Shortage of doctors may hit rural healthcare delivery

Kaushiki - November 26, 2012

Recently, the Standing Committee on Health and Family Welfare submitted its report to the Parliament on the National Commission for Human Resource for Health Bill, 2011. The objective of the Bill is to “ensure adequate availability of human resources in the health sector in all states”. It seeks to set up the National Commission for Human Resources for Health (NCHRH), National Board for Health Education (NBHE), and the National Evaluation and Assessment Council (NEAC) in order to determine and regulate standards of health education in the country. It separates regulation of the education sector from that of professions such as law, medicine and nursing, and establishes professional councils at the national and state levels to regulate the professions. See here for PRS Bill Summary. The Standing Committee recommended that this Bill be withdrawn and a revised Bill be introduced in Parliament after consulting stakeholders. It felt that concerns of the professional councils such as the Medical Council of India and the Dental Council of India were not adequately addressed. Also, it noted that the powers and functions of the NCHRH and the National Commission on Higher Education and Research (to be established under the Higher Education and Research Bill, 2011 to regulate the higher education sector in the country) were overlapping in many areas. Finally, it also expressed concern over the acute shortage of qualified health workers in the country as well as variations among states and rural and urban areas. As per the 2001 Census, the estimated density of all health workers (qualified and unqualified) is about 20% less than the World Health Organisation’s norm of 2.5 health workers per 1000 population. See here for PRS Standing Committee Summary. Shortfall of health workers in rural areas Public health care in rural areas is provided through a multi-tier network. At the lowest level, there are sub health-centres for every population of 5,000 in the plains and 3,000 in hilly areas. The next level consists of Primary Health Centres (PHCs) for every population of 30,000 in the plains and 20,000 in the hills. Generally, each PHC caters to a cluster of Gram Panchayats. PHCs are required to have one medical officer and 14 other staff, including one Auxiliary Nurse Midwife (ANM). There are Community Health Centres (CHCs) for every population of 1,20,000 in the plains and 80,000 in hilly areas. These sub health centres, PHCs and CHCs are linked to district hospitals. As on March 2011, there are 14,8124 sub health centres, 23,887 PHCs and 4809 CHCs in the country.[i] Sub-Health Centres and Primary Health Centres

§ Among the states, Chhattisgarh has the highest vacancy of doctors at 71%, followed byWest Bengal(44%),Maharashtra(37%), and Uttar Pradesh (36%). On the other hand, Rajasthan (0.4%), Andhra Pradesh (3%) and Kerala (7%) have the lowest vacancies in PHCs.
§ Nine states do not have any doctor vacancies at all at the PHC level. These states includeBihar, Jharkhand andPunjab.
§ Ten states have vacancy in case of ANMs. These are: Manipur, Uttar Pradesh, Chhattisgarh,Gujarat,Goa, Himachal Pradesh, Tamil Nadu, Haryana, Kerala and Andhra Pradesh.
§ The overall vacancy for ANMs in the country is 5% while for doctors it is 24%.

Table 1: State-wise comparison of vacancy in PHCs

	Doctors at PHCs			ANM at PHCs and Sub-Centres
State	Sanctioned post	Vacancy	% of vacancy	Sanctioned post	Vacancy	% of vacancy
Chhattisgarh	1482	1058	71	6394	964	15
West Bengal	1807	801	44	10,356	NA	0
Maharashtra	3618	1326	37	21,122	0	0
Uttar Pradesh	4509	1648	36	25,190	2726	11
Mizoram	57	20	35	388	0	0
Madhya Pradesh	1238	424	34	11,904	0	0
Gujarat	1123	345	31	7248	817	11
Andaman & Nicobar Isld	40	12	30	214	0	0
Odisha	725	200	28	7442	0	0
Tamil Nadu	2326	622	27	9910	136	1
Himachal Pradesh	582	131	22	2213	528	24
Uttarakhand	299	65	22	2077	0	0
Manipur	240	48	20	984	323	33
Haryana	651	121	19	5420	386	7
Sikkim	48	9	19	219	0	0
Meghalaya	127	23	18	667	0	0
Delhi	22	3	14	43	0	0
Goa	46	5	11	260	20	8
Karnataka	2310	221	10	11,180	0	0
Kerala	1204	82	7	4232	59	1
Andhra Pradesh	2424	76	3	24,523	2876	12
Rajasthan	1478	6	0.4	14,348	0	0
Arunachal Pradesh	NA	NA	NA	NA	NA	0
Assam	NA	NA	NA	NA	NA	0
Bihar	2078	0	NA	NA	NA	0
Chandigarh	0	0	NA	17	0	0
Dadra & Nagar Haveli	6	0	NA	40	0	0
Daman & Diu	3	0	NA	26	0	0
Jammu & Kashmir	750	0	NA	2282	0	0
Jharkhand	330	0	NA	4288	0	0
Lakshadweep	4	0	NA	NA	NA	0
Nagaland	NA	NA	NA	NA	NA	0
Puducherry	37	0	NA	72	0	0
Punjab	487	0	NA	4044	0	0
Tripura	NA	NA	NA	NA	NA	0
India	30,051	7,246	24	1,77,103	8,835	5
Sources: National Rural Health Mission (available here), PRS.Note: The data for all states is as of March 2011 except for some states where data is as of 2010. For doctors, these states are Bihar, UP, Mizoram and Delhi. For ANMs, these states are Odisha and Uttar Pradesh.

Community Health Centres

§ A CHC is required to be manned by four medical specialists (surgeon, physician, gynaecologist and paediatrician) and 21 paramedical and other staff.
§ As of March 2011, overall there is a 39% vacancy of medical specialists in CHCs. Out of the sanctioned posts, 56% of surgeons, 47% of gynaecologists, 59% of physicians and 49% of paediatricians were vacant.
States such as Chhattisgarh, Manipur and Haryana have a high rate of vacancies at the CHC level.

Table 2: Vacancies in CHCs of medical specialists

	Surgeons	Gynaecologists	Physicians	Paediatricians
State	% of vacancy
Andaman & NicobarIsland	100	100	100	100
Andhra Pradesh	74	0	45	3
Arunachal Pradesh	NA	NA	NA	NA
Assam	NA	NA	NA	NA
Bihar	41	44	60	38
Chandigarh	50	40	50	100
Chhattisgarh	85	85	90	84
Dadra & Nagar Haveli	0	0	0	0
Daman & Diu	0	100	0	100
Delhi	0	0	0	0
Goa	20	20	67	66
Gujarat	77	73	0	91
Haryana	71	80	94	85
Himachal Pradesh	NA	NA	NA	NA
Jammu & Kashmir	34	34	53	63
Jharkhand	45	0	81	61
Karnataka	33	NA	NA	NA
Kerala	NA	NA	NA	NA
Lakshadweep	0	0	100	0
Madhya Pradesh	78	69	76	58
Maharashtra	21	0	34	0
Manipur	100	94	94	87
Meghalaya	50	NA	100	50
Mizoram	NA	NA	NA	NA
Nagaland	NA	NA	NA	NA
Odisha	44	45	62	41
Puducherry	0	0	100	NA
Punjab	16	36	40	48
Rajasthan	57%	46	49	24
Sikkim	NA	NA	NA	NA
Tamil Nadu	0	0	0	0
Tripura	NA	NA	NA	NA
Uttar Pradesh	NA	NA	NA	NA
Uttarakhand	69	63	74	40
West Bengal	0	57	0	78
India	56	47	59	49
Sources: National Rural Health Mission (available here), PRS.

[i]. “Rural Healthcare System in India”, National Rural Health Mission (available here).

States and State Legislatures

Government of Karnataka’s response to the COVID-19 pandemic (Feb 2020–April 14, 2020)

Prachi Kaur - April 15, 2020

As of April 13, 2020, there have been 260 confirmed cases of COVID-19 in Karnataka. Of these, 70 have been discharged and 10 have died.[1] In order to contain the spread of the disease, both, the Central and State governments have come up with a series of policy responses. In this blog, we take a look at the key measures taken by the Government of Karnataka in this regard as of April 14, 2020.

Movement restrictions

To contain the spread of COVID-19 in the state, the Government of Karnataka took the following measures to restrict the movement of people in the state:

On March 13, the Directorate of Health and Family Welfare ordered the closure of various establishments such as theatres, pubs, gyms, malls, swimming pools, and educational institutions until March 21. The order also directed all international passenger arrivals to be mandatorily home quarantined for 14 days.[2]
On March 20, the above order was revised to extend the closure of said establishments until April 1. The order also banned all religious gatherings.[3]
Further, on March 23, all bus services to and from the nine districts that had reported COVID-19 positive cases were completely stopped until April 1.[4]
The central government later announced a 21-day country-wide lockdown starting March 25.[5] This was followed by the announcement of a pass system by the Bengaluru Commissioner of Police on March 25 to regulate the movement of people in Bengaluru City.[6]
On April 6, District Collectors were empowered to issue inter-district transport passes.[7]
On April 14, the Prime Minister announced the extension of the lockdown till May 3, 2020.[8] On April 15, the Ministry of Home Affairs issued guidelines on the measures to be taken by governments until May 3. As per these guidelines, to mitigate hardship to the public, select activities will be permitted from April 20 onwards. These include health services, agriculture and related activities, financial sector, MNREGA works, cargo movement etc. In addition, subject to conditions, commercial and private establishments, industrial establishments, government offices, construction activities etc, will also be permitted.[9]

Essential Goods and Services

The pass system in Bengaluru City facilitated the movement of personnel involved in manufacturing and providing essential goods and services.
On April 2, the government announced that it will distribute the excess stock of milk to poor people for free.[10]
On April 6, the government declared that rations for the month of April will be supplied to people without the usual OTP authentication process.[11]

Health Measures

Karnataka Epidemic Disease COVID-19 Regulations 2020

On March 11, 2020, the government released the Karnataka Epidemic Disease COVID-19 Regulations 2020 to prevent the spread of COVID19 in the state. These regulations specify the protocol for hospitals to follow for screening and treating COVID-19 patients. These regulations are valid for one year.[12]

Preventive measures

On February 5, 2020, the Department of Health & Family Welfare and AYUSH services issued the Terms of Reference for district-level teams to take preventive measures against the spread of COVID-19.[13] The terms relate to various administrative and complementary aspects related to COVID19 management. These include activities of various teams, human resource management, training and awareness generation etc.

Following this, on April 6, 2020, the Department also issued instructions to all districts to prepare a District Level Crisis Management Plan to prevent large outbreaks of COVID-19.[14]

Setting up of fever clinics, isolation centres etc

On March 4, the state government issued guidelines to the district administration to ensure hospitals maintain a 10-bed isolation ward for COVID-19 patients.[15]

On March 31, the government issued orders to establish fever clinics as the first points of contact for COVID-19 suspect patients. These fever clinics would have COVID-19 Rapid Response team of one doctor, two nurses and a health care worker.[16]

Personnel measures

On March 30, the Department of Health & Family Welfare invited applications from doctors for immediate appointment (on contract basis) in Urban Primary Health Centres in Bengaluru City.[17] Subsequently, on April 2, the state government issued orders to extend the tenure of retiring medical professionals from March 31, 2020 to June 30, 2020.[18]

On March 26, all Registered Medical Practitioners were permitted to provide telemedicine services during the lockdown period. Telemedicine services will be available for minor, non-COVID-19 ailments, and existing patients only.[19]

For more information on the spread of COVID-19 and the central and state government response to the pandemic, please see here.

[1] Novel Coronavirus (COVID19) Media Bulletin, Karnataka, Department of Health and Family Welfare, last accessed on April 15, 2020, https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/14-04-2020(English).pdf

[2] GOK order No. DD/SSU/COVID-19/17/19-20, Directorate of Health and Family Welfare, Government of Karnataka, March 13, 2020,

https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Notification(Covid-19)-Dir-HFWS.pdf

[3] Revised GOK order No. DD/SSU/COVID-19/17/19-20, Directorate of Health and Family Welfare, Government of Karnataka, March 20, 2020 https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Revised-Order-COVID-19(20-03-2020).pdf

[4] Order No. STA-6/SCP/PR-20/2019-20, Directorate of Transport, Government of Karnataka, March 23, 2020, https://transport.karnataka.gov.in/storage/pdf-files/restrictions.pdf

[5] Order No. 1-29/2020-PP, National Disaster Management Authority, March 24, 2020, https://mha.gov.in/sites/default/files/ndma%20order%20copy.pdf.

[6] Order No.02 / CP-BLR/Covid-19/2020, Commissioner of Police, Bengaluru City, March 25, 2020, https://karnataka.gov.in/storage/pdf-files/covid_rules/Covid_pass.pdf

[7] Order of Chief Secretary, Government of Karnataka, April 6, 2020, https://ksuwssb.karnataka.gov.in/frontend/opt1/images/covid/Orders/IMG-20200406-WA0005.jpg

[8] “PM addresses the nation for 4th time in 4 Weeks in India’s fight against COVID-19” Press Release, Prime Minister’s office, April 14, 2020, https://pib.gov.in/PressReleseDetail.aspx?PRID=1614255

[9] No.40-3/2020-DM-I(A), Ministry of Home Affairs, April 15, 2020, https://www.mha.gov.in/sites/default/files/MHA%20order%20dt%2015.04.2020%2C%20with%20Revised%20Consolidated%20Guidelines_compressed%20%283%29.pdf

[10] Proceedings, Government of Karnataka, April 2, 2020, ,https://ksuwssb.karnataka.gov.in/frontend/opt1/images/covid/Orders/GO%20Free%20Milk%20%20(1).pdf

[11] RD 158 TNR 2020, Government of Karnataka, April 6, 2020, https://ksuwssb.karnataka.gov.in/frontend/opt1/images/covid/Orders/IMG-20200406-WA0015.jpg

[12]Karnataka Epidemic Disease COVID-19 Regulations 2020, Government of Karnataka, March 11, 2020, https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Exercise-of-Powers-COVID-10(11-03-2020).pdf

[13] No. JRO(1A)/148/2019-20, Department of Health & Family Welfare and AYUSH Services Government of Karnataka, February 5, 2020, https://ksuwssb.karnataka.gov.in/frontend/opt1/images/covid/Circulars/%E0%B2%B8%E0%B3%81%E0%B2%A4%E0%B3%8D%E0%B2%A4%E0%B3%8B%E0%B2%B2%E0%B3%86%20%E0%B3%A8%E0%B3%AA.pdf

[14]No. HFW 87 ACS 2020 Department of Health & Family Welfare and Medical Education, April 6, 2020, https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Circular-Preparation%20of%20District%20Level%20Crisis%20Management%20Plan%20for%20COVID-19(06-04-2020).pdf

[15]Circular No. HFW 47 CGM 2020 (P), Government of Karnataka, March 3, 2020, https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Guidelines-Isolation-Ward.pdf

[16]No. HFW 73 ACS 2020, Government of Karnataka, March 31, 2020, https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Circular-Establishment%20of%20Fever%20Clinic%20and%20Movement%20Protocol%20for%20Suspect%20Cases%20of%20COVID-19(31-03-2020).pdf

[17]No. HFW 71 ACS 2020, Department of Health & Family Welfare and Medical Education, March 30, 2020, https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Order%20-%20Immidiate%20Appointment%20of%20Contract%20Doctors%20in%20BBMP%20(30-03-2020).pdf

[18] No. 40 HSH 2020 (B), Government of Karnataka, April 2, 2020, https://ksuwssb.karnataka.gov.in/frontend/opt1/images/covid/Circulars/Extension%20of%20service%20reg_001.pdf

[19]No. HFW 54 CGM 2020, Government of Karnataka, March 26, 2020, https://karunadu.karnataka.gov.in/hfw/kannada/nCovDocs/Order-Registered%20Medical%20Practitioners%20(26-03-2020).pdf