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.