Determinants of Workforce Availability and

Performance of Specialists and General Duty

Doctors in Health and F.W. Department of

Uttarakhand

NHSRC Study

2009

Conducted by SCM Social Policy Research Institute, Jaipur

1 Contents

Executive Summary

1.0 Background 1.1 Geography & Demography 1.2 Health Profile of Uttaranchal 1.3 Study Partners 1.4 Objectives of the study 1.5 Methodology

2.0 HRH: Availability and Short-fall

3.0 Observations 3.1 Haridwar 3.2 Pithoragarh 3.3 Udham Singh Nagar 3.4 Responses from Doctors 3.5 Determinants of the Performance of Doctors 3.6 Facilities as we saw them

4.0 Projections 5.0 Suggestions

Appendices

2 Chapter 1 Background and Methodology

1.1 Geography & Demography:

Uttarakhand came into existence on 9th November 2000 as the 27th state of India. Uttarakhand is surrounded internationally by Nepal on the east, China on the north, and within the country by Himachal Pradesh in the west and U.P. in the south.

The state has been carved out from the erstwhile state of Uttar Pradesh by combining the hill districts of Uttarkashi, Chamoli, Rudraprayag, Tehri Garhwal, Dehradun, Pauri Garhwal, Pithoragarh, Bageshwar, Almora, Champawat and Nainital with the districts of Udham Singh Nagar in the Terai region and Haridwar in the foothills. About 63 percent of the state is covered by rich forests. About 93 percent of the area is hilly and the remaining 7 percent is covered by plains. The State comprises of 13 districts, 49 tehsils, 95 blocks, and 16,414 villages. The state has 86 cities/towns of which only five cities have a population of more than 100,000. As per the 2001 census, the population of Uttrakhand is 8.5 million with a population density of 159 persons per square kilometers. The districts in the plains are densely populated in comparison with the hilly areas. Three densely populated districts account for more than half of the state's population. The population size of districts varies from 224,542 of Champawat district to 1,447,187 of Hardwar district. The decadal growth rate of the state between 1991 and 2001 was 19.2 percent with substantial inter-district variations. While the sex ratio for the state as a whole is 964, the child sex ratio (0-6 years) is 906.

3

Uttarakhand is predominantly rural with 74 percent of the population living in 16,414 villages. More than four-fifths of the villages have a population of less than 500. Another 10 percent villages have a population size between 500 - 999 and 6 percent villages have population of more than 1,000. Small-sized, scattered villages without road connectivity pose a major challenge to health service delivery. Hill districts are at a disadvantage compared with districts in the plains.

The scheduled castes (SC’s) constitute 17 percent of the population and the proportion of the scheduled tribes (ST’s) is 3 percent. The literacy rate in Uttarakhand is among the highest in the country. About 73 percent of the population in the state is literate and the literacy rate is better in the hill districts than in the plains. Eighty-four percent of males are literate compared with 60

4 percent of females. In sum, the hill districts of Uttarakhanda, although sparsely populated and with a large number of small scattered villages, are better off than the plain districts in terms of the sex ratio and literacy.

1.2 Health Profile of Uttarakhand

A broad overview of the health profile can be taken by looking at the comprehensive health indicators and comparing them with national averages as given below:

Indicator Source Uttarakhand India Total population (Census 2001) 8.489 1028.61 (in million)

Decadal Growth (%) (Census 2001) 19.20 21.54 Crude Birth Rate (SRS 2007) 21 23.1 Crude Death Rate (SRS 2007) 6.7 7.4 Total Fertility Rate (SRS 2007) 2.55 2.7 Infant Mortality Rate (SRS 2007) 48 55 Maternal Mortality (SRS 2004 - 2006) 301 254 Ratio Sex Ratio (Census 2001) 964 933 Schedule Castes (Census 2001) 1.517 166.64 population (in million)

Schedule Tribe (Census 2001) 0.256 84.33 population (in million)

Female Literacy Rate (Census 2001) 59.6% 53.7 %

Uttarakhand has more than 3,000 health facilities to cater to the medical, health care and F.W. needs of the people. While a CHC, on an average, covers 306 villages, a PHC covers an average of 70 villages and a Health sub-center an average of 10 villages. While each CHC covers an average of four PHCs, there are on an average seven sub- centers with each PHC. As per 2001 Census data, a sub-center covers an average population of 3575, a PHC of 26,403 and a CHC of 114,732.

5 Health Institution Number Medical Colleges 3 Hospitals 17 Base Hospitals 3 TB/Leprosy Hospitals 22 Female Hospitals (R) 24 Sub-centres 1765 Primary Health Centres 45 Urban FWCs 2 Additional PHCs 187 Community Health Centres 49 Dispensaries 322 Ayurvedic Dispensaries 516 Unani Hospitals 05 Unani Dispensaries Nil Homeopathic Hospitals 107 Homeopathic Dispensaries Nil

1.3 Partners of this Study:

1.3.1 NHSRC: The National Health System Resource Center is an autonomous organization set up by the Ministry of Health and Family Welfare, Government of India as a centre of excellence for facilitating the Union and the State governments in the implementation of the NRHM. It was established in 2007. It is undertaking research studies which investigate the operation of current strategies to find out their strengths and weaknesses, thus suggesting mid-course corrections. There is a full time advisor on human resources in NHSRC whose main concern is to investigate and suggest the measures to elicit the best possible performance from the available health manpower. NHSRC is also working on the estimated requirement of human resources on health through the Indian Public Health Standards to be deployed in the peripheral facilities in

6 different states. It is in this context, the NHSRC has undertaken, in selected states, a study on the workforce determinants in the functioning of generalist and specialist doctors in rural facilities.

1.3.2 SCMSPRI : The Shiv Charan Mathur Social Policy Research Institute was founded in Jaipur, Rajasthan in 1985 with a view to undertaking research on social and economic policies, examine the impact of development programmes and projects of the government. Its mandate is to help government in policy formulation and initiating / modifying on-going development programmes. The institute has undertaken several research projects in areas ranging from agriculture, education and health to mineral and oil exploration. Over the last one decade, it has developed expertise in the health sector by developing district action plans for the NRHM and evaluating operations of HIV/AIDS control and reproductive health. It is with this background that the SCMSPRI has undertaken the current study with the support by NHSRC.

1.4 Objectives of the study:

The basic objective of this study is to assess the determinants of availability and performance of specialists and general duty Medical officers in the three sampled districts i.e. Pithoragarh, Haridwar and Udham Singh Nagar of Uttarakhand.

The detailed objectives of the study are as under;

1. To study the processes of recruitment and deployment of medical officers and specialists and their effectiveness, especially in the under serviced areas.

2. To study the workforce management issues such as postings, transfers, promotions, continuous professional development through structured career paths, in-service trainings, appraisals, recognition of work, medical & insurance benefits and grievances handling system and to suggest remedial measures.

7 3. To study the compensation package and incentives provided to attract medical officers and specialists to rural areas. The study would also examine the problems in implementing the incentive packages and their impact on service delivery.

4. To analyze the gaps in the support system which include provisions of on-campus residence, children’s education, supportive supervision and promotions.

5. To review the educational and training programmes for enhancing the capacity of doctors and to suggest a revised strategy, if necessary.

6. To assess the gaps between the services expected to be provided as per IPHS at facility levels and the services being currently provided. Based on this, to recommend capacity building processes for optimizing efficiency and effectiveness of the general and specialist doctors.

7. To conduct a situation analysis of the existing facilities, the number of facilities required, and the staff required per facility as per the IPHS.

1.5 Methodology: The study involved all interaction with policy makers, directors and consultants at the state level; executives and managers at district level and doctors at the cutting edge level.

To carry out the stipulated task, three districts of Uttarakhand were taken as samples on the basis of their human development indices. The Udham Singh Nagar district was selected as a high value HDI district while Hardwar district was selected as a low HDI value district and Pitthoragarh was selected as a medium HDI value districts. The focus of observations in the three districts was:

a. Assessing the policies of recruitment, deployment, postings and trainings of generalist and specialist doctors as experienced by them.

b. Assessing the gaps between the services they are expected to provide as per the IPHS and the training and infrastructure needed for them to achieve this.

8 c. Assessing the specialist/generalist doctors’ preferences (first, intermediate and last) for postings & transfers and to develop the objective criteria for underserved areas.

Simple objective criteria of performance such as outpatients seen per day, laboratory tests done by a PHC doctor and night duties per month performed in the PHC were taken in consideration.

Five CHCs were selected from each district. Two PHCs from the area of each CHC - one remotest and another nearby the CHC - were selected. District/Sub district hospital of the district was also selected for a detailed study.

Thus, 16 institutions were identified and selected from a district for the study. In addition to the institutional survey, 40 doctors (30 general duty medical Officers and 10 specialists) were also identified and interviewed to get their views in Format D. The thirty generalist doctors interviewed included ten from CHCs and twenty from PHCs. All attempts were made to interview specialists from CHCs. Wherever the specialists were not available in the sampled CHC, specialists from the district hospital of the respective district were approached. Institutional information was collected in Format C.

The total sample selected from the 3 districts of Uttarakhand was as under:

District Hospitals CHC PHC GDMO Specialists Haridwar 2 5 9 29 11 Pithoragarh 2 4 12 30 10 US Nagar 1 5 10 21 19

9 Since there are only four CHCs in Pitthoragarh district, we took all of them in our study sample. Consequently, we took up three PHCs from each of these CHCs to achieve the desired sample of PHCs in the district.

Strategical design of this study demands to interview 40 doctors in each district out of whom 30 should have been generalists. But this consideration could not be fulfilled in Udham Singh Nagar because of the large number of vacancies of generalist doctors in the peripheral facilities of the district. Eventually the survey team had to rely on the district hospital to interview the doctors available there. Thus, in Udham Singh Nagar, 19 of the 40 interviewed doctors were specialists.

Chapter 2

HRH in Uttarakhand: Availability and Short-fall

The government of Uttarakhand has taken up several steps in enhancing the capacity of its health systems. It has embarked on the formulation of a comprehensive, integrated, specific health and population policy. This policy reflects the needs, aspirations and views of the people of Uttarakhand. It aims at eradicating polio, reducing leprosy to

10 below 1/10,000, reducing RTI below 10% by 2007, reducing mortality on account of TB, Malaria and other vector and water-borne diseases, reducing the prevalence of blindness to 0.3%; and reducing the IDD by 50% by 2010.

The current position of the human resources for health in the public sector of the State is as follows:

Particulars Sanctioned In position Shortfall FHW(ANM) at Sub Centers & 2039 1897+142* 142 PHCs ANM NRHM 1631 1631 0 MPWs(M) 552 397 155 LHVs 345 340 5 Doctors (GDMO+SMO+MO) 1922+259+90 946+195+43 976+64+47 Radiographers 94 70 24 Laboratory Technicians 266 132 134 Pharmacists 732 715 17 Nurses Gr.II 777 626 151 Nurses Gr.I 251 143 108 * Contractual ** No cadre for specialists

The health system of the state is having a strength of 900 doctors from provincial medical services. 284 doctors have also been hired on contract basis. The Government has a shortfall of 1087 doctors in the State. In view of the difficult terrain of most of the districts, the doctors are largely concentrated in the four districts i.e. two in the plains and two closer to the plains. Thus there is also a misdistribution of doctors in the state. This is happening in spite of a transfer policy which clearly specifies that priority should be given to doctors for posting in their home districts. The private practice varies from place to place. While the doctors in Dehradun are highly practice minded, in Nainital district it is not so. In most of the hilly districts the scope for private practice seems to be limited.

11 The general Administration Department of the state has classified the districts according to location into ‘ sugam ’, ‘ durgam ’ and ‘ ati-durgam ’ on the basis of their altitude and approach. Medical department has made a provision of additional incentives for serving in the later two, but the impact of this incentive has not proved to be encouraging so far. Tehri, Pauri-Garhwal and Bageshwar fall in the most difficult category ( ati-durgam ) where a general duty doctor on contract is paid the highest i.e. Rs. 35,000/- p.m... Although contractual positions for the Indian System of of medicine could be filled to some extent but in luring the allopath this strategy has not worked. The Proposal to give priority to the in-service generalists in post-graduate admission as an incentive is also under consideration of the Health department. As a first step in this direction, the state government has already tied up with the medical colleges within the state to keep 16 post-graduate seats for in-service candidates of the state.

There is a shortage of specialists throughout the state. Surgeons are available only in six districts. There is an acute shortage of anesthetists. Obstetricians are also not available in difficult areas. Specialists available within the state also remain misdistributed e.g. there are three radiologists in the district hospital of Hardwar, while there is no radiologist in the district hospitals at high altitudes. The State Government is trying with the medical colleges of U.P. to block certain post-graduate seats exclusively for specialists for Uttarakhand.

A Radiologist was transferred from the district hospital, Nainital to Bageshwar in late 2008. He did not join the new place and brought pressure on the system to review his transfer. In early 2009, he was posted at District Hospital, Hardwar where already two doctors in the specialty of radio-diagnosis were available. Thus, while Hardwar had more specialists than required, Bagheshwar does not have even one in spite of technology available there.

The state government has also made a provision for hiring the services of 51 super- specialists in the cities. This provision remained limited to the state capital i.e. Dehradoon. Services of only seven doctors from different super-specialties could be drawn by the Doon Hospital in the capital.

12 The state Health department has a full strength of pharmacists with 294 persons on the sanctioned positions scattered throughout the State. The state government has sanctioned 266 posts of Lab Technicians against the requirement of 294. But only 132 positions are occupied, indicating a shortfall of 162 Technicians. Similarly, for the Nurse Midwife/staff Nurse, it has sanctioned 368 posts against the requirement of 624, but only 292 positions are occupied, thus indicating a shortfall of 332 Nurses.

While there are only 866 doctors against the sanctioned strength of 1798 at PHCs, indicating a vacancy of 932 positions, the situation of specialists at CHCs is as given below:

Required Sanctioned In Position Vacant Shortfall Position (R) (S) (P) (S-P) (R-P) Surgeons 55 44 15 29 40 Obstetricians & 55 44 30 14 25 Gynecologists Physicians 55 34 4 30 51 Pediatricians 55 41 18 23 37 Total Specialists 220 163 67 96 153

The strategy adopted during the 11 th Five Year Plan is to provide medical and health services in the remotest and most disadvantaged blocks in the state so that the state achieves its goals to reduce the TFR to 2.1; CBR to 19.9; increase contraceptive prevalence to 55%; reduce IMR to 28 and MMR to below 100,by 2010. Between 2007 and 2012, state has planned to establish 3080 new sub centres and 35 new CHCs. With this background, deploying doctors and eliciting best possible work from them is all the more crucial.

13 Chapter 3 Observations

3.1 Haridwar:

Haridwar district spread over 2360 sq km forms the western part of Uttarakhand. The height from the sea level is 249.7 meters. This district was a part of Saharanpur Divisional Commissionairate in UP before its inclusion in the newly created state of Uttarakhand. The district is surrounded by Saharanpur in the west, Dehradun in the north and east, Pauri Garhwal in the east, Muzzaffar Nagar and Bijnor of U.P. in the south. The district headquarter is situated in Roshnabad, at a distance of about 12 kms from the railway station.

The district is administratively subdivided into three tehsils i.e. Haridwar, Roorkee and Lashkar. There are six development blocks i.e. Bhagwanpur, Roorkee, Narsan, Bahadrabad, Lashkar and Khanpur. As per the 2001 census, the population of the district was 1,444,213.

Demography (Census 2001) Total Population 1447187 Urban 446275 Rural 1000912 Sex Ratio 865 Decadal Growth Rate (%) 28.70 Density (Per Sq Km) 613 Literacy rate 63.75 Male 73.83 Female 52.10

14 Percent SC Population 21.69 Percent ST Population 0.22 Birth Rate 29.5 Death Rate 7.5 IMR 48

The district has 159 sub-centers, 25 PHCs and 6 CHCs. There are 2 district hospitals, 11 homeopathic dispensaries and 27 ayurvedic and unani dispensaries. There is only one govt allopathic dispensary in Haridwar.

3.2 Pithoragarh

Pithoragarh is one of the last districts in the northern India adjoining Tibet. The district forms the north-eastern part of the Kumaon Division It is bounded by Tibet on the north, Nepal on the east, district Almora on the south and the districts of Almora and Chamoli on the west, with an area of 7,242 sq. km.

Pitthoragarh has been divided into six tehsils viz. Munsyari, Dharchula, Didihat, Gangolihat, Berinag, Pithoragarh and two sub-tehsils Dewalthal, Kanalichhina having its head quarters at Pithoragarh and the Commissionairate head quarter is at Nainital. There are eight development blocks, three towns, 64 nyaya panchayats and 644 gram panchayats in the district. There are 1672 villages out of which 1579 are inhabited. As per the 2001 census, the total population of the district is 462,289. The total literacy rate of the district is 75.95. The population density is 65. The number of health sub-centers, PHCs and CHCs in Pitthoragarh is 154, 18 and 4 respectively. There are three hospitals and 32 allopathic dispensaries in the district. In addition, the district also has 57 ayurvedic and seven homeopathic dispensaries.

15 Demography (Census 2001) Total Population 462289 Urban 59833 Rural 402456 (87.05%) Sex Ratio 1031 Decadal Growth Rate 10.9 Density 65 Literacy rate 75.9 ()a Male 90.1 Female 62.6 Percent SC Population 23.0 Percent ST Population 4.2

There are 34 generalist doctors against a sanctioned strength of 93. The district has 13 specialist doctors against the requirement of 38. 29 positions of pharmacists out of 72 sanctioned are lying vacant. Although there are only two vacancies of ANMs out of 177 sanctioned positions, but there are only seven staff Nurses Gr I against 12 positions and only 38 staff nurse Gr II against 43 positions. Likewise, the dearth of technicians is reflected in terms of only seven filled against sixteen positions sanctioned.

3.3 Udham Singh Nagar Udham Singh Nagar is the industrial hub of Uttarakhand. It covers an area of 2908 sq. km. It is sourrounded by Nanital and Champawat in north, Nepal in east and UP in west and south west.

The district comprises of seven development blocks namely Khatima, Sitarganj, Kichha, Gadarpur, Bazpur, Kashipur and Jaspur. As per 2001 census, there are 674 viilages in the district, out of which around one third of the villages have population of 500 or less while more than 50% villages are inhabited by 500 – 2000 persons. The population density of 424 persons per sq. km. reflects it to be the densest part of the state.

Demography Total Population Census 2001 1235614 Urban 403014 Rural 832600 (67.38%)

16 Sex Ratio 902 Decadal Growth Rate (%) 22.79 Density (per sq km) 424 Literacy rate Total 64.86 Male 75.22 Female 53.35 Percent SC Population 13.2 Percent ST Population 8.9 Crude Birth Rate 28.6 Crude Death Rate 6.5 IMR 61.7 CPR 55.5 TFR 2.5

There are 77 sanctioned positions of generalist doctors out of which 43 are lying vacant. 14 of the 20 sanctioned positions of laboratory technicians are also lying vacant. Amongst the nursing cadre, 5 of 74 positions of staff nurse Gr II, one of the 15 positions of staff nurse Gr I and one post out of 188 positions of ANMs are lying vacant. Three of the 67 posts of pharmacists and two of the 11 posts of radiologists are lying vacant.

The population of Udham Singh Nagar is 1,235,614 and the density of population is424 persons per sq. km. The district has 153 sub centers, 25 primary health centers and 5 community health centers. In addition there are eight state allopathic dispensaries, 20 ayurvedic and five homeopathic dispensaries and two Hospitals in the district.

3.4 Responses from Doctors

In the three sampled districts: Pitthoragarh, Haridwar and Udham Singh Nagar, 120 doctors were interviewed. 25 of them were specialists and 95 generalists. There were 91 male and 29 female doctors. 86 of the 120 doctors were in the age group of 26-45 years and only 11 of them were 56 years and above. Three-fourths of these doctors were inducted through Public Service Commission. We could find only half of the doctors we planned to interview in the peripheral facilities due to high vacancies in the field.

17 Eventually, we had to depend on doctors working in district hospitals to collect the desired information.

Profiles of the doctors working in the health system indicated that 93 of the 120 Doctors have had their schooling in the cities with only 27 of them coming up from a rural background. 105 of these 120 were from the allopathic stream. Since it was planned to collect responses from doctors deployed at the CHC/PHC level, 15 doctors from the Indian system of Medicine also came in this fold. We could find only three Doctors who were inducted after 2006. Only 30 of the doctors are working in the government health system since 1985 or earlier. While six specialists were inducted between 1976-85, nine between 86-95 and nine between 96-05; no specialist has been inducted after 2006. Only four of the interviewed doctors had gone through their medical education after paying a capitation fee. Although the specialists’ cadre is lacking in Uttarakhand, we found 20 doctors with M.D.s and 13 with M.S. qualification in our sample of 120. In addition, 32 carried diplomas and one was a qualified DNB. Out of these 66 Doctors with post- graduate qualification, only two did their post-graduation on capitation seats.

Tracking the service history of doctors indicated that 107 of the 120 doctors were deployed at rural facilities on their first posting. Two-third of them got their first posting at a place of their liking. Half of them stayed at the first place of posting for more than two years and one-fifth could carry on at the first place of their posting for more than five years. One-third of the doctors have not faced any transfer, but one-sixth have had four or more transfers in their career. Nine of the 21 doctors who had repeated transfers admitted it as a punishment given to them. Beside the transfers, the doctors are sometimes sent to another facility for temporary posting. 14 of the 120 Doctors have carried out such temporary duties away from their stations of posting. In this background, it may be noted that 60 percent of the inter-viewed doctors were aware of the transfer policy of the State.

One-fourth of the doctors did not know their pay scale. One-third of them are satisfied with the emoluments they are getting. Amongst the two-third of the doctors who 18 expressed their dissatisfaction with the emoluments they were getting, the major reason enumerated by them was low payment against the heavy duty they had to perform, low wages in comparison to equivalent positions in private sector, and low salaries in comparison to the equivalent civil services. Two-third of the interviewed doctors did not favor private practice. The chart below shows the reasons for dissatisfaction among doctors in the context of emoluments paid to them.

While one-fourth of the doctors admitted of having seen their job-responsibilities in a written form, 82% of those who have not seen their job-responsibility boasted of knowing their exact role. Half of the doctors expressed satisfaction on the authority delegated to them. 40% of doctors are fully using the funds allocated to them and 18% of them are exercising full authority in rewarding and punishing their subordinates.

While 18 of the 120 doctors have secured one promotion in their career, only one doctor has had two promotions in his career. Out of 19 such doctors, four could get promotion only after completing sixteen or more years of service while the remaining 15 were rewarded with promotion between 5 – 15 years of their service.

19 112 0f the 120 doctors said that they were supervised but only 71 of them admitted it as a regular phenomenon from which they could learn something. Half of the interviewed doctors said that they were also monitored by the community representatives.

Three-fourth of the doctors have not participated in any CME during the last two years. Many of them do not get an opportunity as they are not authorized to go as per their wish and in some cases, there is unavailibility of other doctors to shoulder the responsibility in case of their absence. Of the 27 who have attended a CME, 11 attended only once while eight participated more than thrice. This indicates that doctors, who have the will to participate in a CME can look for an opportunity by their own efforts. In the last two years, 55% doctors have not attended any training program. The doctors who have attended training program may have found them relevant and useful and could relate it to their area of work. Approximately, half of the doctors have attended at least one in- service training program in last two years.

The state health department has a system of performance appraisal. 81% doctors reported that a regular performance appraisal system exist in the department. The performance is being evaluated and appraised by the Chief Suprintendent/ Chief Medical Suprintendent (CS/CMS). It is also done by the Chief Medical Officers (CMOs) and in a few cases by the Principal Medical Officer (PMO). The performance appraisal is kept confidential. Doctors do not receive any feedback on their appraisal. Even if the performance is above the mark, no appreciation is given to them. Doctors seldom get any kind of appreciation by their superiors. There is an absence of a reward system on carrying out quality work but in failing to do so, they are punished. If the performance is found unsatisfactory, they do receive a memo after their appraisals have been registerted through a full beaurocratic procedure. When enquired about the system of Grievance handling, 75% doctors said that redressal of grievances is not taken into account while 25% stated that there was a grievance redressal system.

The leave provision for doctors exist and is like the other government department of the state. Some of the doctors said that they were not able to avail the leave easily. Many times there was excessive workload and there was a shortage of staff and they were not granted leave when they required it. Contractual doctors are entitled to casual leave only.

20 The doctors are getting sufficient support as far as space, instruments, drugs, staff, support from the community is concerned.

All interviewed doctors said that they stayed at the location of their posting. 60-65% of the doctors said that they stayed in government quarters along with their families and adequate educational facilities were available for their children. Social activities providing them recreation and leisure are held in their vicinity.

Around 64% doctors are working on call duties i.e they have to provide their services as and when they are asked to do so. Generally, the generalists have to work in the night shifts whereas the specialists are less demanded for night duties. All the doctors seemed to be confident in carrying out the task they were supposed to perform, but 61% of the generalists felt that they were overburdened.

3.5 Status of Facilities

Status of CHCs:

21 We visited 14 CHCs selected in the three sampled districts but found stark differences in their resourcefulness and efficiency. While the distribution of generalists at a CHC was even between the districts, the availability of specialists at a CHC was uneven. In Udham Singh Nagar, 24 specialists were found working in five CHC, but in Pitthoragarh and Hardwar, only two and three specialists respectively were working at CHCs. None of the CHCs surveyed in the latter two districts has medical and surgical specialists. Obstetricians are not at all available at a CHC in any of the three districts. Laboratory services at a CHC two districts were dismal for want of laboratory technicians. Nursing support seems to be relatively better. Nurse deployment was also found to be comparatively better in Udham Singh Nagar.

With an average number of 30, 30 and 23 in-door beds at the CHC’s of Pithoragarh, Udham Singh Nagar and Haridwar respectively, beds situation seems to be satisfactory. All CHCs have operation theatres and duty rooms for doctors, but only two-third of the CHCs have functional toilets in their doctor’s duty rooms. Staff quarters exist in all the CHCs.

Even when infrastructure seems complete, physical amenities are lacking. Erratic power supply is a problem in the CHCs of Hardwar although generators/inverters do exist at all of these facilities. CHC. In Pithoragarh, for want of regular water supply, there is a problem in the conduct of normal work. All CHCs have ambulances and Telephone facility exists at all the CHCs in Pithoragarh and Udham Singh Nagar but only at 40% CHCs in Hardwar. The availability of Computers with an internet facility differ. While four of the five CHCs visited in Hardwar had this facility, in Pithoragarh and Udham Singh Nagar, the facility exists only in 70% and 40% CHCs respectively.

The availability of equipment was also looked into at all the CHCs visited. It was found that all the CHCs have examination tables, functional BP instruments in the OPD and functional delivery tables and instruments required for routine delivery, including

22 episiotomy. One CHC in Udham Singh Nagar did not have a functional OT table. OT lights were not functioning in one CHC in Udham Singh Nagar and two CHCs in Pitthoragarh. One CHC each in Udham Singh Nagar and Pithoragarh and two CHCs in Hardwar did not have Boyle’s apparatus for giving anesthesia. Only 60%-80% surgical instruments were available. One CHC in Udham Singh Nagar did not have an autoclave. The blood storage facility exists at one CHC each in Hardwar and Udham Singh Nagar and two CHCs in Pithoragarh. At one CHC in Pithoragarh, the X-ray machine is not available, while 60% ultrasound machines are available in Pithoragarh and 20% in the remaining two districts.

The average daily OPD attendance at the CHCs of Pithoragarh, Udham Singh Nagar and Hardwar was 82, 183 and 125 respectively; average attendance of in-patients was 3.37, 8.4 and 1.3 respectively. In Udham Singh Nagar, doctors and nurses are providing 24 x 7 services but it is not so in the other two districts. Bed occupancy at CHCs was determined from the available records. It was found to be 23% at Pithoragarh, 21.6% at Udham Singh Nagar and 9.07% at Hardwar. The cumulative numbers of deliveries conducted in the five sampled CHCs during the month of May 2009 were 22, 131 and 151 at Pithoragarh, Udham Singh Nagar and Hardwar respectively which indicated that the average number of deliveries conducted at CHC range from one to five. Caesarian section at CHC was reported only in Udham Singh Nagar. ANC clinics are held on a weekly basis and the average attendance at these clinics ranges from 21 at Pithoragarh to 76 at Hardwar and 93 at Udham Singh Nagar. The average number of children covered through immunization clinics conducted on weekly basis at CHCs was 13.75, 58.6 and 68.1 respectively for Pithoragarh, Udham Singh Nagar and Haridwar respectively.

While the monthly meetings for doctors at CHCs are a regular feature, meetings for Rogi Kalyan Samitis are held irregularly. The number of RKS meetings was 28, 17 and 8 at Pithoragarh, Udham Singh Nagar and Hardwar respectively.

Status of PHC’s:

23 Each PHC has a generalist doctor. In Pitthoragarh and Haridwar, at two PHCs each, doctors were not available. The total number of nurses/LHVs at the PHCs varied from four at Hardwar to 13 at Pithoragarh and 38 at Udham Singh Nagar. This is an indication of misdistribution of nurses/LHVs at CHCs. Lab technicians could be found and at one PHC in Hardwar, indicating the non-availability of laboratory services at PHC level.

The number of functional beds at a PHC varied from two to four. While 90% PHCs in Udham Singh Nagar have operation theatres, only half of the PHCs in Hardwar and 40% in Pithoragarh have the OT facility. Half of PHCs in Haridwar, 60% in Udham Singh Nagar and 89% in Pitthoragarh have duty rooms for doctors, but functional toilets in these duty rooms are available only in 67%, 70% and 60% PHCs respectively. Staff quarters for doctors are available at half of the PHCs in Pitthoragarh, 60% of PHC in Udham Singh Nagar and 67% PHCs of Haridwar.

The availability of general facilities in the three sampled districts are poor. Water supply is remarkably good in Udham Singh Nagar and Haridwar but is below average in Pitthoragarh. Electricity supply is available 24 hrs in Udham Singh Nagar but the situation is not so good in Pitthoragarh and Haridwar. Generator/inverter is available in almost all PHCs in Udham Singh Nagar but it is not so in Pitthoragarh and Haridwar. Facilities such as ambulances, telephone and computer with internet are very poor in these districts except for the telephone facility in Udham Singh Nagar.

In one-third of the PHCs of Haridwar, functional B.P. instruments are not available. Two of ten PHC visited in Haridwar and four of ten PHCs visited in Pitthoragarh do not have functional delivery tables. Half of the PHCs in Udham Singh Nagar and Pithoragarh and one-third of the PHCs in Haridwar do not have instruments for delivery and episiotomy. X-Ray and ultra-sound machines are available at selected PHCs in the three districts visited.

As far as services are concerned, beside the OPD services, in-door facilities do exist, but the bed-occupancy is less than ten percent. Services for ANC, PNC and immunization are available but the record shows that the coverage and consistency are far from the desired.

24 Although all the PHCs of the state have regular electricity and water supply connection, 56 PHCs are located at stations without all-weather motor-able approach road. 42 PHCs have a telephone facility and at 42 PHCs, computer facility is also available. 47 of the PHCs have 24 hour delivery facility with availability of labor rooms and operation theatres.

3.6 Determinants of Performance

Multiple factors determine the performance of doctors working in the public system of Uttarakhand. On the basis of interviews conducted with 120 doctors in the peripheral facilities in different districts of Uttarakhand and a number of state level officers in Dehradoon, one general observation which has emerged is that the main attraction of joining the government system is the security provided by the job. Since the doctors join their services directly at the facilities assigned to them without receiving any orientation, they develop their perceptions and convictions on the basis of their interactions held in earlier years of their job with the subordinates and the communities where they are deployed. Whether generalists or specialists, all the doctors came directly from medical colleges where they are trained for a singular role of healing the sick. Like their role models in medical colleges, they assume- in the peripheral facilities where they are posted- that whoever is sick will always approach them when in need any they would exercise in best of their skills and expertise in curing the sick. But the demand of the system is much more than playing simply as provider for curative services in need.

Salary is the prime mover in eliciting the expected performance from an employee in any organization. The same holds true for doctors deployed in the peripheral facility. The old value of holding nedicine as a service rather than profession has gradually faded. Although it is still preached that medicine should not be practiced as a merchandise, increasing privatization and accepting the terms of private partners in public-private- partnerships by the government itself is fast changing the perceptions of doctors at the

25 cutting edge. In spite of the fact that transaction initiated through the Sixth Pay Commission favoring the increase in the salaries, doctors are dissatisfied with their new pay. It is mainly because the emoluments available in the private sector are far more that which is provided by the government.

Transfer in government jobs is reality everywhere. Yet every employee tries to shun it once he gets a choice posting. This is all the more applicable with the doctors who with the passage of time develop a clientele at the place of their posting. In Uttarakhand, although private practice does not seem to be a major issue- except for two largest urban areas (Dehradoon and Udham Singh Nagar)- other interests of doctors make them stick to the places where they are. Alternatively, if they are not satisfied with their current posting, it is reflected in their performance. Systems are more often than not indifferent to this critical component. This is the point where interference from local politicians begins which has its strength as well as weakness in upholding the viability of health centers.

Residence and security at the place of posting is equally important. Although most of the peripheral health facilities in Uttarakhand have residential quarters on their premises their upkeep and maintenance makes them unattractive. It was also observed in Haridwar that doctors prefer to stay in the heart of the main town or the center of village if the facility is far away from the habitation, as this promotes a sense of security. Children’s education is also a determinant in opting for residence away from the health center if the schools are at a distance. In fact, many doctors prefer to compromise with the status of living away from their families if good schools are not available at the place of their posting. Since the fact of getting a better performance from doctors living on campus cannot be denied, matching individual needs of doctors with the station where they are deployed becomes crucial.

A doctor’s job involves a team work. It is all the more true in the context of delivering specialist services. With a dearth of nursing staff throughout Uttarakhand, it remains a challenge for doctors to perform effectively. Our rapid facility assessment yielded that operation theatres, in-door wards and duty rooms from where emergency services are to be provided were not in a satisfactory status in most of the facilities. Although the health

26 system of the state has consistently attempted to enhance the capacity of its doctors owing to the lack of infrastructure in the peripheral facilities, such trainings and CMEs go in vain.

There seems to be a lack of supportive supervision. Our interviews with doctors in the periphery facilities indicate that they would love to be supervised frequently, provided the supervisor gives them an opportunity to learn something new! It implies that any technical supervision should aim at enhancing their capacity on the spot and administrative supervision gives them timely feedback and desired help. The latter is also linked with providing relief to their grievances and to expedite their pending appeals/enquiries etc. In fact, the morale of an employee related to disciplinary matters has its repercussions on the whole system. Provisions for leave reserves doctors seem to have not been thought of. Thus leave when need is often not available. If the system resolves these matters expeditiously, the performance of doctors at the peripheral facilities can be enhanced to a great extent.

It was also observed that doctors who hails from a rural background; they adjust at a rural facility easily and consistently while the ones educated and reared up in the urban culture keep struggling with their rural posting.

Last but not the least is the lack of a logical referral system which keeps both- generalists and specialists- disillusioned on their role. While there is a dearth of specialists throughout Uttarakhand, in the limited positions where they are available, if they do not deliver their specialty, it is all the more disappointing.

27 28 Chapter 4

Projections

The National Rural Health Mission has initiated a long cherished desire of bringing all the public health facilities to a certain specific standard to deliver quality service expected by them. The common standards set for the whole country are known as ‘Indian Public Health Standards’. Although the government of Uttarakhand is conscious of the need for a higher number of health facilities and manpower at the peripheral facilities assessing the needs in the context of the IPHS revealed that the gap is much more than realized by their health department. The table shows the number of CHCs, PHCs, and specialists and generalists required at these facilities.

year population PHCs MOs CHCs Required as Required Required Specialists per the IPHS as per as per Required the IPHS the IPHS as per the IPHS For 11 Districts of Hilly Rural Area 2009 5207262 260 520 65 260 2010 5306200 265 530 66 264 2011 5407018 270 540 68 272 2012 5509751 275 550 69 276 For 2 Districts of Plain Rural Area 2009 2127328 71 142 18 72 2010 2167747 72 144 18 72 2011 2208934 74 148 18 72 2012 2250904 75 150 19 76 * Total 239 medical officers and 67 specialists working in rural areas at CHC and PHC.

By the end of March 2012 which is the last year of NRHM, the state will need additional 39 CHCs and 118 PHCs. This implies that 700 generalists and 352 specialists will be required to man the peripheral health facilities in the rural areas of the state.

29 Chapter 5 Suggestions

Uttarakhand will soon complete a decade of its existence but it seems that the state is still having its teething troubles. Since the state was carved out from Uttar Pradesh, all the departments in the government, including peripheral health facilities were inherited as a part of an inefficient large system. This unique topography in terms of a difficult terrain and more than 90% of villages having a population of less than 1000 added to the challenge of managing public systems of the state. Health professionals including the doctors in the Medical and Health department are largely the old timers of Uttar Pradesh who opted to work in Uttarakhand. It is these very professionals who brought with them an organization culture which needs multifaceted interventions. Some suggestions for ensuring optimum availability and efficient performance of doctors are as follows:

5.1 Streamline induction of doctors: Since the present strength of the doctors is less than half of the requirement, there is an urgent need to streamline the induction process. It can be initiated by setting up a calendar of recruitment. Health department of the state would submit its requirements to the state Public Service Commission initially with one year interval and in long run at two year’s interval to reduce the gap on its sanctioned strength. Concurrently, the state cabinet may consider the estimates projected on the basis of the changing demography and health sector needs to avoid the situation of vacancies in the future. These estimates taken in consideration, the need for district leave-reserve positions and deputations for training required by doctors.

5.2 Induction training of Doctors should be a part of the recruitment process. Doctors should not be deployed at the peripheral facilities without orienting them to the administrative and financial procedures, processes and mechanism of functioning. Induction trainings must give priority to issues crucial in setting up the desired organization behavior. A balanced approach in orienting the fresh recruits on the operation of national health programme may be followed Timely and well organized induction training can go a long way in enhancing the capacity of the health systems.

30 5.3 Efficiency of the systems can be enhanced by organizing in-service trainings at regular frequency for all the doctors. Such in-service trainings should have a balanced mix of managerial and technical issues. It should be taken on priority in the state where many doctors are not very well aware of their own job responsibility, leave aside knowing the responsibility of each and every team member they are supposed to be leading.

5.4 Trainings, transfers and timely promotions can be made meaningful only on the availability of Personnel Management Information System at the Directorate level. It can immediately help in identifying and redeploying a number of doctors in the field with post-graduate qualifications who are working as generalists. Human Resource Cell at the state level needs to be strengthened to retrieve and maintain the PMIS and to give effective directions to the district level officers in nominating the right persons for in- service trainings and their deployment for temporary duties. PMIS may also expedite the redressal of grievances of doctors and calling for convening of Departmental promotion committees in time.

5.5 Strengthening Medical Colleges and Nursing Schools: There is a need to develop a mechanism by which graduates passing out from the three medical colleges of Uttarakhand can be retained within the state. One way is to keep certain seats reserved for the state’s bona fides who are willing to continue in the state just after graduation. Seats for post-graduation need to be increased immediately. In-service doctors of the state who are willing to continue in the department for the remaining period of their service be given more seats in admission for MD/MS courses. Similarly Nursing Schools need to be strengthened to fill up the gap in the cadre of nurses.

5.6 Since the doctors hardly get one or two promotions during their career, opportunities for promotions have to be created. Morale building to elicit the best performance at the peripheral facilities can be enhanced by making provision of time-scale jumps to the higher pay scales for the maximum number of doctors.

5.7 Since full financial support to enhance the quality of services is available under the NRHM, Facility Survey to equip each PHC/CHC on IPHS is an urgent need. Equipping each CHC with instruments/equipments required by specialties of medicine, surgery,

31 pediatrics and obstetrics will not only enhance the faith of people in the health facilities but will give satisfaction to the doctors on their work site. A facility survey will also indicate the need for improving the wards, duty rooms, operation theatres and residential facilities in the field. They may be taken up in a campaign mode by initiating minor civil works.

5.8 The problem of retaining doctors in rural facilities is universal. India is passing through crossroads where a serious introspection is required to examine the compatibility of a five-and-half year trained allopath doctor with a remote rural facility. Smaller states like Uttarakhand should realize their potential in experimenting. Innovations for raising health manpower with knowledge and skills above nursing and with full competence for handling primary care with a positive attitude to stay consistently in villages is the need of the hour. If the health sector of the state can prepare itself to talk to the medical council of India and the medical bureaucracy, it may set up a pace for many other states to follow.

5.9 Last but not the least, is developing and sticking to the letter and spirit of HR policy which may take care of transfers, promotions and redressal of grievances in time. It may help build a positive organization culture to elicit the best performance from doctors everywhere. Someone has to accept the challenge of changing the mentality of political masters if policies have to achieve their objectives in time. Proactive leadership from politicians on the suggestions given above, combined with enhancing the convergence with other social sectors where the determinants of health are hidden, can give a boost to a doctor’s performance.

32 Appendix I- Demography and Health Facilities in Uttarakhand

Districts Population Population Female CHCs PHCs SCs 2001 Density literacy Rate Dehradun 1282143 332 71.20 7 23 167 Uttrakashi 295013 37 46.69 3 11 81 Tehri 604747 148 49.42 5 26 190 Pauri Garhwal 697078 133 65.70 5 30 218 Chamoli 370359 42 61.63 5 10 104 Rudraprayag 227439 115 59.57 2 9 65 Nainital 762909 451 69.55 4 18 136 Almora 630567 159 60.56 4 27 195 Pithorgarh 462289 65 62.59 4 18 154 Bageshwar 249462 108 56.98 2 12 77 Champawat 224542 126 54.18 2 5 66 Haridwar 1447187 613 52.10 6 24 159 (Plain) U.S. Nagar 1235614 451 53.35 6 26 153 (Plain)

33 Appendix II- Format for Survey of Facilities (Format D)

34 Appendix III- Format for Survey of Facilities: CHC/PHC (Format C)

35 Uttranchal Sex-wise Distribution S. No. Items Year/ Period Unit Statistics 1. Total Population 2001 Lakh 84.89 (i) Male 2001 Lakh 43.26 (ii) Female 2001 Lakh 41.63 (iii) Decennial Growth Rate 1991-01 Percentage 19.20 2. Rural Population 2001 Lakh 63.10 (i) Male 2001 Lakh 31.44 (ii) Female 2001 Lakh 31.66

Scheduled Castes S. No. Items Year/ Period Unit Statistics 1. Total Population 2001 Lakh 15.17 (i) Male 2001 Lakh 7.81 (ii) Female 2001 Lakh 7.36 2. Rural Population 2001 Lakh 12.56 (i) Male 2001 Lakh 6.42 (ii) Female 2001 Lakh 6.14 Scheduled Tribes 1. Total Population 2001 Lakh 2.56 (i) Male 2001 Lakh 1.31 (ii) Female 2001 Lakh 1.25 2. Rural Population 2001 Lakh 2.40 (i) Male 2001 Lakh 1.23 (ii) Female 2001 Lakh 1.17

Religion wise breakup S. No. Items Year/ Period Unit Statistics 1. Hindus 2001 Lakh 72.12 2. Muslims 2001 Lakh 10.12 3. Christians 2001 Lakh 0.27 4. Sikhs 2001 Lakh 2.12 5. Buddhists 2001 Lakh 0.13 6. Jains 2001 Lakh 0.09 7. Others & religion not stated 2001 Lakh 0.04

Literates (Age above 6 Years) S. No. Items Year/ Period Unit Statistics 1. Total 2001 Lakh 51.06 (i) Male 2001 Lakh 30.09

36 (ii) Female 2001 Lakh 20.97 Literacy Rate 1. Total 2001 Percentage 71.62 (i) Male 2001 Percentage 83.28 (ii) Female 2001 Percentage 59.63

Sex-wise Labour Force (Main Worker) S. No. Items Year/ Period Unit Statistics 1. Total 2001 Lakh 31.34 (i) Male 2001 Lakh 19.96 (ii) Female 2001 Lakh 11.38 2. Rural 2001 Lakh 24.99 (i) Male 2001 Lakh 14.37 (ii) Female 2001 Lakh 10.62 Category-wise Labour Force 1. Main Workers 2001 Lakh 23.22 (i) Cultivator 2001 Lakh 10.67 (ii) Agricultural Labourer 2001 Lakh 1.43 (iii) Household Industry 2001 Lakh 0.49 (iv) Other 2001 Lakh 10.63 2. Marginal Workers 2001 Lakh 8.12 (i) Cultivator 2001 Lakh 5.03 (ii) Agricultural Labourer 2001 Lakh 1.17 (iii) Household Industry 2001 Lakh 0.23 (iv) Other 2001 Lakh 1.69

CBR, CDR, IMR and TFR (S.R.S. Data) S. No. Items Year/ Period Unit Statistics 1. Crude Birth Rate 2002 Per '000 of Popu. 17.0 (i) Rural 2002 Per '000 of Popu. 18.1 (ii) Urban 2002 Per '000 of Popu. 16.2 2. Crude Death Rate 2002 Per '000 of Popu. 6.4 (i) Rural 2002 Per '000 of Popu. 9.0 (ii) Urban 2002 Per '000 of Popu. 4.4 3. Infant Mortality Rate 2002 Per '000 of Live Births 41 (i) Rural 2002 Per '000 of Live Births 62 (ii) Urban 2002 Per '000 of Live Births 21 4. Total Fertility Rate (NFHS-2) 2002 Per Female 2.6

Uttaranchal - Public Health and Welfare

State Allopathic Hospitals and Dispensary Items Year/ Period Number

37 (i) District Level Hospital 2006-2007 11 (ii)Distt. Female Hospitals 2006-2007 6 (iii)Base Hospitals 2006-2007 3 (iv) P.H.C./Additional P.H.C. 2006-2007 232 (v) Community Health Centre 2006-2007 49 (vi) State Allopathic Hospitals 2006-2007 322 (vii) Joint/ Women Hospital 2006-2007 40 (viii) Tehsil/ Distt. Level Pregnancy Centre 2006-2007 24 (ix) Health Post 2006-2007 9 (x) Tuberculosis Hospital/Clinic 2006-2007 18 (xi) Leprosy 2006-2007 3 (xii) Beds in Govt. Hospitals 2006-2007 7767

Family Welfare Services Items Year/ Period Number (i) Women & Child Welfare Centre 2006-2007 2 (ii) Main Center 2006-2007 84 (ii) Women & Child Welfare Sub-Centre 2006-2007 1765

Ayurvedic & Unani Hospital Items Year/ Period Number (i) Ayurvedic Hospital 2006-2007 513 (ii) Unani Hospital 2006-2007 5 (iii) Homeopathic Hospital/Dispensary 2006-2007 106

38