Haryana
The growth of Haryana state provides new opportunities. The Government of the
state of Haryana is engaged in the process of re‐assessing the public health care
system to arrive at policy options developing and harnessing the available human
resources to make greater impact on the health status of the people. As part of
this effort, one should attempt to address the following 3 questions.
1. How adequate are the existing human and material resources at various levels
of care (namely from Sub Centre level to district hospital level) in the state; and
how optimally have they been deployed?
2. What factors contribute to or hinder the performance of the personnel in
position at various levels of care?
3. What structural features of the health care system as it has evolved affect its
utilization and its effectiveness?
From the analysis of the situation in its totality, one may proceed to
make recommendations towards a policy on workforce management, with
emphasis on organizational, motivational and capability building aspects. One has
to see how existing resources of manpower and materials can be optimally
utilized and critical gaps identified and addressed. The question is that how the
facilities at different levels can be structured and reorganized to provide health
care to all the people without any discrimination.
A study was conducted‐ a questionnaire based survey of facilities that was applied
on a sample of 128 Sub centres, 64 PHCs and 32 CHCs, also 356 employees of 8
cadres were interviewed in Chhatisgarh and analysis was done. There are certain
similarities of situation and a lot can be gathered from their experience. There are
four types of stake holders in health service system in the state.
1. The employees and their associations.
2. The officers at the national, state and district level.
3. The Medical profession and professional bodies.
4. Civil society.
It is noted that in the last decade the department of health in Haryana has seen a
lot of new developments:
However the constraints that the system has inherited are considerable. A larger
plan to reach a basic set of services for each level of the three tier health care
system is needed. It has been tried to chart out the contours of such a plan and
project an approach to reaching it. In the larger interests of improving the system
the aim is to set out all the lacunae in workforce management and rationalization
of services, explore its causes and set down the possibilities for immediate and
long term action to improve and strengthen it.
Situational Analysis
Adequacy of “Sanctioned Facilities”
As per existing norms one sub centre is planned for every 5000 population, one
PHC for every 30,000 and one CHC for every 80,000‐1,20,000 population. For
tribal areas the norm is one sub centre per 3000 population, one PHC per 20,000
population and one CHC per 80,000 population.
SNO FACILITY AT PRESENT‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐SHOULD BE
1 SUBCENTRE
2 PHC
3 CHC
4 SPECIALISTS IN CHC
SURGEON
PHYSICIAN
PAEDIATRICIAN
GYNECOLOGIST
ANAESTHETIST
We need 572 Sub Centre more. 98 more PHCs are needed along with the staff
and other infrastructure required. We need 63 more CHCs.
Location of Facilities with relation to access:
Amongst existing facilities there is considerable loss of utilization due to improper
location and improper distribution. In many of the cases, there is considerable
maldistribution. And this is compounded by improper choice of village within the
section or sector and the choice of venue within the village.
Adequacy of staff and their Utilization with Relation to Functionality of Centres:
Even the female para medical staff is not adequate in numbers. There are serious
shortfalls in all other staff. Female worker has to share the greater part of the
work load. Many categories of staff at sub centre and PHC level are characterized
by poorly designed work schedules and are poorly utilized with high degree of
redundant work time. Rationalisation of paramedical work time offers therefore,
the most effective route to addressing staff adequacy.
The current work description of Multi Purpose Health Worker (MPPW) female is
unrealistic and is being coped with developing a focus on just one or two tasks
and informal local arrangements. As a result a number of essential services are
completely left out (eg. Early recognition of child hood pneumonia or proper
treatment or diarrhea or adolescent health care etc.) and a quality of a number of
other services, like antenatal care are seriously compromised (very few pregnant
women get their BP taken and blood and urine tested).
Rationalisation of Drugs and Consumables supply:‐
The essential drug list is not being implemented. The main deficits are a failure to
procure the entire items of the list, a failure to send samples for quality control
and a failure to exclude drugs not on the list. Other element of the drug policy are
also not in place. Thus procurement is problematic and sporadic, occurring once
or twice a year with quotas to peripheral facilities to distribute the drugs.
There are numerous breaks in supply and the distribution system appears to be
unresponsive to changing needs. Restriction of drugs to a narrow spectrum and
breaks in supply are not even perceived as serious within the system reflecting
poor perception of quality of care issues.
The problem with consumable is even more serious than with drugs. Laboratory
chemicals seem the worst affected but even gauze and bandages, needles and
needle holders could be in short supply repeatedly.
Rationalization of Equipment:
Low investment minor equipment like Sahil’s Haemoglobinometer or material
required to test Haemoglobin or Blood Pressure apparatus and infant weighing
machines, which, if used, will need replacement frequently. Another group is
‘major equipment’ like ECG, USG(Ultrasound) and Xrays which require less
replacement but require trained manpower to operate. In minor category, there
may be considerable under utilization. Due to quality of care issues many of these
instruments/ equipment are not utilized. If utilized then they require replacement
for which ready system of purchases and restocking is required.
In major equipment, the main problem is mismatches between equipment supply
and man power to use it (e.g ECG machines without any one who operate it),
between equipment supply and level of services currently provided at that level
(e.g. Halothane‐ a drug used for anaesthesia, was sent at
CHC levels where there was no anesthetist, neonatal care units where there are
no caesarean operations done, Colour Doppler equipments supplied where there
is no vascular, cardiologist or cardio thoracic surgeon available), between
equipment supply and consumables available to use (e.g. X‐ray machines running
out of X‐ray film) and between equipment purchase and maintenance.
At one level all such mismatches are attributable to failures of concerned officials/
officers. But at another level it points to a governance/ administrative failure,
with one committee maximizing purchases, and another set of persons looking at
distribution and no one looking at training and maintenance or eventual
utilization of equipment.
Infrastructure Adequacy:
The short falls in basic availability of its own buildings is well known. Toilet
construction and maintenance too are major infrastructural inadequacies.
Maintenance of buildings is also poor and many buildings are old and need
extensive renovation or replacement. Now after SKS formation repairs could be
possible.
No Light at Sub Centre: Problems with electricity supply are also there. Generator
back up is not available at many places. Inverter at CHC level is available‐ but are
not of sufficient time capacity.
Problems with water supply are however considerable. Most of these facilities
have a bore well and hand pump so that they are functional. However any
hospital with in patient facilities, even if it were for only conducting normal
delivery, would require running tap water, bathing facilities and toilets separately
for staff and for patients. How many of CHCs and PHCs have such a water supply
arrangement? Waste management based on segregation of wastes with proper
disposal of each category of biological waste is a relatively untouched area of
intervention.
Service Conditions
(Transfer; promotion; financial burdens; personal security, accommodation for
staff)
The lack of a fair transparent system of transfer is easily one of the greatest
causes of workforce dissatisfaction and demoralization. Some staff spend their
lifetimes working in remote areas seeking and never getting a transfer whereas
others perceived to be able to personally and unfairly influence decision making
to get priority postings through out their career. This makes less staff willing to
serve in rural areas and when they are so posted, do their work with such a deep
rooted sense of frustration and anger that the quality of the work suffers. The
problems of doctors not willing to serve in rural areas should be seen only in this
context and should not even be held out against the medical profession unless a
basic transfer policy has been put in place.
Promotions need to be regular and timely and fair. Otherwise it leads to a
situation of deep dissatisfaction that runs through the entire department. It has
also been observed that many times
the position of authority starting from the top most and proceeding through the
Civil Surgeon upto Senior Medical Officer are held in an adhoc and arbitrary
manner.
Further the opportunities for an active career plan for a talented doctor or one
who is able to work hard and perform more are absent. For paramedical staff too
the lack of any possibility of promotion let alone a career plan acts as a great
demotivation from taking any initiative. These are all remediable aspects that
need to be urgently attended to.
Another major problem is personal security, again a problem maximal with
MPHW females.
Violence and sexual harassment, covert and overt affects about 10% but creates a
sense of insecurity in all. In Delivery Huts these type of problems have come to
light recently.
No definite pattern of venue: Another basic service issue is accommodation. At no
level is there adequate housing for all staff. Available housing facility many times
is not worth living. The focus has been on developing government housing for
doctors first. At the CHC level there is accommodation available, especially for
doctors. But it is seldom adequate to house even half the staff or even half the
number of doctors. Available accommodation is also underutilized because
of many factors.
Laboratory Services:
Laboratory services at the sub centre are almost absent. By laid down norms four
basic tests‐
Blood pressure checking, weighing of pregnant women and children, blood
haemoglobin estimation and urine testing for sugar and albumen (also E.S.R) are
expected to take place here.
These above tests like BP check however do take place in PHCs but even here they
are not regular.
The lab technicians are not available at many places. Slide test is being done
routinely. The PHC, as per norms, has a basic laboratory which can do about 20
basic diagnostic tests, has almost been
forgotten within the system. Microscope availability is there but underutilized.
In CHCs the laboratory is active to some extent but perform most of the time two
tests, the blood smear examination for malarial parasites and the sputum
examination for Acid Fast bacillus
(AFB). The list of desirable diagnostics at the CHC level is over 40 tests. At most of
the CHCs the workload of these two tests is heavy. Also as a consequence,
reaching back time, gets lengthened considerably (on an average 10 days to 20
days). The blood smear examination has increasingly taken the form of a
“modern” ritual denoting medical care devoid of content. Target of slide making is
also a cause for it. There is no major perception of the lack of laboratory services
as a serious lacunae‐ again reflecting on the weaknesses in under standing and
lack of emphasis of quality issues in medical care.
Referral Services:
The current referral services have two forms. Firstly there is a fund placed at the
disposal of the Panchayat for use to hire/pay for transport to shift needy patients
to a hospital. There is an understanding that this must be used for high risk and
complication of child birth. Funds flow and even awareness of this provision in
Panchayats is low and because of other structural constraints (lack of vehicle;
inability to call vehicle in time etc.) its utilization is very low even as the need for
referral goes unanswered.
The other referral is the patient being asked orally or with a slip to go and seek
treatment at a higher centre. This brings no advantage to patient or to the system
and is perceived by the patient as the referral facility having deliberately or
otherwise failed to deliver its services. There are no clear norms for what is to be
referred and when and there are no mechanism to monitor referral to reduce
unnecessary referral and insist on necessary ones. There is no feedback of any
sort. In short there is no referral system (Now this also do not exist).
The third system is that there is no need of referral system for going to corporate
hospitals for treatment. The rates are fixed. You go directly, get the treatment,
pay the bills and get the money reimbursed. It has created more problems. Those
who can not pay from their pocket in advance are at loss in such an arrangement.
Few get advance for treatment also.
Integration with Indian System of Medicines:
There is large manpower in (Indian System of Medicine) ISMs available in the
state level and more pertinent in the districts. Then utilization for public health
goals is minimal. The utilization of their indigenous curative care services is also
minimal. Their integration with the public health system is yet to be perceived.
The bottle neck is not their willingness. The members individually and as a
department welcome such role allocation. However the administrative unification
at the district level and the programmatic synergy at the level of programme
design have not been planned for.
Training:
Training programmes are few and are driven exclusively by the vertical health
programmes of the day, largely funded from external donors or the central
government. As a result whatever trainings are taking place are arbitrary in choice
of trainees and fragmented as strategy. Most training programmes are of one or
two days and relate to a single disease and an immediate campaign for example a
one day leprosy training or two days on HIV family counseling or one day on
blindness control and so on. Some persons have received many such training
programmes in diverse area while some have received none. Then again the
MPHW (F) had a special round of training in
Reproductive and Child Health (RCH). The vertical orientation of training leads to
closely associated work of other diseases not being taught even in much longer
capability building trainings. Thus e.g. the supervisors are trained on blood smear
examination for malarial parasites but doing a differential count on the same slide
would not be emphasized.
Almost no training is based on building competencies to attain a level of clinical
service in a given facility. We therefore, have a situation where there is a
perception with senior officials that the system is being flooded with training
programmes. Yet the system can not guarantee that in such centres of PHCs or
CHCs of a given district, the level of knowledge and skills needed is now available.
It may not even be able to state, faculty wise what level of skill building has been
achieved and what are the gaps. All these problems can be said to be true of
Information
Education Communication (IEC) also.
Structural Issues:
Governance:
It is not adequate to locate all problems only at the administrative level. Some of
the key administrative decisions are often taken at the political level. Of these,
transfers, promotions and purchases, which are purely administrative activities
have in practice become central areas of political decision making.
The policy frame works for the state remain weak. Most current practices in
administration are inherited, having been handed down as traditional practices,
rather than having been shaped by active policy frameworks that guide decision
making. What policy initiatives have been taken remain weak in implementation.
For example, the essential drug list is adopted but purchases have not been
guided by it. Patients are facing great problem because of high cost of drugs
which they are compelled to purchase.
Another illustration relates to senior appointments and tenure. If a policy has to
be implemented then a capable person or team must be put in place, monitored,
allowed the time frame for that person to show results and the person must be
changed if he/she fails to deliver. This requires a clear transparent system of
senior appointments, a secure tenure, a clear set of goals and mandate for the
person to achieve and periodic review of the same. We note that in contrast to
this ideal all incumbent officers many of them are holding their posts in an
officiating capacity. Appointments become a prerogative of power and influence.
There is no surety of tenure. Administrative arbitrariness in such areas are to be
recognized as indicators of poor performance.
Significantly even recruitments that are to take place on regular basis are not
taking place. Fresh recruitments have been therefore, only contractual, even
where there are vacant posts. This is again an issue of governance. The problem is
that there is a cynicism about policy making itself.
There is a feeling, often justified by experience as with essential drugs list that
anything can be passed as policy statement without any binding on its
implementation. Normally the ministry would lay down policy and the directorate
would be answerable for its implementation. The ministry would be the main
vehicle of ensuring accountability and transparency of the directorate and be
answerable to the legislature for it. The creation of a state health society is meant
to facilitate not weaken this relationship. However, when the separation between
governance and implementation is lost and the ministry itself is responsible for
implementation, as in the current nature nature of the state health society, or
when the ministry is unable to ensure policy based implementation in core
administrative areas, then health sector reform goes beyond the administrative
realm to that of the reform of governance. One would then have to look to the
legislature, the judiciary and institutions of civil society to ensure accountability.
The question we pose is that in the core administrative areas‐ tenure, transfers,
promotions, purchases and transparency is it a technical and managerial failure or
a failure of governance? If it is an inability to formulate a transfer and promotion
policy or organize a system of purchases then is it a technical and managerial
questions? If not, then, it is a failure of governance.
State Level Work Organisation:
Annexure‐IV??????
The inability to de‐concentrate powers and responsibilities at this level is a key
problem and may be the main reason for being unable to keep to project
schedules. The experiences of other states may be helpful in this regard. A related
diversion is the need or professionalization at the state leadership level. Though
they have very relevant practical experience, professional training in public health
management, health policy and in hospital administration has been weak.
Epidemiology is seen as a separate specialty area‐ not as something basic to
health planning and few are conversant with its methods. Administration would
be perceived as nothing more than knowing the rules and common sense. There
have been serious efforts in improving this situation by training inputs, but these
are minimal and for this level of leadership rather too late. A medical
administrative state cadre may be suggested. Even in relative areas of pure
management and administration like infrastructure development and purchases
and logistics, the system has not made use of qualified management skills, which
are easily available on the market.
Decentralization:
Yet another major issue of decentralization of powers to districts. Currently all
district officers perceive districts as having very limited powers‐ in all of the above
aspects of administration as well as in training and programme planning. Indeed
for the main post they are only implementing agencies for national health
programmes and medico‐legal work. Their own terms of selection, transfer and
monitoring have all the same organizational and motivational problems common
to other sections and it seriously compromises their work out put. Thus while
decentralization of powers and finances is essential, it needs to be born in the
context of these key administrative reforms being carried out.
Currently elected panchayats have a negligible role in the health sector and even
in this the support and programme design needed for them to be effective is not
available.
Financing of Health Care:
Financing of health care is an important issue and that budgetary allocation on
each facility and workforce relate to out comes. Also that what is adequate
utilization or wasteful relates to amount of investment that has gone into it.
These financial matters should also become the agenda.
Mapping the private sector and exploring its possibility of synergy with the public
health system and developing a policy framework for its growth and regulation
are yet issues that need to be addressed.
Regulating Private Hospitals and Nursing Homes:
Mapping the private sector and exploring its possibility of synergy with the public
health system and developing a policy framework for its growth and regulation
are yet issues that need to be addressed. Owing to the poor health delivery
system in the state, the public sector in the state, there is a mushroom growth of
private hospitals and nursing homes. Some of them indulge into a variety of
malpractices. There is an urgent need for regulating private services, both to
protect the consumers and contain costs. A system of accredition can be thought
of as a mechanism to regulate the private health providers.
It is recommended that a committee with Health Minister as the Chairperson and
some senior medical officers of the state and representatives of the private health
providers be constituted to evolve this mechanism.
Urban Health is another major area which needs more attention. There is already
a realization that health care for the urban poor and public health programmes in
the urban context is grossly inadequate and there is an urgent need to develop
viable cost effective models of health care delivery.
Functional states and design of specific health programmes needs to be
examined. These are closely related to workforce issues and allow considerable
scope for rationalization. Such programmes include the various national disease
control programmes, the reproductive and child health programmes and the
strategies of epidemic management.
Current Information, Education Communication (IEC) strategy needs to be
examined;
one ofthe most important dimensions of public health strategy. This area needs
to be developed in a more creative way.
The services which are supposed to be delivered by Sub Centres, PHCs and CHCs
are to be as per the latest laid down norms.
Recommendations
1. Adequacy of facilities:
Increasing Numbers of Peripheral Health Facilities.
Increasing Sub Centres to ensure sub centres as per population norms i.e. one
sub centre for every 5000 population
Rural population of Haryana is 1,50,29,989. So 3005 centres are required. We
have only 2433 Sub Centres. We need 572 Sub Centre more. One male and one
female health workers are required for each Health Sub Centre. So we need 3005
male MPHW and 3005 Female MHW. We have 425 Male MHW and 1909 Female
MPHW. The gap is very disturbing for 2433 Sub centres even we need 2008 Male
MPHW and 524 Female MPHW workers.
According to latest norms one Female MPHW is added for each Health Sub
Centre. Hence we need 2433 Female MPHW in addition to earlier requirements.
Increasing PHCs to ensure that there is a PHC on every 30,000 population as per
the norms. There are 411 PHCs. We need 509 PHCs. Hence 98 more PHCs are
needed along with the staff and other infrastructure required.
Increase peripheral health facilities in urban centres i.e. create a comprehensive
urban health plan which includes a network of urban health centres.
Increase number of CHCs so as to confirm to the population norms: One CHC for
80,000 population because density of population is higher in Haryana or at the
most for 1,00,000 population. Rural population is 1,50,29,989,. So we need 150
CHCs in total. Even if one CHC for 1,20,000 population is followed, we should have
125 CHCs. We have 87 CHCs at present. We need 63 or 38 more CHCs along with
the infrastructure and human resource. At present there is one CHC for 3 PHCs.
Adoption of minimum norms of service delivery and provisioning for it. One of the
most important recommendations of the HARC is the adaptation of
recommended norms on service delivery for each facility‐ the Sub Centre, the
PHC, the CHC and the civil and district hospitals. These norms may be widely
disseminated and health sector planners must be informed about the same.
(AnnexureIV)
II. Problem of Location of these Facilities:
1. Block level mapping (GIS based): It is required to prepare block level maps
showing all villages with existing Sub Centres and PHCs in all blocks as well as
demarcating various sections and sectors according to population norms Based on
this to search out ideal location for Sub Centres and PHCs and compare this to
where they are currently located. This may be most efficiently done on GIS based
software created for this purpose.
2. Optimum Location of These Facilities: This would consider geographical
optimum as also take into account economic activity, like the village weekly
market and common bus stand for 5‐6‐villages, locate the centre in coherence
with such activity so as to make it easier and more likely for people to access the
Sub Centre or PHC or CHC. This may be included as a parameter in the GIS data
base. This data base may also reflect location preferences with a quick
stakeholder analysis.
3. Reallocation Possibilities: Based on the above inputs decision is to betaken on
location at first for all facilities where Government constructions are needed like
in. Sub Centres without buildings, sectors without PHCs, v/s sectors with PHCs
operating from rented buildings. Where necessary infrastructure has already been
constructed these facilities may be classified into those that are by location
completely unusable; those that may be continue to be used unless there are
alternate uses for the current building and funds to build one at ideal location,
and a third category where current location of facilities is acceptable. Based on
this a plan of construction priority for each block may be drawn up.
4. Constructions Only According to Plans: Once such a plan is drawn up for each
block funds may be sought from internal budgetary mechanisms and from
external agencies, insisting all the while that all constructions must be in
accordance with the plan. The approval of designs of the buildings and the
construction would be done at the district level under approval from the
empowered body which is made at the state level to look at purchases,
maintenance, and infrastructure development.
5. No 100 Bed Hospitals: in any block or district should be built till all district
hospitals and all CHCs staffed and functional as envisaged.
III. Restructuring Staffing Patterns, Redefining Jobs and Adequacy of Manpower
Recalculating Manpower Gaps: Gaps in staffing should be re‐calculated after
planning for multi‐skilling and redistribution of existing staff such that there are
no redundant manpower.
Two Female MPWs in each Sub Centre: Sub Centres may plan for two female
MPHWs and one male MPHW. The job description and work load of the MPHW(F)
needs to be lessened and made realistic except for institutional delivery and IU CD
insertion, every task done by women can be done by men also. When there will
be two female MPW, the number of population for female will become half which
will help in quality service.
Multiskilling all PHC Paramedicals: The PHC staffing pattern needs restructuring to
ensure utilization of man power and better functioning of the facility. PHCs may
plan for having three or four male multi skilled employees with a male multi
skilled supervisor and three or four female multi skilled workers and a female
multi skilled supervisor. There would also be two medical officers one male (and
one female‐MBBS or Ayush MO) in every PHC. These multi skilled workers must
be skilled in dressing, drug dispensation (pharmacists task) and first contact
curative care and in basic laboratory package as well as in RCH. Between them
they should be able to keep the PHC functional for 24 hrs., should provide
institutional delivery and the other services as proposed in the service delivery
norms. After this multi skilling and revision of job descriptions, cadre restructuring
may follow this. No one is to be dropped unless one is not willing for multiskilling.
New recruitments should be into the multi skilled category and many existing
cadres would die away. Some like staff nurse would function as multi skilled staff
when posted in PHC but can play the role of staff nurse when posted in CHC and
district hospitals. It can be said that such retraining and re deployment would
solve a substantial part of the manpower vacancy problem. Each PHC may also
have two staff personnel at class IV qualifications.
Rationalization of Development of Medical Doctors at the PHC level:
Differentiated strategy according to difficulty levels: The ideal would be two
medical officers at every PHC (as in Tamil Nadu), preferably one lady doctor. The
number of posts need to be increased as per the requirement. The vacant jobs
should be advertised immediately and filled. However, this may not immediately
be realized due to shortage of potential recruits and the difficulty in finding even
one medical officer per remote area.
Therefore, it can be suggested that PHCs be categorized into most difficult,
difficult and easy and a different strategy be adopted for each. The incentives in
form of‐i) increase in rural health allowance to Rs. 2500 per month. At present Rs.
250 is being given for the last 20 years (ii). The rural health service prerequisite
for applying for MD/MS is 2 years, it can be one year if one serves in category C
PHC for one year. (iii) During PG course one is given salary for two years and only
honorarium for the 3rd year. One should get the salary for third year also. (IV)
After completing the course he should be allowed to work for one more year as
senior resident with full pay so that he/she can have practical confidence. (V)
Special pay package for categorized PHCs ranging from 5000‐8000 per month
along with NPA 25% or the doctors be allowed private practice after duty hours as
in Rajasthan.
24 hour Multi skilled Paramedical Based Services in all PHCs: It can be
recommended that in all PHCs irrespective of category, 24 hour service with
emphasis on institutional delivery be insisted on by multi‐skilling and deploying
paramedicals. The multi skilled paramedical worker should also be trained in
emergency care management at Primary level. It can be emphasized that by
paramedical worker we mean the current MPHWs or Pharmacists or staff nurses
currently in service with further training inputs and not the legitimization of under
qualified allopathic practice that also goes by the name of paramedical course.
The role of doctor in PHC would be to provide leadership and on the job training
and a referral back up for this team. Where a doctor is resident, the doctor is
available on call 24 hrs. to back up this team.
Daily Visits by CHC Based Doctors for Most Difficult PHCs:
Where no medical doctors are available currently, where access is a problem and
accommodation facilities are low (category C), even as efforts are made to fill
these posts, the backing up is done by daily visits and in a few distant PHCs two or
three visits per week of a medical doctor from the respective CHCs. The doctor
would be required to be available during working hours from 9 am to 5 pm at
headquarters and his stay at PHC would be insisted on only if adequate
accommodation governmental or rental are and proper security arrangements
are available. Even in this, exemption may be given for special reasons as long as
stay in nearby block town as part of the CHC team and daily attendance is regular.
Family accommodation at the CHC would be easier to organize. In other words we
should not insist on medical doctors staying in PHCs designated category C‐ most
difficult (one considers that the above approach with mobile doctors but fixed
facilities may be more cost effective than mobile hospitals when combined with
the use of multi skilled paramedicals.
Strengthening BAMS Doctors Role While Keeping Medical Officers Options
Open:
The use of medical officers with BAMS (Ayurvedic System) to fill up vacancies
where no medical officers are currently available is welcome. However all the
service issues discussed earlier about MBBS doctors equally affect functionality.
More over currently they would be unable to deliver the notified services at the
PHC level and special training would be needed to close the gaps. The post of the
allopathic doctor should be retained and the search to fill this post should
continues with offer of better incentives. Also if training transfer and promotion
policies are put in place, these vacancies would certainly be much less. By
integrating ISM sector with the allopathic sector we may also approximate the
ideal of two medical officers per PHC much faster and have less underutilized
manpower in our hands.
The CHCs be Strengthened by:
Appointment of six Medical Officers at least.
Four of these at least should be specialist (physician, pediatrician, surgeon,
gynecologist) mix. If there are a number of PHCs not having doctors to be looked
after with visits, the number posted here may increase further? One Anesthetist
must also be posted in every CHC otherwise the other specialists will become
defunct. The four medical officers norm is sub critical. SMO can call specialist on
payment per hour if need be.
Adequate Multi Skilled Male and Female Paramedical Staff:
Who can manage the necessary support work and multi skilled imaging
technicians who can also manage X‐rays, USG and ECG too? In addition there
would be a unskilled worker category of undifferentiated, inter changeable class
IV functionaries‐ chaukidar, peon, sweeper, waterman‐ all rolled into one. Six
qualified staff nurses, two qualified laboratory technicians and an ophthalmic
assistant are also a must at this level.
Redesignating the Block Extension Educator:
The block level extension educator may be renamed the block senior paramedical
supervisor and be responsible for capability building. IEC and supervision of sector
supervisors.
Adequate Clerical and Accounting Staff at least two, be provided to every CHC
along with computer and printer.
IV Rationalisation of Work Allocation and Approaches to Improve Outreach: In
Addition to the above measures, Improving Outreach Requires:
Reorganisation of MPHW Work Schedule:
MPHWs may be required to tour for three days a week, instead of the present
one or two days a week. One day a week should be devoted to review and
drawing supplies from
PHCs. The remaining two days a week should be devoted to clinical work and
other services provided at Sub Centre. These two days are fixed and her clienteles
should know that he/she is available there in her headquarters on these two days.
In each field visit days, he /she would visit a specified number of houses and hold
meetings with one of the four indentified local groups. Once a month he/she
should attend a Block Level Review and Training. If there are two MPHWs posted
their two days at the headquarters may be fixed in such a way that the Sub‐centre
is open on four previously specified days every week, which is better than the
current, one day a week or so.
Revised MPHW Job Description:
• Immunisation‐ children and pregnant women largely at the village visit and
camps but supplemented by immunization at the sub centre.
• Antenatal care and post partum care at sub centre, with visits to these
pregnant women (unable/ unwilling to come).
• Motivation and facilitation for all methods of contraception
• Training and support to local women health committees and Mahila Saksharta
Samooh activists.
• Regular house visits, such that every house hold is visited once every 15 days
or
one month) for a set of “case detection, follow up and counseling activities” along
with first contact curative care where required. (this include all national
programmes related activities).
• Focal group discussions/ health education sessions/ health camps during
village
visits.
• Curative care during field visits on three days and at Sub Centre on two days.
• Response to epidemic using a graded epidemic response protocol. In addition
to
the above male worker would have the following tasks:
• Addressing make youth on adolescent problems and STD control
• Interaction with Panchayats, SKS and with local leaders for facilitation of health
programmes.
• In addition to the above female MPHWs shall have the following tasks:
• Assistance at childbirth
• IUCD insertion
• Addressing adolescent girls on health problems.
Out Reach Camps:
As a rule health camps are beset with problems. They are wasteful of resources,
they disturb routine activity. They alter priorities of the persons and problems
attended to and they create a high visibility for low priority and inadequate
activities mostly symptomatic or even irrational curative care for trivial illness.
However in villages or clusters of villages where one or other service has less than
50% coverage or there is a large number of persons to be reached, a health camp
which reduces and brings down to a manageable level the burden of unfinished
service delivery would be welcome. Health camps therefore, should be preceded
and driven by health needs identified by MPHWs (Panchayats or Mahila Saksharta
Samooh or SKS) rather than programme targets to be met above. Thus a blindness
treatment camp preceded by a careful identification of those needy and driven by
such needs with a carefully planned follow up, or an immunization camp for
measles where a survey shows that over half the children have not received it, is
much more useful than declaring a series of camps first and then trying to
mobilize the clientele for it.
V. Rationalisation of Drugs and Consumable Supply:
• The essential Drug List:
The essential drug list needs to be implemented. In particular the expanded list of
drugs adopted for Health Sub Centre and PHCs has to become available to them
at once. This is to be accompanied by training on standard treatment guidelines
and drug formulary for the expanded list. The essential drug list may also
incorporate all consumables and minor equipment (frequently replaceable). A
quick process of appeal can be built in where a
Civil Surgeon or programme officer appeals for being permitted to purchase a
drug outside the list, but this must be done with prior permission and with due
process. Upto 10% of the budget may go to such outside the list purchases. Any
violation of the drug list should invite disciplinary action or else it would be
difficult to get a meaningful drug policy into place.
Distribution: Systems where pharmaceuticals, consumables and equipment will
reach from district level warehouses to peripheral facilities in a routine manner
are essential. A number of equipment that MPHWs use requires frequent
replacements like BP apparatus and thermometer and they should also be
therefore, a part of consumables management.
The drug and supplies policy should reflect this. It can be recommended that a
distribution system based on the “PASS BOOK” like in Tamil Nadu is urgently
needed so that distribution can be all year around and responsive to patterns of
usages. In this system each facility has a passbook, which reflects the amount of
drugs in stock. When the stock falls to below three months usage, a level fixed at
the district level for each drug then the facility immediately indents for the drug
to the district warehouse which in turn supplies the drug to the PHC in the same
week. When the district stock falls below a three months supply an order is sent
off the next day and within a month the item would reach the concerned district
warehouse.
• Procurement
We recommend that the pre‐qualification of suppliers and the prices negotiation
be done at the state level by an empowered body in a transparent and open
manner. When the district warehouse stock falls below its three month figure
then the same drug is immediately procured at approved rates. Therefore, all
subsequent districts orders are through this empowered body and supplies would
be sent directly to the districts. This body would arrange for quality testing of
drugs also.
• Drug Policy
All of the above should be incorporated in a separate drug and consumables
policy. The adoption of such a drugs and consumables policy for the state is
another urgently required policy measure.
VI. RATIONALISATION OF EQUIPMENT‐PROCUREMENT AND UTILISATION
• Smaller low cost equipment that is frequently replaceable must be dealt with
as for consumables.
• Larger equipment, which is costlier and requires training to make operational,
needs to be purchased and deployed only as part of block and district level plans
linked to service quality deliverables. This would ensure that there is no mismatch
between equipment purchase and infrastructure, between equipment and skilled
manpower available, between equipment and related consumables supply and
that the purchase of equipment is linked to quality improvements in the package
of services offered at this level.
• Purchase can have the same policy of pre‐qualification and price negotiation at
the state level with districts while placing orders. The same empowered body
which implements drug and supplies procurement and distribution may
undertake all equipment purchase.
Further such a body would ensure that adequate arrangements are made for
maintenance and such arrangements are renewed.
VII. INFRASTRUCTURE ARRANGEMENTS
• There is an ongoing effort to build 30 bedded hospitals with a modern
operation theatre in every designated CHC. This is a welcome effort and deserves
to be strengthened. At the level of the block ensuring bed occupancy of these 30
beds is itself a challenge. Therefore, the attempt to take on 100 bed rural
hospitals is ill advised and would be diverting funds away from this basic goal
which is far from complete.
• Given the large gap in infrastructure our recommendation is that a plan be
drawn up for closing the gaps prioritizing sector PHC and CHCs and completely
integrating with ISM infrastructure. Sub‐centres would be only next in priority and
institutional delivery in sub‐centres and need not be insisted on at this stage.
Once the plan is drawn up one set of blocks be prioritized and the gap closed in
that set of blocks along with closing equipment and manpower gaps before
moving to the next set of blocks.
Thereby the entire infrastructure requirements for the state would be met over a
five year period without having to face the gross under utilization of
infrastructure as is currently faced. If there are financial constraints to
infrastructure development the evidence of good utilization would help to
overcome them. Currently utilization is so poor that both state finance
departments and external donors feel justified in shying away from infrastructure
investments. This coordinated development of infrastructure is the heart of the
Enhance Quality in Primary Health Centres (EQUIP) programme‘s
rationale.
• Attention may be given to closing the gaps regarding water supply and power
supply and to ensuring that separate toilets for staff as well as bathing facilities
for men and women are also in place in each of the PHC and CHC structures.
Inadequately recognized priority areas are waste disposal system, drainage and
sewerage all of which needs to be put into place in all PHCs and CHCs.
• Telephones are one of the most immediately remediable problems and same
urgency needs to be given to this issue.
• There is much effort at computerization at state level and providing computers
andweb‐access with training to use this would enhance monitoring and support
capabilities tremendously. It should be possible to priorities this and within a
finite time frame achieve this capability at least for PHCs and CHCs and later for
SubCentre (SCs) as well. Computerisation in the present day is also a culture that
may be encouraged.
VIII. SERVICE CONDITIONS
Transfer; Promotion; Financial burdens; Personal Security, Accommodation for
Staff
• Transfer Policy
A clear policy on transfer is well‐perceived and long overdue reform measure.
This is needed for all categories of staff but particularly for the male and female
multipurpose workers and their supervisors and the medical staff. A committee
composed of some senior officials, some motivated workers identified by the
department and some representatives of the workers service associations should
evolve such a policy that is considered fair, transparent and easy to implement at
the earliest.
The following principles should be considered while developing the transfer
policy:
• Pressure for transfers would be reduced by making MPHW selection into a
block level cadre and other category selection including medical officers, other
than
Class‐I officers into a district level cadre.
• The authority for the transfer shall be a district and state level transfer
tribunals.
The tribunal may be made up of a three‐person board chaired by the Civil Surgeon
and Programme Officer of the district, with one of the board members appointed
by the Deputy Commissioner and another by the Employees Association.
• A roster of request for transfer should be maintained. Transfer shall be
considered in that seniority. Within the same transfer seniority shall prevail.
• All cadres may apply for transfer stating their three preferred choices.
• All postings in the district shall be classified into very difficult ( C ) and medium
difficult ( B) and choice postings (A). Every staff shall be required to serve roughly
equal time in all these levels of difficulty.
• After ten years in one area transfer is mandatory as also a matter of right, but
can be according to choice if the chosen post is vacant. Transfer out of a difficult
area would not be mandatory but would be an employee’s right if the required
period of service has been given.
• Mutual transfers shall be allowed but without contradicting any of the above
clauses.
• Persons in the last ten years of service may be exempted from mandatory
transfer.
• All promotions may be considered only after five years in difficult posting or
ten years in medium posting is completed.
Promotion Policy for Para medicals
Regular Prompt Promotion with Six Months Pre‐Promotion Training:
Prompt promotion of MPHWs to sector supervisors may be ensured. Before they
take up the task as sector supervisors both MPHWs male and female may
undertake a six‐month training programme (Currentlly male supervisors do not
have to undergo this training though women supervisors have to). There is a large
backlog and urgency needs to be given to prompt implementation of these
promotions.
Fast‐Track Promotion: We also recommend an additional system in which a
portion of total Lady Health Visitors (LHV) and male sector supervisor posts (25%)
may be reserved for promoting MPHWs on the basis of their willingness to serve
in difficult areas if they had not done so in the past, and an examination of their
skills and knowledge after a minimum period of service eg. seven years of service.
We expect that this will motivate some enthusiastic functionaries to volunteer to
serve in more difficult areas. If those promoted are not able to fulfil their
commitment and get transferred to non‐difficult areas before fulfilling their five
year commitment, their appointment as LHV/Sector supervisor will be revoked
and they will be reinstated as MPHWs.
For those MPHWs already in difficult areas, a promotion in this channel may
induce them to continue their services in these areas.
We understand that in difficult areas multiskilled sector supervisors would have
to play a major role in running 24 hr.services at sector level (See alongwith
recommendation on multi‐skilling in next sections). In such a contexts such a
parallel channel where some younger more dynamic persons become available at
the supervisors grade would the useful to initiate this
process.
Redesignation of the Block Extension Educator (BEE): T h e B l o c k extension
educator does not do block extension education and may be renamed block
senior paramedical supervisor. He would have a special responsibility in training,
capability building, IEC and supervision. This promotion should be seniority cum
merit promotion based on adequate testing of training capability from within the
cadre of all sector supervisors who have completed a certain number of years.
One Time Bound Seniority Based Promotion for All:For all other service
categories promotions and benefits there shall be one time –bound seniority
based promotion from selection cadre to senior cadre.
Promotion Policy and Career Plan For Medical Officers
Negative attitudes to the service and to their work amongst medical officers must
be recognized to be as a failure to understand and care for this cadre and due to
poor structuring of health systems‐ not “lazily” blamed on the medical officers.
The lack of transfer policy and frank discrimination in transfers is one important
reasons for demoralization. The lack of promotion avenues is another. For doctors
other than promotions the ability to enhance their skills, their prestige within the
profession, their prestige in society and their contribution to science are all
important motivational aspects that need to be provided for. Their inability to
make a career plan where they can enhance clinical skills or get other
promotional or career opportunities later is a problem. The system would reap
rich benefits if it saw the desire for career advancement of the doctors as an
opportunity instead of as a problem.
The key recommendation on promotions for doctors are:
Contractual appointments must be seen as adhoc arrangements made so far
had to be stopped because of legal reasons. Regular appointments may remain
the mainstay of the workforce. The vacant posts should be filled up at the earliest.
Timely, time bound promotions to senior grades and specialist grades needs to
be ensured.
There should be a scale like this‐ Starting 8000, after 4 years 10000, after 9 years
12000, after 14 years 14300 for all.
Ranking in reference to other Govt. Officials at District level: Earlier Civil
Surgeon used to be at 3. It should be restored.
Skill retention for specialists. The feeling of professional dissatisfaction may be
higher especially in postgraduates serving as medical officers and needs to be
addressed through better professional opportunities. Every postgraduates could
be linked to CHCs, which they attend on periodic occasions for providing specialist
services. Thus a surgeon should be able to perform operations on certain days
and so on. And they should be able to send for investigations at higher centres
directly and have access to drugs related to their field of specialization, which
normally we would not expect a PHC doctor to handle and so on.
Choice of stream for Class‐I Officers. After ten years of service when they enter
class‐I officer status the doctors may be given a choice between a clinical stream
(If necessary of a district cadre) or a state level administrative cadre with
opportunities for advancement professionally in both these streams.
Financial Burdens of MPHWs.: The department should provide for adequate
allowance to MPHWs to carry out routine paper work. Payments should be
prompt and be made on half‐yearly or annual basis.
Also, unfair reductions and false statements on expenses made on travel and
other programme purposes should be eliminated. The assistance cell (discussed
later) should be available for confidential complaints in this regard.
Personal security: Creating a Women Employees Assistance Cell at District
Level.
This must be recognized as an issue for MPW females. The Supreme Court
has already laid down the procedures under the VISAKA guidelines and these
may be publicized and implemented.
We also recommend a Women Employees Assistance Cell in all districts that will
provide legal aid, counseling and protection and some degree of grievance
redressal particularly to the MPHW female workers. The WEAC should meet every
quarter and have a confidential postal access. It should take up all issues
confidentially and in non‐confrontational manner. It should not hesitate to
recommends firm administrative or legal action where necessary, with adequate
publicity for it to act as a deterrent. The WEAC should be headed by a woman
outside the health departmentwith some experience of work on women’s issues.
The WEAC should be nominated by the
District Collector in consultation with the Civil Surgeon.
Accommodation
Block Level‐Government Housing Plan: All accommodation for medical staff at
CHC level should be part of a government housing development plan common to
all government departments so that adequate supporting infrastructure and
facilities can be developed. This can be done with private partnerships, not only
to speed implementation, but also to bring in investment. The accommodation so
provided should be adequate for all staff. Work could start with prioritization of
more difficult blocks so as to speed up development there.
Sector Level‐Category‐wise Priorities: All PHCs in medium category difficulty
should be prioritized for building government accommodation, for all the staff in
a cost effective manner.
This would act as an incentive for staff to work there. In “most difficult” category
areas accommodation may be planned for para medical staff as a priority at this
stage.
Sub‐Centre Buildings: Sub‐centre buildings may not be seen as a priority except
where the complete block level planning is completed. It is best to prioritise those
Sub‐centres where there are no rooms available on rent or alternate building
available for developing infrastructure then
only move to other centres. Some institutional delivery is not being insisted on at
HSC level,
rented accommodation with a store and a consultation/ immunization room
available and paid for by the government should be adequate for most SCs in the
immediate period. When a new building is undertaken, the current design of
MPW accommodation cum SC facility may be continued even though institutional
delivery is not insisted on as this space has other uses to merit its retention.
Where needed and when the systems of referral have developed it may be easily
be designated for institutional deliveries.
IX..LABORATORY SERVICES
• Multi skilled Cadre for PHCs: Since the current number of laboratory
technicians is adequate only to man the CHCs, a greater effort should be made on
multi‐skilling other cadre to undertake this work at the sector level. Over a few
years every support staff should have these basic skills.
• Basic Set of Tests for PHC: The basic laboratory set of tests provided at the PHC
must include blood haemoglobin estimation, total count, differential counts,
bleeding time and clotting time, blood smear examination for parasites, urine
examination for albumin, sugar, ketones, bile salts and pigments, microscopy of
urine, sputum acid fast microscopy, grams staining of sputum, csf, stool
microscopic examination for ova and cysts and hanging drop examination of
stools. The sickling test may also be considered. All these tests require very basic
skills and are easily taught. The most difficult of these is the BSE (Blood smear
examination) for malarial parasite and sputum for AFB but given that multiskilling
in this is already accepted, ability to train in this wider range of tests should not
be considered a problem.
• Training Approach: This set of tests can be taught to a team member‐ primarily
by the medical officer. Training programmes at the district level would only
supplement this.
The medical officer would only need a one week package to be refreshed on this
if there is a good text to follow along with proper teaching materials organized
well. Charts and guidebooks that both doctors and multi‐skilled staff can refer to
along with pictures of microscopic appearances should also be available in every
centre and their absence is a serious remediable problem.
• CHC tests as Per Standard Treatment Guidelines: The set of tests to be
available in a CHC have been described as part of the state’s standard treatment
guidelines and service delivery norms should be able to conduct the following
diagnostics:. Broadly the CHC should be able to conduct the following diagnostics:
Basic blood biochemistry, and microscopic studies with grams stain,
cerebrospinal, pleural, peritoneal fluid examination. Immunological testing esp.
for hepatitis, typhoid,
AIDS and syphilis.
Basic Imaging: X‐ray, ECG and ultrasound be the norm for all CHCs.
Every CHC should also have the capability to take and send samples for
microbiological cultures and histo‐pathological studies at the district level where
relevant.
• Upgraded Laboratory Technicians at CHC: The qualified laboratory technician
at the CHC level should be upgraded to provide this much larger package of tests
then what is currently available. Where still gaps remain public private
partnerships to close these gaps may be prioritized. The laboratory technicians
and the X‐ray technicians should work under the supervision and guidance and
quality control of a suitable district level officer in addition to the block medical
officer.
• Sub‐Centre Level Tests: At the SC level urine testing for albumen and sugar and
blood testing for haemoglobin should be implemented. In addition it should be
possible to train a cadre of NGOs and “trainers of ASHA programmes” and male
MPHWs to do Blood smear examination (BSEs) and sputum AFB testing along with
the above. Thus reducing reporting time of blood smears to less than 24 hours,
for all habitations. This would require investment by the government in a
microscope and a basic kit and a piece rate payment arrangement by which these
essentially private service providers can be remunerated for diagnostics done for
the public system.
X. REFERRAL SYSTEM
• Defining Referral Needs
The importance of a referral system can not be over emphasized. Broadly,
between the PHC and the CHC, or between the CHC and the district hospital, the
following reasons necessitate the need for a good referral system:
a. For establishing the diagnosis for which laboratory investigation not available at
the PHC/ CHC are needed.
b. For establishing the diagnosis for which a second opinion or an expert opinion
not available in the PHC/CHC is needed.
c. For management of case whose diagnosis is known and infrastructure, staff,
equipment is adequate but for whom drugs are available only at the next level
e.g. epilepsy.
d. For management of a case whose diagnosis is known but where a quality of
equipment or infrastructure or staff is needed which is not available in the PHCe.
g. all in –hospital care or surgical care etc.
Under condition a & b, referral is a one time event and with a good quality,
prompt feedback the case can be further managed at the PHC level. This referral
therefore, enhances the quantity and quality of services provided by the PHC.
Condition C is avoidable and requires that the drugs be available at the PHC. The
new essential drug list has a number of drugs included in the primary health
centre list so as to avoid such referrals altogether and if needed this may be
supplemented by allowing special indents.
Condition “d” may occur as an emergency or in routine out patient
circumstances.
Some of these cases would need to be followed up at the higher level for all time
to come. But many would be able to be sent back for follow up to the primary
level once the acute crisis is over. Availability of this referral enhances the
credibility of the PHC.
• Designing Effective Feedback in a Referral System
We can thus see that most of the above referral purposes need a referral system,
the heart of which is the feedback arrangement to the primary level. If such a
system is well in place the capabilities of the PHC and the medical officer there
are dramatically increased. In our situation of illiteracy and low schooling and
mystification of medical practice sending a note back with the patient is not a
reliable, accountable or effective referral system. In addition to sending the note
back with the patient the feedback data on referred patients, whether it be
expert opinion, or laboratory investigation, or instructions for follow up should be
transmitted in writing through the health system and available for verification.
Eventually this feedback should be electronically transferred through Web and
Will systems.
• Block Level Ambulance Services
A good transportation system is essential for any referral system to function
properly. It is suggested that in addition to the ambulance with the CHC a block
level ambulance service be developed in partnership with local community
organizations to transport patients and this be tied to the referral systems. It is
also essential to construct a referral system between SC and PHC and between
female Accredited ASHA and PHC based on similar principles of specifying
situations that need referral and arranging for a strong feedback mechanism.
Good communication between different tiers is needed as well and this should
be linked to the ambulance service.
• Referral Fund with Panchayats: The referral fund currently placed at the
disposal of panchayats may be operationalised through ASHA and with links to
the above mentioned ambulance system. The ASHA should be authorized to
arrange the required funds for referring needy patients and even accompanying
patients to PHC and CHC especially for certain categories of illness like high
risk pregnancy or life threatening emergencies and so on.
XI. INTEGRATION WITH INDIGENOUS SYSTEM OF MEDICINE
• Need to Integrate at Level of Public Health System: Integration of the ISM
structure with the mainstream public health services is desirable for a number of
reasons. There is a substantial investment entailed in these systems. Utilisation
is however extremely low both in terms of utilization ISM services and in terms
of it sub‐serving public health goals. By integrating the ISM network with the
public health programmes a substantial income in outcomes can be expected of
little extra cost.
• Defining ISM Package of Services at Each Level: Integration requires as a
first step the definition of what package of services each category of personnel
and facility in the ISMs would provide.
• Multi skilling ISM Personnel for Public Health Functions: Integration
requires, based on the above, a multi‐skilling of personnel to serve new roles,
new job descriptions and administrative changes to facilitate such synergy. It
also requires adequate policies of transfers and promotions and skill up
gradation so that they too do not face the de‐motivational factors that the
mainstream is already seized with.
• Sharing Infrastructure: If either the ISM facility or the mainstream sector
PHC does not have adequate infrastructure, a PHC building or the existing
infrastructure may be shared. Thus in working out areas of coverage priority be
given to closing the gap between number of sectors and the number of PHCs.
We note that if there is a synergistic deployment of the two, the current gap
between number of sectors and the number of PHCs, largest gap in the system as
would be adequately closed.
• Making a Common District and Block Public Health Plan: At the district
level the district Ayurvedic officer serve as part of the health planning committee
and this plan is integrated as a subset under the district health plan of the Civil
Surgeon’s office and the district health society. At the block level coordination
is by the SMO. At the sector level ISM facilities may be asked to perform
public health tasks in a section allotted to them also.
XII. TRAINING: The goal of the training policy shall be to ensure that all the
requisite skills to attain a specific quality of care for a given facility becomes
available at that level. This is true for
para‐medicals as well as for medical officers.
To achieve this goal we recommend an in‐service training package with following
features:
• For Paramedicals: Multiskilling
Minimum Periodic Re‐training: The training policy must specify that every two
years at least 15 days of training per MPW and health supervisor (male and
female) must be received.
Training Roster: A roster of all MPHWs and health supervisors should be
maintained at the block and district level just for this purpose denoting last
training attended, topics and number of days of training in each. The block
medical officers may coordinate with district training centre to see that all their
health workers have received the mandatory training.
Syllabus: The syllabus for it should be built up to include.
Changes in health programme guidelines of national health programmes‐ best
addressed through two day sensitization programmes, whenever such a change is
made.
Renewal of care area of their work‐RCH programme for MPHWs (at least 15
days) and national programmes for male workers.
Multiskilling training in which female workers learn more about national
programmes and about basic laboratory skills and male workers learn about RCH
and adequate levels of basic laboratory skills.
Adequate training for first contact curative care.
A modified IEC programme capability with focus on interpersonal and
community mobilization skills along with better understanding of a multicultural
and ethnically
diverse society.
• On‐the Job Training: The supervisors should be held responsible for on the job
training of the health workers and periodic evaluation of knowledge and skills of
health workers be used to ensure that they perform this task adequately, as they
should be accountable for this in their juniors. The medical officers must be
equipped to evaluate the supervisors on training in most areas and in some areas
like basic laboratory services they should be capable of providing the training on
the jobs.
• Integrate Training Funds: All training funds from various programmes are
deployed in such a way that even as the objectives of that grant is realized, the
training goals the state has set itself is also advanced within the same space.
• Training Cell to Precede and Prepare for SIHFW: A training cell for in‐service
MPHWs and supervisors training needs to be constituted in the SIHFW that is
constantly doing training needs assessment, training material development,
master trainer training of district centres, supervision of training rosters and
training evaluation.
• For Medical Officers
Continuing Medical Education: We recommend a Continuing Medical Education
scheme for medical doctors to upgrade their knowledge and skills. This should
replace the current practice of upgrading their knowledge through sporadic
camps of national disease programmes. The envisaged CME scheme should also
be useful for promotion purpose. A CME should be pursued as a very useful
intervention strategy in health care delivery system.
Minimum Skill‐Mix for CHC: Having defined a minimum package of services at
the CHC as essential to meet public health goals one needs to a put in place a
road map by which the desirable skill mix needed for delivering such a package of
services would become a reality. We make the following suggestions in this
regard:
Decide on what skill mix is needed in each CHC and what the gaps are. The focus
is on emergency obstetric care but the skill mix approach need not be confined to
this alone.
Draw up a schedule of providing short term trainings so that existing medical
officers and specialists fill up the gaps with acquired basic skill sets other than in
areas which their primary specialization. Thus a surgeon may also learn to do
Caesarean section or ENT and ophthalmic work, or a physician may learn
paediatric functions and so on.
Where gaps still remain one may use public private partnership to fill up the
gaps.
XIII. STATE AND DISTRICT LEVEL ORGANISATION
Promotions and Tenure at the State Level
Prompt and Regular Appointments: All vacancies must be filled up at the
directorate (directors, deputy directors, Civil Surgeons and programme officers at
the state level) must be filled up within a period of six months on a regular basis
from eligible staff at that level or by promotion, (except those posts that are to be
recruited from the outside on a
consultancy/ contract basis where it could take up to an year). For programme
officers at the district level and block medical officers must be filled up within the
same timeframe but in the event of creating a separate administrative cadre
where these are entry points they could take longer, up to a year.
