IIDM India 2 Determinants of Workforce Availability and Performance- Bihar IIDM India 3 Determinants of Workforce Availability and Performance- Bihar

Acknowledgement

We are thankful to National Health System Resource Center, New Delhi (NHSRC) for assigning this study to our Institute and subsequently providing administrative support in the completion of the study. Our special thanks are due to Dr. D. Thamma Rao Advisor (Human Resources for Health) NHSRC New Delhi for providing administrative as well as academic & Technical support through out the study.

Our Special Thanks are due to Dr. A. K. Tiwari, State Programme Officer Cum State Surveillance Officer, State Health Society Bihar, Mr. Ajit Kumar Singh, State Facilitators- NHSRC, Bihar for providing academic & field level support through out the study.

Our special thanks are due to all CMHOs & Dy. Superintendents of interviewed sample Health Institutions of Bihar. Our Special Thanks are due to all DPMs of Kaimur Bhabhua, Ara, Samastipur, Nawada, Kishanganj, Vaishali, & Sitamadi.

We place on record our appreciation to Dr. P.K. Bajaj for Institutional & field level data collection & participation in workshop. We are thankful to Dr. Rajeev Mohan and Dr. M. K. Mishra for their academic support & guidance in data collection.

We gratefully acknowledge the immense help received from Dr. I.C. Tiwari Our Advisor, Health System Research, in data analysis & report writing.

We also place on record our thanks to our team of research officers involving Mr. Dinesh Chandke &

Ms. Payal Tiwari for their efforts in data collection processing and data tabulation.

Dr. S. K. Trivedi Ph.D

Director IIDM India 4 Determinants of Workforce Availability and Performance- Bihar

List of contents

EXECUTIVE SUMMARY ...... 7 CHAPTER-1 ...... 12 INTRODUCTION ...... 12 1.Objectives of the study ...... 13 2. Scope of work ...... 13 CHAPTER- 2 ...... 15 BIHAR STATE – A BRIEF PROFILE ...... 15 1.Physical features ...... 15 2.Administrative units ...... 15 3.Demography ...... 15 4.Vital statistics rates ...... 16 5.Socio-economic indicators ...... 17 6.Organisation of Health Services in Bihar ...... 17 7.Health Institutions in Bihar ...... 18 8.Staff Position in Public Sector Health Facilities in Bihar ...... 18 9.Pay Scales ...... 19 CHAPTER -3 ...... 20 Methodology of the Study ...... 20 1.Sampling Design for Study ...... 20 2.Sampled institutions visited and respondents interviewed ...... 22 3.Process of data collection ...... 22 CHAPTER - 4 ...... 24 RESULTS ...... 24 1. Results of facility survey ...... 24 2. Profile of the doctors interviewed ...... 43 3. Facilities available to the doctors at place of work ...... 44 4. Service Conditions of Doctors in Bihar ...... 46 5. Human Resource Policy for doctors in Bihar ...... 57 CHAPTER - 5 ...... 66 CONCLUSIONS AND RECOMMENDATIONS ...... 66 Recommendations ...... 68 IIDM India 5 Determinants of Workforce Availability and Performance- Bihar

Annexure I ...... 70 Annexure II ...... 72 IIDM India 6 Determinants of Workforce Availability and Performance- Bihar

LIST OF ABBREVIATIONS USED

ACR Annual Confidential Report

AYUSH Indian System of Medicine (Ayurveda, Yoga, Unani, Sidha, Homeopathy)

BDS Bachelor of Dental Surgery

BPSC Bihar Public Service Commission

CHC Community Health Centre

CME Continuing Medical Education

DH District Hospital

DNB Diplomate of National Board

GDMO General Duty Medical Officers

GOI Government of India

HR Human Resource

HRA House Rent Allowance

IIDM Indian Institute of Development management

IMR Infant Mortality Rate

IPHS Indian Public Health Standards

I.V. fluid Intravenous fluid

M.D. Doctor of Medicine

M.S. Master of Surgery

NHSRC National Health System Resource Centre

NRHM National Rural Health Mission

NSDP Net State Domestic Product

OPD Out Patients Department

ORS Oral Rehydration Salt

OT Operation Theatre

PHC Primary Health Centre

RCH Reproductive Child Health

SDH Sub Divisional Hospital

SRS Sample Registration System IIDM India 7 Determinants of Workforce Availability and Performance- Bihar

EXECUTIVE SUMMARY

Background of the study:

Recognizing the importance of human resource for health as the core issue for achieving effective delivery of public health services in rural areas, the National Rural Health Mission (NRHM) has taken a number of initiatives to address the problem of manpower shortage, particularly in the underserved areas, faced by the States,

The National Health System Resource Centre (NHSRC) Delhi, created under NRHM to provide technical support to the Mission, commissioned the present study to study human resource policies and practices in the state of Bihar with an overall objective of assessing the productivity, coverage and outreach of health system. The study focused on the issues related to medical manpower (doctors) only.

Methodology of data collection

It was decided, in consultation with NHSRC and the officials of the State, to focus the study in districts with low composite (socio-economic) index. Five districts out of 23 districts with low composite index and one control district with high composite index were included in the study. The districts and the institutions (district hospital, Sub Divisional Hospital, Community Health Centres and Primary Health Centres) within it were selected using multi stage sampling technique. The investigators from the study team visited the districts and collected data from the institutions and interviewed the doctors using pre-designed and pre- tested proforma.

Findings

1 Survey of the health facilities showed that physical facilities in most of the institutions e. g. 24- hour water supply, operation theatre, 24-hour power supply with generator/ inverter back up, ambulance and telephone facilities and computer were available in all the district hospitals and SDH with a few exceptions.

2. Bed strength in most institutions including district hospitals, SDH and CHCs was inadequate. However, all the PHCs had six beds as per the recommendations of GOI.

3. Equipment availability at the health facilities was assessed by noting the presence/ absence of operating tables, OT lights, delivery tables, Boyle’s apparatus, Sterilizers/ Autoclaves, and surgical equipments. All the District hospitals and most SDH were found to be well equipped and the equipments were in working condition. But several of the CHCs and PHCs surveyed lacked essential equipments.

4. Availability of doctors at all the facilities was inadequate, particularly that of Specialist cadre. Except at district hospitals Specialists were not available at other facilities (SDH, CHCs and PHCs). Out of 56 cadre posts of specialists sanctioned in the surveyed districts only 16 (28.6%) were filled up. There was also no relationship between the bed strength of the district hospital and the sanction of Specialist post. About one third (31%) of GDMOs possessed post-graduate qualifications and were able to offer specialist services. IIDM India 8 Determinants of Workforce Availability and Performance- Bihar

5. Availability of General Duty Medical Officers was better than the Specialist as 70% of the sanctioned posts (131 out of 186) in all the health facilities (District Hospitals, SDH, CHCs and PHCs) surveyed were filled up. Availability of GDMOs has improved in recent years by appointment of doctors on contract basis raising the availability to 81%. But the distribution of doctors is not even. The availability of GDMOs varied between 33 to 100 per cent of sanctioned posts in different institutions.

6. Drug availability at the health facilities in the surveyed districts was assessed by checking availability / stock out of eight selected essential drugs. While there was no stock out of drugs at the District hospitals, and most SDHs, supply was irregular at the CHCs and PHCs causing stock outs of different drugs for varying duration.

7. Bihar follows a policy of open recruitment of doctors. Almost three fourth (71.4%) GDMOs, Specialists and Administrative grade officers were recruited through Bihar Public Service Commission (BPSC). But in recent years a large number of GDMOs have been appointed on contract basis, bye-passing the lengthy selection process of the BPSC, to meet the shortage of doctors.

8. The existing pay structures for doctors in Bihar Health Services are lower than the pay scales of Government of India as recommended by the VI Pay Commission. Doctors employed on contract basis, on the other hand, are paid fixed consolidated salary. Almost ninety per cent of the doctors of all cadres- GDMOs, Specialists and Administrative group- were not satisfied with their present pay.

9. The doctors of Bihar Health Services receive other service benefits e.g. free accommodation or house rent allowance in lieu of accommodation, different types of leave, pension, gratuity, etc. But these benefits are not available to the doctors appointed on contract.

10. Nearly sixty per cent doctors of GDMO cadre and Administrative grades (61% and 57% respectively) were of the opinion that government doctors should be permitted private practice. On the other hand, two thirds of the Specialists were not in favour of government doctors being permitted private practice.

11. Eighty per cent of doctors interviewed stated that their work load was heavy . They are also required to be on emergency duty / call duty, which places extra burden on them, particularly when there is no roster system due to shortage of doctors. Some of them are also required to do administrative duties related to management of hospitals/ health centres.

12 Poor working conditions e.g. insufficient space, inadequate availability of equipments and instruments, shortage of drugs and lack of support staffs (nursing and other paramedical) were reported by 33%, 41%, 48% and 33% doctors respectively. A larger proportion of Specialist doctors than the GDMOs pointed out to these deficiencies.

13. Many doctors stay in private houses and sometimes away from their place of posting as only about one quarter of them have been provided government accommodation. The house rent allowance paid to them is not sufficient to meet the rent of private housing.

14. Doctors also expressed dissatisfaction with the educational opportunities available to their children and their personal security at the place of their posting. IIDM India 9 Determinants of Workforce Availability and Performance- Bihar

15. The State does not provide any incentive to its doctors for undergoing higher education. For example, it does not have any preference / reservation of seats for in-service doctors for admission to post graduate programs conducted by the medical colleges of the State.

16. The State does not have any clear training policy for its doctors. They do not receive induction training on recruitment.

17. Most doctors of Bihar Health Services are not knowledgeable about the policy of the government regarding transfers, postings, promotions etc. About 84% of the doctors of all cadres had not received any promotion during their service tenure. They also do not have any written document outlining their job responsibility.

18. A system of annual performance evaluation in the form of Annual Confidential Report exists which is confidential in nature. But there is no formal system of on the job supervision and feed back. As expressed by the doctors during interview the experience of the doctors about the supervision was negative in most cases (88.5%). IIDM India 10 Determinants of Workforce Availability and Performance- Bihar

Recommendations

1. The State should create a full fledged Human Resource Division within the Directorate of Health Services with dedicated and specialized staff and budget so that HR planning, succession planning, monitoring and management functions can be carried out effectively.

2. The Department should develop a computerized data base of all doctors – Specialists and GDMOs, contract doctors for their posting, transfer, promotion, training status, etc. The data base will help in efficient management of Human Resource.

3. The State should carry out a quick study to find out the requirement of staff at different health facilities as per the bed strength, in patient and out patient load, current availability of staff and develop a strategy to meet the demand of doctors at each of the facilities.

4. The State should develop short and medium term human resource plan and take appropriate action for recruitment of doctors to bridge the gaps between demand and supply.

5. The supply and demand gaps can be reduced by taking policy decisions as compulsory rural posting after graduation for specified period, reserving seats in medical colleges for post-graduate admission for such doctors who have done compulsory rural posting / in-service doctors working in difficult/ rural areas, giving incentive for post-graduate studies in the form of accelerated promotions, extra increments, raising the age of retirement, etc.

6. There is shortage of specialist doctors in the health cadre. To meet this deficiency the GDMOs with post-graduate qualifications should be posted as per the service needs of the institutions. Where Specialist doctors cannot be posted due to shortage of such personnel the possibility of entering into private –public partnership for specialist services may be explored. Such an initiative will help reduce patient load at higher institutions of health care e.g. district hospital / medical college hospital or the patients going to private sector facilities, all of which involve high opportunity cost which most patients are unable to afford.

7. Currently the pay scales of the Specialist doctors and the GDMOs are identical. Specialist doctors and GDMOs with post-graduate qualification and rendering specialist services should be paid extra allowances.

8. Staff working on contractual basis is denied benefits which are available to regular cadre doctors. The State should ensure that contract doctors are regularized within a specified period. This will help to attract doctors to join government service. Contract doctors who have served the State for a specified period should be given preference in selection through Public Service Commission.

9. Promotions act as important incentive for doctors joining government service. A policy of time bound promotion for doctors, as is available to doctors of Central Health Services, should be evolved and implemented. Promotions should be linked to post-graduate training and in-service training attended by the doctors, IIDM India 11 Determinants of Workforce Availability and Performance- Bihar

10. The State should carry out a rapid survey of all its health facilities to find out shortage of equipments, instruments, diagnostic facilities and take urgent steps to meet the minimum needs for patient care. Besides improving patient care, this step will increase job satisfaction of the doctors.

11. The State should adopt a time bound transfer policy where a doctor gets a chance to move to cities after serving in remote/ rural areas for a fixed period. This will also help remove the concern of the doctors regarding educational opportunities for their children.

12. The State has already taken a number of initiatives/ policy decisions to reduce the manpower shortage e.g. giving rural area allowance, up-gradation of skills of doctors by short term training, starting DNB training program in selected district hospitals for in-service doctors, etc. These initiatives should be implemented on fast track. If necessary, an empowered committee of Principal Secretaries of concerned departments may be constituted to remove administrative hurdles and expedite action. IIDM India 12 Determinants of Workforce Availability and Performance- Bihar

CHAPTER-1 INTRODUCTION

Health manpower is a critical input required for delivery of efficient and effective health services to the community. In keeping with growth of the health infrastructure and the expanding scope of the health services human resource needs in India has increased rapidly during the last couple of decades. New medical colleges and paramedical training institutions have been established in the country, both in the public and public sectors, to meet the increasing needs of medical personnel in the country.

There are, however, critical gaps in the availability of health manpower in the public sector facilities in most states in India. Health manpower deficiency is both quantitative and qualitative. While adding numbers to the existing workforce is important, it is imperative that the workforce is properly managed and motivated to enhance their productivity and attain optimum level of utilization. Health service delivery is a labour intensive endeavor. It consumes up to 70 to 90 percent of the total health budget. Appropriate management of health workforce should, therefore, be a priority goal.

The National Rural Health Mission (NRHM) recognized the importance of human resource for health as the core issue for achieving effective delivery of public health services in rural areas. The Mission has initiated several strategies to meet the manpower shortage being faced by State governments. Some of the strategies implemented under NRHM have been: appointment of contractual staff, wide range of incentives to increase staff motivation, conducting in-service training, development of career paths, promoting private-public partnership, promotion of alternative service providers, etc.

The most crucial issues are the recruitment, retention and performance of medical officers and specialists. There are many dimensions to the management of the medical workforce for better health outcomes. These include policies related to recruitment, motivation, support strategies to make them available in underserved areas through compensation packages and good working environment to improve their skills. The other areas, such as conflict of interest situation arising from unregulated private practice by the public service providers, with adverse impact on the workforce performance, also need to be examined in a systematic manner.

The strategies initiated under NRHM need to be monitored and evaluated to see if the critical gaps, as identified, have been bridged to strengthen the system and thereby promote efficiency and quality of public sector health services.

Several states have established systems to address some of these issues while others lack policies for optimal workforce management and human resource development. There is a need to study and understand these experiences with different workforce strategies and help states in formulating policies and systems related to human resource management. IIDM India 13 Determinants of Workforce Availability and Performance- Bihar

1. Objectives of the study The National Health System Resource Centre (NHSRC) at Delhi is an apex body created under NRHM to provide technical support to the Mission. The present study has been commissioned by NHSRC to study human resource policies and practices in the state of Bihar with an overall objective of enhancing the productivity, coverage and outreach of health system. The study focused on the issues related to medical manpower only. The specific objectives of the study were to examine:

1. Manpower Planning & Assessment System in the state 2. Manpower (doctor) supply position 3. Incentive Schemes for doctors 4. Service Delivery Status in the state 5. Performance Appraisal & Personnel Management Issues related to doctors 6. Gaps in the support system

2. Scope of work Scope of work under different objectives of the study, as stated above, are:

Study Manpower Planning & Assessment a- Conduct situation analysis of • requirement of the Medical Officers and Specialists for the existing facilities in the state. • number of facilities required, • staff required per facility as per IPHS, • staff required as per other norms currently in use (if any) in the State and • actual number of sanctioned posts. b- Studying the processes of recruitment and deployment of Medical officers and Specialists and their effectiveness, especially in the under-serviced areas in the state. c- Identifying measures to be adapted for restructuring the policies for enhancing the availability of doctors in rural areas.

Study Manpower Supply: Study the educational strategies for ensuring availability of doctors and specialists in under-serviced areas such as

• Pre- PG rural service requirements, • Preferred access for underserved communities, • Public private divide, • Costs of education and • Socio economic & cultural background of medical students. • Identifying policy gaps to generate suitable and qualified workforce for the public health sector based on the findings. IIDM India 14 Determinants of Workforce Availability and Performance- Bihar

Study of Incentive Schemes to attract and retain doctors in the public sector: • Study the compensation package and incentives offered and the adequacy of these incentives to attract medical officers and specialists to rural areas. • Examine the incentives offered with respect to how many were able to avail them. • Identify the problems in implementation of these packages and their impact on service delivery & estimating the enhanced package required for attracting HRH (human resource for health) to specified difficult areas. • Identify compensation packages including financial and non-financial incentives that would succeed in bringing doctors to underserved areas.

Study Service Delivery Status: • Assess the gaps between the services expected to be provided as per IPHS at facility levels, • Identify the services currently provided • Identify services practically feasible with available personnel. • To recommend a core set of skills and capacity building processes for optimizing efficiency and effectiveness of the doctors and specialists.

Study the Performance Appraisal & Personnel Management Issues • Study the policies in place and assessing gaps in: • performance measures and indicators, • appraisals, • recognition of work, • postings, transfers, promotions, • continuous professional development through structured career paths, • in-service training, • medical & insurance benefits and • grievance handling systems.

Study the gaps in the support system which include • rural infrastructure, • living and working conditions, • supportive supervision and assistance. • Identifying steps to enable Medical Officers and Specialists to achieve the expected levels of effectiveness, especially with respect to under-serviced areas. IIDM India 15 Determinants of Workforce Availability and Performance- Bihar

CHAPTER- 2 BIHAR STATE – A BRIEF PROFILE

Health of the community is influenced by several factors- socio-cultural, economic, demographic, political, etc. These are considered as determinants of health. Some of these factors have been briefly examined in this chapter to understand health status of Bihar in its perspective.

1. Physical features Bihar is one of the eastern states of the Republic of India. It is located between 83-30’ to 88-00’ longitude. It is bounded by Nepal in the north, Jharkhand in the south, West Bengal in the east and Uttar Pradesh in the west. The State is part of Gangetic plain of Northern India. The Ganga is joined in the state by several important rivers e.g. Gandak, Burhi Gandak, Baghmati, Kosi, etc. which have their origin in Nepal and Sone Bhadra in Madhya Pradesh. The State is endowed by fertile soil and water resources. However, with the creation of Jharkhand State carved out of Bihar, the State has been deprived of its rich and varied mineral resources. The state is divided into two unequal halves by the river Ganga which flows through the middle from west to east. It has a total land mass of 1,095.49 sq. km. With a population of 83 million, Bihar is the third largest state in the country. It has a population density of 881 persons per sq. kilometer which is more than double the national average of 324 persons per sq. kilometer.

Bihar has always been an important political entity and part of Indian history. Patna (Pataliputra) was the capital of Mauryan Empire which was founded by Chandra Gupta Maurya and later ruled by Emperor Ashok. Bihar has a rich cultural heritage. Bodh Gaya in Bihar is a Buddhist place in the state which is visited by Buddhist pilgrims from all over the world. In olden days Nalanda had a world renowned university where students from several countries came for study. Bihar played a very important role in the Indian Freedom Movement.

2. Administrative units The state has nine revenue divisions, 38 districts, 101 Sub –Divisions and 534 Community Development Blocks. Its 45,103 revenue villages are covered by 8,471 Village Panchayats. The total number of towns in the state is 130. Patna, the state head quarter, is the largest city in the state.

3. Demography The Census of India, 2001 recorded the population of Bihar as 82 .87 million. The rural to urban population ratio is approximately 3:1. The decadal population growth rate of the state during 1981- 91 was 23.38, which rose to 28.43 per cent during the nineties (1991-2001). The national decadal growth rates during the corresponding periods were 23.86 and 21.34 which shows that the state has slipped badly in controlling the population growth rate. Gender ratio (female per 1000 males) in the state is 919 (Census 2001). The projected population of Bihar is 96.38 million (2010) and is expected to cross 100 million by 2013. The Total Fertility Rate in Bihar is 4.3 against 2.9 in India. Unless effective measures are taken for IIDM India 16 Determinants of Workforce Availability and Performance- Bihar

population control, the State’s population will keep on increasing at an alarming rate. Demographic profile of Bihar is presented in table 1.

4. Vital statistics rates The Crude Birth Rate of Bihar is 28.9 per 1000 population as against 22.8 in India. Interestingly, the Crude Death Rate in the State per 1000 population is 7.3 as against 7.4 in India. The Infant mortality Rate (death of children below one year per 1000 live births) at 56 in the State is also quite comparable to the national figure of 53. Maternal Mortality Ratio (number of deaths among women due to causes related to pregnancy and child birth per 100,000 live births), in Bihar it is, on the other hand, much higher than the national rate, being 312 and 254 respectively.

Table 1. Demographic Profile of BIHAR

Demographic characteristics Bihar India

Total population in mill. (Projected 2010) # 96.389 1176.742

Male population in mill. (Projected 2010) # 49.980 609.107

Female population in million (Projected 2010) # 46.409 567.634

Urban population ratio to total population 10.46 27.82

Sex ratio (female / male) 919 933

Decadal growth rate of population 28.62 21.3%

Density of population (per sq. km.) 881 267

Schedule caste population (%) 15.47 16.2

Schedule tribe population (%) 0.89 8.2

Expectation of life at birth (2006-10)

Male 67.1 65.8

Female 66.7 68.1

Birth rate(SRS Bulletin Oct 2009) 28.9 22.8

Death rate (SRS Bulletin 2009) 7.3 7.4

Infant mortality rate (per 1000 live births) (SRS, Oct.2009) 56 53

Under five mortality rate - 57

Maternal mortality ratio ( SRS - 2004-2006)* 312 254

Total fertility rate (2004)* 4.3 2.9

Source: National Health Profile, 2006, Central Bureau of Health Intelligence, MOHFW, GOI, New Delhi

# Projected population is based on Census Final Population Totals, Census of India, 2001

* Statistical Report, Registrar General of India, 2004. IIDM India 17 Determinants of Workforce Availability and Performance- Bihar

5. Socio-economic indicators Bihar is among the States in India which have not been able to keep pace with the rapid socio-economic development post Independence. There are several important factors which have caused low rate of economic development in Bihar.

Although the overall literacy rate in Bihar has increased from 13.5 in 1951 to 47.5 per cent in 2001, it is still much lower as compared to the national average of 64.8 per cent (Census of India, 2001). Only about one third (33.6%) of women in Bihar are literate. It is generally agreed that female literacy plays an important role in determining the health status of members of the family. Low female literacy is one of the important factors contributing towards poor health status of the population in Bihar.

The per capita NSDP (2002-04) of Bihar at current prices is Rs. 6015. Forty three percent of people in Bihar live below the poverty line as compared to 26 per cent national figure. The rural urban gap in persons below poverty line in Bihar is larger (44 per cent and 33 per cent respectively) than in India as a whole (27% and 24% respectively). Human Development Index of Bihar (a composite index of literacy, income, IMR, etc) is 0.367 as compared to 0.472 in India.

Table 2. Socio-Economic Indicators of Bihar

Socio-economic Indicators Bihar India

Literacy rate (2001 Census) 47.0 64.8

Male 59.7 75.3

Female 33.1 53.7

% population below poverty line 42.6 26.1

Rural 44.3 27.1

Urban 32.91 23.6

6. Organisation of Health Services in Bihar At the state level the Minister of Health reviews and oversees the activities and provides direction to the programs of Department of Health (excluding Medical Education, Family Planning and Indian System of medicine). The administrtave head of the Department of Health is Principal Secretary Health and is supported by Special Secretary, Additional Secretary, Deputy Secreaties and other Secretariat level officers. The Directorate of Health (Health, Medical Education, and Family Welfare) is headed by the Director General of Health Services. He is supported by Directors of Health Services, Additional Director, Joint Directors (Planning, Communicable Diseases, Reproductive and Child Health, etc.), Deputy Directors, State Program Officers (Leprosy, Tuberculosis, Filariasis, etc) and other technical officers. Regional level health organisation is headed by Regional Deputy Director. At the District level the chief of medical and health services is Chief Medical and Health Officer and is supported by Civil Surgeon of the District Hospital and District level Program officers (RCH, Malaria, Tuberculosis, etc.). Specialists and General Duty Medical Officers (GDMOs) are responsible for delivery of medical care at the district level institution (District Hospital) and institutions below it (Sub Divisional Hospitals, Referal Hospitals, Community Health Centres, PrimaryHealth Centres). The medical cadre, is thus comrised of General Duty Medical Officers (GDMOs) and Specialist. Administrative level officers (Civil Surgeon, Chief Medical and Health Officer, etc.) are drawn from either GDMOs or Specialist cadres, based on seniority and merit. IIDM India 18 Determinants of Workforce Availability and Performance- Bihar

7. Health Institutions in Bihar There are six medical colleges in the State, located at Patna (two), Muzaffarpur, Darbhanga, Gaya, Bhagalpur ,Kishengunj and Katihar. Out of 38 districts only 25 have district hospitals while in 11 districts hospitals are under construction. The State has 23 Sub Divisional Hospitals, 70 Referal Hospitals, 533 PHCs, 1243 Additional PHCs and 8858 Sub Health Centres. There are currently very few Community Health Centres in the State. But it is proposed to upgrade the PHCs in the State to CHCs

Number of District Hospitals, Sub Divisional Hospitals,CHCs, PHCs and SHCs in Bihar is shown in Table 3.

Table 3. No. of District Hospitals, SDHs, CHCs, PHCs & Sub Health Centres , Bihar

Institutions Existing Taken up in 2006-07 Targets for Targets for 2008-09 No. 2007-08

Sub Health Centres 8858 3106 1663

Additional PHCs 1243 - 662 331

PHCs 533 62+ New 73 --

(APHC to be upgraded to PHC)

PHCs to CHCs 533 - 201 201

FRUs (76 sanctioned) - - 50 26

Referal Hospitals 70 - - -

Sub Divisional Hosp. 23 20 (new construction) - -

District Hospitals 25 11 (new construction - -

Medical College Hospitals 6 3

8. Staff Position in Public Sector Health Facilities in Bihar As stated above the state has presently two cadres of medical personnel i.e. that of Specialists and General Duty Medical Officers. The sanctioned posts and availability of staff is shown in Table 4. Number of vacant posts, particularly of the specialist cadre, is huge which affects the delivery of health care to the people. In recent years a large number of contractual appointments of GDMOs and Specialists have been made in the state to reduce the staff deficiency.

Table 4. Number of Specialists and GDMOs sanctioned & Posted in Bihar

Staff position Specialists GDMOs

No. % No. %

Posts sanctioned 2967 - 7096 -

Posts filled up 319 10.75 3038 42.81

Posts vacant 2648 89.25 5562 57.19

Total 2967 100 7096 100 19 IIDM India 20 Determinants of Workforce Availability and Performance- Bihar

CHAPTER -3 Methodology of the Study

Information from the field were collected by the investigators to assess the status of health services in Bihar through

1. Survey of the health facilities covered under the study 2. Interview of the doctors to elicit their personal characteristics and their perception about the health services

Data collection from institutions and the respondents was done on a sample basis. The following sampling procedures and design were employed for this purpose:

1. Sampling Design for Study A multistage sampling design was used for data collection in the field.

Stage I: Selection of the districts: There are 38 districts in Bihar. The State has ranked the districts using a composite index of development. Development index wise ranking of the districts is shown in annexure I There are 15 districts in the State which have composite development over 0.40 while the remaining have composite index of less than 0.40 Since the overall objective of the study on manpower was to study the factors associated with poor availability of medical manpower in the State and to seek solutions to enhance the productivity, coverage and outreach of health system it was decided, in consultation with NHSRC and the officials of the State, to focus the study in districts with low composite index. Five districts out of 23 districts with low composite index (less than 0.40) were included in the study while one district from high composite index was included as a control. Using purposive sampling procedure Vaishali district (composite index 0.42) was selected as a control as it is the nearest district to Patna, the State headquarter, and is the district of choice for posting by the medical officers.

The districts with low composite development index (less than 0.40) were grouped in five zones based on direction and distance of the districts from the state head quarter. One district from each of the five zones was randomly selected for study.

The following 5 districts were selected as given below (see map):

1. Nawada South Zone 2. Sitamarhi North Zone 3. Samastipur Central Zone 4. Kaimur (Bhabhua) West Zone 5. Kishanganj East Zone 6. Vaishali Control district (with > 0.40 index) IIDM India 21 Determinants of Workforce Availability and Performance- Bihar

The investigators from the study team visited the selected districts and collected data from the institutions (office of CMHO/ District hospital). and interviewed the doctors using pre-designed and pre-tested proforma (Proforma for Institution for collection of data on facilities)

Visit to Kishen Gunj district revealed that there was no district hospital. In view of this, district hospital Ara was selected as a replacement sample.

Stage-II: Selection of the Sub districts Hospital / Civil Hospital In each district one Civil Hospital/ Sub District Hospital having more than 30 bed hospital was selected on random basis.

Stage-III: Selection of the CHCs In each district 2 CHCs/ Referral hospital were selected on the basis of distance from the district Head Quarter: the nearest CHCs & the farthest CHC from the district HQ.

Stage-IV: Selection of the PHCs/ Additional PHCs In each CHCs/ Referral Hospital area one PHC/ Additional PHC was selected randomly. But preference was given to PHC providing services round the clock (24X7 PHC) if available.

Stage-V: Selection of respondents Administrative officers / Doctors (GDMO/ Specialists) were interviewed by the investigators to collect data from the staff (respondents). The doctors working in the hospitals/ health facilities are busy looking after the patients and are sometimes not available for interview. Convenience criteria was, therefore, used for selecting the required number of Specialists and GDMOs from among the doctors present on the day of visit and who could spare time for interview.

At the district level the respondents were:

a- Chief Medical and Health Officer of the district. b- Dy. Superintendent of the District Hospital c- Six Specialists & five GDMOs at the district Hospital

At the Sub district hospital the respondents were:

Four Specialists & five GDMOs at the Sub district Hospital / Referral Hospital

At the CHC/ Referral hospital level the respondents were:

Five GDMOs

At the PHC/ Additional PHC level the respondents were:

Two GDMOs

To ensure the availability of respondents the sampling was done at the district level in consultation with District Program Manager/ CMHO. Sometimes there was no doctor present at the sampled institution. In such cases data was collected from nearby PHC/ Additional PHC in the same area. IIDM India 22 Determinants of Workforce Availability and Performance- Bihar

2. Sampled institutions visited and respondents interviewed The total number of institutions visited and the doctors interviewed for data collection during the study is shown in the following the Table below.

Table 5. Number of Institutions visited and Doctors Interviewed in the six sampled districts

Institution Institution Doctors Proforma Total

Proforma Specialists GDMO proforma

State H.Q 1 - - 1

District Hospital. 1x 6 district =6 6x 6 districts= 36 5x6 districts =30 78

Sub Divisional 1x 6 districts= 6 4x 6 district = 24 5x6 dist = 30 60 Hospital

CHC / Referral 2 x 6 districts = 12 No specialists 5x 12 CHC =60 72 hospital available

PHC 2x 6 districts = 12 No specialist posted 2x12 PHC =24 36

Total 36 60 144 247

3. Process of data collection

1. Review of the instruments for data collection The data collection instruments were designed and finalized by the National Health System Resource Centre to maintain uniformity of study in different states. A two day review meeting was, however, held at IIDM to discuss the instruments for data collection. The meeting was attended by senior consultants and the investigators. The background and the objectives of the study, data collection process, methodology, study instruments, interview technique and quality control issues were explained to the participants. An overview of health system in Bihar was given. Each item of the instrument was reviewed and, where necessary, discussed to understand the items. Clarifications were also obtained on some issues from NHSRC where the purpose and meaning of questions were not clear. The investigators also carried out mock interview on data collection. The role of different members of the team, the investigators, supervisors and team leaders was explained. This was followed by preparation of schedule of visits for data collection. The State Mission Director and Coordinator were also consulted before finalizing the dates of field visits.

2. Consultation with State and District level health officials The Directorate of Health Services and the Mission Director of NRHM were visited by the senior consultants to brief them about the objectives and the scope of the study. Letters were issued by them to the Chief Medical Officers of the districts to be visited for field study outlining the objectives of the study and instructing them to extend their support to the research team. State level visits were also made to collect information about the organization of health services in the state, number of posts of doctors and specialists sanctioned and in place, health institutions in the state and other aspects of the study.

The same process was adopted at the district level by the field investigators to elicit the co-operation and support of the district officials for the study. Consultation was made with them to select the institutions on IIDM India 23 Determinants of Workforce Availability and Performance- Bihar

sample basis for facility survey. The district officials also issued letters to the officers’ in-charge of the health facilities to facilitate data collection.

3. Data collection in the field The field investigators carried out facility survey and interview of the doctors using the study instruments. Field investigators were supervised by senior investigators. They reviewed every day the information collected to ensure that the schedules are complete and the data is consistent. Data cleaning and revisit to the facilities surveyed were carried out, as and when required. Any problem encountered by the investigators in data collection was resolved by the supervisors by on the spot visit. Monitoring of the field work was undertaken by the consultants and by IIDM office. Data entry and data analysis was done at the IIDM office by technical persons who were part of the study from the very beginning of the study. IIDM India 24 Determinants of Workforce Availability and Performance- Bihar

CHAPTER - 4 RESULTS

The results of the study are presented in this chapter under the following five headings;

1. Results of facility survey of the health institutions covered under the study 2. Profile of the doctors interviewed 3. Opinion of the doctors about the facilities available at work place 4. Service terms and conditions of doctors 5. State policies about human resource management

1. Results of facility survey Facility survey was carried out in 35 health institutions, which included six District Hospitals, five Sub Divisional Hospitals, eight Community Health Centres and sixteen Primary Health Centres. District-wise number of health facilities studied is shown in Table 6. In Kishangunj district there was no district hospital so District hospital of Ara was included as a replacement sample. As such, district hospital was the only institution surveyed in Ara district while in other districts Sub Divisional Hospitals (SDH), CHCs (Community Health Centres) / Referral Hospitals and PHCs (Primary Health Centres) were also covered besides the District Hospital. Among other types of institutions, Samastipur did not have any SDH while in Sitamarhi district no CHC was available for study.

Table 6. Health Facilities surveyed in the Sample Districts Institutio Ara Kaimur Kishanganj Nawada Samastipur Sitamarhi Vaishali Total ns

DH 1 1 0 1 1 1 1 6

SDH 0 1 1 1 0 1 1 5

CHC 0 1 1 2 2 0 2 8

PHC 0 3 2 2 3 4 2 16

Total 1 6 4 6 6 6 6 35 IIDM India 25 Determinants of Workforce Availability and Performance- Bihar

Health Facilities surveyed in the Sample Districts DH 4 4 3 3 SDH 3 2 2 2 2 2 CHC 1 1 1 1 1 1 1 1 1 1 1 1 0 0 0 0 0 0 PHC 0 Ara Kaimur Kishanganj Nawada Samastipur Sitamarhi

1.1 Physical facilities in the health institutions surveyed in the sampled Districts A check list of items was prepared to study the physical facilities at the institutions. The list included presence/ absence of Operation Theatres, 24-hour water supply, 24- hour power supply, inverter/ generator as a back up for power interruption, ambulance, telephone, and computer with internet connection etc.

District-wise information about physical facilities in the surveyed districts showed that except non- availability of 24-hour power supply in Newada, Samastipur and Sitamarhi districts all other physical facilities e. g. 24- hour water supply, operation theatre, generator/ inverter, Ambulance and telephone facilities and computer were available at all the district hospitals surveyed.

Table 7. Availability of physical facilities at District Hospitals Ara Kaimur Kishanganj Nawada Samastipur Sitamarhi Vaishali Physical facilities at District hospitals covered under the study

District Hospital (N=1)

Operation Theatre Yes Yes 0 Yes Yes Yes Yes

Water Supply -24 Hours Yes Yes 0 Yes Yes Yes Yes

Electricity – 24 Hours Yes Yes 0 No No No Yes

Generator/ Inverter Yes Yes 0 Yes Yes Yes Yes

Ambulance Yes Yes 0 Yes Yes Yes Yes

Telephone No Yes 0 Yes Yes Yes Yes

Computer with Internet Yes Yes 0 Yes Yes Yes Yes Note: There was no District Hospital in Kishangunj district.

Physical facilities available at Sub Divisional Hospitals, Community Health Centres and Primary Health Centres in different districts are shown in the Table 8, 9 and 10 respectively. IIDM India 26 Determinants of Workforce Availability and Performance- Bihar

One Sub Divisional Hospital (SDH) was studied in each of the districts included in the sample. Samastiput district, however, did not have any SDH. In the Sub Divisional Hospitals surveyed all the physical facilities were available except that in Sitamarhi district 24-hour water supply, uninterrupted power supply, ambulance and telephone facilities were not present. Twenty-four hour water supply and power supply were also not available at SDH in Vaishali district. SDH in Newada district lacked 24- hour power supply and computer facility. (Table 8).

Facility survey of the Community Health Centres revealed that out of eight CHCs covered under the facility survey three did not have 24-hour power supply. These CHCs were in Kishengunj, Newada and Vaishali districts. Absence of 24-hour water supply was noted in one CHCs each of Samastipur district and Vaishali district while Kishengunj and Vaishali district CHCs did not have ambulance facility. (Table 9)

Table. 8. Physical facilities at the Sub Divisional Hospitals

Kaimur Kishanganj Nawada Samastipu Sitamarhi Vaishali Physical facilities at Sub Divisional r ospitals

Operation Theatre Yes Yes Yes 0 Yes Yes

Water Supply -24 Hours Yes Yes Yes 0 No No

Electricity – 24 Hours Yes Yes No 0 No No

Generator/ Inverter Yes Yes Yes 0 Yes Yes

Ambulance Yes Yes Yes 0 No Yes

Telephone Yes Yes Yes 0 No Yes

Computer with Internet Yes Yes No 0 No Yes Note: There was no Sub Divisional Hospital at Samastipur

Table 9. Physical facilities at the Community Health Centres

Physical facility at Kaimur Kishanganj Nawada (n=2) Samastipur Vaishali Community Health (n (n=1) (n=2) (n=2) Center =1 )

Operation Theatre Yes Yes No Yes Yes Yes Yes Yes

Water Supply -24 Hours Yes Yes Yes Yes Yes No Yes No

Electricity – 24 Hours Yes No Yes No Yes Yes Yes No

Generator/ Inverter Yes Yes Yes Yes Yes Yes Yes Yes

Ambulance Yes No Yes Yes Yes Yes Yes No

Facility survey of fifteen PHCs in the six districts of Kaimur, Kishengunj, Vaishali, Nawada, Samastipur and Sitamarhi showed that a large number of them lacked essential facilities like 24 hour water supply or 24 hour power supply. (Table 10). Within a given district while facilities were satisfactory in one/ two IIDM India 27 Determinants of Workforce Availability and Performance- Bihar

PHCs, the remaining PHCs were inadequately equipped. Out of 15 PHCs surveyed eight did not have an Operating Room, nine did not have 24- hour water supply, five did not have 24 –hour power supply, four did not have ambulance and three did not have telephones.

Table 10. Physical facilities at the Primary Health Centres covered under survey

Physical Kaimur (n=3) Kishangan Nawada Samastipur (n=3) Sitamarhi (n=4) Vaishali facili j (n= (n= ties (n= 1) 2) at 2) Prim ary Heal th Cent er

Operation Yes No No Yes Yes Yes Yes Yes No No No Yes No No No Yes Thea tre

Water No No Yes Yes Yes Yes No Yes No Yes No No No Yes No No Supp ly -24 Hou rs

Electricity – No No Yes Yes Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes 24 Hou rs

Generator/ Yes Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes Yes Yes Inve rter

Ambulance Yes No Yes Yes Yes Yes Yes Yes No No Yes Yes No Yes Yes Yes

Telephone Yes No Yes Yes Yes Yes Yes Yes No Yes Yes Yes No Yes Yes Yes

Computer Yes No Yes Yes Yes No Yes Yes No No No Yes No No Yes Yes with Inter net

Considering the physical facilities at all the institutions (DH, SDH, CHC, PHC) together operation theatres were present in three fourth (74.3%) of the institutions surveyed. Twenty four hour water supply and electricity supply was available in 77.1 and 48.6% facilities respectively. Power supply in many districts in Bihar is erratic. But this deficiency has been taken care of by the State by supplying electricity generating sets / invertors to the health facilities. Standby electricity generation facility was available in all the institutions (95.3%) except in one facility in Samastipur and Sitanarhi each. But generators/ Invertors are no substitute for regular power supply as the alternate power supply system cannot fully meet the power requirements of the institutions. Ambulance services were available in more than three fourth (82.9%) IIDM India 28 Determinants of Workforce Availability and Performance- Bihar

facilities. Telephone and computer with internet connection were available in 80% and 60% facilities respectively

1.2 Equipments availability in the health facilities Equipment availability at the health facilities was assessed by noting the presence/ absence of operating tables, OT lights, delivery tables, Boyle’s apparatus, Sterilizers/ Autoclaves, and surgical equipments.

All the District hospitals were found to be well equipped. Operating tables, OT lights, delivery tables, Boyles Apparatus (for anesthesia), Sterilizers/ Autoclaves and surgical equipments were present and in working condition in all the district hospitals except at Samastipur district hospital where OT light was not functional. (Table 11).

Similarly, the Sub Divisional hospitals had all the equipments mentioned above in working condition. But Boyle’s apparatus was not present in working condition at two SDH i.e. in Nawada and Vaishali districts. (Table 12)

The equipments included under facility survey at District and SDH were essential items. It was nice to note that the equipments were present in all the institutions and was in working condition with a few exceptions. The State should ensure that the missing items are supplied on priority basis and a good system for maintenance and repairs is developed.

Table 11. Availability of Equipments at the District Hospitals

Ara Kaimur Kishanganj Nawada Samastipur Sitamarhi Vaishali Equipment availability at District Hospital (n=1) Functional Delivery & Episiotomy Yes Yes 0 Yes Yes Yes Yes

Functional OT light Yes Yes 0 Yes No Yes Yes Functional OT table Yes Yes 0 Yes Yes Yes Yes Boyle’s Apparatus (for Anesthesia) Yes Yes 0 Yes Yes Yes Yes

Instruments for Surgery Yes Yes 0 Yes Yes Yes Yes Sterilizer/ Autoclave Yes Yes 0 Yes Yes Yes Yes Note: There was no district hospital at Kishangunj district. IIDM India 29 Determinants of Workforce Availability and Performance- Bihar

Table 12. Availability of Equipments at Sub Divisional Hospitals

Kaimur Kishanganj Nawada Samastipur Sitamarhi Vaishali Equipment availability at Sub Divisional Hospital Functional Delivery & Episiotomy Yes Yes Yes 0 Yes Yes

Functional OT light Yes Yes Yes 0 Yes Yes Functional OT table Yes Yes Yes 0 Yes Yes Boyle’s Apparatus (for Anesthesia) Yes Yes No 0 Yes No

Instruments for Surgery Yes Yes Yes 0 Yes Yes Sterilizer/ Autoclave Yes Yes Yes 0 Yes Yes Note: No SDH at Samastipur district.

Community Health Centres / Referral Hospitals are expected to provide services of Surgical, Medical, Paediatrics, and Obstetric/ Gynaecology specialists and should be equipped accordingly. The availability of equipments was, however, not very satisfactory at the Community Health Centres. Except at two CHCs, Boyle’s apparatus was not available at the remaining i.e. at six CHCs. In one out of the two CHCs in Nawada district functional delivery table, operating table and OT light were not available. (Table 13). In Bihar some of the PHCs have been designated as Community Health Centres but they have not been upgraded with the required number of beds, operating room facilities etc. Hence the deficiencies were observed at these institutions.

Several of the PHCs surveyed also lacked essential equipments e.g. functional OT lights, Boyle’s apparatus, delivery tables and Sterilizer/ Autoclave, instruments for surgery, etc. (Table 14).

Table 13. Availability of equipments at CHCs

Equipments at Community Kaimur Kishanganj Nawada Samastipur Vaishali Health Center (n=1) (n=1) (n=2) (n=2) (n=2)

Functional Delivery & Episiotomy Yes Yes Yes No Yes Yes Yes Yes Functional OT light No Yes Yes No Yes Yes Yes Yes Functional OT table Yes Yes No No Yes Yes Yes Yes Boyle’s Apparatus (for Anesthesia) No No Yes No No No No Yes Instruments for Surgery No Yes Yes Yes Yes Yes Yes Yes Sterilizer/ Autoclave Yes Yes Yes Yes Yes Yes Yes Yes IIDM India 30 Determinants of Workforce Availability and Performance- Bihar

Table 14. Availability of equipments at the PHCs

Primary Health Kaimur Kishangan Nawada Vaishali Samastipur Sitamarhi (n=4) Center (n=3) j (n=2) (n=2) (N=3) (n=2)

Functional Delivery & Yes Yes Yes Yes Yes Yes Yes Yes Yes No N Yes Yes N Yes Yes Episiotomy

Functional OT light Yes No Yes Yes No No Yes Yes Yes No N Yes No N Yes Yes

Functional OT table Yes Yes Yes Yes Yes Yes Yes Yes Yes No N Yes Yes N Yes Yes

Boyle’s Apparatus Yes No Yes No No Yes Yes Yes No No N Yes Yes N Yes Yes (for Anesthesia)

Instruments for Surgery No Yes Yes Yes Yes No Yes Yes Yes No N Yes Yes N Yes Yes

Sterilizer/ Autoclave Yes Yes Yes Yes Yes Yes Yes Yes Yes No N Yes Yes N Yes Yes

Examination tables and B.P. instruments were present in the Out Patients Department of different institutions in all the districts. The exceptions were two facilities in Samastipur district where examination table were not present in the OPDs. (Table 15)

Table 15. Facilities available at Out Patients Department

Ara Kaimur Kishanganj Nawada Samastipur Sitamarhi Vaishali Total (N=1) (N=6) (N=4) (N=6) (N=6) (N=6) (N=6) (N=35)

Examination Table in 1 6 4 6 4 6 633 OPD

Functional BP 1 6 4 6 6 6 635 Apparatus IIDM India 31 Determinants of Workforce Availability and Performance- Bihar

Facilities available at Out Patients Department

6 6 6 6 6 6 6 6 4 4 4 4 2 1 1 0 Ara Kaimur (N=6)Kishanganj Nawada Samastipur Sitamarhi (N=4) (N=6) (N=6) (N=6)

Examination Table in OPD Functional BP Apparatus

1.3 Availability of X-Ray, Ultra Sound and Blood Storage / Banking facilities (Table 16) X-Ray machines were present in 19 out of 35 (54.3%) facilities. But if PHCs are excluded where X-Ray machines are not mandatory as per the government norms, then all the other institutions (District hospitals, SDH, CHCs) were having X-Ray machines. Sonography facility was, however, available at only 2 institutions i.e. District Hospital Ara and District Hospital Vaishali.

Blood bank/ blood storage facilities were present in 7 out of 35 facilities (20%). Under RCH program blood bank / blood storage facilities are recommended in all the hospitals providing Emergency Obstetric Care. This deficiency needs to be taken care of to strengthen emergency obstetric care facilities in all the designated institutions identified for this purpose. IIDM India 32 Determinants of Workforce Availability and Performance- Bihar

Table 16. Facilities of Blood banking, X-Ray and Sonography at the institutions surveyed

Ara Kaimur Kishanganj Nawada Samastip Sitamarhi Vaishali ur

District Hospital (N=1 in each district, except Kishengunj)

Blood Storage /Banking Yes No 0 No Yes Yes Yes Facilities

X-Ray Machine Yes Yes 0 Yes Yes Yes Yes

Ultrasound Machine Yes No 0 No No No Yes

Kaimur Kishangan Nawada Samastipu Sitamarhi Vaishali j r

Sub Divisional Hospital (N=1 at each district) Blood Storage /Banking Facilities No Yes No 0 No No

X-Ray Machine Yes Yes Yes 0 No No Ultrasound Machine No No No 0 No No Note: There was no SDH in Samastipur district.

Community Health Center Kaimur (n=1) Kishanganj (n=1) Nawada (n=2) Samastipur (n=2) Vaishali (n=2) Blood Storage / Blood Banking Facilities No 0 No No Yes No No No

X-Ray Machine Yes 0 No No Yes Yes Yes Yes Ultrasound Machine No No No No No No No No

Primary Health Center Kaimur Kishangan Nawada Vaishali Samastipur Sitamarhi (n=4) (n=3) j (n=2) (n=2) (n=3) (n=2)

Blood Storage /Banking Facilities N N N NYesN NoNo N N N N N N N N

X-Ray Machine N N N N No N NoYesYeN N N N N N N

Ultrasound Machine NNNNNoNNoNoNNNNNNNN

Note: Yes represent availability of the resource while no means not available IIDM India 33 Determinants of Workforce Availability and Performance- Bihar

To sum up, the findings of facility survey in the surveyed districts, it can be stated that basic facilities for service delivery are available in most institutions in the districts, although several deficiencies were observed in some institutions. The facilities enquired were basic minimum and are not very costly. What, therefore, needs to be done by the State is that facility survey of all the health facilities in the State should be completed on priority basis and missing items/ instruments are made available to the institutions to remove the deficiencies. Sufficient funds are available under RCH program and with a little better management initiative the health facilities in the State can be improved considerably. This will not only improve the service delivery at the government institutions, particularly the RCH services, but will also enhance job satisfaction of the doctors.

1.4 Availability of beds in the institutions surveyed Beds available in different types of institutions in the surveyed districts are shown in Table 17

Table 17. District-wise availability of beds in different health institutions

District Distt. Hosp. SDH CHC- I CHC-II PHC

Ara 147 - - - -

Kaimur 120 36 30 - 6

Kishangunj No DH 60 30 - 6

Nawada 120 6 6 6 6

Samastipur 82 - 36 30 6

Sitamarhi 90 30 - - 6

Vaishali 120 6 30 30 6

Note: In Ara district only district hospital was studied .

As noted earlier, Kishangunj district did not have any district hospital. District hospital Ara was therefore, studied as a replacement sample. In the district hospitals the bed strength varied between 82 (Samastipur) to 147 in Ara district with mean as 113 beds per district.

Samastipur district did not have any Sub Divisional Hospital. Kishangunj sub Divisional Hospital (which did not have a district hospital) had maximum number i.e. 60 beds. In the remaining districts bed availability was: Kaimur 36, Samastipur 30, and Nawada and Sitamarhi 6 each.

No Community Health Centre was present in Sitamarhi district. In Nawada district two institutions (PHCs) were designated as CHCs (but not yet functional) and their bed strengths were six each. In the remaining districts bed strength of CHCs was thirty each which was as per the established norm of Government of India. Bed availability in the PHCs in the districts surveyed was as per the GOI norm i.e. six each. Thus, the bed availability in the CHCs and PHCs was as per the national norms, with a few exceptions.

1.5 Availability of doctor (GDMOs and Specialists) in the institutions Surveyed The State of Bihar has a sanctioned cadre strength of 2967 Specialists and 7096 GDMOs. Against the sanctioned posts only 319 Specialist doctors and 3038 GDMOs are working (Jan 2010), which means 89% and 57% vacancies respectively. IIDM India 34 Determinants of Workforce Availability and Performance- Bihar

1.5.1 Posts of doctors sanctioned and available in the surveyed district hospitals

District-wise number of posts of Specialists sanctioned and in position is shown in Table 18

Table 18. Specialist posts sanctioned and in position in the surveyed districts hospitals

District Regular posts Contractual posts

Sanctioned Posted % Filled Sanctioned Posted % Filled

Ara (147) 0 0 0 0 0 0

Kaimur (120) 31 7 22.6 4 4 100

Nawada (120) 7 3 42.9 3 0 0

Kishengunj * ------

Samastipur (82) 8 2 25 1 1 100

Sitamarhi (90) 9 3 33 - - -

Vaishali (120) 1 1 100 - - -

Total 56 16 28.6 8 5 62.5

* No district hospital.

Note: Figures in parenthesis are the number of beds in different district hospitals

Out of 56 cadre posts of Specialists sanctioned in the surveyed districts only 16 (28.6%) were filled up. Similarly, out of 8 contractual posts of Specialist sanctioned only 5 (62.5%) were filled. Ara District hospital, which had largest number of beds, was not having any sanctioned post of Specialist, neither the cadre post nor the contractual. Kaimur district hospital with 120 beds had the largest number of Specialists – 7 regular cadre and 4 contractual- working. Vaishali district with 120 beds had only one Specialist Thus, large numbers of sanctioned posts of Specialist were vacant in the districts. There was also no relationship between the bed strength of the hospitals and the sanction of Specialist post.

The posts of GDMOs sanctioned and in position in different district hospitals are shown in Table 19.

Table 19. GDMOs posts sanctioned and in position in the surveyed district hospitals

District Regular posts Contractual posts

Sanctioned Posted % filled Sanctioned Posted % filled

Ara 15 15 100 - 3 Extra posts*

Kaimur 20 6 30 4 5 Extra posts*

Nawada 9 8 88.9 0 0 0

Kishengunj ------

Samastipur 4 9 Extra posts* - 3 Extra posts*

Sitamarhi 9 12 Extra posts* - - -

Vaishali 11 10 90.9 - 3 Extra posts* IIDM India 35 Determinants of Workforce Availability and Performance- Bihar

District Regular posts Contractual posts

Sanctioned Posted % filled Sanctioned Posted % filled

Total 68 60 88.2 4 14 Extra posts*

* Extra number of GDMOs was working than the sanctioned posts

The position about the availability of GDMOs in the district hospitals was somewhat better as compared to the availability of Specialists. (Table 19). Out of 68 cadre posts of GDMOs sanctioned in the surveyed districts 60 (88.2%) were filled up. Further against 4 contractual posts of GDMOs sanctioned 14 were found to be working. Additional posts of GDMOs working than sanctioned could be due to:

• Doctors from the other institutions (CHCs/PHCs) in the district were withdrawn and posted in the district hospitals due to heavy work load of patients at the district hospitals • The state had allowed the districts to fill up the posts on contract basis as per the need and availability of doctors.

This has somewhat improved the availability of doctors at the district hospitals. But the fact remains that the availability of doctors- both Specialists and GDMOs- is low and needs to be corrected in the interest of the quality of patient care. When judged from the angle of availability of doctors as per IPHS standards the staff deficiency is much acute. Recommended staff for district hospitals as per IPHS is shown at annexure 2.

The bed strength of the district hospitals surveyed under this study ranged between 82 (Samastipur) to 147 (Ara). The IPHS recommends posts of 34 doctors (Specialists and GDMOs) for every district hospital with bed strength of 100-200. Calculated on this basis the six district hospitals under consideration should have total around 200 doctors. Against this requirement total availability of doctors in the six district hospitals is only 136 (Specialists and GDMOs- regular and Contractual appointees). The short fall in the availability of doctors, thus, becomes obvious.

1.5.2 Posts of doctors sanctioned and available at Sub Divisional Hospitals

There was no Sub Divisional Hospital in Samastipur district. In Ara district no SDH was surveyed as only Ara district hospital was studied as replacement sample because Kishengunj district did not have a district hospital. Results of medical staff availability in the SDH of remaining five districts are shown in Table 20

Table 20. GDMO posts sanctioned and working at Sub Divisional Hospitals

District Regular cadre posts Contract GDMO posted GDMO posts GDMO working % availability sanctioned

Kaimur (36) 6 9 50% extra GDMO 11

Kishangunj (60) 8 7 87.5 0

Nawada (6) 3 2 66.7 0

Sitamarhi (30) 7 2 28.6 0 IIDM India 36 Determinants of Workforce Availability and Performance- Bihar

District Regular cadre posts Contract GDMO posted GDMO posts GDMO working % availability sanctioned

Vaishali (6) 7 5 71.4 2

Total 31 25 80.6 13

Note: Figures in parenthesis indicate the number of beds at the SDH.

IPHS recommends 9 posts of Specialist for every Sub Divisional Hospital with 31-50 bed strength. But in the present study no Specialists was sanctioned nor available at any of the five SDH surveyed. The patient care at these hospitals was dependent on GDMOs only. Kaimur SDH had 50% extra GDMOs working against the sanctioned six posts. It had also 11 contract GDMOs working. Thus the staff availability at Kaimur SDH with 36 beds was exceptionally good. Vaishali district had 71% doctors available as compared to the posts sanctioned (five against 7 post sanctioned). But this deficiency was compensated by posting of two GDMOs on contract basis. Incidentally, Vaishali had only six beds in its Sub Divisional Hospital. The SDH in the remaining three districts i.e. Kishangunj, Nawada and Sitamarhi had less number of GDMOs working than post sanctioned and they also did not have any doctor on contract basis. SDH of Sitamarhi was the worst hit as it was working with less than 30% sanctioned posts of doctors with total 30 bed strength.

The IPHS recommends total 22 doctors (including 9 posts of Specialists) for Sub Divisional Hospitals with 31-50 bed strength and 32 doctors with 51-100 bed strength. In this study Kishengunj SDH had 60 beds. The hospital was working with 7 doctors against 32 recommended. At the other 2 SDH (Kaimur and Sitamarhi with bed strength of 36 and 30 respectively) total 32 doctors were available against IPHS recommended strength of 44. Thus, not only shortage of doctors was observed at SDH but sanction and posting of doctors did not have any rationality.

1.5.3 GDMOs posts sanctioned and in position in CHCs and PHCs Posts of GDMOs sanctioned and their availability in the Community Health Centres and Primary Health Centres surveyed is shown in Table 21 and Table 22 respectively.

A Community Health Centre is supposed to function as a first referral unit where services of specialists, 30 beds, operating facilities, blood bank facilities, etc should be available. As per IPHS a CHC should have 15 doctors with minimum four specialists, one each in Medicine, Surgery, Paediatrics, and Obstetric and Gynaecologist. Services of an anesthetist should also be available. IIDM India 37 Determinants of Workforce Availability and Performance- Bihar

Table 21. GDMO Posts sanctioned and their availability at CHCs in the surveyed districts

District Posts sanctioned Doctors % filled GDMOs working (Cadre posts) available on contract

Kaimur (30) 5 1 20 2

Kishengunj (30) 4 2 50 0

Nawada CHC I (6) 5 2 40 2

CHC II (6) 5 2 40 0

Samastipur CHC I (36) 5 4 80 1

CHC II (30) 5 2 40 1

Vaishali CHC I (30) 5 3 60 0

CHC II (30) 5 4 80 2

Total 39 20 51.3 8

In the six districts covered in this study Sitamarhi did not have any CHC. In Navada district the PHCs have been designated as CHC but the number of beds available is only six in each of the two CHCs covered under this study. In the remaining districts, CHCs with 30 beds each were available to provide specialist services. (Table 21)

No post of Specialist was, however, sanctioned by the State at any of the CHCs. At these centres only GDMOs were posted. Many of the GDMOs had post-graduate qualification and as such were in a position to extend specialist services.

Availability of GDMOs at the CHCs was inadequate as only half (51%) of the sanctioned posts were filled up. Appointment of contractual GDMOs at CHCs has been made in some districts. Apart from the contractual appointments to meet the shortage of doctors there does not appear to be any strategy to attract doctors to public sector hospitals.

The picture which emerges by this study about the medical staff availability at CHC level is not very encouraging. The State should look into the problem of medical staff shortage at CHCs and should take appropriate steps to improve the availability of specialist services to the community. If this problem is not addressed suitably the persons in need of specialist services will either turn to higher centres of care e.g. district hospital or medical college hospital or fall back on the private sector services. Either situation is not a desirable one due to several reasons, including high opportunity cost of availing services at district/medical college hospitals or private sector hospitals. Over 40% of the population in the State is below poverty line. For the BPL families availing Specialists services is almost impossible. Hospitalization is known to be an important cause of indebtedness of poor families. IIDM India 38 Determinants of Workforce Availability and Performance- Bihar

Table 22 GDMO posts sanctioned and available at PHCs in the surveyed districts

District Posts sanctioned Doctors % filled GDMOs posted (Cadre posts) available on contract

Kaimur PHC I 3 2 67 0

PHC II 3 1 33 0

PHC III 3 2 67 0

Kishengunj PHC I 3 1 33 2

PHC II 3 2 67 0

Nawada PHC I 3 3 100 0

PHC II 3 2 67 1

Samastipur PHC I 3 2 67 3

PHC II 3 3 100 0

PHC III 3 0 0 0

Sitamarhi PHC I 3 1 33 2

PHC II 3 2 67 1

PHC III 3 1 33 0

PHC IV 3 2 67 2

Vaishali PHC I 3 1 33 1

PHC II 3 1 33 1

Total 48 26 54.2 13

Availability of doctors is also low at the PHCs as can be seen from table 22. The State has sanctioned three posts of GDMO in each of the PHCs visited under this study. The IPHS also recommends posting of three doctors (including one female doctor) at every PHC Against 48 posts of GDMOs sanctioned for the PHCs studied only 26 (54.2%) were filled up. Appointment of additional doctors at PHCs on contract basis has helped to somewhat improve the medical staff availability. Adding up the contractual GDMOs availability to the regular cadre posts the percent of doctors available goes up to 81.3 per cent. But the distribution of doctors is not even as the availability of GDMOs varies between 33 to 100 per cent in different institutions. One of the PHC in Samastipur district was working without a doctor. Proper planning and monitoring of posting of doctors is, therefore, needed to improve staff availability and thereby service quality.

1.6 Supply of drugs at the health facilities To assess the supply of drugs at the health facilities eight drugs which are essential in nature and are commonly used was prepared and their availability /stock out was studied. These drugs were I.V. fluid, Iron tablets, Paracetamol tablet, Brufen tablet, Ampicillin/ Amoxycilin tablets, Inj. Adrenaline, Inj. 39 IIDM India 40 Determinants of Workforce Availability and Performance- Bihar

At the Sub Divisional Hospitals the supply of essential drugs was more irregular. Except Iron tablets, which is supplied by GOI under RCH program, and I.V. fluids there was stock out at one or more than one hospital during the reference period. (Table 23). There was more than one time stock out for Paracetamol tablet and ORS. The period of stock out for different drugs, which were out of stock, ranged between 15 days to 365 days. A year long stock out of Inj. Adrenline and Inj. Methergene, both of which are life saving, is a matter of concern.

Table 24. Availability of some essential drugs at CHCs and PHCs Iron Brufen IVFluids Ampicillin Adrenaline Methergine Paracetamol ORS-powder /Amoxycillin

Community health center (N=8)

Number of CHC reporting stock outs 3 4 1 1 0 1 2 0

Number of times stock outs 3 6 1 1 0 1 2 0

Total Number of days 211 310 365 365 0 365 180 0

Note: No CHC at Sitamarhi district

Primary health center (N=16)

Number of PHCs reporting stock outs 5 6 5 5 2 5 3 2

Number of times stock outs 8 7 6 5 2 5 3 2

Total Number of days 385 700 1420 1147 240 1825 1095 425

At the CHCs also different drugs were out of stock for varying periods of time in one or more institutions. (Table 24). The exceptions were ORS and I.V. fluids. The availability of drugs was the worst at the Primary Health Centres where all the drugs enquired were out of stock at different health facilities at different period of time. The number of health facilities reporting stock outs for different drugs ranged between 2 to 6 (out of 16 PHCs studied).

Availability of essential drugs at the health facilities all the time is an important factor in the delivery of quality health care. Non-availability of drugs at the government health facilities is an important reason of people not availing services of these institutions. It is, therefore, necessary that the State evolves a system of drug supply to its health facilities which is dependable.

Efficiency of district level administration also plays important role in ensuring drug supply at different institutions within a given district. District-wise availability of essential drugs was analyzed and the results are shown in Table 25. IIDM India 41 Determinants of Workforce Availability and Performance- Bihar

In Ara district only one facility (district hospital) was studied. There was no stock out of drugs at District hospital Ara during the reference period.

In Kaimur district, in the six facilities studied, there was no stock out of I.V. fluid. But for other drugs stock outs were reported by all the districts. The number of institution reporting stock outs ranged between 1 to 3 and the average number of days of stock outs ranged between 121 days to 365 days.

Kishan Gunj district reported stock out of only one drug (paracetamol) from one of the institutions surveyed and the duration of non-availability of the drug was of a short duration of 15 days only.

Nawada, Samastipur, Sitamarhi and Vaishali districts presented varying picture about the availability of essential drugs and period during which stock out was observed.

The above brief account of availability of drugs in different institutions in the districts studied demonstrates that there is a need to improve essential drug supply system in the State.

Table 25. District-wise availability of drugs at the surveyed health facilities Iron Brufen IVFluids Ampicillin Adrenaline Methergine Paracetamol ORS-powder /Amoxycillin

District –Ara Number of Health Institutions-1 (District Hospital)

No of facilities having stock outs Nil Nil Nil Nil Nil Nil Nil Nil

District –Kaimur Number of health Institution -6 (DH, SDH, CHC & 3 PHC)

No of facilities having no stock outs 3 3 4 4 4 2 5 6

Stock outs 1 times 3 3 2 2 2 4 1 -

Average number of days 240 233 304 274 121 365 273 -

District –Kishanganj Number of health Institution -4 (SDH, CHC and 2 PHC)

Number of facilities having no stock outs 4 3 4 4 4 4 4 4

Stock outs 1 time - 1 - - - - -

Average number of days - 15 ------

District-Nawada Number of health Institution -6 (DH, SDH, 2 CHC & 2 PHC)

Number of facilities having no stock outs 4 3 5 5 6 2 5 6

Stock outs 1 times 2 - 1 1 - 4 1 - IIDM India 42 Determinants of Workforce Availability and Performance- Bihar Iron Brufen IVFluids Ampicillin Adrenaline Methergine Paracetamol ORS-powder /Amoxycillin

Average number of days 45 - 365 365 - 365 60 -

District-Samastipur Number of health Instituation-6 (DH, 2 CHC & 3 PHC)

Number of facilities having no stock outs 4 4 4 5 5 3 4 4

Stock outs 1 times - - - - - 2 1 1

Average number of days - - - - - 365 365 365

Stock outs 2 times 1 1 1 - - - - -

Average number of days 37 37 47 - - - - -

District – Sitamarhi Number of health Instituation-6 (DH, SDH, & 4 PHC)

Number of facilities having no stock outs 6 4 2 4 5 1 2 6

Stock outs 1 times - 2 4 2 - 5 4 -

Average number of days - 92 277 243 - 183 365 -

Stock outs 2 times - - - - 1 - - -

Average number of days - - - - 45 - - -

District –Vaishali Number of health instituation-6 (DH, SDH, 2 CHC & 2 PHC)

Number of facilities having no stock outs 2 2 4 3 5 4 4 5

Stock outs of days 2 3 2 3 1 2 2 1

Average number of days 90 120 365 192 60 365 242 60

Stock outs 2 times 2 1 ------

Average number of days 15 13 ------IIDM India 43 Determinants of Workforce Availability and Performance- Bihar

2. Profile of the doctors interviewed

2.1 Distribution of doctors as per their designations and place of posting Bihar health services has two sub cadres: GDMOs (General Duty Medical Officers) and Specialists. The third group of doctors comprises Civil Surgeons, Chief Medical and Health Officers, Directors of Health Services, etc. who carry out the administrative functions. This is not a separate cadre but GDMOs and Specialists are promoted on the basis of their seniority and yearly performance report as officers of administrative group.

Out of the 161 doctors interviewed in this study 140 were GDMOs, 12 were Specialists and 9 belonged to administrative group. (Table 26). All the Specialists were posted at District hospitals. Similarly, all doctors engaged in administrative work were posted at district level or State level organizations/ offices. Out of 140 GDMOs, one third (67 i.e. 32.9%) were posted at District Hospitals, 40 (28.6%) at PHCs and 27 (19.3%) each at Sub Divisional Hospitals and CHCs. Place of posting-wise distribution of doctors interviewed is given in Table 26.

Table 26. Place of posting of doctors (GDMOs and Specialists) interviewed

Place of posting GDMOs Specialists Administrative Total

No. % No. % No. %

District 46 32.9 12 100 9 100 67 41.6 Hosp./Office

SDH 27 19.3 - - - - 27 16.8

CHC 27 19.3 - - - - 27 16.8

PHC 40 28.6 - - - - 40 24.8

Total 140 100.0 12 100 9 100 161 100

2.2 Educational qualification of doctors Educational qualification of doctors is shown in table 27. All the Specialists were having post-graduate qualification e.g. MD/MS or diploma in different specialties. Among the GDMOs and administrative group doctors about a third (30.7% and 33.3% respectively) were having MD/MS (post-graduate) qualifications. Majority of GDMOs (86 out of 140 i.e. .61.4 per cent) were graduates only. Seven GDMOs (5%) had BDS (Bachelor of Dental Surgery) qualification and 4 (2.9%) were graduates of Indian System of Medicine (AYUSH). Most of the doctors working in the State health services were thus allopathic medical graduates and a little over one third (36 per cent) had post-graduate qualification. The M.B.B.S. qualified and MD/MS qualified doctors’ ratio was 2 to 1. To meet the shortage of doctors, particularly for rural areas, and to promote Indian System of Medicine induction of AYUSH doctors in government service is often talked about at different fora. But in actual practice, no serious effort in this direction seems to have been made in the country and Bihar is no exception.

Table 27. Educational qualification of doctors interviewed 44 IIDM India 45 Determinants of Workforce Availability and Performance- Bihar

3.2 Physical space at work place One third of the doctors (33%) stated that the space available at the work place was inadequate. But, the proportion of such doctors was higher among the Specialists and Administrative group (42% and 44% respectively).

3.3 Opinion of doctors about instruments and equipments available for work Only about 41% doctors stated that the equipments and instruments available to them for work were adequate. More Specialist grade doctors (83%) were not satisfied with the equipments and instruments available for work. Specialist doctors need specialized equipments and instruments for providing good clinical care which, if not available, adversely affects the quality of care and hence a cause of dissatisfaction. This is also supported by the facility survey carried out during the study. To quote one example, Ultrasonography machine, which is now commonly used diagnostic equipment, was available at only 2 institutions (district hospitals). The State should undertake facility survey of its institutions and provide minimum essential equipments and instruments as per IPHS. This will improve quality of care and patient and provider satisfaction with the services offered at the government health facilities.

3.4 Opinion of doctors about availability of drugs and other supplies Drugs and other supplies are needed to provide good quality clinical care. Nearly half of the doctors (48%) felt that supply of medicines and other consumables were not adequate. A larger proportion of Specialist doctors (58.3%) than the GDMOs cadre staff was not satisfied with the logistic supplies available to them. The reason is obvious because the specialist doctor’s need for drugs and other supplies are somewhat different in nature and quantity. Most of the Administrative group staff (56%) was also not satisfied with the consumables available to them.

Table 28. Working facilities available to doctors

GDMOs Specialists Administrative Total (n=161) Group(n=9) (n=140) (n=12)

Adequate Physical Space

Yes 95 67.9% 7 58.3% 5 55.6% 107 66.5%

No 45 32.1% 5 41.7% 4 44.4% 54 33.5%

Adequate Instruments & Equipments

Yes 60 42.9% 2 16.7% 4 44.4% 66 41.0%

No 80 57.1% 10 83.3% 5 55.6% 95 59.0%

Adequate logistical Support

Yes 73 52.1% 5 41.7% 5 55.6% 83 51.6%

No 67 47.9% 7 58.3% 4 44.4% 78 48.4%

Adequate Support Staff

Yes 51 36.4% 1 8.3% 1 11.1% 53 32.9%

No 89 63.6% 11 91.7% 8 88.9% 108 67.1% IIDM India 46 Determinants of Workforce Availability and Performance- Bihar

GDMOs Specialists Administrative Total (n=161) Group(n=9) (n=140) (n=12)

Support from the Community

Yes 77 55.0% 3 25.0% 5 55.6% 85 52.8%

No 63 45.0% 9 75.0% 4 44.4% 76 47.2%

3.5 Opinion of doctors about availability of support staff Doctors need support staff e.g. nursing staff, technicians and other service personnel to help them carry out their work. Two third (67%) of the doctors interviewed did not find the support staff available to them as adequate. The proportion of doctors of Specialist cadre and Administrative cadre who found the support staff as inadequate was higher (92% and 89% respectively) than the doctors of GDMO cadre (64%).

3.6. Opinion of doctors about support from the community Community support and understanding is essential to make the working environment of doctors pleasant and rewarding. Less than half of the doctors interviewed (47%) were not satisfied with the community support. This can be addressed to a large extent by education of the public, both attending the health facilities and community in general. Studies have shown that public satisfaction with services available from government health facilities in general is low. Much of this is due to high expectations of the community about the range and quality of care, staff behaviour etc. Public education through a variety of communication channels and by establishing public- health facility forums can improve image of the government institutions at an affordable cost. Rogi Kalyan Samities which have been created at hospitals and health centres should take an initiative to educate the public.

4. Service Conditions of Doctors in Bihar

4.1 Method of recruitment, transfers and postings of doctors Bihar follows a policy of open recruitment of doctors. Almost three fourth (71.4%) GDMOs, Specialists and Administrative grade officers were recruited by Bihar Public Service Commission (BPSC) through a process of selection by examination and interview. The process of selection through the Bihar Public Service Commission is fair and transparent but is time consuming. To meet the immediate service needs, therefore, a large number of GDMOs have been appointed in recent years on contract basis, by-passing the BPSC selection process. Doctors on contract basis are appointed on the basis of interview. (Table 29). They receive a fixed amount as salary and are not eligible to get service benefits like pension, gratuity, seniority in service, earned leave, etc. which is available to doctors appointed through BPSC.

Table 29. Method of recruitment of doctors

Process of selection GDMOs Specialists Administrative Total (n=161)

(n=140) (n= 12) (n=9) No. %

Exam & Interview (Bihar PSC) 95 12 8 115 71.4

Contractual 40 -- 40 24.8 IIDM India 47 Determinants of Workforce Availability and Performance- Bihar

Other 5 - 1 6 3.4

GDMOs Specialists Exam & 5 0 Exam & Interview Interview (Bihar 40 PSC) 0 Contractual Contractual(Bihar PSC) 95 Other Other

12

Administrative Exam & Interview 1 0 (Bihar PSC) Contractual

Other

8

4.2 Doctors’ liking of place of first posting Majority of the doctors (56.5%) did not like their place of first posting. (Table 30). This was true in case of all categories of doctors i.e. GDMOs, Specialists and Administrative group. Fifty-four and 56 per cent of GDMOs and Administrative group doctors respectively did not like their first place of posting against 83 per cent Specialist doctors. Thus larger proportion of Specialists did not like their first place of posting although they were posted at district hospitals. May be, their expectations about place of work was higher than what they were offered.

Table 30. Liking of place of first posting

Liking of place of first GDMOs (n=140) Specialist (n=12) Administrative Total (n=161) posting No % No. % (n=9) No. %

No. %

Yes 64 45.7 2 16.7 4 44.4 70 43.5

No 76 54.3 10 83.3 5 55.6 91 56.5 IIDM India 48 Determinants of Workforce Availability and Performance- Bihar

Liking of place of first posting 100 83.3 80 54.3 55.6 60 45.7 44.4 Liked 40 16.7 20 Disliked 0 GDMOs Specialist Administrative

4.3 Transfer system for doctors in Bihar Majority (67%) of the doctors interviewed were aware of existence of transfer policy in the State (Table 31). Among the administrative group of doctors all were knowledgeable about the transfer policy. This is because all of them were senior in service and were dealing with administrative issues and thus had better knowledge of transfer policy.

Among the doctors who were not knowledgeable about the State’s transfer policy many were on contract service.

Table 31. Doctors’ awareness about transfer policy in the State GDMOs (n=140) Specialists (n=12) Administrative Group(n=9) Total (n=161)

Yes 92 65.7% 7 58.3% 9 100.0% 108 67.0%

No 48 34.3% 5 41.7% 0 - 53 33.0%

4.4. Frequency of transfers Nearly one fourth (25%) of doctors had not been transferred even once since joining service. (Table 32). Most of them were newly recruited doctors on contract basis. But majority (58 per cent) of the doctors had been transferred three or more times since joining service. All the doctors in the Administrative group had got transferred four or more times. The reason is obvious because the doctors in this group were persons with long years of service and hence were transferred several times during their tenure of service. Table 32. Number of times transferred [since joining service] GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total (n=161)

No Transfer 40 28.6% - - - - 40 24.8%

Once 16 11.4% 1 8.3% - - 17 10.6

Twice 9 6.4% 2 16.6% - - 11 6.8

Thrice 15 10.7% 1 8.3% - - 16 9.9%

Four & above 60 42.9% 8 66.7 9 100% 77 47.8% IIDM India 49 Determinants of Workforce Availability and Performance- Bihar

Number of times transferred [since joining service]

120% 100% GDMOs 100% 80% 66.70% 60% 43% 29% Specialists 40% 16.60% 11% 8.30% 8.30% 20% 0% 0% 6% 11% 0% 0% 0% 0% No Transfer Once Twice Thrice Four & Administra tive Group above

4.5. Basis of transfer of doctors Transfer rules of government staff, as notified by the General Administration Department from time to time, are applicable for doctors also. All the doctors in the Specialist cadre and Administrative group and nine tenth (90%) of GDMOs were transferred on routine basis. Five GDMOs were transferred on the basis of recommendation while one each on promotion and as punishment. Since most transfers were routine in nature it should not be a cause for dissatisfaction among the doctors. (Table 33)

Table 33. Basis of Transfer GDMOs (n=140) Specialists Administrative Group Total (n=161) (n=12) (n=9)

Routine 90 90% 12 100.0 9 100.0 111 91.7%

Recommendation 5 5% 0 - 0 - 5 4.1%

On Promotion 1 1% 0 - 0 - 1 0.8

Punishments 1 1% 0 - 0 - 1 0.8

Performance 3 3% 0 - 0 - 3 2.5%

Basis of Transfer

100%100% 100% 90% GDMOs (n=140)

Specialists 50% Administrative 5% 0% 0% 1% 0%0% 1% 0%0% 3% 0%0% Group (n=9) 0% Routine Recommendation On Promotion Punishments Performance IIDM India 50 Determinants of Workforce Availability and Performance- Bihar

4.6. Work load of doctors Eighty per cent of doctors interviewed stated that their work load was heavy . GDMOs, Specialists and doctors of Administrative group shared this opinion. (Table 34). Only one doctor, who belonged to the Specialist cadre, said that the work load was low.

Table 34. Work load of doctors GDMOs (n=140) Specialists (n=12) Administrative Group (n-9) Total

Heavy 111 79.3% 9 75.0% 9 100.0% 129 80.1

Sufficient 29 20.7% 2 16.7% 0 - 31 19.3

Low 0 - 1 8.3% 0 - 1 0.6%

Work Load of doctors

0% Administrative 0% Low 100.00% 8.30% Specialists 16.70% Sufficient 75.00% 0% GDMOs 20.70% Heavy 79.30%

0% 20% 40% 60% 80% 100% 120%

4.7 Emergency duty / Call duty performed by doctors The doctors in Bihar, as elsewhere, attend every day to their routine work e.g. OPD, patient care in wards, operation theatres, etc. Duty rosters are also prepared for doctors for emergency duty/ call duty. During this study it was observed that doctors are on call duty by rotation in all the District Hospitals, Sub Divisional Hospitals and CHCs to attend to emergencies. But when the staff availability at the health facility is low the doctors are often required to be on call duty almost every day. It was noted earlier that Bihar has posted three doctors at every PHC and in most places they are on call duty on fixed days in a week. But there are some PHCs (one in Kaimur, 2 in Sitamarhi and 2 in Samastipur) where doctors are on call duty every day due to shortage of doctors for rotation. (Table 35)

Table 35. Emergency duty / Call duty performed by doctors

GDMOs n=140) Specialists (n=12) Administrative Group (n= Total (n=161) 9)

Call Duties

Yes 97 69.3% 10 83.3% 4 44.4% 111 68.9%

No 43 30.7% 2 16.7% 5 55.6% 50 31.1% IIDM India 51 Determinants of Workforce Availability and Performance- Bihar

4.8 Administrative functions performed by the doctors Sometimes doctors have to act as administrative head and are required to look after the health facility or the district. Certain powers are vested in them for the purpose of managing the institution/ office. The doctors were asked if they possessed certain powers to discharge their administrative duty.

Table 36. Opinion of doctors about administrative authority vested in them GDMOs (n=140) Specialists (n=12) Administrative Total (n=161) Group(n=9)

Can use Funds 29 20.7% - - 8 88.9% 37 23.0%

Can recruit Staff 2 1.4% - - 4 44.5% 6 3.7%

Can post Staff 2 1.4% - - 3 33.3% 5 3.1%

Can reward staff 5 3.6% - - 5 55.6% 10 6.2%

Can take action 8 5.7% - - 7 77.8% 15 9.3% against staff Punish

No response 111 79.3% 12 100.0% 1 11.1% 124 77.0%

Note: Multiple responses hence percentage total is more than 100.

Only about a quarter (23%) of the doctors had administrative responsibilities and hence certain powers vested in them. (Table 36). Most doctors belonging to administrative group enjoyed administrative powers ranging from use of funds ((99%) to recruit staff (45%), post staff (33%) and rewarding or taking action against the staff. Specialists, on the other hand, did not have any administrative powers because the management of the hospital/ health centre was the function of the civil surgeons / Block Medical Officers. Among the GDMOs, only a small number of doctors were involved in management function, mostly at the CHC/ PHC level. These doctors were given administrative responsibility over and above their clinical responsibility.

4.9 Pay Scale and Service benefits of the doctors in Bihar 4.9.1 Pay Scales

For the purpose of salary structure the State has divided the doctors of Bihar health services in the following three groups: GDMO cadre, Specialist cadre and Combined Administrative posts. The pay scales of the doctors in the State are given below:

IIDM India 53 Determinants of Workforce Availability and Performance- Bihar

Table 37. Take Home Pay of doctors GDMOs Specialists Administrative Total

(n=140) (n=12) Group(n=9) (n=161)

Less than 15000 5 3.6% 0 - 0 - 5 3.1%

15000-25000 47 33.6% 1 8.3% 0 - 48 29.8%

25000-35000 52 37.1% 3 25.0% 2 22.2% 57 35.4%

35000-45000 30 21.2% 8 66.7% 4 44.4% 42 26.1%

45000 & above 6 4.3% 0 - 3 33.3% 9 5.6%

4.9.3 Satisfaction of doctors with the present pay

Almost ninety per cent of the doctors of all cadres- GDMOs, Specialists and Administrative group- were not satisfied with their present pay. (Table 38). Low pay could be an important reason for doctors not joining government service or leaving service. IIDM India 54 Determinants of Workforce Availability and Performance- Bihar

Table 38. Satisfaction of doctors with present pay

GDMOs (n=140) Specialists (n=12) Administrative Group Total(n=161) (n=9)

Yes 13 9.3% 1 8.3% 1 11.1% 15 9.3%

No 127 90.7 11 91.7% 8 88.9% 146 90.7%

Satisfaction of doctors with present pay

91.70% 100% 90.70% 88.90% 80% Yes 60% 40% 9.30% 11.10% 20% 8.30% No 0% GDMOs Specialists Administrative Group

4.9.4 Opinion of the doctors about private practice

The State does not pay any Non Practicing Allowance to its doctors. The doctors, therefore, carry out private practice outside their duty hours. Private practice diverts the attention and time of the doctors from patient care. The GOI and several States follow the policy of prohibiting doctors from private practice and payment of NPA instead.

The doctors who were interviewed in this study were asked to give their views on allowing government doctors private practice. Nearly sixty per cent doctors of GDMO cadre and Administrative grades (61% and 57% respectively) were of the opinion that government doctors should be permitted private practice. On the other hand, two thirds of the Specialists were not in favour of government doctors being permitted private practice. (Table 39)

Table 39 Opinion of doctors if Private Practice should be permitted

GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total (n=161)

Yes 86 61.4% 4 33.3% 5 55.6% 95 59.0%

No 54 38.6% 8 66.6% 4 44.4% 66 41.0%

4.9.5 Other service benefits available to the doctors in Bihar

In addition to pay and allowances, the doctors are entitled to leave and retirement/ death benefit (Pension, Gratuity, Provident Fund and Leave Encashment). Leave benefit consist of casual leave, special casual leave, earned leave, medical leave, maternity leave, study leave and extra-ordinary leave. Admissible pay is available to the doctors during most of these leave period. Medical re-imbursement / IIDM India 55 Determinants of Workforce Availability and Performance- Bihar

free treatment at government health facilities are also available to the government doctors working in the State).

Among the doctors who were interviewed during the study 131 (81.4%) stated that they were clear about the leave rules (Table 40). Most doctors (29 out of 30) who were not clear about the leave rules belonged to GDMO cadre. A large number of doctors in GDMO cadre are new recruits and are on contractual appointment and this could be the reason for their not knowing the lave rules.

Table 40. Knowledge about Leave Policy

GDMOs(n=140) Specialists (n=12) Administrative Group (n=9) Total (n=161)

Yes 111 79.3% 11 91.7% 9 100.0% 131 81.4%

No 29 20.7% 1 8.3% 0 - 30 18.6%

About one third (31%) of the doctors stated that they were not able to avail leave due to them (table 41). Most of these doctors (48 among 50) belonged to GDMO cadre. Difficulty in availing leave could be lack of clarity about leave rules as well as due to absence of other doctors at their place of posting.

Table 41. Able to avail leave GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total(n=161)

Yes 92 65.7% 11 91.7% 8 88.9% 111 68.9%

No 48 34.3% 1 8.3% 1 11.1% 50 31.1%

4.9.6 Personal facilities available to Bihar Health Service doctors

Financial package is an important factor to attract doctors towards government job and to retain them. But other factors e.g. availability of residential accommodation, facilities for schooling of children, availability of opportunity to pursue higher education, etc. also play important role in this process. The doctors were asked a set of questions to elicit information on these issues. Their responses are given in table 42.

4.9.7 Residential accommodation for doctors

Only about a quarter of doctors (26%) of Bihar Health Services stay in government quarters. None of the Specialists and over half (57%) of the doctors of Administrative group who were interviewed informed that they did not stay in government quarters. This is mainly because sufficient number of suitable residential houses is not available at the place of posting, particularly in rural areas. The doctors, therefore, stay in rented houses or in their personal houses when government accommodation is not available.

About one tenth (9%) of the doctors interviewed did not stay at the place of their posting. These doctors belonged exclusively to GDMO cadre. On the other hand, every Specialist and Administrative group doctor was staying at the place of posting in spite of the fact that most of them (100% and 56% respectively) did not stay in the government quarters. Staying away from the place of posting adversely IIDM India 56 Determinants of Workforce Availability and Performance- Bihar

affects quality of care as the doctors are not available when cases requiring emergency care are brought to the health facilities. (Table 42).

Interestingly, wife and children of the doctors were not staying with the interviewed doctors in about half (49%) the cases. Even among the Administrative group doctors, who are posted in district head quarters because of their seniority 44% did not have their families with them. One reason for this could be that they are not satisfied with the facilities available for education of their children. Only 18%, 17% and 22% of GDMOs, Specialists and Administrative group doctors respectively expressed the opinion that they were satisfied with the opportunities available for education of their children. (Table 42)

About one quarter of doctors were satisfied with the social activities available to them while only 18% were satisfied with the security arrangements. None of the Specialists was satisfied with the social life or his security. So was the case with the GDMOs and Administrative group doctors in whom three fourth or more were dissatisfied with social life or security arrangements. These two factors could be the important reasons, besides others, of the families of the doctors not staying with them. In any case, availability of accommodation, security, social life, etc. are complex issues and cannot be commented upon without further in-depth study.

Table 42. Facilities available to doctor of Bihar Health Services GDMOs (n= 140) Specialists (n=12) Administrative Group Total (n=9) (n=161)

Stay in Government Quarters

Yes 37 26.4% 0 - 5 55.6% 42 26.1%

No 103 73.6% 12 100.0% 4 46.4% 119 73.9%

Stay in the Place Posting

Yes 125 89.3% 12 100.0% 9 100.0% 146 90.7%

No 15 10.7% 0 - 0 - 15 9.3%

Wife & Children Stay with you

Yes 66 47.1% 8 66.7% 5 55.6% 79 49.1%

No 74 52.9% 4 33.3% 4 44.4% 82 50.9%

Satisfied with facilities for Children’s’ Education

Yes 25 17.9% 2 16.7% 2 22.2% 29 18.0%

No 41 29.2% 6 50.0% 3 33.3% 50 31.1%

No 74 52.9% 4 33.3% 4 44.4% 82 50.9% Response

Satisfied with Social Activity

Yes 38 27.1% 0 - 2 22.2% 40 24.8%

No 102 72.9% 12 100.0% 7 77.8% 121 75.4% IIDM India 57 Determinants of Workforce Availability and Performance- Bihar

GDMOs (n= 140) Specialists (n=12) Administrative Group Total (n=9) (n=161)

Satisfied with Security

Yes 27 19.3% 0 - 2 22.2% 29 18.0%

No 113 80.7% 12 100.0% 7 77.8% 132 82.0%

5. Human Resource Policy for doctors in Bihar

The doctors who were interviewed at the health facilities were asked some questions related to human resource management policy of the State. The key findings related to HR issues are discussed below.

5.1 All doctors in Bihar are in a single cadre of Bihar Health Services. There is no separate cadre of Public Health doctors which is the case in several States in India. As stated earlier doctors of Bihar Health Services are divided into two sub cadres; GDMOs and Specialists

5.2 Training of doctors 5.2.1 Policy for in-service training of doctors

As informed by the respondents the State does not have any strategy for training of in-service doctors.

5.2.2 Induction training of doctors

Doctors in Bihar do not receive any induction training. This is a big deficiency of the HR system. Doctors coming out of the medical colleges do not have sufficient information about the working conditions and the system within which they have to perform their duty. They are, therefore, not at ease and confident while performing their duty during the initial period of their posting. Doctors working at PHCs and Community Health Centres are also expected to know about the national health programs.

The findings of the doctors interview shown in the following table (Table 40) confirm that several of them were not confident in performing their duty at the time of joining service. The proportion of doctors having confidence for performing different tasks varied between 54% to 95% for different tasks. (Table 43). The largest proportion of doctors stating that they were confident was for attending outpatient and in-patient cases (95% and 92% respectively). The proportion was the lowest for administrative work and conducting surgeries (58% and 54% respectively). Interestingly, the Specialists were least confident in conducting normal deliveries and surgeries (33% and 42% respectively) which could be due to the fact that specialization, while increasing their level of confidence in their subject areas, adversely affects the level of confidence for doing tasks other than their own specialty. A larger proportion (42%) of doctors of all categories stated lack of confidence for administrative work as compared to other tasks like patient care. The above findings show that induction training of doctors should be undertaken for every doctor entering service whether they are regular doctors or appointed on contract. IIDM India 58 Determinants of Workforce Availability and Performance- Bihar

Another, HR management step which should be taken by the government is to provide a written job description. Most doctors, particularly Specialists and Administrative group officers, did not have written job responsibility and hence absence of clarity of their role. (Table 44)

Table 43 Confidence of doctors in performing their duty at the time of joining

GDMOs (n=140) Specialists Administrative Group (n= Total (n=161) (n=12) 9)

Attending Outpatients

Yes 133 95.0% 11 91.7% 9 100.0% 153 95.0%

No 7 5.0% 1 8.3% 0 - 8 5.0%

Attending Emergencies

Yes 123 87.9% 11 91.7% 9 100.0% 143 88.8%

No 13 12.1% 1 8.3% 0 - 18 11.2%

Seeing inpatients

Yes 127 90.7% 12 100.0% 9 100.0% 148 91.9%

No 13 9.3% 0 - 0 - 13 8.1%

Conducting normal Deliveries

Yes 91 65.0% 4 33.3% 6 66.7% 101 62.7%

No 49 35.0% 8 66.7% 3 33.3% 60 37.3%

Conducting Surgeries

Yes 76 54.3% 5 41.7% 6 66.7% 87 54.0%

No 64 45.7% 7 58.3% 3 33.3% 74 46.0%

Administrative work

Yes 80 57.1% 6 50.0% 6 66.7% 92 58.4%

No 60 42.9% 6 50.0% 3 33.3% 69 41.6%

Attending Meeting

Yes 107 76.4% 12 100.0 7 77.8% 126 78.3%

No 33 23.6% 0 - 2 22.2% 35 21.7%

Supervision

Yes 99 70.7% 9 75.0% 7 77.8% 115 71.4%

No 41 29.3% 3 25.0% 2 22.2% 46 28.6% IIDM India 59 Determinants of Workforce Availability and Performance- Bihar

Table 44 Availability of written job description to doctors

GDMOs (n=140) Specialists Administrative Group Total (161) (n=12) (n=9)

Yes 37 26.4% 0 - 1 11.1% 38 23.6%

No 103 73.6% 12 100% 8 88.9% 123 76.4%

5.2.4 Opportunities for post-graduate training for doctors

Most doctors aspire to increase their knowledge and competence by undergoing further training by joining post-graduate programs or special training. But Bihar does not offer any incentive to doctors working in the state health services to go for higher education. For example, no preference is given to doctors working in rural areas for admission to post-graduate courses in its medical colleges, nor there is any seat reserved for post-graduate admission for in-service doctors. The State also does not offer any incentive to doctors for undergoing higher education.

5.2.5 Program related training of doctors

The State carries out short / medium term training of a few days/ weeks for its doctors. These are either refresher training or are training for program related updates. The training is generally organized as per the requirements of national programs e.g. HIV/AIDS, Vector-borne Diseases Control, Tuberculosis, Leprosy, RCH etc. More than half (56.5%) the doctors interviewed had attended training organized by the State in the past (Table 45). Doctors of the Administrative group seem to have a little advantage over the other cadres in attending the training programs. Majority of the doctors (85%) interviewed stated that they would like to attend training program in future which shows their keenness to improve their knowledge and skill to perform their work in a better way (Table 46).

Table 45. Attended Training organized by the State in the past.

GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total (n=161)

Yes 78 55.7% 7 58.3 % 6 66.7% 91 56.5%

No 62 44.3% 5 41.7% 3 33.3% 70 47.3%

Table 46 Like to Attend Training in Future

GDMOs (n=140) Specialists (n=12) Administrative Group Total (n=161) (n=9)

Yes 119 85.0% 11 91.7% 7 77.8% 137 85.1%

No 21 15.0% 1 8.3% 2 22.2% 24 14.9%

IIDM India 60 Determinants of Workforce Availability and Performance- Bihar

5.2.6 Continuing Medical Education for doctors

Attending conference/ seminars or training programs organized by professional bodies are useful for doctors to improve/ update their knowledge and skill. Only one third (53 out of 161 i.e. 33%) doctors interviewed informed that they had attended CME programs. (Table 47). Proportion of doctors attending CME was highest among the specialists (67%) and lowest among the GDMOs (29%). This may be due to the fact that most Specialists are members of their respective Professional Associations/ Societies which regularly organize CME programs. Three fourth (74%) of the doctors interviewed expressed their interest in attending CME programs. (Table 48) The proportion of such doctors was the lowest (50%) among the Specialists.

Table 47. Doctors who attended CME programs

GDMOs (n=140) Specialists Administrative Total (n=161) (n=12) Group(n==9)

Yes 41 29.3% 8 66.7% 4 44.4% 53 33%

No 99 70.7% 4 33.3% 5 55.6% 108 67%

Table 48. Doctors who would like to attend CME in future

GDMOs (n=140) Specialists (n=12) Administrative Group Total (n=161) (n=9)

Yes 107 76.4% 6 50.0% 7 77.8% 120 74.4%

No 33 23.6% 6 50.0% 2 22.2% 41 25.6%

5.3 Supervision and appraisal system

5.3.1 Supervision

Doctors of Combined Administrative post e.g. Deputy Directors/ Regional Directors supervise the doctors at the district level and below. The Chief Medical Officers and Civil Surgeons supervise the doctors working in the District Hospitals, Sub Divisional Hospitals, CHC and PHCs. Majority of the doctors (98.1%) stated during interview that they are supervised by their seniors. (Table 49)

Table 49. Supervised by superiors

GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total (n=161)

Yes 138 98.6% 11 91.7% 9 100.0% 158 98.1%

No 2 1.4% 1 8.3% 0 - 3 1.9%

Although the supervision is mostly routine in nature but most doctors (87%) interviewed stated that they learnt new things from the supervisors who visited them. Among the Specialists, only three fourth learned IIDM India 61 Determinants of Workforce Availability and Performance- Bihar

new things from their supervisors which could be due to their special nature of work where generalist doctors (Administrative cadre) could hardly contribute to their learning (Table 50).

Table 50. Learn Anything New After the Superiors Visit

GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total (n=161)

Yes 123 87.9% 9 75.0% 8 88.9% 140 86.9%

No 17 12.1% 3 25.0% 1 11.1% 21 13.1%

As expressed by the doctors during interview the experience of the doctors about the supervision was negative in most cases (88.2%) (Table 51).

Table 51. Supervisory Experience Positive/Negative

GDMOs (n=140) Specialists (n=12) Administrative Group Total (n=161) (n=9)

Positive 11 7.9% 1 8.3% 0 - 12 7.5%

Negative 124 88.6% 9 75.0% 9 100% 142 88.2%

No 5 3.5 2 16.6 - - 7 4.3% Response

5.3.2 Existence of Feedback System When asked about the existence of feedback system from the supervisors about two thirds of doctors replied in affirmative (62%). Almost 90 per cent officers of Administrative Group stated that they received feed back from their supervisors. The corresponding proportion among the Specialist and GDMOs was 50% and 61% respectively (Table 52).

About sixty per cent doctors stated that they received appreciation for their work while 48% stated that their work was criticized. An equal proportion of doctors said that their grievances were heard by the supervisors. Appreciation of work and listening to the staff grievances by the Supervisors is good in terms of supervisory functions by the seniors. But about half of the doctors interviewed said that their work was criticized which cannot be considered as a good supervisory practice. This high lights the fact the supervisory cadre staff needs training in supervisory skills.

Table 52. Feed back system

GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total(n=161)

Feedback Mechanism exists

Yes 85 60.7% 6 50% 8 88.9% 99 61.5% IIDM India 62 Determinants of Workforce Availability and Performance- Bihar

GDMOs (n=140) Specialists (n=12) Administrative Group (n=9) Total(n=161)

No 55 39.3% 6 50% 1 11.1% 62 38.5%

Appreciation of work by supervisors Grievances heard by supervisors Yes 86 61.4% 5 41.7% 7 77.8% 98 60.9% Yes 77 55.0% 8 66.7% 7 77.8% 92 57.1% No 54 38.6% 7 58.3% 2 22.2% 63 39.1% No 63 45.0% 4 33.3% 2 22.2% 69 42.9% Criticism of work by supervisors

Yes 64 45.7% 6 50.0% 7 77.8% 77 47.8%

No 76 54.3% 6 50.0% 2 22.2% 84 52.2%

5.3.3 Performance appraisal system-

The state follows a performance appraisal system for all its doctors. The appraisals are done through Annual Confidential Reports (ACR). The senior officers prepare ACR for doctor working under them. Seventy per cent of the doctors said that a formal evaluation system exists for performance evaluation. (Table 53) But among the GDMOs, only two thirds (66%) were aware of the existence of formal evaluation system.

Table 53. Existence of Formal Evaluation system

GDMOs (n=140) Specialists (n=12) Administrative Group (9) Total (n=161)

Evaluation Done

Yes 93 66.4% 11 91.7% 9 100.0% 113 70.2%

No 47 33.6% 1 8.3% 0 - 48 29.8% IIDM India 63 Determinants of Workforce Availability and Performance- Bihar

Mechanism of performance evaluation

Confidential 87 62.1% 11 91.7% 9 100.0% 107 66.5%

No 53 37.9% 1 8.3% 0 - 54 33.5% response

Absence of knowledge about the formal evaluation system could be due to presence of a large number of contract staff in GDMO cadre who are not very knowledgeable about the government system. Two third of the doctors interviewed informed that the ACR is confidential and its contents are shared by the supervisory officers.

The ACRs are important documents for promotions of the doctor from one grade to another. For promoting the doctors from GDMO /Specialist grade to Combined Administrative post the seniority of officers and ACR reports are important criteria.

5.4 Promotion policy for doctors of State Health Services

5.4.1 Knowledge about existence of promotion policy

A little less than half (48%) of the doctors interviewed were not knowledgeable about the promotion policy for doctors in the State. Even among the Administrative group about one tenth of the doctors did not know the promotion policy. (Table 54). Among the Specialists two thirds stated that they did not know about the promotion policy for doctors in the State. This indicates that the promotion policy is not shared by the State with the doctors.

Table 54 Knowledge about existence of promotion policy

GDMOs (n=140) Specialists (n=12) Administrative Group Total(n=161) (n=9)

Yes 71 50.7% 4 33.3% 8 88.9% 83 51.6%

No 69 49.3% 8 66.7% 1 11.1% 78 48.4%

5.4.2. Promotions during the tenure of service

About 84% of the doctors of all cadres had not received any promotion during their service tenure. Although proportion of doctors with two or more promotions was less than ten per cent among all doctors combined together, proportion of such doctors among the Administrative cadre was as high as 44 per cent. (Table 55) This was due to the fact that the tenure of doctors to reach the administrative cadre is long and hence they become entitled for promotions because of their seniority. IIDM India 64 Determinants of Workforce Availability and Performance- Bihar

Table 55. Promotions during the tenure of service [Since joining service]

GDMOs (n=140) Specialists(n=12) Administrative Group Total (n=161) (n=9)

No 121 86.4% 11 91.7% 3 33.3 % 135 83.9% promotion

Once 12 8.6 1 8.3% 2 22.2% 15 9.3%

Twice 7 5.0% 0 - 0 - 7 4.3%

Thrice 0 - 0 - 4 44.4% 4 2.5%

5.5 Compulsory rural service for doctors The State has not introduced any system of compulsory rural service for the doctors graduating from its college. There is also no linkage between rural area service and admission to post –graduate courses in the colleges run by the government or private management.

5.6 New HR initiatives taken / proposed by the government Under the NRHM initiatives a number of new human resource management initiatives have been taken / proposed by the government in the recent years. They are:

• An incentive of Rs. 3000 per month for doctors working in rural / difficult areas • Graduate doctors trained for specialized tasks e.g. Caesarian section will be paid an incentive of Rs. 4000 per month • A district cadre of contractual appointments and a state cadre of Specialist Sub Cadre and GDMO cadre at State level. GDMO sub cadre requires 2 years of rural service for entry and 6 years rural service for promotion. Contractual doctors working in Public Health System will get benefit in Bihar Public Service examination. This scheme has been approved in 2007 and is in the process of implementation. • State Health Services Board proposes to initiate a three year DNB (Family Physician) training program in selected district hospitals of the State for 20 Medical Officers posted at CHCs. After three years training these doctors will be posted at CHCs / referral hospitals for providing Caesarian Section and Anaesthetists services. • Anaesthetists, Gynaecologists and Paediatricians will be hired on payment of Rs. 1000 per case for Emonc services. • SHSB has invited offers from Human Resource Consultancy Services for assisting the State for recruitment of doctors and paramedical and management staff. IIDM India 65 Determinants of Workforce Availability and Performance- Bihar IIDM India 66 Determinants of Workforce Availability and Performance- Bihar

CHAPTER - 5 CONCLUSIONS AND RECOMMENDATIONS

Based on the results of this study on health manpower (doctors) availability in Bihar and factors influencing it as well as review of the manpower management policy and the practices in the State, the following broad conclusions can be drawn:

1. The State of Bihar has sanctioned cadre strength of 2967 Specialist doctors and 7096 GDMOs. Against the sanctioned posts only 319 Specialist doctors and 3038 GDMOs are working . In other words, 89% posts of Specialists and 57% posts of GDMOs were vacant (Jan, 2010).

2. Posts of Specialists were sanctioned only in the District Hospitals. The Sub Divisional Hospitals and the CHCs did not have any Specialist doctor.

3. In the district hospitals surveyed, out of 56 sanctioned cadre posts of specialists only 16 (28.6%) were filled up. There was no relationship between the bed strength of the district hospital and the sanction of Specialist post with the result that some districts had advantage over the others in terms of availability of Specialist doctors.

4. Availability of General Duty Medical Officers was better than the Specialist as 70% of the sanctioned posts (131 out of 186) in all the health facilities (District Hospitals, SDH, CHCs and PHCs) surveyed were filled up.

5. Doctors (Specialists and GDMOs) for public sector health facilities are selected through Bihar Public Service Commission which is a time consuming process and is one of the reasons for shortage of doctors. Availability of GDMOs has improved in recent years by the appointment of doctors on contract basis raising the availability to 98% (179 GDMOs working against the sanctioned posts of 186).

6. Distribution of doctors was not even as the availability of GDMOs varied between 33 to 100 per cent against the sanctioned posts in different health facilities. In fact, in some district hospitals and SDH more doctors were working than the posts sanctioned while in the others sanctioned posts were vacant. IIDM India 67 Determinants of Workforce Availability and Performance- Bihar

7. Shortage of doctors resulted in extra work load, more emergency duties and sometimes difficulty in availing leave due to them.

8. Majority (80%) of the doctors interviewed stated that their work load was heavy . Other reasons of shortage of doctors in the public sector health facilities are lack of resources, absence of Human Resource Management system, and reluctance of doctors to serve in government hospitals due to poor working facilities and low remuneration package.

9. One third of the doctors interviewed reported that physical space at work place was not adequate for patient care. Physical facilities like 24—hour water supply, 24-hour power supply, presence of operation theatre, back up power supply system (generator/ invertors), ambulance services and telephone facilities were although satisfactory at district hospitals and SDHs, the same was not so at the lower level health institutions e.g. CHCs and PHCs.

10. Overall availability of equipments (operating tables, OT lights, delivery tables, Boyle’s apparatus, Sterilizers/ Autoclaves, and surgical equipments, X-Ray machines, blood banking/storage facilities, etc.) at the District hospitals and most SDHs were satisfactory. But several of the CHCs and PHCs surveyed lacked essential equipments. Nearly half (49%) the doctors interviewed stated that the hospitals / health centres lacked minimal facilities for work. Larger proportion of specialist doctors complained of inadequate working facilities.

11. Bed strength at various health facilities visited, except at PHCs, was low to meet the in- service patient care demand.

12. Inadequate support staff e.g. nurses and other paramedical staff was also reported by the doctors.

13. No stock out were reported in respect of eight essential drugs checked during visits to district hospitals and most SDH. But at the CHCs stock outs were reported for several essential drugs for varying periods of time. The availability of drugs was the worst at the Primary Health Centres where stock outs were reported from time to time for different drugs.

14. The service conditions of the doctors of the State Health Services left much to be desired. The pay scales of the doctors in the State were much lower than the scales offered by GOI to its doctors. Nearly nine tenth of the doctors were not satisfied with the present pay scales

15 Doctors do private practice outside their duty hours as there is no system of payment of Non Practicing Allowance (NPA), as applicable to doctors of Central Health Service and doctors in some States.

16. Many doctors stay in private houses and sometimes away from their place of posting as only about one quarter of them have been provided government accommodation. The house rent allowance paid to them is not sufficient to meet the rent of private housing.

17. Doctors also expressed dissatisfaction with the educational opportunities available to their children and their personal security at the place of their posting.

18. The in-service doctors neither get any preference nor any seats are reserved for them for admission to post-graduate courses in government medical colleges. IIDM India 68 Determinants of Workforce Availability and Performance- Bihar

19. The State does not have any well thought out system for manpower planning and human resource management. The State also does not have a training policy for its doctors.

Recommendations

1. The State should create a full fledged Human Resource Division within the Directorate of Health Services with dedicated and specialized staff and budget so that HR planning, monitoring and management functions can be carried out effectively.

2. The Department should develop a computerized data base of all doctors – Specialists and GDMOs, contract doctors- their posting, transfer, promotion, training status, etc. The data base will help in efficient management of Human Resource.

3. The State should carry out a quick study to find out the requirement of staff at different health facilities as per the bed strength, in patient and out patient load, current availability of staff and develop a strategy to meet the demand of doctors at each of the facilities.

4. The State should develop short and medium term human resource plan and take appropriate action for recruitment of doctors to bridge the gaps between demand and supply.

5. The supply and demand gaps can be reduced by taking policy decisions as compulsory rural posting after graduation for specified period, reserving seats in medical colleges for post-graduate admission for such doctors who have done compulsory rural posting / in-service doctors working in difficult/ rural areas, giving incentive for post-graduate studies in the form of accelerated promotions, extra increments, raising the age of retirement, etc.

6. There is shortage of specialist doctors in the health cadre. To meet this deficiency the GDMOs with post-graduate qualifications should be posted as per the service needs of the institutions. Where Specialist doctors cannot be posted due to shortage of such personnel the possibility of entering into private –public partnership for specialist services may be explored. Such an initiative will help reduce patient load at higher institutions of health care e.g. district hospital / medical college hospital or the patients going to private sector facilities, all of which involve high opportunity cost which most patients are unable to afford.

7. Currently the pay scales of the Specialist doctors and the GDMOs are identical. Specialist doctors and GDMOs with post-graduate qualification and rendering specialist services should be paid extra allowances.

8. Staff working on contractual basis is denied benefits which are available to regular cadre doctors. The State should ensure that contract doctors are regularized within a specified period. This will help to attract doctors to join government service. Contract doctors who have served the State for a specified period should be given preference in selection through Public Service Commission. IIDM India 69 Determinants of Workforce Availability and Performance- Bihar

9. Promotions act as important incentive for doctors joining government service. A policy of time bound promotion for doctors, as is available to doctors of Central Health Services, should be evolved and implemented. Promotions should be linked to post-graduate training and in-service training attended by the doctors,

10. The State should carry out a rapid survey of all its health facilities to find out shortage of equipments, instruments, diagnostic facilities and take urgent steps to meet the minimum needs for patient care. Besides improving patient care, this step will increase job satisfaction of the doctors.

11. The State should adopt a time bound transfer policy where a doctor gets a chance to move to cities after serving in remote/ rural areas for a fixed period. This will also help remove the concern of the doctors regarding educational opportunities for their children.

12. The State has already taken a number of initiatives/ policy decisions to reduce the manpower shortage e.g. giving rural area allowance, up-gradation of skills of doctors by short term training, starting DNB training program in selected district hospitals for in-service doctors, etc. These initiatives should be implemented on fast track. If necessary, an empowered committee of Principal Secretaries of concerned departments may be constituted to remove administrative hurdles and expedite action. IIDM India 70 Determinants of Workforce Availability and Performance- Bihar

Annexure I Development index wise ranking of the districts

Rank States and UTs Districts Composite Index

1 Bihar Patna 0.51645

2 Bihar Rohtas 0.46383

3 Bihar Bhagalpur 0.45991

4 Bihar Munger 0.44808

5 Bihar Bhojpur 0.44665

6 Bihar Muzaffarpur 0.44451

7 Bihar Siwan 0.44182

8 Bihar Gopalganj 0.43712

9 Bihar Saran 0.43304

10 Bihar Aurangabad 0.42123

11 Bihar Vaishali 0.4193

12 Bihar Buxar 0.41329

13 Bihar Begusarai 0.41099

14 Bihar Darbhanga 0.41082

15 Bihar Jehanabad 0.40399

16 Bihar Nawada 0.39548

17 Bihar Saharsa 0.39332

18 Bihar Khagaria 0.39228

19 Bihar Sitamarhi 0.39083

20 Bihar Nalanda 0.38862

21 Bihar Gaya 0.3854

22 Bihar Purnia 0.38443

23 Bihar Purba Champaran 0.38374

24 Bihar Lakhisarai 0.38331

25 Bihar Madhubani 0.38297

26 Bihar Katihar 0.38032

27 Bihar Madhepura 0.37891 IIDM India 71 Determinants of Workforce Availability and Performance- Bihar

28 Bihar Banka 0.37287

29 Bihar Sheohar 0.37149

30 Bihar Supaul 0.36929

31 Bihar Pashchim Champaran 0.36663

32 Bihar Sheikhpura 0.36333

33 Bihar Araria 0.36329

34 Bihar Samastipur 0.36094

35 Bihar Jamui 0.36032

36 Bihar Kaimur 0.35828

37 Bihar Kishanganj 0.33666

38 Bihar IIDM India 72 Determinants of Workforce Availability and Performance- Bihar

Annexure II Indian Public Health Standards (IPHS) Norms

S H C (Sub- Health Centre)

Manpower Existing Proposed

Health worker (female) 1 2

1 Health worker (male) 1 (funded & appointment by state)

Voluntary worker to keep SHC clean and 1 1 assisting ANM. She is Paid by the ANM from her contingency fund @ Rs.100/pm* (optional) (optional)

Total 2/3 ¾

P H C ( Primary Health Centre)

Existing Recommended

Medical Officer 1 3 (1 female)

AYUSH practitioner Nil 1 (AYUSH)

Account Manager Nil 1

Pharmacist 1 2

Nurse-midwife (Staff Nurse) 1 5

Health workers (F) 1 1

Health Educator 1 1

Health Asstt. (Male & Female) 2 2

Clerks 2 2

Laboratory Technician 1 2

Driver 1 Optional/ may be outsourced

Class IV 4

Total 15 24/25 IIDM India 73 Determinants of Workforce Availability and Performance- Bihar

C H C (Community Health Centre)

In order to provide round the clock clinical services, there is a likelihood of shortage of doctors in 8- hourly shift duties. This shortage can be compensated by resource pooling (Block Pooling Concept) of available doctors posted at Primary Health Centres covered under the CHC. Under the present scenario of shortage of clinical manpower, it is suggested that doctors of PHCs may be located at CHCs while attending to routine OPD duties at PHCs of the catchment area and are required to do shift duties to provide emergency services at CHC. For enabling these doctors to perform duties in wider geographic area, they should be provided with mobile phones and transport facilities to commute from block headquarter to PHC.

Personnel Desirable qualifications Justification Strength

For coordination of NHPs, Block Health Senior most specialists among the management of ASHAs, 1 - Officer specialists Training etc under NRHM & CHC Management etc.

2 Physician MD/DNB, (General Medicine) 1

3 Obst. & Gynae. MD/DNB/DGO (OBG) 1

4 Paediatrician MD (Paediatrics)/ DNB/DCH 1

Essential for utilization of MD (Anesthesia)/ DNB/DA/ Certificate surgical specialities on 5 Anaesthetist 1 course in Anaesthesia 1 year contract or hiring.

6 Surgeon MS/DNB, (General Surgery) 1

Public Health MD (PSM)/MD (CHA)/MD Community 7 1 Manager Medicine or P G Degree with MBA

As per vision 2020 1 8 Eye surgeon MD/ MS/ DOMS / DNB / (Opthalmolgy) approved Plan of Action. (1/5CHC)

9 Dental Surgeon BDS 1

6 10 GDMO MBBS (2female)

Specialist- 11 Post Graduate in AYUSH 1 AYUSH

12 GDMO- AYUSH Graduate in AYUSH 1 IIDM India 74 Determinants of Workforce Availability and Performance- Bihar

Personnel Desirable qualifications Justification Strength

Total 15/16

Nursing & Paramedical Strength

1 Staff Nurse 7

2 Public Health Nurse (PHN) 1

3 ANM 1

4 Pharmacist/compounder 3

5 Pharmacist – AYUSH 1

6 Lab. Technician 3

7 Radiographer 2

8 Ophthalmic Assistant 1

9 Dresser (Red Cross/ St. Johns Ambulance certified) 2

10 Ward Boys / Nursing Orderly 5

11 Sweepers 5

12 Chowkidar 5

13 Dhobi 1

14 Mali 1

15 Aya 5

16 Peon 2

17 OPD Attendant 1

18 Registration Clerk 2

19 Statistical Assistant / Data Entry Operator 2

20 Accountant / Admin. Assistant 1

21 OT Technician 1

Total 52

Grand Total 67 / 68

* Will be appointed under ASHA scheme. IIDM India 75 Determinants of Workforce Availability and Performance- Bihar

** for 24x7 service at OT, Labour Room, casualty, male / female wards & leave reserve.

Central government shall periodically review the staffing norms and modify it somewhat if required. States shall as per provision under NRHM explore keeping part time / contractual staff wherever deficient.

31-50 Beds - Sub-District Hospital

I Doctors 1 Hospital Superintendent 1 1

Medical / Surgery / Obg & Gynae / Dermatologist / Paediatrician/ 2 9 Anaesthetist / Optholmologist / Orthopaedician / Radiologist

3 Casualty/ General Duty Doctors 7

4 Dental Surgeon 1

5 Forensic Specialist 1

6 ENT Surgeon 1

7 AYUSH Physician 2 2

Total 22

1 May be a Public Health Specialist or management specialist trained in public health

2 Provided there is no AYUSH hospital / dispensary in the district headquarter

II Para Medical

1 Staff Nurse 18

2 Hospital worker (OP/ward +OT+ blood bank) 5

3 Sanitary Worker 5

4 Ophthalmic Assistant / Refractionist 1

5 ECG Technician 1

6 Lab. Technician* ( Lab + Blood Storage Unit) 5 (3+2)

7 Lab. Attendant (Hospital Worker) 2

8 Radiographer 2

9 Pharmacist 1 4

10 Matron 1 IIDM India 76 Determinants of Workforce Availability and Performance- Bihar

II Para Medical

11 Physiotherapist 1

12 Statistical Assistant 1

13 Medical Records Officer/ Technician 1

14 Electrician 1

15 Plumber 1

Total 49

* Must have MLT qualification. 1 One from AYUSH

III Administrative Staff

1 Office Superintendent 1

2 Accountant 2

3 Computer Operator 6

4 Driver 1

5 Peon 2

6 Security Staff* 2

Total 14

NB: 1Driver/ vehicle if not outsourced. * To be outsourced &vary as per requirement.

Emergency/ IV Operation Theatre Staff FW OT

1 Staff Nurse 2

2 OT Assistant 2

3 Sweeper 1

Total 5

V Blood Storage Staff

1 Staff Nurse 1

2 MNA / FNA 1

3 Blood Bank Technician 1

4 Sweeper 1 IIDM India 77 Determinants of Workforce Availability and Performance- Bihar

Total 4

94 IIDM India 78 Determinants of Workforce Availability and Performance- Bihar

51 -100 Bedded Sub-District Hospital

I Doctors

1 Hospital Superintendent 1

Medical -2 Surgery-2 Obg & Gyne -2/ paediatrician-2 Anaesthetist-2 / 2 14 Optholmologist / Orthopaedician / Radiologist-2 / Dermatologist

9 3 Casualty Doctors / General Duty Doctors (4 female allopathy)

4 Dental Surgeon 1

5 Public Health Manager 1 1

6 Forensic Expert 1

7 AYUSH Physician 2 2

8 Pathologist- DCP /MD (Micro/Patho / Biochem.) 1

Total 32

1 May be a Public Health Specialist or management specialist trained in public health

2 Provided there is no AYUSH hospital / dispensary in the district headquarter

II Paramedical Staff

50 (including 5 1 Staff Nurse ward incharge)

2 Attendant 1

3 Ophthalmic Assistant / Refractionist 1

4 ECG Technician 1

5 Audiometry Technician 1

6 Lab. Technician (Lab + Blood storage) 5

7 Laboratory Attendant 3

8 Radiographer 3

9 Pharmacist* 5

10 Matron (including assistant matron) 2 IIDM India 79 Determinants of Workforce Availability and Performance- Bihar

II Paramedical Staff

11 Physiotherapist 1

12 Statistical Assistant 1

13 Medical Records Officer / Technician 1

14 Electrician 1

15 Plumber 1

Total 77

III Administrative Staff

1 Junior Administrative Officer 1

2 Accountant 2

3 Computer Operator 6

4 Driver 2

5 Peon 2

6 Security Staff* 2

Total 15

NB: 1Driver/ vehicle if not outsourced. * To be outsourced &vary as per requirement.

IV Operation Theatre Emergency FW OT General O.T. Total

1 Staff Nurse 4 1 5

2 OT Assistant 4 2 6

3 Safai Karamchari 2 1 3

Total 10 4 14

V Blood Storage

1 Staff Nurse 1

2 MNA / FNA 1

3 Blood Bank/Storage Technician 5 IIDM India 80 Determinants of Workforce Availability and Performance- Bihar

4 Safai Karamchari 3

5 Attendant 2

Total 12

Grand Total 150 IIDM India 81 Determinants of Workforce Availability and Performance- Bihar

101-200 Bedded District Headquarters Hospital I Doctors

1 Hospital Superintendent 1

2 Medical Specialist 3

3 Surgery Specialists 2

4 O&G specialist 4

5 Psychiatrist 1

6 Dermatologist / Venereologist 1

7 Paediatrician 2 8 Anesthetist (Regular / trained) 2

9 ENT Surgeon 1

10 Opthalmologist 1

11 Orthopedician 1

12 Radiologist 1

13 Microbiologist 1

14 Casualty / GDMO 6

15 Dental Surgeon 1

16 Forensic Expert 1

17 Public Health Manager 1 1

18 AYUSH Physician 2 2

19 Pathologists 2

Total 34

Note: 1 May be a Public Health / Management Specialist trained in public health

2 Provided there is no AYUSH hospital / dispensary in the district headquarter

II Nursing & Para Medical

1 Staff Nurse* 75 to 100

2 Hospital worker (OP/ward +OT+ blood bank) 20

3 Sanitary Worker 15 IIDM India 82 Determinants of Workforce Availability and Performance- Bihar

II Nursing & Para Medical

4 Ophthalmic Assistant / Refractionist 1

5 Social Worker / Counsellor 1

6 Cyto Technician 1

7 ECG Technician 1

8 ECHO Technician 1

10 Lab. Technician ( Lab + Blood Bank) 12

11 Laboratory Attendant (Hospital Worker) 4

12 Dietician 1

13 PFT Technician -

14 Maternity assistant (ANM) 6

15 Radiographer 2

16 Dark Room Assistant 1

17 Pharmacist 1 5

18 Matron 1

19 Assistant Matron 2

20 Physiotherapist 1

21 Statistical Assistant 1

22 Medical Records Officer / Technician 1

23 Electrician 1

24 Plumber 1

Total 154 / 179

*1 Staff Nurse for every eight beds with 25% reserve. 1 One may from AYUSH

Emergency FW General Total III Operation Theatre OT OT

1 Staff Nurse 8 1 9

2 OT Assistant 4 2 6 IIDM India 83 Determinants of Workforce Availability and Performance- Bihar

3 Sweeper 3 1 4

Total 15 4 19

Blood Total IV Blood Bank Blood Bank Storage

1 Staff Nurse 3 1 4

2 MNA / FNA 1 1 2

3 Lab Technician 1 - 1

4 Safai Karamchari 1 1 2

Total 6 3 9

V Administrative Hospital + JD- HS office

1 Manager (Administration) -

2 Junior Administrative Officer 1

3 Office Superintendent 1

4 Assistant 2

5 Junior Assistant / Typist 2

6 Accountant 2

7 Record Clerk 1

8 Office Assistant 1

9 Computer Operator 1

10 Driver 2

11 Peon 2

12 Security Staff* 2

Total 17

Grand Total 233

NB: 1Driver/ vehicle if not outsourced. * To be outsourced &vary as per requirement. IIDM India 84 Determinants of Workforce Availability and Performance- Bihar

201-300 Bedded Hospital I Doctors 1 Hospital Superintendent 1

2 Medical Specialist 3

3 Surgery Specialists 3

4 O&G specialist 6

5 Psychiatrist 1

6 Dermatologist / Venereologist 1

7 Paediatrician 3 8 Anesthetist (Regular / trained) 6

9 ENT Surgeon 2

10 Opthalmologist 2

11 Orthopedician 2

12 Radiologist 1

13 Microbiologist 1 (under IDSP)

14 Casualty Doctors / General Duty Doctors 20

15 Dental Surgeon 1

16 Forensic Expert 1

17 Public Health Manager 1 1

18 AYUSH Physician 2 4

19 Pathologists 2

Total 61

Note : 1 May be a Public Health Specialist or management specialist trained in public health

2 Provided there is no AYUSH hospital / dispensary in the district headquarter

II Nursing & Para Medical

1 Staff Nurse* 100 IIDM India 85 Determinants of Workforce Availability and Performance- Bihar

II Nursing & Para Medical

2 Hospital worker (OP/ward +OT+ blood bank) 30

3 Sanitary Worker 20

4 Ophthalmic Assistant / Refractionist 2

5 Social Worker / Counsellor 2

6 Cytotechnician 1

7 ECG Technician 1

8 ECHO Technician 1

9 Audiometrician 1

10 Laboratory Technician ( Lab + Blood Bank) 12

11 Laboratory Attendant (Hospital Worker) 4

12 Dietician 1

13 PFT Technician 1

14 Maternity assistant (ANM) 4

15 Radiographer 3

16 Dark Room Assistant 2

17 Pharmacist 1 8

18 Matron 7

19 Physiotherapist 2

20 Statistical Assistant 1

21 Medical Records Officer / Technician 2

22 Electrician 1

23 Plumber 1

Total 207

* 1 Staff Nurse for every eight beds with 25% reserve. 1 Two may from AYUSH IIDM India 86 Determinants of Workforce Availability and Performance- Bihar

Operation Total III Emergency/ FW OT Opth. /ENT A & E Elective Theatre

1 Staff Nurse 5 2 1 3 11

2 OT Assistant 4 2 2 2 10

3 Sweeper 2 1 1 1 5

Total 11 5 4 6 26

IV Blood Bank Blood Bank Blood Storage Total

1 Staff Nurse 3 1 4

2 MNA / FNA 1 1 2

3 Lab Technician 1 - 1

4 Safai Karamchari 1 1 2

Total 6 3 9

V Administrative Staff Hospital & JD-HS office

1 Manager (Administration) 1

2 Junior Administrative Officer 1

3 Office Superintendent 2

4 Assistant 5

5 Junior Assistant / Typist 3

6 Accountant 2

7 Record Clerk 3

8 Office Assistant 2

9 Computer Operator 2

10 Driver 3 IIDM India 87 Determinants of Workforce Availability and Performance- Bihar

11 Peon 2

12 Security Staff* 2

Total 28

Grand Total 331

NB: 1Driver/ vehicle if not outsourced. * To be outsourced &vary as per requirement. 301-500 Bedded Hospital

I Doctors 1 Chief Medical Superintendent 1

2 Medical Specialist 4

3 Surgery Specialists 3

4 O&G specialist 8

5 Psychiatrist 1

6 Dermatologist / Venereologist 2

7 Paediatrician 4 8 Anesthetist (Regular / trained) 8

9 ENT / Ophthalmology / Ortho Specialists (2 each) 6

10 Radiologist 5

11 Microbiologist 1 (under IDSP)

12 Pathologist &Blood Bank In-charge 1

13 Casualty / General Duty Doctors 24 (10 ladies allopathy)

14 Dental Surgeon 1

15 Forensic Specialist 1

16 Public Health Manager 1 1

17 AYUSH Physician 2 4 (2 specialists & 2 MOs)

Environmental Officer / Waste Management officer (1 18 2 each)

Total 77 IIDM India 88 Determinants of Workforce Availability and Performance- Bihar

1 May be a Public Health Specialist or Management Specialist trained in public health.

2 Provided there is no AYUSH Hospital/dispensary in the District Headquarter.

II Nursing & Paramedical

1 Staff Nurse 200 – 250

2 Infection Control Nurse 2

3 Hospital worker (OP/ward, OT& blood bank) 50

4 Sanitary Worker 30

5 Ophthalmic Assistant / Refractionist 2

6 Social Worker / Counsellor 2

7 Dermatology/STD/Leprosy Technician – Lab 1

8 AIDS/STD Counselor cum field Support 2

ECG Technician / ECHO Technician / CYTO 9 3 Technician

10 Audiometrician 1

11 Laboratory Technician ( Lab + Blood Bank) 6+3

12 Laboratory Attendant (Hospital Worker) 2+1

13 Dietician 2

14 PFT Technician 1

15 Maternity assistant (ANM) 4

16 Radiographer 12

17 Dark Room Assistant 8

18 Pharmacist 1 10

19 Matron 9

20 Physiotherapist 2

21 Statistical Assistant 1

22 Medical Records Officer / Technician 2

23 Electrician 2

24 Plumber 2 IIDM India 89 Determinants of Workforce Availability and Performance- Bihar

II Nursing & Paramedical

Total 160

1 Two from AYUSH.

III Operation Theatre Emergency/ FW OT Opth./ ENT A & E Elective Total

1 Staff Nurse 5 2 1 3 11

2 OT Assistant 4 2 2 2 10

3 Sweeper 2 1 1 1 5

Total 11 5 4 6 26

IV Blood Bank

1 Blood Bank In-charge (Doctor – Pathologist) 1

2 Staff Nurse 3

3 MNA / FNA 1

4 Blood Bank Technician 1

5 Sweeper 1

Total 7

V Administrative Staff

1 Hospital Superintendent 1

2 Manager (Administration & Procurement) 1

3 Manager (Finance) 1

4 Manager (HR) 1

5 Account Officer 1 IIDM India 90 Determinants of Workforce Availability and Performance- Bihar

6 Accountant 4

7 Assistant cum Computer Operator 6

8 Driver 4

9 Peon 2

10 Security Staff* 2

Total 23

Grand Total 289

* The number would vary as per requirement and to be outsourced.