentives in

formof

i)increase

in

rural

health

allowance

to

Rs.

2500

per

month.

At

present

Rs.

250 isbeinggiven for the last20years (ii).Theruralhealthserviceprerequisite

forapplyingforMD/MS is2years, itcanbeoneyear ifoneserves incategoryC

PHCforoneyear.(iii)DuringPGcourseoneisgivensalaryfortwoyearsandonly

honorarium for the3rdyear.One shouldget the salary for thirdyearalso. (IV)

Aftercompletingthecourseheshouldbeallowedtoworkforonemoreyearas

senior residentwith full pay so that he/she can have practical confidence. (V)

Special pay package for categorized PHCs ranging from 50008000 per month

alongwith

NPA

25%

or

the

doctors

be

allowed

private

practice

after

duty

hours

as

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

emphasison institutionaldeliverybe insistedonbymultiskillinganddeploying


20/42

paramedicals. The multi skilled paramedical worker should also be trained in

emergency care management at Primary level. It can be emphasized that by

paramedicalworkerwemeanthecurrentMPHWsorPharmacistsorstaffnurses

currentlyinservicewithfurthertraininginputsandnotthelegitimizationofunder

qualifiedallopathic

practice

that

also

goes

by

the

name

of

paramedical

course.

TheroleofdoctorinPHCwouldbetoprovideleadershipandonthe jobtraining

anda referralbackup for this team.Where adoctor is resident, thedoctor is

availableoncall24hrs.tobackupthisteam.

DailyVisitsbyCHCBasedDoctorsforMostDifficultPHCs:

Wherenomedicaldoctorsareavailablecurrently,whereaccessisaproblemand

accommodationfacilities

are

low

(category

C),

even

as

efforts

are

made

to

fill

theseposts,thebackingupisdonebydailyvisitsandinafewdistantPHCstwoor

threevisitsperweekofamedicaldoctor from the respectiveCHCs.Thedoctor

wouldbe required tobeavailableduringworkinghours from9am to5pmat

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.

Familyaccommodation

at

the

CHC

would

be

easier

to

organize.

In

other

words

we

shouldnotinsistonmedicaldoctorsstayinginPHCsdesignatedcategoryC most

difficult (one considers that the above approachwithmobiledoctors but fixed

facilitiesmaybemorecosteffectivethanmobilehospitalswhencombinedwith

theuseofmultiskilledparamedicals.

Strengthening BAMS Doctors Role While Keeping Medical Officers Options

Open:

The use ofmedical officerswith BAMS (Ayurvedic System) to fill up vacancies

where nomedical officers are currently available iswelcome.However all the

service issuesdiscussedearlieraboutMBBSdoctorsequallyaffect functionality.

Moreovercurrentlytheywouldbeunabletodeliverthenotifiedservicesatthe

PHClevelandspecialtrainingwouldbeneededtoclosethegaps.Thepostofthe


21/42

allopathic doctor should be retained and the search to fill this post should

continueswithofferofbetter incentives.Also iftrainingtransferandpromotion

policies are put in place, these vacancies would certainly be much less. By

integrating ISM sectorwith the allopathic sectorwemay also approximate the

idealof

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

afterwith

visits,

the

number

posted

here

may

increase

further?

One

Anesthetist

must also be posted in every CHC otherwise the other specialistswill become

defunct.Thefourmedicalofficersnorm issubcritical.SMOcancallspecialiston

paymentperhourifneedbe.

AdequateMultiSkilledMaleandFemaleParamedicalStaff:

Who can manage the necessary support work and multi skilled imaging

technicianswho can alsomanage Xrays,USG and ECG too? In addition there

wouldbe

aunskilled

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

supervisorand

be

responsible

for

capability

building.

IEC

and

supervision

of

sector

supervisors.

AdequateClericalandAccountingStaffatleasttwo,beprovidedtoeveryCHC

alongwithcomputerandprinter.


22/42

IVRationalisationofWorkAllocationandApproachestoImproveOutreach:In

Additiontotheabovemeasures,ImprovingOutreachRequires:

ReorganisationofMPHWWorkSchedule:

MPHWsmaybe required to tour for threedaysaweek, insteadof thepresent

one or two days a week. One day a week should be devoted to review and

drawingsuppliesfrom

PHCs. The remaining two days aweek should be devoted to clinicalwork and

otherservicesprovidedatSubCentre.Thesetwodaysarefixedandherclienteles

shouldknowthathe/sheisavailablethereinherheadquartersonthesetwodays.

Ineachfieldvisitdays,he/shewouldvisitaspecifiednumberofhousesandhold

meetingswith one of the four indentified local groups.Once amonth he/she

shouldattendaBlockLevelReviewandTraining.IftherearetwoMPHWsposted

theirtwodaysattheheadquartersmaybefixedinsuchawaythattheSubcentre

isopenon fourpreviously specifieddayseveryweek,which isbetter than the

current,onedayaweekorso.

RevisedMPHWJobDescription:

Immunisationchildren

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,suchthateveryhouseholdisvisitedonceevery15days

or

onemonth)forasetofcasedetection,followupandcounselingactivitiesalong


23/42

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:

Asarulehealthcampsarebesetwithproblems.Theyarewastefulofresources,

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

activitiesmostly symptomatic or even irrational curative care for trivial illness.

Howeverinvillagesorclustersofvillageswhereoneorotherservicehaslessthan

50%coverageorthereisalargenumberofpersonstobereached,ahealthcamp

whichreducesandbringsdowntoamanageable level theburdenofunfinished

servicedeliverywouldbewelcome.Healthcampstherefore,shouldbepreceded


24/42

anddrivenbyhealthneedsidentifiedbyMPHWs(PanchayatsorMahilaSaksharta

SamoohorSKS)ratherthanprogrammetargetstobemetabove.Thusablindness

treatmentcampprecededbyacarefulidentificationofthoseneedyanddrivenby

such needs with a carefully planned follow up, or an immunization camp for

measleswhere

asurvey

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

mobilizetheclienteleforit.

V.RationalisationofDrugsandConsumableSupply:

TheessentialDrugList:

Theessentialdruglistneedstobeimplemented.Inparticulartheexpandedlistof

drugsadopted

for

Health

Sub

Centre

and

PHCs

has

to

become

available

to

them

atonce.This istobeaccompaniedbytrainingonstandardtreatmentguidelines

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

drugoutside the list,but thismustbedonewithpriorpermissionandwithdue

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: Systemswhere pharmaceuticals, consumables and equipmentwill

reach fromdistrict levelwarehouses toperipheral facilities ina routinemanner

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

neededsothatdistributioncanbeallyeararoundandresponsivetopatternsof

usages.Inthissystemeachfacilityhasapassbook,whichreflectstheamountof


25/42

drugsinstock.Whenthestockfallstobelowthreemonthsusage,alevelfixedat

thedistrict levelforeachdrugthenthefacility immediately indentsforthedrug

tothedistrictwarehousewhichinturnsuppliesthedrugtothePHCinthesame

week.Whenthedistrictstockfallsbelowathreemonthssupplyanorderissent

offthe

next

day

and

within

amonth

the

item

would

reach

the

concerned

district

warehouse.

Procurement

Werecommendthattheprequalificationofsuppliersandthepricesnegotiation

be done at the state level by an empowered body in a transparent and open

manner.When the districtwarehouse stock falls below its threemonth figure

then the same drug is immediately procured at approved rates. Therefore, all

subsequentdistrictsordersarethroughthisempoweredbodyandsupplieswould

be sent directly to the districts. This bodywould 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

anotherurgently

required

policy

measure.

VI.RATIONALISATIONOFEQUIPMENTPROCUREMENTANDUTILISATION

Smallerlowcostequipmentthatisfrequentlyreplaceablemustbedealtwith

asforconsumables.

Largerequipment,whichiscostlierandrequirestrainingtomakeoperational,

needstobepurchasedanddeployedonlyaspartofblockanddistrictlevelplans

linkedtoservicequalitydeliverables.Thiswouldensurethatthereisnomismatch

betweenequipmentpurchaseandinfrastructure,betweenequipmentandskilled

manpower available, between equipment and related consumables supply and

thatthepurchaseofequipmentislinkedtoqualityimprovementsinthepackage

ofservicesofferedatthislevel.


26/42

Purchasecanhavethesamepolicyofprequalificationandpricenegotiationat

the state levelwith districtswhile 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

bedsis

itself

achallenge.

Therefore,

the

attempt

to

take

on

100

bed

rural

hospitals is ill advised andwould be diverting funds away from this basic goal

whichisfarfromcomplete.

Given the largegap in infrastructureour recommendation is thataplanbe

drawnup for closing thegapsprioritizing sectorPHCandCHCsand completely

integratingwithISMinfrastructure.Subcentreswouldbeonlynextinpriorityand

institutional delivery in subcentres and need not be insisted on at this stage.

Oncethe

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

departmentsandexternaldonorsfeel justifiedinshyingawayfrominfrastructure

investments.Thiscoordinateddevelopmentof infrastructure is theheartof the

EnhanceQualityinPrimaryHealthCentres(EQUIP)programmes

rationale.


27/42

Attentionmaybegiventoclosingthegapsregardingwatersupplyandpower

supplyandtoensuringthatseparatetoilets forstaffaswellasbathing facilities

formen andwomen are also in place in each of the PHC and CHC structures.

Inadequately recognizedpriorityareasarewastedisposal system,drainageand

sewerageall

of

which

needs

to

be

put

into

place

in

all

PHCs

and

CHCs.

Telephonesareoneofthemostimmediatelyremediableproblemsandsame

urgencyneedstobegiventothisissue.

Thereismucheffortatcomputerizationatstatelevelandprovidingcomputers

andwebaccesswith training touse thiswouldenhancemonitoringandsupport

capabilities tremendously. It should be possible to priorities this and within a

finitetimeframeachievethiscapabilityat leastforPHCsandCHCsand laterfor

SubCentre(SCs)aswell.Computerisationinthepresentdayisalsoaculturethat

maybeencouraged.

VIII.SERVICECONDITIONS

Transfer; Promotion; Financial burdens; Personal Security, Accommodation for

Staff

TransferPolicy

A clear policy on transfer iswellperceived and long overdue reformmeasure.

Thisisneededforallcategoriesofstaffbutparticularlyforthemaleandfemale

multipurposeworkersandtheirsupervisorsandthemedicalstaff.Acommittee

composedofsomeseniorofficials,somemotivatedworkersidentifiedbythe

departmentandsomerepresentativesoftheworkersserviceassociationsshould

evolvesuch

apolicy

that

is

considered

fair,

transparent

and

easy

to

implement

at

theearliest.

The following principles should be considered while developing the transfer

policy:


28/42

Pressure for transferswouldbe reducedbymakingMPHW selection intoa

block level cadre andother category selection includingmedicalofficers,other

than

ClassIofficers

into

adistrict

level

cadre.

The authority for the transfer shall be a district and state level transfer

tribunals.

ThetribunalmaybemadeupofathreepersonboardchairedbytheCivilSurgeon

andProgrammeOfficerofthedistrict,withoneoftheboardmembersappointed

bytheDeputyCommissionerandanotherbytheEmployeesAssociation.

Aroster

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

areawouldnotbemandatorybutwouldbeanemployeesright if therequired

periodofservicehasbeengiven.

Mutualtransfersshallbeallowedbutwithoutcontradictinganyoftheabove

clauses.

Persons in the last ten yearsof servicemaybe exempted frommandatory

transfer.

Allpromotionsmaybeconsideredonlyafter fiveyears indifficultpostingor

tenyearsinmediumpostingiscompleted.


29/42

PromotionPolicyforParamedicalsRegularPromptPromotionwithSixMonthsPrePromotionTraining:

PromptpromotionofMPHWstosectorsupervisorsmaybeensured.Beforethey

takeup

the

task

as

sector

supervisors

both

MPHWs

male

and

female

may

undertake a sixmonth trainingprogramme (Currentllymale supervisorsdonot

havetoundergothistrainingthoughwomensupervisorshaveto).Thereisalarge

backlog and urgency needs to be given to prompt implementation of these

promotions.

FastTrack Promotion:We also recommend an additional system inwhich a

portionoftotalLadyHealthVisitors(LHV)andmalesectorsupervisorposts(25%)

maybe

reserved

for

promoting

MPHWs

on

the

basis

of

their

willingness

to

serve

indifficultareasiftheyhadnotdoneso inthepast,andanexaminationoftheir

skillsandknowledgeafteraminimumperiodofserviceeg.sevenyearsofservice.

Weexpectthatthiswillmotivatesomeenthusiasticfunctionariestovolunteerto

serve in more difficult areas. If those promoted are not able to fulfil their

commitmentandget transferred tonondifficultareasbefore fulfilling their five

year commitment, their appointment as LHV/Sector supervisorwill be revoked

andthey

will

be

reinstated

as

MPHWs.

For those MPHWs already in difficult areas, a promotion in this channel may

inducethemtocontinuetheirservicesintheseareas.

Weunderstand that indifficultareasmultiskilledsectorsupervisorswouldhave

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

thesupervisors

grade

would

the

useful

to

initiate

this

process.

RedesignationoftheBlockExtensionEducator (BEE):TheB lockextension

educator does not do block extension education and may be renamed block

seniorparamedicalsupervisor.Hewouldhaveaspecialresponsibility intraining,


30/42

capabilitybuilding, IECandsupervision.Thispromotionshouldbesenioritycum

meritpromotionbasedonadequatetestingoftrainingcapabilityfromwithinthe

cadreofallsectorsupervisorswhohavecompletedacertainnumberofyears.

OneTime

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 structuringofhealth systems notlazilyblamedon themedicalofficers.

Thelack

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

importantmotivational aspects that need to be provided for. Their inability to

make a career plan where they can enhance clinical skills or get other

promotionalor careeropportunities later isaproblem.The systemwould reap

rich benefits if it saw the desire for career advancement of the doctors as an

opportunityinstead

of

as

aproblem.

Thekeyrecommendationonpromotionsfordoctorsare:

Contractual appointmentsmustbe seenasadhoc arrangementsmade so far

had tobestoppedbecauseof legal reasons.Regularappointmentsmay remain

themainstayoftheworkforce.Thevacantpostsshouldbefilledupattheearliest.

Timely,timeboundpromotionstoseniorgradesandspecialistgradesneedsto

beensured.

Thereshouldbeascalelikethis Starting8000,after4years10000,after9years

12000,after14years14300forall.

Ranking in reference to other Govt. Officials at District level: Earlier Civil

Surgeonusedtobeat3.Itshouldberestored.


31/42

Skillretentionforspecialists.Thefeelingofprofessionaldissatisfactionmaybe

higherespeciallyinpostgraduatesservingasmedicalofficersandneedstobe

addressed throughbetterprofessionalopportunities.Everypostgraduatescould

belinked

to

CHCs,

which

they

attend

on

periodic

occasions

for

providing

specialist

services.Thusa surgeon shouldbeable toperformoperationson certaindays

andsoon.And theyshouldbeable tosend for investigationsathighercentres

directly and have access to drugs related to their field of specialization,which

normallywewouldnotexpectaPHCdoctortohandleandsoon.

ChoiceofstreamforClassIOfficers.Aftertenyearsofservicewhentheyenter

classIofficer

status

the

doctors

may

be

given

achoice

between

aclinical

stream

(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

otherprogrammepurposes shouldbeeliminated.Theassistancecell (discussed

later)shouldbeavailableforconfidentialcomplaintsinthisregard.

Personalsecurity:CreatingaWomenEmployeesAssistanceCellatDistrict

Level.

ThismustberecognizedasanissueforMPWfemales.TheSupremeCourt

hasalready

laid

down

the

procedures

under

the

VISAKA

guidelines

and

these

maybepublicizedandimplemented.

WealsorecommendaWomenEmployeesAssistanceCell inalldistrictsthatwill

provide legal aid, counseling and protection and some degree of grievance


32/42

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

recommendsfirmadministrativeor legalactionwherenecessary,withadequate

publicityfor

it

to

act

as

adeterrent.

The

WEAC

should

be

headed

by

awoman

outsidethehealthdepartmentwithsomeexperienceofworkonwomensissues.

TheWEACshouldbenominatedbythe

DistrictCollectorinconsultationwiththeCivilSurgeon.

Accommodation

Block LevelGovernment Housing Plan: All accommodation formedical staff at

CHClevel

should

be

part

of

agovernment

housing

development

plan

common

to

all government departments so that adequate supporting infrastructure and

facilitiescanbedeveloped.Thiscanbedonewithprivatepartnerships,notonly

tospeedimplementation,butalsotobringininvestment.Theaccommodationso

providedshouldbeadequate forallstaff.Workcouldstartwithprioritizationof

moredifficultblockssoastospeedupdevelopmentthere.

Sector LevelCategorywise Priorities: All PHCs in medium category difficulty

shouldbe

prioritized

for

building

government

accommodation,

for

all

the

staff

in

acosteffectivemanner.

Thiswouldactasanincentiveforstafftoworkthere.Inmostdifficultcategory

areasaccommodationmaybeplannedforparamedicalstaffasapriorityatthis

stage.

SubCentreBuildings:Subcentrebuildingsmaynotbeseenasapriorityexcept

wherethecompleteblocklevelplanningiscompleted.Itisbesttoprioritisethose

Subcentres

where

there

are

no

rooms

available

on

rent

or

alternate

building

availablefordevelopinginfrastructurethen

onlymovetoothercentres.Someinstitutionaldeliveryisnotbeinginsistedonat

HSClevel,


33/42

rented accommodation with a store and a consultation/ immunization room

availableandpaidforbythegovernmentshouldbeadequateformostSCsinthe

immediate period. When a new building is undertaken, the current design of

MPWaccommodationcumSCfacilitymaybecontinuedeventhoughinstitutional

deliveryis

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

multiskillingothercadre toundertake thisworkat thesector level.Overa 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 foralbumin,sugar,ketones,bilesaltsandpigments,microscopyof

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

skillsandareeasily taught.Themostdifficultof these is theBSE (Blood smear

examination)formalarialparasiteandsputumforAFBbutgiventhatmultiskilling

inthisisalreadyaccepted,abilitytotraininthiswiderrangeoftestsshouldnot

beconsideredaproblem.

TrainingApproach:Thissetoftestscanbetaughttoateammember primarily

bythe

medical

officer.

Training

programmes

at

the

district

level

would

only

supplementthis.

Themedicalofficerwouldonlyneedaoneweekpackagetoberefreshedonthis

if there isagood text to followalongwithproper teachingmaterialsorganized

well.Chartsandguidebooksthatbothdoctorsandmultiskilledstaffcanreferto


34/42

alongwithpicturesofmicroscopicappearancesshouldalsobeavailable inevery

centreandtheirabsenceisaseriousremediableproblem.

CHC tests as Per Standard Treatment Guidelines: The set of tests to be

availablein

aCHC

have

been

described

as

part

of

the

states

standard

treatment

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

microbiologicalculturesandhistopathologicalstudiesatthedistrict levelwhere

relevant.

UpgradedLaboratoryTechniciansatCHC:Thequalified laboratorytechnician

attheCHClevelshouldbeupgradedtoprovidethismuchlargerpackageoftests

thenwhat

is

currently

available.

Where

still

gaps

remain

public

private

partnerships to close these gapsmaybeprioritized. The laboratory technicians

and theXray technicians shouldworkunder the supervisionandguidanceand

qualitycontrolofasuitabledistrict levelofficer inadditionto theblockmedical

officer.

SubCentreLevelTests:AttheSClevelurinetestingforalbumenandsugarand

bloodtestingforhaemoglobinshouldbeimplemented.Inadditionitshouldbe

possibletotrainacadreofNGOsandtrainersofASHAprogrammesandmale

MPHWstodoBloodsmearexamination(BSEs)andsputumAFBtestingalongwith

theabove.Thus reducingreporting timeofbloodsmears to less than24hours,

for all habitations. This would require investment by the government in a


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microscopeandabasickitandapieceratepaymentarrangementbywhichthese

essentiallyprivateserviceproviderscanberemuneratedfordiagnosticsdonefor

thepublicsystem.

X.REFERRAL

SYSTEM

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. Formanagementof casewhosediagnosis is known and infrastructure, staff,

equipment isadequatebut forwhomdrugsareavailableonlyat thenext level

e.g.epilepsy.

d.Formanagementofa casewhosediagnosis isknownbutwhereaqualityof

equipmentor

infrastructure

or

staff

is

needed

which

is

not

available

in

the

PHC

e.g.allinhospitalcareorsurgicalcareetc.

Under conditiona&b, referral isaone timeeventandwithagoodquality,

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 thismay be

supplementedbyallowingspecialindents.


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Condition d may occur as an emergency or in routine out patient

circumstances.

Someofthesecaseswouldneedtobefollowedupatthehigherlevelforalltime

tocome.

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

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,

or

laboratory

investigation,

or

instructions

for

follow

up

should

be

transmittedinwritingthroughthehealthsystemandavailableforverification.

EventuallythisfeedbackshouldbeelectronicallytransferredthroughWeband

Willsystems.

BlockLevelAmbulanceServices

Agood

transportation

system

is

essential

for

any

referral

system

to

function

properly.ItissuggestedthatinadditiontotheambulancewiththeCHCablock

levelambulanceservicebedevelopedinpartnershipwithlocalcommunity

organizationstotransportpatientsandthisbetiedtothereferralsystems.Itis


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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

littleextra

cost.

DefiningISMPackageofServicesatEachLevel:Integrationrequiresasa

firststepthedefinitionofwhatpackageofserviceseachcategoryofpersonnel

andfacilityintheISMswouldprovide.


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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

publichealth

tasks

in

asection

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

availableatthatlevel.Thisistruefor


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paramedicalsaswellasformedicalofficers.

Toachievethisgoalwerecommendaninservicetrainingpackagewithfollowing

features:

For

Paramedicals:

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

trainingattended,

topics

and

number

of

days

of

training

in

each.

The

block

medicalofficersmaycoordinatewithdistricttrainingcentre toseethatalltheir

healthworkershavereceivedthemandatorytraining.

Syllabus:Thesyllabusforitshouldbebuiltuptoinclude.

Changesinhealthprogrammeguidelinesofnationalhealthprogrammes best

addressedthroughtwodaysensitizationprogrammes,wheneversuchachangeis

made.

Renewalof care areaof theirworkRCHprogramme forMPHWs (at least15

days)andnationalprogrammesformaleworkers.

Multiskilling training in which female workers learn more about national

programmesandaboutbasiclaboratoryskillsandmaleworkerslearnaboutRCH

andadequatelevelsofbasiclaboratoryskills.

Adequatetraining

for

first

contact

curative

care.

A modified IEC programme capability with focus on interpersonal and

communitymobilizationskillsalongwithbetterunderstandingofamulticultural

andethnically


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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

campsofnationaldiseaseprogrammes.TheenvisagedCMEschemeshouldalso

beusefulforpromotionpurpose.ACMEshouldbepursuedasaveryuseful

interventionstrategyinhealthcaredeliverysystem.


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MinimumSkillMixforCHC:Havingdefinedaminimumpackageofservicesat

theCHCasessential tomeetpublichealthgoalsoneneeds toaput inplacea

roadmapbywhichthedesirableskillmixneededfordeliveringsuchapackageof

serviceswould

become

areality.

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.

Wheregaps still remainonemayusepublicprivatepartnership to fillup the

gaps.

XIII.STATEANDDISTRICTLEVELORGANISATION

PromotionsandTenureattheStateLevelPrompt and Regular Appointments: All vacancies must be filled up at the

directorate(directors,deputydirectors,CivilSurgeonsandprogrammeofficersat

thestatelevel)mustbefilledupwithinaperiodofsixmonthsonaregularbasis

fromeligiblestaffatthatlevelorbypromotion,(exceptthosepoststhataretobe

recruitedfromtheoutsideona

consultancy/contractbasiswhere it could takeup toanyear).Forprogramme

officersatthedistrictlevelandblockmedicalofficersmustbefilledupwithinthe


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same timeframe but in the event of creating a separate administrative cadre

wheretheseareentrypointstheycouldtakelonger,uptoayear.

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