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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.
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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.
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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
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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
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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
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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.
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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
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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
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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
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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.
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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.
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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:
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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.
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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,
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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.
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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
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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,
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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
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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.