We do not need any more AIIMS. We do not need any more CHCs. Look at whatever is available now. Make them work first and then build new ones. Deliver on your promises, make them complete and then make new promises in the Budget. This is sound advice.
From the outside, 11 out of 18 All India Institutes of Medical Sciences (AIIMS) built recently are impressive to look at. They are gigantic structures built in the cities of various States as a Centrally Sponsored Scheme (CSS) under the Ayushman Bharat Health Infrastructure Mission. But what lies inside is hollow and a disappointment for patients. These academic institutions have 40% vacancy in teaching and research faculties.
How do students get trained in specialities with such a vacancy rate of teachers? These academic centres are supposed to provide specialist doctors to district and Community Health Centres (CHC). Roughly, when it comes to specialist posts, two thirds in the rural areas and one third in the urban areas are vacant. Thus, instead of creating more new AIIMS we need to strengthen existing medical colleges.
The ground reality
The Health Dynamics of India 2022-23 report presents a shocking and sad picture — 79.9% vacancy in 5,491 rural CHCs in 757 districts in India. Further, only 4,413 specialists are available against the 21,964 staff needed. Since the year 2014, the shortfall of specialists in CHCs has hovered around the 17,500 mark despite more post-graduate medical seats having been created — 72,627 in 731 medical colleges. Specialists are unwilling to work for want of important conditions such as decent staff quarters, schools for children and complementary peer doctor’s support. If there is a specialist available, the poor from rural and tribal areas need not travel to far-away district headquarters hospitals or a medical college hospital. In a CHC, there is supposed to be a first referral unit of 30 beds with four to five specialists for every 1.6 lakh to 2 lakh population. CHCs are crippled as there is a perennial shortage of specialists — a problem that has persisted for many years. Yet, States construct more CHCs to utilise the funds available under the CSS. Ever since the National Rural Health Mission (NHRM) was launched, in 2005, till last year, 2,145 CHCs have been added in Bihar, Rajasthan, Tamil Nadu, Uttar Pradesh and West Bengal.
There is another catch. States have to draw 60% of this fund from the 15th Finance Commission allocation, and not from the regular annual central allocation. Moreover, this is a capital infrastructure investment and the recurrent expenditure for maintenance of these new infrastructure facilities has to be met out of the annual health budget of the State. Apart from construction, the cost of human resources for medical education and health services can be met partially from the CSS. The dearth of skilled human resources for the health sector in service and non-availability in the open market for appointment, makes utilisation of budgetary provisions difficult. There was a deplorable 29% budgetary utilisation of the CSS in 2022-23 and only 50% in financial year 2023-24. Only the construction contractors made gains from such capex intensive allocation.
The lesson is this: do not reduce the central health Budget to only a capex pool for infrastructural activities, without having matching funds for other components such as drugs, diagnostics, ambulance facilities, emergency care and salaries of temporary staff recruited for the operationalisation of such health institutions built with CSS funds. If the aim of the CSS is to improve the health of the people, it must target the operational outcomes rather than sinking capital only in the mere construction of buildings that are under lock and key for years.
Emergencies and specialised care for referred cases from primary care institutions cannot wait for these white elephants to become live and operationalised. They seek ‘purchased care’ from the exploitative and unregulated private sector. There is the risk of patients facing a “debt trap” for patients. There is already a patient flow to over-utilised and strained tertiary care institutions in district hospitals or medical college hospitals. Current needs are being met “somehow”. There is no denial of this. But things can be much better if there are specialists.
Ghost CHCs
There are 785 districts in the country (as in local government directory data by the Ministry of Panchayati Raj and the National Informatics Centre, Government of India) but only 714 have a district hospital that provides tertiary care. There was a model of subdistrict specialised care in the form of a first referral unit, or FRUs — four per district in 600 districts of the country to provide emergency obstetric and neonatal care. Other requirements were having an obstetrician, anaesthetist, paediatrician with operation theatre and blood bank or blood storage unit. This was designed and partially operationalised under the Child Survival and Safe Motherhood Programme (1992-97).
CHCs are 30 bed units with five specialists — physician, surgeon, obstetrician, paediatrician and anaesthetist — to ideally serve a population of 1.6 lakh to 2 lakh. There are 5,491 CHCs in 785 districts, i.e., seven CHCs in a district, which is unnecessary. With the availability of only 4,413 specialists in India. it is obvious that these are ghost CHCs with less than one (0.8) specialist per CHC available. It is a mockery of public health. If we assume, for theoretical sake, that there is a uniform distribution of all five specialists in equal number in the pool of 4,413 specialists, we can afford to have just 882 sets of specialists to operationalise just one CHC other than a district hospital for specialised care. All those surgical theatres, labour rooms, and other amenities that have been built are a sheer waste of tax-payer’s money.
There must be careful planning with the available number of specialists, with the best infrastructure created for a joint placement of five sets of specialists in one or two CHCs at the sub district level for specialised care. Period. There should be no room for any political pressure. When specialists are jointly posted, there is team support for professional achievement and family life. Having decent staff quarters with running water and 24-hour power backup will go a long way in boosting staff morale and stemming employee attrition.
Discussion on and addressing the issue of generating more specialists for postings at the sub-district level is another issue that can go on in parallel.
Students and medical service
From this point on, all government service sponsored seats for post-graduate medical education must be linked to a CHC or district hospital posting. The government must ensure this and there has to be an undertaking by the medical student aspirants. There can be a priority reservation for those aspirants who undertake a seven- to 10-year service bond in CHCs in underserved districts or areas. Those who are willing to go in for only a short-term assignment can be posted under the National Health Mission (NHM) — the NHRM and the National Urban Health Mission have been merged as the NHM — with a higher incentive package but without pension benefits. In the crisis now, this is a crucial step that will meet staff needs.
Creating a cadre of family medicine specialists with specialised skill training in essential and emergency surgical interventions, trauma care, emergency obstetrics and newborn care, and intensive medical care are only short cuts as it takes a lot more time to ensure that the shortage of specialists is resolved.
What is needed now is to manage things with the resources that are available in a smart and efficient manner.
Dr. K.R. Antony is a paediatrician and public health consultant in Kochi, Kerala, and formerly with UNICEF
Published – November 05, 2024 12:00 pm IST
