CONTENTS

Preface

Acknowledgement

1.0 Back Ground and Methodology 1-9

1.1 Geography & Demography

1.2 Health profile of Rajasthan

1.3 Partners of this study

1.4 Objectives

1.5 Methodology

2.0 HRH in Rajasthan: Availability, Short-fall and Requirement 10-13

2.1 Human Resources for Health in the Public system of the State

2.2 Medical Colleges in the State

2.3 Public Health Facilities in Rajasthan

3.0 Survey Results 14-43

3.1 Bharatpur

3.2 Bikaner

3.3 Jhalawar

3.4 Sirohi

3.5 Responses from Doctors

3.6 Facilities as we saw them

4.0 Projections for Medical Manpower 44-47

5.0 Determinants of Performance of Doctors 48-50

6.0 Recommendations 51-58

Appendices 59-68

PREFACE

One of the biggest challenges to the health sector has been extremely poor capacity

building at every rung of health care givers, beginning from the members of the district health committees, the medical officers working in the clinical sector and in the administrative positions and up to the chief district medical and health officers. The situation is further worsened by a shortfall in the human resource at every level, especially for specialists like anesthetists, radiographers and dentists. It is also noticed that there has been quite a mismatch in the number of medical-officers and specialist medical officers posted at a place and the actual requirement at the place. Similarly, the number of beds provided at the different levels like the PHC and the CHC are also not according to the actual needs. There is a tremendous shortage of pathological test laboratories and lab technicians, and well as other common diagnostic tools.

In order to study and understand the issues for optimal workforce management and human resource development and to develop action plan for addressing the HR issues this study on determinants of workforce availability and performance of specialists and general duty medical officers was taken up by the institute in association with the NHSRC. This included assessing the gaps between the services expected and those provided at a facility level, along with analyzing the recruitment, compensation, transfer and training policy of medical officers and specialists.

It is found that there has been no serious effort for in-service trainings and except for a few medical officers, we did not find anybody really keen to get any training. The state governments will have to take a serious decision to organize different types of training programmes for medical officers and specialist medical officers to meet their HR requirements right from the induction level upto attaining the age of at least 50 years. It is essential that a mandatory foundational course training for 3 - 4 months should be held at the induction level at a State's Institute of Public Administration along with other state service officers, so that they have a comprehensive view of a state's administrative system and its needs. There is hardly any human resource training for the freshly recruited in the heath service.

As far as postings and transfers are concerned we hear from time to time that a policy is in the offing but then political interference and clout wielding doctors take over. It is felt that the state government should set up a committee to formulate a detailed set of guidelines for postings and transfers of MOs, MHOs and others. There should also be detailed directions how to keep a doctor motivated even while working in a remote

area or in adverse climatic conditions. This committee should also advise on the priorities to be given to those medical officers who have spent a certain amount of time in difficult areas, for selection for post graduate seats.

What is generally prevalent is not only a gap between the required number of posts and the sanctioned posts but also a shortfall between the sanctioned posts and of those which had been filled up. The shortfall at various levels leads to serious problems of coping up with the need of preventive and curative programmes running in the district. For specialist medical officers, it is very important to be in touch with the latest developments in their field of specialization for which they need to be invited for the conferences and programmes which are held quite regularly.

For a country like India, it is important to have a closely integrated care delivery system which should be able to offer high quality and cost effective services. Primary, secondary and tertiary hospital care should have a close co-ordination beginning from prevention and keeping an electronic medical record of a village, so that whenever the medical history of a villager is required it can be extracted from a computer or the villager himself can keep such a record with him, as he keeps his land records, voting cards and ration cards. He may be given a particular identity number. In a similar way, the district level health official can keep a record of the work done by the primary care physicians, specialists, hospitals and laboratories. This helps in improving care quality and the delivery system. We must simultaneously develop best practices through interaction with other districts and interaction within the district amongst the health care deliverers working there. This may also lead to quicker communication of what is happening in a district.

It is necessary that the medical officers at the primary care level should be responsible for a patient's overall care, but the specialists in the district or at the nearest CHC should be under instructions to guide a general care physician. On the basis of the data kept, even if a patient transferred to a special care facility at a higher level, his health record will be very helpful in taking care.

The other important role which should be played by a district level Medical and Health Officer is to keep a healthy relationship with the private hospitals in the area. This may, however, require in our bureaucratic system, some control on the private hospitals by the CM & HO. There is no system of official reference from a primary care unit to a specialist or to a more senior person at a higher level. It needs to be developed so that a patient does not have to start all over again when he meets a specialist or a more senior and experienced doctor at a higher level. There is also a need to keep an eye on the number of patients a primary care doctor or a specialist has seen during a period of time. This would help in assessing the pressure at that primary level as well as the competence of the doctor. The IT database not only provides information on the personal history of health of a patient but can be a very useful tool in looking at the health scenario of a village or a district at a particular time. The ultimate need is that

we should know how physicians, nurses and other health functionaries are interacting with the patients and whether they are indifferent to the needs of the patients. We keep on hearing the complaints of the doctors about difficult postings and transfers, but we should also ensure that the care delivery for which these doctors are responsible is being done efficiently.

It is time we develop under the Indian context a combination of a good data environment, a strong end-to-end process, clear communication and a patient centric focus.

For any improvement in the general health of the masses, specially in the rural area, in the country, it is not enough to train the medical and para-medical staff and the administrative officials attached with the Medical and Health Department, but also the seekers of health which is a very illiterate, ill-informed, easily snubbed and wrapped up in superstition. It is necessary to train this target group through the Panchayati Raj Institutions and the voluntary organisations working in the area to demand their basic constitutional rights to good health. Most of the states, in the last few years, have prepared charters of the services they are providing at a government institution whether it is the registration of khatedari lands or the right to information. It is, therefore, necessary that from the sub-centre level to the district hospital level this charter of the services which the medical care institutions should provide to the health seekers should be written on one of the walls for the information of all those who come there.

(Dr. Sudhir Varma) IAS (Retd)

Director, SCM SPRI

ACKNOWLEDGEMENTS

The Institute has been working in the realm of health sector for the past few years and

realized that the biggest challenge to the health sector is Human Resource Development. Issues like recruitment, deployment, transfer and training needed to be looked into for developing suitable policies for optimal work force management. This study is an attempt to address some of these crucial issues along with conducting situational analysis of the human resource requirement and the services available at the health facilities. The idea was to come up with the suggestions to enable the medical officers to achieve the expected levels of effectiveness, especially with respect to under-serviced area. Keeping in view, the objectives and research questions, detailed tools were designed, field tested and adopted to the local settings. A two day intensive training programme was conducted at the Institute for the investigators and supervisors with support from NHSRC. The investigators were then put on observed field work. Data was collected according to the prescribed methodology for the study. Data thus collected, were carefully entered, cleaned and analyzed. The findings have been tabulated and suitably documented. We believe the findings would be useful in developing suitable policies for optimal workforce management and human resource development. On behalf of the institute, I express our deep sense of gratitude to NHSRC for providing technical support and guidance. The support of Dr. T. Sunder Raman and Dr. D. Thamma Rao and others are gratefully acknowledged. Our heartfelt gratitude Shri RK Meena, IAS, Shri Praveen Gupta, IAS, Shri Bhawani Singh, IAS and the officials of the state health department for their support. We are indebted to Dr. Sudhir Varma, Director and Shri Pradeep Mathur, Member Secretary, SCM-SPRI for their continued support. The study could not have been completed without the support of Dr. Shiv Chandra Mathur who ably led the research team. Thanks are due to Shri Pradeep Sharma, Shri Ranveer Singh, Shri Yogeshwar, Shri Yogesh Chhipa, Shri Raghuveer Singh and Ms. Aditi Vyas.

(Manish Tiwari) Joint-Director, SCM SPRI

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BACKGROUND & METHODOLOGY

1.1 Geography & Demography

Rajasthan is the largest state of the country occupying 10.42 percent of

it‟s land area. More than half of the state is part of Thar desert. South-

east of the state is traversed by Aravali hill ranges. There are 41,353

inhabited villages and 222 urban agglomerations. Many of the state‟s

villages are besieged in difficult topography of desert or hill belt. Lack of

surface water, low literacy and feudal legacy adds to the backwardness of

the State. Administratively, Rajasthan has 33 districts with 237

development blocks which are clubbed in seven divisions:

Ajmer Division : Ajmer, Bhilwara, Nagaur, Tonk.

Bharatpur

Division : Bharatpur, Dholpur, Karauli, Sawai Madhopur.

Bikaner Division : Bikaner, Churu, Ganganagar, Hanumangarh.

Jaipur Division : Jaipur, Alwar, Jhunjhunu, Sikar, Dausa.

Jodhpur Division : Barmer, Jaisalmer, Jalore, Jodhpur, Pali, Sirohi.

Kota Division : Baran, Bundi, Jhalawar, Kota.

Udaipur Division : Banswara, Chittorgarh, Pratapgarh, Dungarpur,

Udaipur, Rajsamand

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According to Census 2001, State‟s population was 56,437,122 persons

with 29,381,657 males & 27,091,465 females. Population of scheduled

castes and scheduled tribes in the State was 17.15% & 12.56%

respectively. State had a population density of 165 as against 324

recorded as national average in 2001 showing thin distribution of

population in the state. Rajasthan has shown a marginal decline in

decadal growth rate from 28.44 in 1991 to 28.33 in 2001. It is much

higher than the national average of 21.34 between 1991 and 2001.

Incidentally the sex ratio of Rajasthan has shown an increasing trend

from 910 in 1991 to 921 in 2001. Yet it is significantly less than the sex

ratio of India i.e. 933 in 2001. The Child sex rate is worse at 909 The

rural women the literacy rate is any which becoming a major hurdle in

conveying health information. The state has a literacy rate of 61.03 in

2001, which is also lower than national average of 65.38 recorded in

2001. The literacy rate for females is only 43.85 for rural women the

literacy rate is only 37.33 which is becoming a major hurdle in conveying

health information.

Three primary demographic indicators elicited in recent nationwide

survey have revealed maternal mortality ratio of 388 per lakh live births,

(SRS 2004-06) infant mortality rate of 65 per thousand live births, and a

total Fertility Rate of 3.2 (NFHS-3).

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Sampled Districts of Rajasthan

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1.2 Health Profile of Rajasthan

A broad overview of health profile can be assessed by looking at

comprehensive health indicators and comparing them with national

averages for the same, which is as follows:

Table 1.1

Indicator Source Rajasthan India

Total population Census 2001

56.51 million

1028.61 million

Decadal Growth (%) Rate Census 2001 28.41 21.54

Crude Birth Rate SRS 2007 27.9 23.1

Crude Death Rate SRS 2007 6.8 7.4

Total Fertility Rate SRS 2007 3.4 2.7

Infant Mortality Rate SRS 2007 65 55

Maternal Mortality Ratio SRS 2004 – 06 388 254

Sex Ratio Census 2001 921 933

Child Sex Ratio

BPL Population (%) BPL Census-02 22.66 % NA

Scheduled Caste population

Census 2001 9.69 million 166.64 million

Scheduled Tribe

population

Census 2001 7.10 million 84.33 million

Female Literacy Rate Rural

Female L.R.

Census 2001 43.9 % 53.7 %

Development of health care delivery system in Rajasthan has largely

depended on centrally sponsored projects which on random basis has

created opportunities to establish new health facilities. Starting with one

district hospital in the biggest urban agglomeration of each district and

one PHC with three sub-centers in each rural development block in mid-

fifties, it now has more than 13,000 health care facilities in Rajasthan.

Most of these facilities have come up in last three decades through

inputs received in projects supported by UNFPA and World Bank.

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Within the first decade of the twenty-first century, two major events have

influenced the structure and functioning of the health care delivery in

the public domain. First is part of the series of Health System

Development Projects in taking place throughout the country. National

Rural Health Mission is the other major intervention meant to rejuvenate

the public health facilities of the state.

Rajasthan State Health Systems Development Project (RHSDP) is a World

Bank supported project with focus on secondary health facilities. It is a

six year long project between 2004 and 2010, with an outlay of Rs

472.56 crores. As a part of the capacity development of health system,

RHSDP has made provision of a series of in-service trainings for General

Duty Doctors and specialists to enhance their knowledge and skills in

medical care delivery.

The NRHM has adopted a synergistic approach by relating health to its

determinants viz. nutrition, sanitation, hygiene and safe drinking water.

It also aims at mainstreaming the Indian systems of medicine to facilitate

health care. On the software front, NRHM is trying to enhance the

capacity of health systems by making provisions for deploying manpower

at peripheral facilities on contractual basis.

Although a number of private hospitals and poly-clinics exist in large

cities, medical and health care in the State is largely delivered through

public facilities. It comprises of 127 hospitals, 367 CHCs, 199

dispensaries, 118 MCW centers, 1503 PHCs, 37 Urban PHCs, 13 Aid

posts and 10951 sub centers as on 31.03.2009. Available in-door bed

strength of the public system is 43,779. A health facility in Rajasthan on

an average serves an area of approximately 26 sq. km. and population

of 4244. Each in-door bed serves an average population of 1291.

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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

Centre and the States in executing the National Rural Health Mission. It

started functioning from 2007-2008. 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 remedial measures to elicit the best

possible performance from the available manpower deployed in the

respective facilities. NHSRC is giving technical support to all states. It is

in this context, NHSRC has undertaken in selected states, a study on

workforce determinants in the functioning of generalist and specialist

doctors in rural facilities.

1.3.2 SCM SPRI: 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. It

aims at helping Government in policy formulation and initiating /

modifying on-going development programmes. SCM SPRI has undertaken

several research projects in areas ranging from agriculture, education

and health to mineral and oil exploration. Over the last couple of years, it

has been working on issues concerning the health sector by preparing

District Action Plans for the health sector under the NRHM and

evaluating operations of the programme for HIV/AIDS control and

reproductive health. It is with this background that SPRI has undertaken

the study on “Determinants of Workforce Availability and Performance of

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Specialists and General Duty Medical Officers in Rural facilities of

Rajasthan”.

1.4 Objectives

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.

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 provision

of on campus residence, children‟s education, supportive

supervision and assistance, promotions and will make appropriate

recommendations.

5. To review the educational and training programmes for enhancing

the capacity of doctors and 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 services being currently provided.

Based on this, to recommend a capacity building processe for

optimizing efficiency and effectiveness of the general and specialist

doctors.

7. To conduct a situation analysis of the existing facilities, number of

facilities required, and the staff required per facility as per IPHS.

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1.5 Methodology

The study involved interaction with policy makers, directors and

consultants at the State level; executives and managers at district level

and doctors at the cutting edge level working at the facilities in the rural

areas.

1. It used simple objective criteria of performance for each situation

such as outpatients seen per day, laboratory tests done for a PHC

doctor, night duties per month performed in the PHC etc

In order to carry out the stipulated task, four districts of Rajasthan were

taken on a sample basis. Jhalawar district was selected as a high HDI

district while Bikaner and Sirohi districts were selected as medium HDI

districts and Bharatpur was selected as a low HDI districts. The focus of

observations in the four districts was.

a. Assessing the policies of recruitment, deployment, postings and

trainings of generalists and specialist doctors as experienced by them.

b. Assessing the gaps between the services they are expected to

provide as per IPHS and training and infrastructure needed for them to achieve this.

c. Assessing the specialists/doctors preferences (first, intermediate and last) for postings and transfers and to develop the objective criteria for underserved areas.

In order to test the sample, five CHCs were selected from each district,

two PHCs from the area of each CHC - one remotest and another near

the CHC. 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.

The institutional information was collected in form C (See appendix).

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The total sample collected from the four districts of Rajasthan was as under:

Table 1.2

District DH CHC PHC Generalists Specialists

Bikaner 1 5 10 30 10

Bharatpur 1 5 10 30 10

Jhalawar 1 5 10 30 10

Sirohi 1 5 10 30 10

In addition to an institutional survey, 40 doctors (30 general duty

medical officers and 10 specialists) were also interviewed on a pre-

designed format (Form-D in Appendix). Thirty generalists interviewed

included ten doctors from the CHC and twenty from PHC‟s. All attempts

were made to interview the ten specialists from CHC but as and where

they were not available at the CHC, specialists from respective district

hospital were approached.

While in Sirohi, Bikaner and Bhartpur, specialists from district Hospital

were included, in Jhalawar, the research team had to interview certain

specialists from the district Hospital which has recently been upgraded

as Medical College Hospital.

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2

HRH IN RAJASTHAN: AVAILABILITY, SHORTFALL & REQUIREMENT

2.1 Human Resources for Health in the Public System of the State

Medical, Health and Family Welfare Department of Government of

Rajasthan is headed by three Directors i.e. one each for Public Health;

RCH; and HIV/AIDS. They are assisted by 8 Additional Directors, one

State Leprosy Officer, 21 Joint Directors and 92 Deputy Directors. Out

of 92 positions of Deputy Directors, 34 positions are designated as

C.M.&H.O. with a distribution of one position for each district while the

state capital – Jaipur – being the largest by population has two positions

of C.M.&H.O. with well defined geographic areas for each. Each C.M.

&H.O. is assisted by a couple of Dy. C.M. & H.O.S. in each district. As of

July 2009 (when the data of this study were compiled), the post of one

Additional Director, 15 Deputy Directors and the State Leprosy Officer

were lying vacant. There are 52 positions of Dy.CM&HO in the State out

of which 16 were lying vacant.

The cadre of specialist doctors is divided into two groups. There are 280

positions of senior specialists and 1819 positions of junior specialists.

The senior-most senior specialist in each of the district hospital

irrespective of his or her specialty is assigned the task of Principal

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Medical Officer (PMO). The same convention is followed in the Satellite

Hospitals located at six divisional headquarters. Currently 600 positions

of specialists are lying vacant. Their specialty-wise distribution is given

in the appendix.

All the doctors in the health sector of the state government are initially

inducted as generalists irrespective of their possessing additional

technical qualifications besides being allopathic medical graduates.

Induction appointment is designated as Medical Officer. Conventionally

they are recruited through the Rajasthan Public Service Commission

(RPSC). When vacant positions cumulate to a certain level in the

department, an indent is sent through the government to the RPSC. But

in between, ad-hoc contractual appointments are made at the district

level to cope up with the vacancies. It is only in 2008 that induction

posts have been divided in two groups and now there are 1265 posts of

Medical Officers and 2477 positions of Rural Medical Officers. The next

promotion of generalists is on the post of Senior Medical Officers (SMO).

There are 816 positions of SMOs out of which 154 were lying vacant in

June 2009. Status of other important positions is given below:

Table 2.1

Particulars Sanctioned In position shortfall

FHW(ANM) at Sub Centers & PHCs 15130 14202 928

MPW(M) 2433 2427 6

LHV 1980 1300 680

Rural Medical Officers* 2477 2241 236

Total Specialists 2099 1499 600

Radiographers 337 269 68

Laboratory Technicians 2571 2179 392

Nurse Gr.II 11529 11256 273

Nurse Gr.I 2227 1673 554

* A separate cadre carved out from the positions of Medical Officers Source: D.M. & H.S., GoR, Jaipur, June 2009.

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NRHM has a target of creating 70,525 contractual positions including

48,372 positions for ASHA-Sahyoginis in collaboration with the women

and Child Development Department. The other large contingent to be

inducted on contract is of ANM/GNM at sub-center level numbering

7,500 and staff nurses numbering 3704. As far as doctors are concerned,

the Mission targets hiring the services of 135 allopath specialists on

contract and 1100 doctors along with 33 specialists from the AYUSH

stream.

2.2 Medical Colleges in the State

Most of the Doctors functioning in the Department of Medical, Health

and Family Welfare of Government of Rajasthan have received their basic

medical education from the Medical Colleges within the State. The first

Medical College in Rajasthan was started in Jaipur in 1947. After the

lapse of a decade four more Medical Colleges were started at Bikaner in

1958; at Udaipur in 1962; at Ajmer and Jodhpur in 1965. After the lapse

of another three decades another Medical College was started in 1993 at

Kota. This enhanced the capacity of the State to produce 650 doctors

(Allopathic) annually. Incidentally these six Medical Colleges owned by

the State Government were located on the basis of one College in each of

the administrative division of the State. The State has a policy of giving

admission exclusively to the bonafide residents of Rajasthan till a

Supreme Court directive forced the State government to adjust 15

percent seats on the basis of all India competition. By the beginning of

this decade, all the six Colleges except Kota have a provision for post

graduation in all disciplines.

The state government has started a Medical College in Jhalawar in 2008

but it is run by a society. Although proposed to be managed through a

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public-private partnership model, it is being run by the Health

department of the State. Within the last five years, two Medical Colleges

have come up in the private sector – both at the outskirts of Jaipur city.

A couple of Medical Colleges in the private sector are in the pipeline.

Currently, the State is producing one thousand medical graduates

annually.

2.3 Public Health Facilities in Rajasthan

The preventive, promotive and curative health services in Rajasthan are

provided through an infrastructure of 127 hospitals which include the 25

hospitals attached to the Medical Colleges and 32 district hospitals, 368

community health centers, 1521 rural primary health centers, 118 MCH

centers, 199 dispensaries and 10791 sub-centers and 43,779 beds.

There is also a large network of private sector clinics and hospitals.

The number of health institutions as on the facility register of the D.M. &

H.S. of Rajasthan in June 2009 are given below:

Table 2.2

Health Institutions Number

Medical Colleges 8

Hospitals 127

Sub-centres 10791

Primary Health Centres 1521

Urban PHCs 37

Community Health Centres 368

Dispensaries 199

Ayurvedic Dispensaries 3539

Unani Hospitals 3

Unani Dispensaries 102

Homeopathic Hospitals 9

Homeopathic Dispensary 178

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3

SURVEY RESULTS

3.1 Bharatpur

Bharatpur is the eastern-most district of Rajasthan. The town of

Bharatpur which is the district headquarters is only 50 Km west of Agra

All the important places of Bharatpur are connected by roads. In the

district 317 village panchayats and 911 villages are connected by roads

and 60 village panchayats, 828 villages are to be connected.

According to Census 2001, the population of the district is 2101142 with

a sex ratio of 854. The density of population is 414 persons per sq.km.

The literacy rate is 63.6. DLHS under RCH in 2002 brought out a CBR of

28.3; TFR of 3.8; CDR of 7.1; IMR of 64.6; unmet contraceptive need of

15.2%; and safe deliveries at 39.3%.

Bharatpur town is also the divisional headquarter of four eastern

districts of the state. The organizational structure of the health

department of the district is given below:-

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JOINT DIRECTOR

CMHO

Dy CMHO (FW) BCMHO (9) RCHO

I/C CHC (13) DTO DLU

PMO

DPMU I/C PHC (57)

DPM

DAM SS JS SMO MO

DA SC (417)

Facilities surveyed have been shown in this map

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Human Resources as on date of Survey

The 498 government health facilities within this district are distributed

as follows:

Table 3.1

Hospitals 4

CHCs 13

Dispensaries 4

MCW Centers 3

Primary Health Centers 57

Sub Centres 417

Source: C.M. & H.O., Bharatpur, June, 2009

Almost 4400 persons are covered by a health post which is more than

the state average. Availability of beds is 1300 over 77 institutions. The

area served by an institution was 11 sq.km which is much less than the

state average while per bed served population was 1616 much more than

the state average. Out of the sanctioned positions of specialists, 35 are

lying vacant while 52 of the 149 sanctioned positions of generalists were

lying vacant in May-June 2009.

3.2 Bikaner

With eight tehsils and 923 villages, Bikaner district has a total

geographical area of about 30,248 sq. km. The total population of the

district is 1,902,000 with a literacy rate of 57.54%. DLHS-RCH, 2002 in

Bikaner district gave a CBR of 29.9; TFR of 3.5; CDR of 5.0; IMR of 55.6

unmet need for contraceptives 18.8% and safe deliveries at 31%.

Bikaner town is also the head quarters for northern division of the state.

The structure of its public health system is as follows:-

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Facilities surveyed have been shown in this map

JOINT DIRECTOR

CMHO

Dy CMHO (FW) Dy CMHO (H) BCMHO (5) RCHO

I/C CHC (10) DTO SS JS SMO MO

I/C PHC (38)

SC (312)

DM DPMU

IDSP DPM

DAM

DA

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Current status of public health facilities in the district is as follows:

Table 3.2

Hospitals 7

CHCs 10

Dispensaries 11

MCW Centers 4

Primary Health Centers 38

Urban PHCs 3

Sub Centres 312 Source: C.M. & H.O., Bikaner, June, 2009

The availability of in-door patient bed in these institutions is 2329. Each

institution on an average serves an area of 71 sq. km much more than

the state average while average population served is 4349 again more

than the state average. There are 17 positions of specialists and 77 of

generalists in the district. Three in each category were lying vacant in

May-June 2009. Each indoor bed serves an approximate population of

719 less than the state average

3.3 Jhalawar

Jhalawar is situated in the south-eastern region of Rajasthan, which is

known as Hadoti (Hadavati). The total area of the district is 6928 km2.

Around 21% of this area is forest area.

The district covers an area of 6928 sq kms. It is subdivided into 6 sub

divisions, 7 tehsils, 6 blocks, 4 sub tehsils, and 1618 revenue villages.

The population of the district a 11, 80, 342, with a population density of

190 persons per sq km and a literacy rate of 58% and a female literacy

rate of 63%.

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Facilities surveyed have been shown in this map

DISTRICT HEALTH ORGANOGRAM - JHALAWAR

JOINT DIRECTOR (KOTA)

CMHO

Dy CMHO (FW) Dy CMHO (H) BCMHO (6) RCHO

I/C CHC (14) DTO DLU

PMO I/C PHC (30)

SS JS SMO MO SC (232)

PC DMCHC DM DPMU

RHSDP IDSP DPM DAM

DA

20

SCM SPRI, Jaipur

In all 326 health facilities exist in the district:-

Table 3.3

Hospitals 2

CHCs 14

Dispensaries 3

MCW Centers 3

Primary Health Centers 30

Sub Centres 232 Source: C.M. & H.O., Jhalawar, June, 2009

The number of indoor beds in the district is 1253 only. The area served

by an institution is 19 sq. km. much less then the state average while the

population served by an institution is 3621. Per bed served is less than

the state average 1291. 23 out of 45, again much less than the state

average sanctioned positions of specialists and 9 out of 60 positions of

generalists were lying vacant during May-June 2009.

DLHS under RCH in 2002 in Jhalawar district brought out a CBR of

21.6; TFR of 2.6; CDR of 5.9; IMR of 55.1; unmet contraceptive need of

16.6%; and safe deliveries at 51.9%.

3.4 Sirohi

Sirohi district is situated in the south-west of Rajasthan. It has an area

of 5139 kms2 It is the third smallest district of Rajasthan, after

Dungarpur and Banswara.

The total population of the district is 850,756 with a density of

population of 166 persons per sq. km. and the literacy rate of 54.39%

female only. DLHS under RCH in 2002 in Sirohi district brought out a

CBR of 27.1; TFR of 3.3; CDR of 6.5; IMR of 79.5; unmet contraceptive

need of 20.3%; and safe deliveries at 55.0%.

21

SCM SPRI, Jaipur

Facilities surveyed have been shown in this map

DISTRICT HEALTH ORGNOGRAM - SIROHI

JOINT DIRECTOR (JODHPUR)

CMHO

Dy CMHO (FW) Dy CMHO (H) BCMHO (5) RCHO

I/C CHC (6) DTO

PMO I/C PHC (22)

SS JS SMO MO SC (187)

DPC DMCHC DM DPMU

RHSDP IDSP DPM

DAM

DA

22

SCM SPRI, Jaipur

The health infrastructure of the district comprises of the following

institutions.

Table 3.4

Hospitals 2

CHCs 6

Dispensaries 3

MCW Centres 1

Primary Health Centres 22

Sub Centres 187 Source: C.M. & H.O., Sirohi, June, 2009

In all, 221 health institutions are located in the district. Each institution

serves an average area of 23 sq km lesser than the state average and an

approximate population of 3851 again lesser then the state average.

There are 509 indoor beds in health facilities; each bed serving an

average population of 1672 much more than the state average. There are

45 positions of specialists and 69 posts of generalists out of which 23

and one respectively were lying vacant in June 2009.

3.5 Responses from doctors

In each of the four districts, forty doctors were interviewed. This

included ten designated specialists and thirty doctors working as

MO‟s/SMO‟s. In Bharatpur owing to vacancies of doctors in the

peripheral areas (52 positions of generalist doctors are lying vacant in the

district) 17 doctors from district hospital were interviewed. Since the

district hospital, Jhalawar has been upgraded to a Medical College

Hospital, more CHCs had to be visited, and thus 28 of the 40

respondents from this district were from CHC‟s.

23

SCM SPRI, Jaipur

Table 3.5

Present place of posting

Current Posting

District Total

Bikaner Bharatpur Jhalawar Sirohi

District Hospital

11 17 1 13 42

CHC 15 15 28 12 70

PHC 14 8 11 15 48

Total 40 40 40 40 160

Amongst the 160 doctors, 42 were from the district hospitals, 70 from

CHCs and 48 from PHCs. In all 18 respondents were non-allopathic

doctors. Twelve of them were from Ayurveda and six from Homeopathy.

Table 3.6

Year of recruitment

Year of Recruitment

District

Total Bikaner Bharatpur Jhalawar Sirohi

G S G S G S G S G S

1976-1985 0 6 1 5 2 5 2 7 5 23

1986-1995 4 3 5 4 5 2 10 4 24 13

1996-2005 13 3 7 4 14 2 6 4 40 13

2006 to-date 9 2 14 0 9 1 7 0 39 3

Total 26 14 27 13 30 10 25 15 108 52

G = GDMO S= Specialist

More than half of the respondents have less than 15 years of service

meaning thereby that they have yet not touched mid-career point. One-

fourth of them have joined only in last four years, while only 28 of the

160 have completed 25 years of service, out of whom 23 are specialists.

24

SCM SPRI, Jaipur

There is one specialist amongst three generalists in the Doctors who

joined between 1996 and 2005 (13:40); while in the younger Doctors

joining after 2006, it is one specialist amongst thirteen generalists (3:39).

It implies that most of the Doctors in state government groom themselves

as specialists while in service.

Table 3.7

Age wise distribution of respondents

Age

District Total

Grand Total

Bikaner Bharatpur Jhalawar Sirohi

M F M F M F M F M F

Upto 25 0 1 0 0 0 1 1 0 1 2 3

26-35 12 3 12 4 14 4 7 0 45 11 56

36-45 9 3 10 3 9 1 14 2 42 9 51

46-55 6 3 9 0 8 1 10 2 33 6 39

56+ 3 0 2 0 2 0 4 0 11 0 11

Total 30 10 33 7 33 7 36 4 132 28 160

Amongst the 160 doctors interviewed, 28 were lady doctors including five

specialists. Amongst the 28 lady doctors, four were from PHCs, 13 from

CHCs and 11 were posted at district hospitals. While in Bikaner, one-

fourth of the respondents were lady doctors; in other districts, their

proportion was much less. It seems that deployment of lady doctors in

rural facilities is marginal. More than two-thirds of the Doctors were

between the age of 26 to 45 years and only 11 of the 160 were above 55

years of age.

25

SCM SPRI, Jaipur

Table 3.8

Completed Schooling

Place District

Total Bikaner Bharatpur Jhalawar Sirohi

Village 14 9 8 17 48 Tehsil HQ 21 24 19 14 78

City 5 7 13 9 34 Total 40 40 40 40 160

Only 34 of the 160 Doctors have had their schooling in cities. It implies

that most of the doctors in the public system of the state are from a rural

background.

Table 3.9

Doctors with higher qualifications

Qualification District

Total Bikaner Bharatpur Jhalawar Sirohi

Diploma 3 3 4 3 13

MD 7 8 6 6 27

MS 7 5 4 9 25

Total 17 16 14 18 65

In all 65 doctors possessed additional qualification (27 MD‟s, 25 M.S.

and 13 with a diploma) including the 40 specialists i.e. ten specialists

from each of the four district as part of a formal sample of the study.

This included 13 general surgeons, 13 physicians, 11 pediatricians, 5

gynecologists-obstetricians, 3 chest specialists, 4 ENT surgeon, 4 eye

specialists, and 13 with diploma in different disciplines.

More than half of the respondents have less than 15 years of service, i.e.

they have not yet touched a mid-career point. One-fourth of them have

26

SCM SPRI, Jaipur

joined only in last four years, while only 28 of the 160 have completed 25

years of service (out of whom 23 are specialists). There is one specialist

in proportion to three generalists among the doctors who joined between

1996 and 2005 (13:40); while the younger doctors joining after 2006, it is

one specialist in proportion to thirteen generalists (3:39). It implies that

most of the doctors in state government became specialists while in

service.

111 of the 160 respondents entered in the service through the Rajasthan

Public Service Commission.

Table 3.10

Duration of stay at first place of posting

Durations of

Stay

District Total

Bikaner Bharatpur Jhalawar Sirohi

< 1 year 15 10 8 8 32

1-2 12 14 15 13 54

3-5 10 7 16 13 46

> 5 year 3 9 1 6 19

Total 40 40 40 40 160

More than half stayed for less than two years on their first posting while

19 of the 160 interviewed could continue for more than five years at the

first place of posting. It seems that those who do not like their first place

of posting managed the desired change.

27

SCM SPRI, Jaipur

Table 3.11

Number of times transferred

Number of times

transferred

District Total Bikaner Bharatpur Jhalawar Sirohi

None 7 12 13 11 43

One 11 7 7 8 33

Two 4 7 4 5 20

Three 5 1 4 2 12

Four or more 11 12 9 11 43

More than 10 2 1 3 3 9

Total 40 40 40 40 160

While one-fourth respondents have not experienced transfer, one-fourth

has borne it on four or more occasions. Nine of the 160 respondents have

borne transfer on more than ten occasions. Half of the doctors did not

like the place of their first posting. More than half stayed for less than

two years at the place of their first posting.

Table 3.12

Perception of Respondent on Transfer

Basis of

Transfer

District Total

Bikaner Bharatpur Jhalawar Sirohi

Routine 21 12 14 12 59

Recommendation 5 8 8 7 28

On Promotion 4 5 1 5 15

Punishments 3 3 4 5 15

Total 33 28 27 29 117

While 28 of the 160 respondents admitted of indulging in canvassing for

transfer to fetch a choice place, 15 had borne transfer as punishment at

28

SCM SPRI, Jaipur

least once. More than three-fourth doctors expressed their ignorance on

transfer policy.

The issue of temporary postings was also looked into. Only one Medical

Officer in Jhalawar reported having been sent to another PHC on more

than two occasions to look after the work of another officer. Thus

against a general impression, doctors are not moved frequently from their

place of posting.

117 of the 160 doctors are paid in the scale of 16800-39100. 15

generalists in their first two years of service are getting a fixed amount of

Rs. 8000/ p.m. while three specialists are getting a basic of over Rs.

30100/ p.m. More than two-third doctors are not satisfied with their

present salary. One-third of the doctors dissatisfied with their salary felt

it was less in context of their length of service and qualification. One-

fourth of them felt it was less in comparison to payment in the private

sector.

Table 3.13

Promotion in the Carrier

First

promotion

District

Total Bikaner Bharatpur Jhalawar Sirohi

Within first 5

years

0 0 0 0 0

5-15 years 6 3 4 5 18

16-25 years 2 4 3 5 14

> 25 years 0 0 1 1

Total 8 7 7 11 33

Only 11.25 percent Doctors got promotion within 5 to 15 years of their

joining state service.

29

SCM SPRI, Jaipur

More than three-fourth of doctors desired that private practice should be

allowed.

70 percent respondents admitted their ignorance on any written

document on „Job Responsibilities of Health Professionals in Rajasthan‟,

yet 88 percent of these „ignorant‟ were aware of their job responsibility.

While trying to measure the managerial capacity of the doctors, we came

to know that only 27.5 percent of them fully used the allocated funds;

12.5 percent of them said that they could recruit subordinate staff; only

seven percent known that they could move the staff within their

jurisdiction; and only one in ten doctors knew that they could reward or

punish their subordinates.

95 percent doctors admitted that they were supervised on their job and

two-third of the supervised lot felt it as a regular phenomenon. 133 of the

152 supervised doctors felt that supervision helped them to learn

„something new‟ from their supervisors. More than half of the doctors

admitted that their work was also being watched by people‟s

representatives also.

More than half (54 percent) of the doctors have not attended any „CME‟

during the last two years and half of those who attended have not

participated in more than two in last two years bringing down to the

average of one CME per year. 30 percent of the respondents admitted

that they were not interested in CME.

More than 60 percent (98 of the 160) doctors have attended at least one

in-service training in last two years and only 60 percent of those who

attended training found it to be relevant. Thus training process requires

a thorough review.

30

SCM SPRI, Jaipur

Three-fourth of the doctors admitted that their performance was

regularly appraised albeit through a confidential process. Almost all

contractual doctors indicated that their performance appraisal was not

documented. One-fourth of the doctors admitted that they were witness

to appreciation/criticism being communicated formally to their

colleagues. Only one-fourth of doctors carried the perception of

grievances redressed formally in time, it seems that many more might

be bearing with their grievances anonymously.

Three-fourth of the doctors interviewed are well aware of all leave

privileges but less than half of the Doctors are able to avail all types of

leave. Those who could not avail leave said that it was owing to their

heavy workload; lack of availability of replacement; and non-availability

of leave when it was desired which kept them deprived of a vacation.

120 generalists and 40 specialists distributed in four sampled districts

were also requested to share their perception on availability of work

space, instruments and drugs, supporting staff, logistics and community

support to them. While all specialists were satisfied with the work space

allocated to them, only 64 % of generalists found it to be satisfactory. 85

% specialists against 64 % generalists were satisfied with the

instruments available to them. While only 68% generalists were satisfied

with the availability of drugs at their facilities, 88% specialists expressed

their satisfaction on this account. 63% of generalists were satisfied with

the support staff provided to them against 80% specialists satisfied on

this account. 98% of specialists were satisfied with community support

against only 62% generalists satisfied on this account. Largely these

observations convince that generalists in the rural facilities seem to work

with a sense of involvement, whereas specialists seem to work with an

indifferent attitude.

31

SCM SPRI, Jaipur

Less than half of the doctors interviewed live in government

accommodation. While in Bharatpur and Bikaner districts 40% of

doctors were availing the facility of on-campus accommodation, in Sirohi

district, the number of such doctors was 60%. This observation was

made in the background of 143 out of 160 doctors admitting that they

were continuously staying at the headquarter station of the facility

assigned to them and 100 of the 160 Doctors admitting that their

families were with them at their work place. Only 38% of these doctors

found that facilities of education of their children were available at their

work place. This data could be much lower if we segregate the doctors

who work exclusively at a PHC.

Table 3.14

Perception of strengths at the time of Joining by Doctors

Confident at

Joining service

District Total

Bikaner Bharatpur Jhalawar Sirohi

Seeing OPD 37 39 34 36 146

Emergencies 28 35 28 29 120

IPD 37 37 29 30 133

Normal deliveries

30 24 21 26 101

Surgeries 11 10 14 11 46

Administrative

work

25 24 22 24 95

Attending

meetings

33 35 29 24 121

Supervision 31 33 29 25 118

Total 40 40 40 40 160

While 70% to 90% doctors felt confident in conducting OPD, attending

emergencies and deliveries right from the beginning of their service, 75%

of them found themselves to be incompetent in attending to

administrative chores. It is only 20% of doctors who got a chance to

32

SCM SPRI, Jaipur

attend an in-service training within first two years where administrative

and financial procedures were taught to them.

Responses which could not be elicited during the interview found their

expression in the situation around the doctors. A couple of them are

expressed in the brief below:

Three specialists and Zero Operations

CHC Khajuwala is situated on the Indo-Pak border in Bikaner district; It has seven

generalists and three specialists. The CHC is well equipped with all the facilities. A

year-and-a-half back a Surgeon was molested after a case operated by him went in

shock. Since than not a single operation has been conducted at CHC, Even for minor

operations, cases are referred to PBM Hospital, Bikaner.

PHC on Highway without Doctor

Visit to a PHC situated on the Jaipur-Bikaner highway close to the CHC Sri-Dungargarh,

revealed the unkempt conditions of the facility. Record keeping shared by the staff

revealed weaknesses in retrieval of data. Villagers gave an impression that Doctor is not

available regularly. During the survey staff apprised that he has gone to CHC to attend a

meeting but he was not available to the peer group of survey team even at CHC till

evening.

Lure of Practice

A specialist at a major CHC in Jhalawar was seen examining the patients at his home

during routine OPD hours. A couple of villagers expressed it as a routine!

Networking for Rotation

At another CHC in Jhalawar, four Doctors seem to have connived to ensure that services

should not suffer; eventually they are attending the facility on rotatory basis to help each

others practice somewhere else!

Distance versus Indifference

Visit to PHC Ghatoli in Jhalawar district revealed dirty bed-sheets and unclean toilet indicating

poor sanitary conditions in the PHC. It was difficult to determine whether indifference of local

management keeps the villagers away from the facility or proximity of CHC (Aklera is only 12

kms from Ghatoli) takes the patients directly to CHC!

Generalists versus Specialists in the District Hospital vis-à-vis District as a whole

District Hospital District as a whole

Generalists Specialists Generalists Specialists

Bharatpur 35 23 65 35

Bikaner 10 9 43 23

Jhalawar Upgraded to Medical College Hospital in 2008 28 3

Sirohi 3 16 28 22

33

SCM SPRI, Jaipur

3.6 Facilities as we saw them

Each of the five CHCs in the sampled districts has thirty indoor beds;

operation theatres and regular water supply. The Abu Road CHC in

Sirohi did not have staff quarters. Lunkaransar CHC in Bikaner did not

have regular electricity supply. In four of the 20 CHCs X-ray machines

were not available.

13 of the 40 PHCs visited were under the fold of 24 x 7 services as per

RCH-2, where a provision for round-the clock delivery exists.

Infrastructure availability in PHCs in different districts was highly

variable.

Morbidity profile of the patients seeking care from public facilities is a

critical determinant of the interest which doctors take at the place of

their posting. Taking this into consideration, attendance at OPD‟s,

indoor patients, deliveries and operations conducted were reviewed at

each facility for 2008.

Out of five CHCs at Bharatpur, Kumher was found to be the busiest

where three generalists and one specialist attended 76,456 out-patients

and 526 indoor admissions. Although Deeg CHC was staffed with three

generalist and two specialists throughout 2008, it had an OPD of 60575

and IPD of 372. Roopwas CHC did not give the data on the plea of

unavailability of appropriate subordinate staff. Amongst the ten PHCs of

the district, Jurhera has the highest number of out-patients numbering

14011 followed by PHC Rudawal (10153), while PHC Behaj attended to

only 177 patients in its OPD in spite of two generalists available to them.

Although PHC Brahambad had no doctor, its IPD recorded 3721 patients

in 2008. Indoor admission at ten PHCs in Bharatpur ranged from three

34

SCM SPRI, Jaipur

admissions at Bansi to 109 admissions at PHC Brahmi. There were no

admission at PHC Pangor and Behaj. Deliveries conducted at CHCs

varied from 206 at Roopwas to 4690 at Bayana. Among the ten PHCs

sampled in Bharatpur, Rudawal recorded 1555 deliveries, against not a

single delivery at Khoh and Ghata. Surgical operations are conducted at

CHC only and their number ranged from 62 at Kumher to 1769 at Deeg.

The OPD load at the CHCs of Bikaner ranged from 77643 at Dungargarh

with one generalist and five specialists, while CHC Khajuwala with ten

doctors including five specialists could attend to only 44375 patients.

Lunkaransar CHC with six doctors attended to only 9069 outpatients as

it happens to be very close to the city. Consequently the indoor

admissions also ranged from 225 at Kolayat to 6857 at Dungargarh.

Load of deliveries borne by CHCs ranged from 361 deliveries at Kolayat to

1782 at CHC Nokha. CHC Dungargarh also conducted 1528 surgical

operations in comparison to 257 surgeries at CHC Lunkaransar.

Coverage of OPD & IPD in Surveyed districts

0

10000

20000

30000

40000

50000

60000

1 2 3 4 5 6 7 8 9 10 11 12

Months 2008

Num

bers

OPD Jhalawar

OPD BikanerOPD Sirohi

OPD BharatpurIPD Jhalawar

IPD BikanerIPD Sirohi

IPD Bharatpur Source: data collected from the surveyed facilities

PHC Gadey attended to 13769 outpatients with a single doctor in

contrast to 3670 outpatients by PHC Kakku. Akkasar and Seruna PHC

did not admit a single patient in 2008 in contrast to 769 indoor

admissions recorded by Mahajan PHC. While Akkasar PHC did not

35

SCM SPRI, Jaipur

conduct any delivery, as many as 422 deliveries were conducted at

Chatargarh PHC. Some of the PHCs are also conducting surgical

operations although minor in nature.

Coverage of OPD in Selected districts

0

10000

20000

30000

40000

50000

60000

1 2 3 4 5 6 7 8 9 10 11 12

Months 2008

Num

bers

OPD Jhalawar

OPD Bikaner

OPD Sirohi

OPD Bharatpur Source: data collected from the surveyed facilities

OPD attendance at the CHC‟s of Jhalawar ranged from 8229 at Dag with

three generalists to 41728 at Jhalra-patan with equal number of

doctors‟- i.e. three generalists! In-door admissions in 2008 at Dag were

380 and at Jhalra-patan 2902. CHC Khanpur with three generalists and

two specialists reported 7436 indoor admissions. The same CHC also

reported highest number of operation and deliveries.

Coverage of Delivery in Surveyed districts

0

500

1000

1500

2000

2500

3000

1 2 3 4 5 6 7 8 9 10 11 12

Months 2008

Num

bers

Delivery Jhalawar

Delivery Bikaner

Delivery Sirohi

Delivery Bharatpur Source: data collected from the surveyed facilities

The OPD attendance at the ten PHCs in Jhalawar district ranged from

1625 for Unhel to 6936 for Jhumki; while PHC Ratlai admitted 820

patients in their indoors against only 14 admissions at Unhel. Deliveries

36

SCM SPRI, Jaipur

conducted at a PHC ranged from 7 at Jhumki to 164 at PHC Panwada.

Surgical operations are not undertaken at any PHC in Jhalawar district.

COverage of Operation in Surveyed districts

0

500

1000

1500

2000

2500

3000

3500

1 2 3 4 5 6 7 8 9 10 11 12

Months 2008

Num

bers

Operat ion Jhalawar

Operat ion Bikaner

Operat ion Sirohi

Operat ion Bharatpur Source: data collected from the surveyed facilities

The OPD at CHC‟s ranged from 3632 at Kalindri to 34,222 at CHC

Pindwara in Sirohi district. Shivganj CHC admitted 2,288 patient in

contrast to 327 admissions at CHC Kalindri. Deliveries conducted at

CHC ranged from 58 at Kalindri to 1,423 at Pindwara throughout 2008.

The OPD attendance at PHC in Sirohi seems to be more than the PHC of

other districts. In 2008, it ranged from 5,060 at PHC Cheenar to 15,378

at PHC Anadra Conduct of deliveries ranged from twelve in a year at

Barloot to 467 deliveries at PHC Sirodi. Two of the ten PHCs visited viz.

Deldar and Jawal has not conducted a single delivery at their facility

throughout 2008. Surgical work at CHC Mount Abu recorded 617

operations in contrast to only 81 operations conducted at CHC Pindwara

during 2008.

Between all the 20 CHCs of the four studied districts, it was observed

that CHC Bayana in Bharatpur conducted an average OPD of 217

outpatients per day with six generalists and four specialists sharing this

load. On the other hand CHC Dag in Jhalawar run exclusively by three

generalists conducted an average OPD of 22 outpatients per day during

2008.

37

SCM SPRI, Jaipur

Amongst the PHCs, Posaliya in Sirohi district conducted an average OPD

of 51 outpatients with a single doctor while Behaj PHC in Bharatpur with

two generalist doctors attended to an average or one outpatient in two

days during 2008.

Coverage of IPD in Surveyed districts

0

1000

2000

3000

4000

5000

6000

7000

1 2 3 4 5 6 7 8 9 10 11 12

Months 2008

Nu

mb

ers

IPD Jhalawar

IPD Bikaner

IPD Sirohi

IPD Bharatpur

Source: data collected from the surveyed facilities

In three of the four districts there is a CHC which has occupancy over

eight out of thirty beds. This includes Dungargarh in Bikaner: Khanpur

in Jhalwar and Deeg as well as Kumher in Bharatpur. Shivganj CHC in

Sirohi district has maximum bed occupancy of 3 out of 30 beds per day.

PHC Anadara in Sirohi district and PHC Ratlai in Jhalawar districts had

average bed occupancy of five out of six indoor beds while 16 out of 40

PHCs had average bed occupancy of Zero.

On the basis of performance in terms of OPD attendance, in-door

admissions, operations performed, and deliveries conducted versus the

availability of staff in general and Doctors in particular, an attempt was

made to identify facilities performing low on the scale of output delivery

for CHC in each district.

38

SCM SPRI, Jaipur

Community Health Centers

Table 3.15

CHC’s of Bharatpur - 2008

Performance Medical Man power

CHC OPD IPD Operation Delivery Specialist MO LT ANM Pharmacist

DEEG 60575 6774 1769 2405 2 3 1 2 0

KAMA 26226 3179 62 1057 3 2 1 2 0

KUMHER 76475 7243 114 2121 1 3 3 4 0

BAYANA 79348 6173 349 4690 4 6 6 7 0

ROOPBAS 17230 1483 NA 1224 2 1 1 10 0

Out of the five CHC‟s visited, performance of Kumher and Bayana

seemed to be the best while Roopbas recorded the lowest number of

patients attended at OPD, in-doors, delivery and nil operations albeit two

specialists and one generalist with a team of ten ANM‟s were deployed to

deliver all these service there. The two specialists working at CHC

Roopbas are a Physician and an Obstetrician. Deliveries in CHC Kama

were lowest.

Table 3.16

CHC’s of Jhalawar - 2008

Performance Medical Man power

CHC OPD IPD Operation Delivery Specialist MO LT ANM Pharmacist

BAKANI 18574 2290 257 634 0 3 1 3 0

Dag 8229 1809 696 700 0 3 1 2 0

Jhalaa-Patan 41778 2902 0 289 3 2 2 1 0

KHANPUR 25542 7436 625 2612 2 3 2 2 0

PIRAWA 30995 5687 325 684 1 4 0 1 0

Although OPD and in-door attendance at CHC‟s of Jhalawar was almost

half in number when compared with CHC‟s of Bharatpur, yet the

proportion of operations and deliveries conducted at these facilities was

high. CHC at Bakani and Dug did not have a single specialist while

Jhalara-Patan had two of them. It seems that later with its closeness to

the district headquarter might be referring all the cases to district

39

SCM SPRI, Jaipur

hospital and not undertaking operations. On the contrary CHC Dag is

doing good number of minor operations only through generalists.

Table 3.17

CHC’s of Sirohi -2009

Performance Medical Man power

CHC OPD IPD Operation Delivery Specialist MO LT ANM Pharmacist

Sivganj 75837 2188 265 438 2 2 2 13 0

M’t Abu 19694 933 617 159 2 2 1 5 0

Pindwara 33722 1848 0 1423 0 3 2 7 0

Kalindri 7264 654 440 116 0 1 2 1 0

Reodar 17784 1144 0 688 0 4 0 4 0

OPD attendance in the CHC‟s of Sirohi ranged from 7264 at Kalindri to

75837 at Sivganj. Similarly in-door attendance ranged from 654 at

Kalindri to 2188 at Sivganj. Principal reason for this might be posting of

only one generalist at CHC Kalindri. Not a single operation was

performed at two of the CHC in the district. Three of the five CHC visited

in the district did not have a single specialist.

Table 3.18

CHC’s of Bikaner -2008

Performance Medical Man power

CHC OPD IPD Operation Delivery Specialist MO LT ANM Pharmacist

Kolayat 10210 225 0 361 0 4 1 7 0

Shridungargarh 77643 6857 0 1675 4 1 1 5 0

Nokha 89975 5378 804 599 4 6 1 10 0

Khajuwala 44375 1835 0 645 3 7 2 9 0

Lunkaransar 54270 5388 522 1082 3 3 2 8 0

With not a single operation throughout 2008, CHC Kolayat and

Khajuwala were observed to be poorly performing CHC particularly when

they were compared with Nokha and Shridungargarh in the same

district. Although CHC Kolayat is being managed by four generalists

only but CHC Khajuwala with three specialists and seven generalists was

attending to only half of the OPD load catered by CHC Nokha. All the

40

SCM SPRI, Jaipur

CHC in Bikaner district had sufficient number of ANM‟s and Laboratory

Technicians.

Primary Health Centers

Table 3.19

PHC of Bharatpur - 2008 Performance Medical Manpower

PHC OPD IPD Operation Delivery MO LT ANM Pharmacist

GHATA 4002 0 0 0 2 1 3 0

RUDAWAL 11015 163 0 1155 2 1 5 0

Bansi Paharpur 2063 3 0 3 1 1 1 0

JHURHARA 14011 78 0 1063 2 1 2 0

DHANWARA 3247 63 0 8 2 1 1 0

BEHAJ 177 0 0 8 2 1 2 0

KHOH 3109 32 0 360 2 0 3 0

PENGHOR 3514 0 0 1 1 0 1 0

SINHARA 4699 90 0 3 1 2 1 0

BRAMBAD 3721 109 0 15 0 1 1 0

In spite of two Generalists working at PHC Behaj, OPD attendance was

only 177 and total number of deliveries conducted throughout the year

was eight only. Performance of PHC Bansi Paharpur and Penghor was

also found to be weak in terms of in-door admissions and operations

conducted. While the PHC at Jhurhara and Rudawal attended to 14011

& 11915 OPD and 78 & 163 in-door patients respectively. Amongst the

two M.O. at PHC Dhanwara and PHC, Khoh, one each is from Ayurveda.

Table 3.20

PHC’s of Jhalawar - 2008

Performance Medical Manpower

PHC OPD IPD Operation Delivery MO LT ANM Pharmacist

MANDAWAR 5173 66 0 13 3 1 2 0

GANGDHAR 5188 177 0 117 1 1 1 1

GHATOLI 2458 102 0 43 1 0 1 0

PANWAR 9014 397 0 164 1 0 1 0

TARAJ 4558 164 0 38 1 0 1 0

AWAR 5047 273 0 172 1 1 1 0

SHIRPOI 4640 281 0 39 1 0 4 0

JHUMKI 6954 36 0 7 1 0 5 0

RATALAI 5175 820 0 18 1 1 9 1

UNTEL 1630 14 0 10 1 0 5 0

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PHC‟s in Jhalawar seems to be doing comparatively better than

Bharatpur. Although PHC Ghatoli was having the lowest OPD in 2008,

yet the in-door admissions were triple the admissions at PHC Jhumki

where OPD attendance of 6954 was recorded. PHC Untel recorded the

weakest performance in terms of 1630 OPD and 14 indoor admissions.

The number of deliveries conducted at PHC varied from 7 at Jhumki to

172 at Awar. PHC‟s have a sanctioned strength of one Generalist, but at

PHC Mandawar, three Medical Officers were found to be working one

each from Allopath, Homeopathy and Ayurveda.

Table 3.21

PHC’s of Sirohi - 2008

Performance Medical Manpower

PHC OPD IPD Operation Delivery MO LT ANM Pharmacist

Sirodi 13317 498 0 467 1 1 2 0

Chanar 5060 112 0 62 2 0 1 0

Nandia 7358 226 118 128 2 1 5 0

Barloot 5285 223 56 12 1 1 3 0

Jawal 5525 80 9 47 1 1 1 0

Delder 5838 43 30 38 1 1 2 0

Paldi 5566 208 0 156 2 1 5 0

Posaliya 18278 361 0 388 1 1 7 0

Virwara 11131 286 120 103 2 1 2 0

Anadar 15378 360 59 679 1 1 2 0

PHC‟s in Sirohi district seems to be doing better than PHC‟s in other

districts. PHC Chanar recorded the OPD of only 5060 while PHC Jawal

and Delder with higher OPD have reported lower in-door admissions.

This might be due to the type of morbidity reported not needing in-door

care. Six of the ten PHC are conducting minor/major operations unlike

most of the PHC‟s in Bharatpur and Jhalawar districts. Deliveries are

also conducted at each PHC albeit their range varied from 12 at PHC

Barloot to 679 at PHC Anadar. This supports the hypothesis that rate of

institutional deliveries in tribal districts is high.

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Table 3.22

PHC Bikaner - 2008

Performance Medical Manpower

PHC OPD IPD Operation Delivery MO LT ANM Pharmacist

Kheruma 8609 0 0 75 1 0 2 0

Kalu 12950 475 281 247 2 1 4 0

Akkasar 4348 0 0 28 1 1 3 0

Kakku 3720 357 20 162 1 0 5 0

Lakhasar 4269 318 5 93 1 1 3 0

Poogal 10602 490 271 481 2 1 4 0

Chattergarh 13096 25 0 430 1 1 2 0

Mahajan 10422 769 0 676 1 1 5 0

Jhadiyala 13769 660 41 289 1 1 1 0

Mukaam 5517 116 0 163 1 1 1 0

OPD attendance at the PHC of Bikaner ranged from 3720 at PHC Kakku

to 13096 PHC Chattergarh. PHC Kheruma and Akkasar did not report

any admission. The number of deliveries conducted at PHC varied from

28 at Akkasar to 676 at Mahajan. In fact, it is the high number of

institutional deliveries at PHC Mahajan, which carried the figure of in-

door admissions to 769. Beside PHC Kalu, at Poogal also, two Doctors

are working.

A couple of critical points which came under observation during the

survey are mentioned here:

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PHC Akkasar PHC Akkasar is situated outside the village in a large building albeit only three of its

rooms are currently in use i.e. one for MO I/c, another for Ayush physician and third

room for dressing and dispensing. A bed has been kept in the corridor for giving

injections to the patients. There has not been any indoor admission during last twelve

months and OPD caters on an average twelve out-patients per day (a low attendance

compared to many other PHC’s of the district). Major portion of the building has huge

cracks in the ceiling. X ray machine and other equipments are lying in unused area

since last two years.

The Public work department of the area has also certified the structure as dangerous in

use.

PHC Ghata More often than not PHC Ghata in Bharatpur functions without power, consequentially

without water. Staff said water for essential use is managed by a helper. Although two

MO’s are posted here but not a single delivery, neither any operation is on record for

2008 albeit OPD attendance for 2008 was 4002 (average eleven out-patients per day)

and in-door attendance of 73 patients indicating six admissions per month.

Hill Station and Hospital

Mount Abu in Rajasthan is a national acclaimed hill station. CHC of Government of

Rajasthan is functioning in this town. Brahmkumaris run multi-specialty “Global

Hospital” in the same town. Between January and December of 2008, CHC has catered

to 19,664 out-patients (54 patients per day); in-door of 933 including conducts of 159

deliveries; and 617 operations. In 2009 most of the surgical cases were referred down to

Abu Road.

Deliveries conducted at District Hospital versus CHC in 2008

District

Hospital

CHC

Conducting

Max deliveries

Bikaner 599 1782 at Nokha

Bharatpur 8639 4690 at Bayana

Sirohi 1945 1423 at Pindwara

Jhalawar - 700 at Dag

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4

PROJECTIONS FOR MEDICAL MANPOWER

In the four sampled districts, the number of facilities in the rural area

was enumerated and projections were built up on the basis of IPHS.

This will give a clue to the number of new facilities to be built up and

Doctors to be inducted within the span of NRHM.

Table 4.1

* Existing number in 2009

There are 6 CHC‟s and 22 PHC‟s as 0f 2008 in Sirohi district. Since it is

a tribal district and its estimated rural population by 2012 will be

1000774, as per IPHS, the number of CHC‟s in the district will have to be

doubled and 28 more PHC‟s have to be established. Eventually the

number of Generalists and Specialists for rural health services will shoot

up from 38 & 10 to 100 & 84 respectively.

Year

Estimated

Population

PHC

(22)*

MO

(38)*

CHC

(06)*

Specialist

(10)*

2009 907894 45 90 11 77

2010 937854 47 94 12 84

2011 968803 48 96 12 84

2012 1000774 50 100 12 84

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Table 4.2

*Figure in parenthesis is current position as of mid-2009.

There are 14 CHC‟s and 30 PHC‟s as of 2008 in Jhalawar district. On

the basis of population norms, the number of CHC‟c in Jhalawar is

already more. Since the estimated rural population by 2012 will be

1335081, as per IPHS, the number of CHC‟s in the district can be

reduced from 14 to 11, and numbers of PHC‟s have to be increased

from 30 to 44. Since there are in all 19 specialists in the district

currently, their number has to be increased by 77 and 15 additional

generalists would be required if number of PHC‟s is raised as per IPHS

norms.

Table 4.3

*Figure in parenthesis is current position as of mid-2009.

Bharatpur is also a plain district where according to IPHS norms and

estimated rural population of 2012, the number of CHC‟s has to be

increased from current strength of 13 to 19 and number of PHC‟s has to

be increased from current strength of 57 to 76. Eventually the number of

Doctors has to be increased from 57 to 76 for Generalists and from 36 to

Year Estimated

Population

PHC (30 )*

MO (73 )*

CHC (14 )*

Specialists (19 )*

2009 1237943 41 82 10 70

2010 1269510 42 84 11 77

2011 1301883 43 86 11 77

2012 1335081 44 88 11 77

Year Estimated Population

PHC (57)

MO (126)

CHC (13)

Specialists (36)

2009 2097428 67 134 17 119

2010 2154479 72 144 18 126

2011 2213080 74 148 18 126

2012 2273276 76 152 19 114

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114 for specialists. It implies that district would demand 78 more

specialists within next three years.

Table 4.4

*Figure in parenthesis is current position as of mid-2009.

Bikaner is a desert district where it is estimated that rural population

would reach to the level of 1803758 by 2012. Based on the IPHS norms

for desert area, the number of CHC‟s in this desert district will have to be

more than doubled i.e. from current number of 10 to 23. Similarly

number of PHC‟s has also to be more than doubled i.e. from current

number of 38 to 90 by 2012. It implies that in next three years, district

will need 105 more Generalists and 147 Specialists.

Rajasthan has an estimated population of 64.72 million as of March

2007. Based on the current growth rate of population, state will require

234 additional CHCs if it has to cope up with the IPHS norms indicated

by GoI and accepted as a strategy for effective delivery of health services

through the NRHM. Likewise the number of PHCs in the State has to be

raised from 1521 of 2009 to 2416 in 2012. Even the number of sub-

centers has to be raised from the current figure of 10,791 to 14,497

between 2009 and 2012.

Increase in the no of facilities will spontaneously demand an increase in

the number of doctors and ancillary health manpower. Estimated

population of Rajasthan in 2012 will be over 72.48 million. State health

system has to raise the number of generalists from the current figure of

4,558 to 4,832 by 2012 as per the IPHS norms. This implies a need for

Year Estimated

Population

PHC (38)*

MO (75)*

CHC (10)*

Specialist (14)*

2009 1567990 78 156 20 140

2010 1642939 82 164 21 147

2011 1721472 86 172 22 145

2012 1803758 90 180 23 161

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274 additional general duty doctors. On the same strategy the number of

specialists has to be raised from 2099 to 2416 between 2009 and 2012.

Eventually 317 additional specialists have to be inducted in the next

three years exclusively for rural health services.

Additional number of facilities and manpower has to be judiciously

distributed in the tribal, plains and desert area of the State as well as

within each district.

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5

DETERMINANTS OF PERFORMANCE OF DOCTORS

Since the study was focused on identifying the factors which determine

the productivity of doctors at the peripheral facilities, a two pronged

strategy was adopted to collect the desired information. On one hand,

direct interactions with doctors working at cutting-edge helped us record

their perceptions, and on other hand observing their work environment

and reviewing the work done by them helped in identifying their

contribution.

Doctors working in rural facilities desire their first postings in a familiar

environment. They feel at home when they can communicate with the

communities to be served by them in their own dialect. This issue is very

important in the first posting. Many doctors in the early career had to

invest a lot of time and energy in managing to reach to the place of their

choice. Influence on their morale‟s during this phase of struggle for

choice posting remains invisible but has its repercussions on the health

system on sustainable basis.

Doctors often begin their career in a conflict between becoming a

specialist at a younger age or remaining a generalist for a long time.

Although the scope for doing post-graduation while in-service has

increased but what bothers the prospective postgraduates is the threat of

not being accepted smoothly in a medical college environment when one

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reaches there as an in-service candidate. More often than not, medical

teachers are prejudiced against candidates who do not join post-

graduation in continuity of their MBBS course. Longer the gap between

completing graduate-ship, and taking to post graduation, more difficult it

becomes difficult to amalgamate with the mainstream of postgraduate

courses.

When doctors compare themselves with the officers from the other state

services, they get a sense of alienation. Within the state while there is

sufficient scope for officers in administrative, police and allied services to

rise in hierarchy, we found that with 3739 generalists (MO and RMO

combined), there are only 815 positions for SMOs, 92 positions for Dy.

Directors and only 21 positions for Joint Directors. Since half of the

Directorships are earmarked for specialty quota, generalists feel defeated

on this front also. Even in the specialist stream, against 1,815 positions

of Junior Specialists, only 280 sanctioned positions of Senior Specialists

are available. A promotion of Specialists heavily depends on the demand

and growth of the concerned spatiality. In late eighties and early nineties,

there was a spurt in the growth of Obstetrics and Pediatrics. In late

nineties, Radiodiagnosis and Orthopedic Surgery came in prominence.

Currently there is a feeling that Dermatology, Psychiatry, Ophthalmology,

and TB & Chest Diseases should receive priority in delivery of health

services in the periphery. In context of Generalists, it seems that lack of

an HR policy makes the Doctors cultivate favor seeking attitude for

survival at the place of their choice.

Medical and Health Department in Rajasthan has debated for decades to

start an induction course. In the last decade with the funds available

from World Bank induction trainings were experimented but it could not

make the inductee as an effective Manager. Reviewing the Induction

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program revealed that it was loaded with a large number of technical

sessions rather than enhancing their capacity to deal with

administrative, financial and behavioral matters. Even within technical

matters, two of the three Directors emphatically demanded doctors

capable of handling medico-legal matters including conduct of post-

mortems, but the current two week Induction trainings have not

envisaged its inclusion.

Contrary to the popular belief, doctors at the peripheral centers loved

being supervised provided it had a supportive intention. Most of them

also look for opportunities to participate in „CME‟ and in-service

trainings. But the problem shared by them was the unavailability of any

replacement if they had to leave their facility to go to attend an academic

program. Most of the doctors want transparency in documenting their

performance appraisal. They also desired quick feedback.

Doctors posted at rural facilities wish to stay on campus for two reasons,

(i) government quarter in a remote village is a better place to live than

any private house in the village; and (ii) the ease in attending emergency

as well as patients in their private practicing hours. Young doctors with

pre-school children did not find any problem in performing their duties

consistently but middle aged doctors were vociferous in their expression

that by mid-thirties, doctors should be placed exclusively at district and

sub-district facilities.

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6

RECOMMENDATIONS

Availability of Doctors at the peripheral facilities is an index of

functioning of health department. Failure to make the services of Doctors

consistently available at peripheral facilities let down the image of health

services delivery. What is generally prevalent in Rajasthan is not only a

gap between the required number of posts and the sanctioned posts but

also a shortfall between the sanctioned posts and of those which had

been filled up. The shortfall at various levels leads to serious problems of

coping up with the need of preventive and curative programmes running

in the district. In this background, there is an urgent need to introspect

the status and process followed in deploying the Doctors in the

periphery. It is all the more important when NRHM is there to support

the desired paradigm shift in managing the health services in each state

of the country. Observations of this study direct us to place following

recommendations for the kind consideration of the Government of

Rajasthan.

Human Resource Cell: All HR matters related to Doctors are currently

dealt by a „Gazetted Cell‟ in the Directorate of Health services and for the

nursing and paramedical personnel, a full time Additional Director (Non-

Gazetted) works in a separate compartment. There is an urgent need to

create a strong “Human Resource Cell” in the Directorate. It should first

develop and retrieve a „Personnel Management Information System‟

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taking care of all the mainstream health professionals. A good PMIS can

go a long way in enhancing the capacity of the health system in terms of

deployment as well as trainings required by health professionals

stationed at different peripheral health facilities. Concurrently it should

take in cognizance the contractual positions created at different facilities

and district/sub-district management units. There is an urgent need to

strike a balance between mainstream and contractual personnel and

utilize the current opportunities to promote a positive organization ethos.

Role ambiguity emerging from the presence of several contractual

professionals around health system can be contained by orienting one

and all on their specific responsibilities. This cell should initiate the

development of an HR Policy which may set transparency in deployment,

transfers and promotions of Doctors in the field. This is an onerous

challenge in a democratic polity but accepting it can set pace for good

governance. Good governance demands that doctors in the peripheral

facilities should be deployed with a vision of establishing a good doctor-

patient relationship. Eventually doctors belonging to the same districts

should be given priority in posting. Once placed, doctor should not be

disturbed for at least five years.

As far as postings and transfers are concerned we hear from time to time

that a policy is in the offing but then political interference and clout

wielding doctors take over. It is felt that the state government should set

up a committee to formulate a detailed set of guidelines for postings and

transfers of Doctors in the Medical, Health and FW Department. There

should also be detailed directions how to keep a doctor motivated even

while working in a remote area or in adverse climatic conditions like the

desert districts of Rajasthan or the tribal hilly tracts of Banswara and

Dungarpur. This committee should also advise on the priorities to be

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given to those medical officers who have spent a certain amount of time

in difficult areas, for selection for post graduate seats.

Opportunities for Promotions: In a total career of three-and-half

decade in the government, an average Doctor hardly gets more than one

opportunity for promotion. It is very frustrating for any conscientious

Doctor when he compares himself with an average officer in any segment

of civil services. In central government and many states in India, based

on “Tikku Commission” recommendations, Doctors - irrespective of their

„general‟ or „specialty‟ stream – are given time-bound promotions. Morale

of every Doctor can be boosted by taking care of logical and rational rise

required like any other civil servant.

Strengthening Medical Colleges and Nursing Schools : State

Government is making a huge investment in managing seven Medical

Colleges in particular and large number of Nursing schools in general.

But it is hardly getting any return in terms of strengthening its own

health services from the professionals passing out from these institutes.

Primarily, there seems to be no dialogue between the Health department

and Medical Education department in this context. It seems that faculty

in the teaching institutes are totally indifferent to the requirements of the

field facilities. Leaderships in the teaching institutes particularly in the

Medical Colleges is in the hands of super-specialists who have a biased

approach for strengthening the general health services. The result of this

mechanism has to be borne in terms of making heavy investments in in-

service trainings of health professionals. Policymakers of the state need

to examine this fact deeply and thoroughly by seeking the expertise of

professionals who have been associated with both the ends of the health

systems for fairly long time.

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Innovations for raising health manpower: Around the country,

critiques of health systems have underlined the incompatibility of

allopath medical graduate with the position of Medical Officer in a

peripheral health facility. Medical Council of India seems to patronize the

medical education in the name of conserving the quality of services to be

delivered by Doctors in the periphery. But the existing system do not

prepare the Doctors with the attitude to retain themselves in rural area.

Above all the heavy education imparted in five-and-half years in the

Medical College alienates an average doctor from rural facility.

Eventually, there is an urgent need to delegate more responsibility to

nursing professionals for the delivery of technical care. Alternatively state

needs to venture by preparing Doctors through a consolidated three year

course with a strong attitude to serve in the rural area. NHSRC can play

a pivotal role in orienting the decision makers in the Medical Council of

India, Vice Chancellor of Rajasthan University of Health Sciences, and

Principals of Medical Colleges. The issues underlined by the working

group of NRHM on medical education needs to be taken in consideration

for any such orientation.

New Facilities: Although NRHM is giving enough cushions to increase

the number of facilities and manpower in the periphery. But it requires

a serious introspection. State neither has the capacity to generate the

required manpower estimated on IPHS norms, nor would it be feasible to

uphold the quality of services in the public system with high number of

facilities. It should rather go in a step-by-step manner by first accepting

the challenge of improving the quality of services to be imparted from the

existing institutes.

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Fixing Accountability: Framework of NRHM guides the health system

to get the public health reports prepared on annual basis for each

district from health activists. Scope for community monitoring and

encouraging the health activists to bring out public health reports

further increases the accountability. Thus the system‟s own creation of

multiple pressures would generate the mechanism to devise urgent

solutions to deliver quality health care from each of its peripheral facility.

Training: One of the biggest problems found almost everywhere in the

health care institutions has been extremely poor capacity building at

every rung of health care givers, beginning from the members of the

district health committees, the medical officers working in the clinical

sector and in the administrative positions and up to the chief district

medical and health officers.

Induction for managing public facilities demands the process which is

followed in inducting civil services officers for administration. Induction

should not be an eyewash in terms of convening a two week program by

recalling a doctor from periphery after he has served there for a couple of

years. The doctors should be asked to report at a state level training

institute on their first appointment where a team of committed trainers

should inculcate a sense of discipline and orient them on administrative

and financial procedures. Induction training of doctors should not be

bogged down with orienting them on managing national programs. There

is an urgent need to inculcate a sense of officer like quality in doctors at

the outset.

Sustained efforts to uphold the capacity generated at induction training

can be maintained by following the “Training Policy for Health

Manpower” developed by the state almost a decade back. The policy

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envisaged mandatory participation in management development

programs at fixed intervals for every officer. This policy inhibits

convening segmented in-service training and frequent orientation in the

name of centrally planned schemes.

There should be continuous Continuing Medical Education (CME)

programme organized at district level with the objectives of covering need

based topics like Right to Information, Basic Accounting, Gender

Training alongwith medical problems in general practice.

Privatization: There is an urgent need to not only regulate the private

sector but also strike a balance between public systems and private

facilities in health sector. In this context, health system should not yield

to pressures from political corners unless their demand matches with the

established norms and capacity of the system in fulfilling the needs of

any new institute to be established.

Infrastructure at the Peripheral Health Facilities: Sustainable

retention demands availability of residential accommodation. Most of the

facilities in the State have quarters for doctors but their upkeep is poor.

Renovating them through a decentralized plan can provide them dignity

and pleasure to the Doctors as residents in the health facility campus.

Telephone connectivity in the modern era is a prime need of each officer.

Thus each Doctor must be given a mobile-cell facility. If the job entails

field work, due care may be taken to provide mobility. Infrastructure at

each peripheral facility needs to be examined to provide appropriate

support to enhance the efficiency. This includes providing facilities for

laboratory investigations, minor operation facility at each PHC and

availability of essential drugs on consistent basis according to the level of

facility. This would call for placing sufficient nursing staff, making

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SCM SPRI, Jaipur

laboratory technicians available, equipping with sufficient material like

syringes, needles, cold chain equipments and surgical material.

Reservation for Post-Graduation: The current scheme of encouraging

doctors to earn rural experience for doing post-graduation while in-

service should be continued. But it needs vigilance. A number of young

doctors manage to seek placement in the peri-urban facilities. The State

should develop a list of remote peripheral facilities of desert/tribal

districts which more often than not have remained unoccupied during

last five years. Working only in such facilities should make a doctor

qualify for entry to post-graduation.

Referral System: Last but not the least Although World Bank funded

Health Systems Development Project has tried to make referral systems

functional, it is not being followed in the desired manner. It is necessary

that the medical officers at the primary care level should be responsible

for a patient's overall care, but the specialists in the district or at the

nearest CHC should be under instructions to guide a general care

physician. On the basis of the data kept, even if a patient transferred to

a special care facility at a higher level, his health record will be very

helpful in taking care.

Some ways to make a doctor go to a far off rural health care institute

are:-

Make loans for medical education easier for students willing to go for

PHCs in the difficult areas.

Increase the role of CHCs.

We may think in terms of giving women doctor‟s flexible hours of

work.

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We may have a type of National Health Service Corps to pay for tuition

fee of doctors in return for work in areas where there is shortage of

doctors.

Can we think in terms of improving the skills of nurses and make

them nurse-practitioners?

Extremely necessary for departments like medical & health is to

compulsorily keep training and leave reserve posts so that regular in-

service training programmes do not suffer.

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APPENDICES

HUMAN DEVELOPMENT INDICES Bharatpur

HDR 1999 HD Update 2007

Human Development index (HDI) 0.561 0.604

Rank in Rajasthan:HDI 15 19

POPULATION 1991 2001

Total population 1651584 2101142

Rural Population (%) 80.60 80.54

Female Population (%) 45.41 46.06

% Population of Scheduled Caste 21.60 21.70

% Population of Scheduled Tribe 2.30 2.24

Density (per sq.Km) 326 414

Decadal growth rate (1991-2001) 27.14 27.22

EDUCATION 1991 2001

Literacy rate all (%) 43.00 63.57

Literacy rate (M) 62.10 80.54

Literacy rate (F) 19.60 43.56

DISTRICT INFORMATION 1991 2001

Total Area(Sq.Km) 5066 5066

Total villages 1454 1472

inhabited villages 2001 1345 1366

uninhabited villages 2001 109 106

Number of Gram panchayat 2002 372 371

Number of CD Blocks 2002 9 9

Towns 2002 10 9

HOUSE HOLD ACCESS to (%) 1991 2001

Electricity 29.50 54.39

Safe Drinking Water 26.00 99.40

Toilet Facilities 12.80 18.77

HEALTH 1991 2002-04

Infant Mortality rate 78.00 64.57**

Life Expectancy at Birth (years) 63.00 53.23*

31.3.1997 31.3.06 (P)

CPR 38.30 34.10

1999-2000 31.12.2007

Population Served Per Medical Institution 3771 4414

Population Served Per Bed 1583 1653

WOMEN AND CHILD 1991 2001

Total fertility rate (2002-04) 5.30 3.87**

Gender ratio; All 832 854

Juvenile sex ratio (ages 0 to 6 year) 870 879

Mean age of marriage (years) 17.20 17.60**

INFRASTRUCTURE / FACILITIES 1997-98 31-12-2007

Rural population services per PHC 26346 30218

1998-99 2004-05

% Electrified villages 99.40 98.78

1998 2006-07

Road (PWD)length per 100 sq km. 38.26 48.01

1998-99 31-12-2007

% Villages with drinking water facilities 99.30 99.71

INCOME AND POVERTY 1992-93 2004-05

Per capita income RS. 3975 13504

LAND USE 1995-96 2000-01

Average land holding (Hect.) 1.76 1.70

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HUMAN DEVELOPMENT INDICES Bikaner

HDR 1999 HD Update 2007

Human Development index (HDI) 0.592 0.779

Rank in Rajasthan:HDI 6 3

POPULATION 1991 2001

Total population 1211140 1674271

Rural Population (%) 60.30 64.46

Female Population (%) 46.95 47.08

% Population of Scheduled Caste 18.60 19.96

% Population of Scheduled Tribe 0.30 0.36

Density (per sq.Km) 44 61

Decadal growth rate (1991-2001) 42.70 38.24

EDUCATION 1991 2001

Literacy rate all (%) 41.70 56.91

Literacy rate (M) 54.60 70.05

Literacy rate (F) 27.00 42.03

DISTRICT INFORMATION 1991 2001

Total Area(Sq. Km) 27244 27244

Total villages 650 778

inhabited villages 2001 580 712

uninhabited villages 2001 70 66

Number of Gram panchayat 2002 189 189

Number of CD Blocks 2002 4 4

Towns 2002 4 3

HOUSE HOLD STATUS (%) 1991 2001

Households with access to

Electricity 47.00 51.00

Safe Drinking Water 59.00 71.44

Toilet Facilities 34.60 44.21

HEALTH 1991 2002-04

Infant Mortality rate 60.00 55.06**

1991 2001

Life Expectancy at Birth (years) 68.80 75.39*

1984-91 2002-04

Crude Birth Rate 35.40 29.89**

31.3.1997 31.3.06 (P)

CPR 28.90 50.00

1999-2000 31.12.2007

Population Served Per Medical Institution 4310 4349

Population Served Per Bed 686 726

WOMEN AND CHILD

1991 2001

Total fertility rate (2002-04) 4.99 3.52**

Gender ratio; All 885 890

Juvenile sex ratio (ages 0 to 6 year) 892 916

Mean age of marriage (years) 16.50 17.00**

INFRASTRUCTURE / FACILITIES

1997-98 31-12-2007

Rural population services per PHC 23200 27673

1998-99 2004-05

% Electrified villages 99.10 76.22

1998 2006-07

Road (PWD)length per 100 sq km. 13.35 17.29

1998-99 31-12-2007

% Villages with drinking water facilities 95.90 99.02

INCOME AND POVERTY 1992-93 2004-05

Per capita income RS. 4400 18633

LAND USE 1995-96 2000-01

Average land holding (Hect.) 10.83 10.16

61

SCM SPRI, Jaipur

HUMAN DEVELOPMENT INDICES Jhalawar

HDR 1999 HD Update 2007

Human Development index (HDI) 0.511 0.614

Rank in Rajasthan:HDI 26 16

POPULATION 1991 2001

Total population 956971 1180323

Rural Population (%) 84.20 85.75

Female Population (%) 47.86 48.08

% Population of Scheduled Caste 17.20 15.64

% Population of Scheduled Tribe 11.90 12.02

Density (per sq.Km) 154 190

Decadal growth rate (1991-2001) 21.91 23.34

EDUCATION 1991 2001

Literacy rate all (%) 32.90 57.32

Literacy rate (M) 48.20 73.31

Literacy rate (F) 16.20 40.02

DISTRICT INFORMATION 1991 2001

Total Area(Sq.Km) 6219 6219

Total villages 1585 1600

inhabited villages 2001 1448 1477

uninhabited villages 2001 137 123

Number of Gram panchayat 2002 251 253

Number of CD Blocks 2002 6 6

Towns 2002 9 8

HOUSE HOLD STATUS (%) 1991 2001

Households with access to

Electricity 28.10 55.83

Safe Drinking Water 51.90 98.92

Toilet Facilities 11.70 15.33

HEALTH

Infant Mortality rate 1991 2002-04

100.00 55.15**

1991 2001

Life Expectancy at Birth (years) 61.20 59.51*

1984-91 2002-04

Crude Birth Rate 36.60 21.60**

31.3.1997 31.3.06 (P)

CPR 41.60 57.50

1999-2000 31.12.2007

Population Served Per Medical Institution 3455 4127

Population Served Per Bed 1333 1004

WOMEN AND CHILD

1991 2001

Total fertility rate (2002-04) 4.47 2.64**

Gender ratio; All 918 926

Juvenile sex ratio (ages 0 to 6 year) 953 934

Mean age of marriage (years) 15.70 15.90**

INFRASTRUCTURE / FACILITIES

1997-98 31-12-07

Rural population services per PHC 25034 36146

1998-99 2004-05

% Electrified villages 91.60 94.75

1998 2006-07

Road (PWD) length per 100 sq km. 18.96 31.64

1998-99 2004-05

% Villages with drinking water facilities 99.70 100.00

INCOME AND POVERTY 1992-93 2004-05

Per capita income RS. 4179 16882

LAND USE 1995-96 2000-01

Average land holding (Hect.) 2.61 2.26

62

SCM SPRI, Jaipur

HUMAN DEVELOPMENT INDICES Sirohi

HDR 1999 HD Update 2007

Human Development index (HDI) 0.52 0.645

Rank in Rajasthan:HDI 23 14

POPULATION 1991 2001

Total population 654029 851107

Rural Population (%) 80.50 82.27

Female Population (%) 48.70 48.54

% Population of Scheduled Caste 19.20 19.15

% Population of Scheduled Tribe 23.40 24.76

Density (per sq.Km) 127 166

Decadal growth rate (1991-2001) 20.66 30.13

EDUCATION 1991 2001

Literacy rate all (%) 33.90 53.94

Literacy rate (M) 46.20 69.89

Literacy rate (F) 17.00 37.15

DISTRICT INFORMATION 1991 2001

Total Area(Sq.Km) 5136 5136

Total villages 461 462

inhabited villages 2001 446 455

uninhabited villages 2001 15 7

Number of Gram panchayat 2002 151 151

Number of CD Blocks 2002 5 5

Towns 2002 6 5

HOUSE HOLD STATUS (%) 1991 2001

Households with access to

Electricity 35.90 61.46

Safe Drinking Water 74.00 97.57

Toilet Facilities 12.80 20.25

HEALTH 1991 2002-04

Infant Mortality rate 119 79.49**

1991 2001

Life Expectancy at Birth (years) 59.20 60.01*

1984-91 2002-04

Crude Birth Rate 33.30 27.16**

31.3.1997 31.3.06 (P)

CPR 33.30 63.20

1999-2000 31.12.2007

Population Served Per Medical Institution 2844 3851

Population Served Per Bed 1285 1672

WOMEN AND CHILD

1991 2001

Total fertility rate (2002-04) 4.73 3.37**

Gender ratio; All 949 943

Juvenile sex ratio (ages 0 to 6 year) 961 918

Mean age of marriage (years) 18.00 18.70**

INFRASTRUCTURE / FACILITIES 1997-98 31-12-2007

Rural population services per PHC 22562 31828

1998-99 2004-05

% Electrified villages 103.40 99.78

1998 2006-07

Road (PWD) length per 100 sq km. 29.01 32.18

1998-99 31-12-2007

% Villages with drinking water facilities 99.60 100.00

INCOME AND POVERTY 1992-93 2004-05

Per capita income RS. 4559 18340

LAND USE 1995-96 2000-01

Average land holding (Hect.) 2.70 2.84

63

SCM SPRI, Jaipur

64

SCM SPRI, Jaipur

65

SCM SPRI, Jaipur

66

SCM SPRI, Jaipur

67

SCM SPRI, Jaipur

68

SCM SPRI, Jaipur

As of March 2009, district wise distribution of facilities is as follows:

Districts Estimated Population as on 31st

March 2007

Population Density

Female literacy

Rate 2001

Child Sex Ratio

CHCs PHCs SCs

Ganganagar 2042200 163 52.44 852 11 41 350

Hanumangarh 1731400 157 49.56 873 9 38 281

Bikaner 1909400 61 42.03 915 10 38 312

Churu 2197200 114 53.35 912 10 59 360

Jhunjhunu 2193000 323 59.31 67 13 70 429

Alwar 3444300 357 43.28 888 24 72 490

Bharatpur 2406800 414 43.56 875 13 57 417

Dholpur 1121400 324 41.84 859 6 22 199

Karauli 1377100 218 44.39 876 7 25 225

Sawaimadhopur 1274300 248 35.17 900 5 22 202

Dausa 1504700 384 42.32 900 7 29 237

Jaipur 6109200 471 55.52 877 18 93 517

Sikar 2626200 296 56.11 882 17 68 495

Nagaur 3191400 157 39.67 920 17 87 612

Jodhpur 3299500 126 38.64 920 15 65 504

Jaisalmer 578200 13 32.05 867 6 14 136

Barmer 2250300 69 43.45 922 14 59 478

Jalore 1656500 136 27.80 924 8 52 366

Sirohi 970100 166 37.15 918 6 22 187

Pali 2078900 147 36.48 927 15 68 426

Ajmer 2494700 257 48.86 923 11 43 286

Tonk 1381400 168 32.15 922 7 45 252

Bundi 1096800 173 37.79 908 7 28 178

Bhilwara 2297800 192 33.48 951 16 63 414

Rajsmand 1123900 256 37.59 935 7 36 218

Udaipur 3026700 196 43.26 944 18 69 535

Dungarpur 1261900 294 31.77 963 7 39 306

Banswara 1712000 298 28.43 972 13 42 325

Chittorgarh 2059800 166 36.39 927 14 38 303

Kota 1794700 288 60.43 902 9 29 158

Baran 1167100 146 41.55 918 9 36 205

Jhalawar 1346000 190 40.02 929 14 30 232

Pratapgarh NA NA NA NA 5 22 156

Total 64724900 165 43.85 921 368 1521 10791