Human Resources for Health in India Strategies For Increasing The Availability Of Qualified Health Workers In Underserved Areas
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- Title
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Human Resources for Health in India
Strategies For Increasing The Availability
Of Qualified Health Workers In Underserved Areas - extracted text
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Human Resources for Health in India
Strategies For Increasing The Availability
Of Qualified Health Workers In
Underserved Areas
June 2010
PUBLIC
HEALTI I
FOUNDATION
OF INDIA
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Human Resources for Health in India
Strategies For Increasing the Availability Of
Qualified Health Workers In Underserved Areas
Authors
Public Health
Foundation of India
National Health
Systems Resource
Center
Krishna D. Rao
Dr. Garima Gupta
(Lead Researcher)
Dr. T Sundararaman
The authors would like to thank the
the WHO for providing technical
Alliance for their financial support
Systems Resource Center and the Sadditional funding and technical su{
SOCHARA
Community Health
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Centre for Public Health and Equity
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Table of Contents
State Strategies For Recruitment and Retention of Health Workers In Underserved Areas
Educational and regulatory measures
............................................
Monetary compensation.........................................................................................
Workforce management policies
Public private partnerships
Multi-skilling and task shifting
1
1
3
3
4
5
Improving Work Force Management Practices in Haryana state to attract and retain
medical professionals in public health service : A Case Study
The human resource for health situation in Haryana
Changing recruitment policies
From attraction to retention
......................
Outcomes
Conclusions..............................................
...6
...8
11
12
14
15
ANNNEXURE- CASE STUDY 1
17
Chhattisgarh’s Experience with 3-Year Course for Rural Health Care Practitioners: A
Case Study
Situation analysis
The policy options in Chhattisgarh
The implementation process of the 3-Year course
Iterating to a solution: The birth of the RMA
Recruitment of RMAs in rural postings
Differences between the 3-year course and MBBS graduates: In training and
aspirations
Lessons from the case
The way forward
31
32
36
ANNEXURE- CASE STUDY 2
38
ii
19
20
21
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27
29
'life
State Strategies For Recruitment and Retention of Health Workers In
Underserved Areas
This report describes the human resource initiatives to recruit and retain health workers in
rural areas adopted by various states in India. The information presented here is based on
a systematic desk review of all the State Programme Implementation Plans (PIP) for the
year 2008- 09 and 2009 - 2010. Under the National Rural Health Mission (NRHM) each
state proposes a plan i.e. the PIP for funding in which existing and proposed schemes and
initiatives are described. The strategies adopted by states have been classified into five
broad categories 1.
2.
3.
4.
5.
Educational and regulatory measures
Monetary Compensation
Workforce management policies
Public private partnership
Multi-skilling & alternative service providers.
This desk review is followed by two case studies that examine some these strategies indepth.
Educational and regulatory measures
It is generally accepted that the tertiary hospital- based model of medical education in an
urban setting provides limited exposure to the future doctors about health needs and
infrastructures of the rural areas. Medical graduates thus develop a preference to work in
urban areas as compared to rural or remote areas. Based on the experiences of missing
doctors from public health systems of rural areas, a strong need was felt to modify the
educational and regulatory reforms at the national and state level. One such measure is
mandatory rural service for the medical graduates. Other measures take advantage of the
strong desire among medical graduates for post-graduate (PG) specialization by linking
this with rural service. Three forms of this linkages exist: compulsory rural service for
admission to PG programs (“Pre-PG Compulsion”), giving incentives to in-service public
sector doctors in PG admission or towards the cost of a PG degree (“In-service PG
incentive”), and compulsory rural service for all PG graduates (“Post-PG Compulsion”).
Finally, some states have a policy of recruiting health workers from rural areas.
Compulsory rural service for medical graduates - Eleven states namely Assam,
Arunanchal Pradesh, Chhattisgarh, Gujarat, Kerala, Manipur, Meghalaya, Nagaland,
Orissa, Tamil Nadu and West Bengal have made it compulsory for all the medical
graduates to serve in rural areas for a duration varying from 1 - 5 years. Usually a bond is
signed and the doctor can opt out of the rural service by paying a penalty equivalent to the
bond amount. The bond amount as found to be as low as Rs. 1,00,000 in Chhattisgarh and
1
as high as Rs. 10 lakhs in the state of Meghalaya. For example, in the state of Assam a
graduate MBBS doctor has to serve in rural areas for a minimum of Five years against a
bond amount of R. 7, 00,000 while in state of Gujarat a doctor has to serve for a
minimum of 3 years against a bond of Rs. 1, 50,000.
Pre-PG Compulsion - Eleven states have made it mandatory for all the graduates to
complete two to three years of rural service for admission to the PG degree programs
(Arunachal Pradesh, Haryana, Himachal Pradesh, Jammu and Kashmir, Maharashtra,
Manipur, Nagaland, Orissa, Sikkim, Tamil Nadu and Tripura). States like Arunanchal
Pradesh, Maharashtra and Tamil Nadu have had this policy in place for the past 15 years.
10% - 30 % of the PG seats are reserved for in-service candidates in Jammu and
Kashmir, Nagaland, Orissa and Tamil Nadu.
In-service PG incentive: Several states give certain benefits to in-service doctors working
in rural areas for pursuing PG studies. These benefits are independent of any kind of
mandate or compulsion. Four states - Andhra Pradesh, Assam, Chhattisgarh and Gujarat
reserve about 10% - 30 % of the total PG seats for in-service doctors completing two three years of service. In-service doctors take the entrance exams but compete for the
reserved seats which increases their changes of admission.
In several states - Kerala, Mizoram and Uttrakhand - preferences to in-service doctors are
given in the forms of additional marks which can be added to the total attained by the
candidate in the qualifying PG exam. The number of marks given is according to the
tenure and the location of service. For example, in the state of Tamil Nadu three years of
rural service is required to be eligible for the PG exams. For those serving in tribal areas
extra marks are given and they are also allowed to appear for the PG exam after two years
of service.
In the state of Arunanchal Pradesh Medical Officers on completion of two years of rural
service are eligible to be sponsored by the State, which will cover all expenses of their PG
training. Tripura also sponsors in-service doctors for PG courses after they complete five
years (with 3 years rural service) of service. In 2008 the state of Nagaland has introduced
DNBE (Course on Family Medicine) which is equivalent to PG for in service doctors.
Post-PG compulsion: In the states of Tamil Nadu and Kerala compulsory service is being
implemented for students for students graduating from PG courses. In Tamil Nadu
specialists graduating from Government PG Colleges have to sign a bond to serve in rural
areas for five years while specialists from private colleges have to serve for three years
against a bond of Rs.5, 00,000. Similar conditions exist in Kerala and Jharkhand (1 year
rural service against a bond of Rs. 5, 00,000).
Rural recruitment: In several states preferential selection of health workers with rural
backgrounds for medical education is earned out based on the belief that these health
workers tend to serve and remain in their native areas. While almost all the states give
2
preferential admission to candidates from rural or tribal background for the Auxiliary
Nurse Midwifery training program, only three states have adopted this measure for the
nursing courses. One such model, the Swalamban Yojana has been started in the state of
Madhya Pradesh in the year 2006-07 with the objective of reducing the lack of staff
nurses in government health facilities. Candidates with rural background are preferably
selected and sponsored for the nursing courses. These sponsored students are bonded to
serve in the rural area of Madhya Pradesh for seven years after passing or otherwise they
will have to pay Rs. 2,00,000 to the government. Nurses of private nursing colleges can
only receive their registration certificate after completion of seven years of rural services.
Monetary compensation
The most common strategy used by states to attract and retain the skilled health personnel
in rural areas is to provide financial incentives. In several states rural postings have been
classified according to their degree of remoteness. In around 18 states (Andhra Pradesh,
Andaman & Nicobar, Chhattisgarh, Haryana, Himachal Pradesh, J& K, Kerala,
Lakshadweep, MP, Maharashtra, Manipur, Nagaland, Orissa, Punjab, Rajasthan, Tamil
Nadu, Tripura and Uttrakhand) health workers, typically general and specialist doctors,
serving in rural areas get ‘difficult area allowance’ in addition to their regular salaries.
Only five of these states - Haryana, Maharashtra, Nagaland, Rajasthan and Tripura - also
give similar incentives to ANMs, nurses and paramedics. Monetary incentive for rural
service given to health workers range from Rs.500 per months in the state of Tamil Nadu
to Rs. 25,000 per month in Haryana.
Workforce management policies
Poor workforce management policies have resulted in poor working environments for
health workers and constrained their performance. One factor that contributed to the acute
shortage of health manpower is the lengthy recruitment procedure followed to recruit
regular staff; it can take between 12 to 18 months from the day the vacancy is advertised
till someone joins service. Linder the NRHM, the recruitment process has been cut sort by
hiring health workers on contract, typically for one year, to fill vacancies. Over 75,000
employees have been added to the public health workforce in the last three years.
Contractual health workers are hired through advertising of the post in newspapers
followed by interviews of the shortlisted candidates. In some states walk-in interviews are
used to speed up the recruitment process. In Orissa and Tamil Nadu contractual doctors
and nurses can be automatically regularized after serving for two years in rural areas.
Other workforce management strategies include employing retired doctors and nurses to
meet the existing human resource shortfalls like in the state of Gujarat, Manipur,
Maharashtra, Nagaland, Orissa, Sikkim, Tamil Nadu and Tripura.
3
Several initiatives are also being implemented in the states to enrich the public service
experience. These include in-service training for health workers to upgrade their skills
and improve perfonnance. Some states have also initiated continuing medical education
for doctors and specialists. Other workforce management initiatives undertaken include
group housing for health workers living in remote areas to enable them to live closer to
their families and have basic amenities and security while working in isolation in far
flung areas. States like West Bengal, Uttrakhand and Chhattisgarh have set up group
housing colonies for the staff. Though it is well known that an absence of transparent
promotion and transfer policies and non-availability of job descriptions are an important
cause of low job satisfaction and workforce attrition, no state has attempted to address
these issues.
Public private partnerships
Various types of ‘Public private partnerships’ have been employed by states to address
the rural health worker shortages or to enable underserved people to receive health
services from qualified health providers. All these models involve engaging with non
government providers to strengthen public services or to achieve health goals.
Contracting-in: Contracting contractual workers to provider health services is popular at
the primary, secondary and the tertiary care level. Almost every state in India employs
contractual doctors to fill vacancies at primary health care facilities. The contracting of
specialist doctors in hospitals is also common practice. In 13 states (Bihar, Gujarat,
Haryana, Himachal Pradesh, Jammu and Kashmir, Jharkhand, Madhya Pradesh, Manipur,
Nagaland, Puducherry, Rajasthan, Tamil nadu and Uttar Pradesh) private specialists work
in the public health facilities either on call basis or on a fixed day of the week. Specialists
are paid on a per case basis or a monthly honorarium to compensate for the days they are
present. Contracting-in of other hospital services like diagnostics, laundry etc. is also
common practice in several states.
Cpntracting-out: Handing over management of government health facilities to
private agencies is not common in India. However, in several states (Arunanchal
Pradesh, Assam, Bihar, Meghalaya, Madhya Pradesh, Orissa, Karnataka and West
Bengal) NGOs and charitable trusts have been given the responsibility of managing a
small number of public health facilities, particularly at the primary care level.
Purchasing services form the private sector: Directly purchasing services from the
private sector is also practiced in several states (Assam, Chhattisgarh, Delhi, Gujarat,
Haryana, Jharkhand, Madhya Pradesh, Uttar Pradesh and West Bengal). Most of this
has been in the area of maternal care (e.g. institutional deliveries). Under these
schemes the cost of care is borne by the State. One of the most successful of these
schemes is the Chiranjivi yojana which was launched in the five pilot districts of
Gujarat in 2005. The scheme involves purchasing maternity services from private
providers through a voucher system so that women below the poverty line can have
4
access to antenatal care, institutional delivery and post-natal care without paying
anything out-of-pocket.
Multi-skilling and task shifting
Multi-skilling and task shifting is used is several states to over come shortages of health
workers in rural and other underserved areas. ‘Multi-skilling’ or adding to the skill set of
existing staff to take on additional roles is commonly used in overcoming shortages of
specialist doctors and district and sub-district levels. Task shifting or the shifting of tasks
to lesser trained health workers is less common but might be scaled-up substantially in
India.
Multi-skilling: In 25 out of 35 states (Arunanchal Pradesh, Andhra Pradesh, Bihar,
Chhattisgarh, Gujarat, Haryana, Himachal Pradesh, J&K, Kmataka, Madhya Pradesh,
Maharashtra, Manipur, Meghalya, Mizoram, Nagaland, Orissa, Puducherry, Punjab,
Rajasthan, Sikkim, Tamil Nadu, Tripura, Uttar Pradesh, Uttarakhand and West Bengal),
many Medical Officers (i.e. general doctors) have been trained in basic emergency
obstetric care (Bemoc), Emergency Obstetric care (Emoc) and life saving anesthesia
skills (USAS). These medical officers are permitted to perform many clinical functions
that were earlier under the specialist’s domain.
Task shifting: To address the problem of few qualified doctors in underserved areas some
states have introduced, or are planning to, carders of non-physician clinicians who will
serve in primary health care settings or below. Assam and Chhattisgarh are the only two
states which have started this course. In Chhattisgarh, there a 31/2 year diploma course Practitioner in Modem and Holistic Medicine - was started in the year 2001 but was
discontinued in 2008. Around 394 graduates of this course have been employed under
NRHM as Rural Medical Assistants (RMA) at PHCs. Assam has introduced a 3 V2 year
diploma course in 2004 is called as - Diploma Holders in Medicine and Rural Health Care
(DMRHC) in Assam. The first batch of 98 graduates would be available to serve in rural
areas from 2009. These clinicians perform almost all the clinical functions expected of a
Medical Officer in a PHC.
5
CASE STUDY - 1
Improving Work Force Management Practices in Haryana state to
attract and retain medical professionals in public health service : A Case
Study
Dr. T. Sundararaman , Dr. Garima Gupta1, Shomikho Raha1, Krishna D.
Rao2
1 National Health Systems Resource Center, New Delhi,
2 Public Health Foundation ofIndia, New Delhi.
6
Improving Work Force Management Practices in Haryana state to
attract and retain medical professionals in public health service
The public health sector in India has been criticized for inefficiency and ineffectiveness.
The reasons for this are many. The majority of public health institutions have gaps related
to availability of human resources, infrastructure, medicine, equipment and support
services. Even where these were present, issues of governance, management and provider
motivation constrained the delivery of services. This led in the nineties, in tune with the
spirit of the times, to limit the government role to a small package of services and for the
rest to rely on market based care supplemented by a range of public private partnerships.
This policy saw a political reversal in the middle of this decade, in part due to
dissatisfaction with the outcomes of the nineties. This political interest in turn led to a
revival of interest in how to strengthen public health systems and central to this was
addressing the issues related to human resources for health. Meanwhile the situation in
human resources had slipped into a crisis and states had literally to pull themselves out of
a pit into which neglect of health systems in the nineties had led them into. We give
below the situation and response in one state- the state of Haryana.
The State of Haryana
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L
The state of Haryana is located in north India and adjoining
the capital city of New Delhi. It was considered to be one of
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the relatively under-developed states of India at the time of
its creation in 1966. Through rapid agricultural and industrial
sector growth it has since become one of the leading states in
terms of agricultural growth and per capita income.
However, according to the National Family Health Survey of
2005/6, Haryana stands at a dismal 18th position in
comparison to other states in terms of institutional delivery
and eleventh for infant mortality (IMR 42). The urban -rural
divide is also sharp with the percentage of institutional deliveries in urban areas being
more than twice (64%) those in rural (27%). Similarly the rural infant mortality (60) is
much higher than the urban infant mortality (44).
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The human resource for health situation in Haryana
Out of all the gaps in delivering quality health services, the most difficult to meet was the
shortage of doctors. As per the state norms there should be at least two medical officers
in all the primary health centers (PHCs), one of which should preferably be a Lady
Medical Officer to provide quality health care services. However these sanctioned posts
were less than the norms with the post of second Medical officer being sanctioned in only
216 PHCs out of 427 PHCs.
At the level of district and sub district hospitals there was an extreme shortage of
specialists especially in relatively more difficult districts like Bhiwani, Jind, Mewat,
Namaul, Sirsa and Kamal. And this is despite the fact that most such hospitals are in fair
sized towns. Of the total of 137 such hospitals that were earmarked for up gradation to
become first referral units (known as FRUs) which could provide emergency obstetric
care there were 91 thirty bedded peripheral rural hospitals called Comprehensive Health
Centers (CHC) and 46 Sub district & District hospitals. These hospitals required a
minimum of 411 specialists (1 Gynecologists, 1 Pediatricians & 1 Anesthetists at least in
each of these hospitals) to provide round the clock Emoc services.1
Out of the total sanctioned 1712 posts of doctors about 502 posts were found to be lying
vacant since a very long duration. About 100 PHCs were functioning without any doctor
till September 2008.2 A shortfall of 211 specialists existed at the level of CHCs with only
45 specialists being in position against the sanctioned posts of 256. While 350 MBBS
doctors were in position against 580 sanctioned posts with a shortfall of 230 at PHC
level3. If the Indian Public Health standard norms are applied to these existing facilities
then the shortfall for specialists at CHC level would become 471 and 910 for medical
officers at PHC level. These figures do not however reflect the shortage of the doctors at
the level of Sub district and District hospital, which if added to these figures would
increase the shortfall manifolds.
Added to this, was the problem of a high level of reported absenteeism among doctors
posted at PHCs and CHCs in rural areas, more so in what was categorized as difficult
areas. Even amongst those posted in rural areas, there was a pressure for transfer to urban
areas, and considerable lack of morale if they could not achieve this. For all these
reasons, health care services delivery at the level of primary health care was found to be
inadequate and inefficient, leaving the rural population of the state largely underserved.
1 State Programme Implementation Plan 2009-10
2
Discussion with Principal Secretary and Finance commissioner Health and Family Welfare,
Haryana
3
• •
Ministry of Health and Family Welfare , Government of India, Bulletin on Rural Health
Statistics, 2008
8
These high level of vacancies - about 29% - were mainly attributed to both poorly
designed work force management policies and the lengthy recruitment process under
Haryana Public Service Commission (HPSC) which took unusually long time for
recruitment. Absence of any formal transfer and promotion policy in the state further
added to the problems of retention of critical human resources within the system.
Irrational transfers and promotions contributed to the high degrees of job dissatisfaction.
Job roles and responsibilities were also not clearly defined leading to a mismatch between
the qualification/ skills and the job requirements. Full potential and skills of the
specialists was not optimally utilized as it was observed that most of the specialists (67
Surgeons, 58 Gynecologists, 55 Physicians and 71 Orthopedic Surgeons) were either
performing non clinical roles or working as general duty medical officers.
The situation of missing professional service providers- doctors, specialists, nurses and
paramedics in difficult and rural areas, drew attention of policy makers to rethink the
existing human resource policy of the state and formulate new policies specific to state’s
requirements.
The process of recruitment
One of the important factors that contributed to the high number of vacancies in the state
was the long recruitment process of the HPSC. Since there is considerable demand for
government jobs, given both its sense of security and sense of authority, most state
governments and the central government have set in place an administrative body entirely
dedicated to recruitments for government service. To ensure selection by merit with
fairness and transparency an elaborate process of selection has been set in place. A
number of vacancies had to cumulate and then be notified to the commission who would
examine it and then advertise the posts, and then announce the examination and interview
dates. The process of selection was such that it could take as much as two years to
complete- which is too long for an applicant to wait. By the time appointments were
made, new vacancies arise and existing vacancies are not filled up fully. Therefore, as
summarized by a senior state official, “A situation of chasing vacancies always existed”.
To overcome this gap the state first attempted the following two measures:
a. To start by providing contractual appointments, which meant a short term contract for
one year, extended annually. This could be made by the state or district health
department without going to the Public service commission. The selection was made
by advertising the post along with the date of interview. Anyone interested in the job
could “walk-in” to the interview and if found suitable could be immediately appointed.
A number of vacancies were reduced by this measure.
b.
Public Private Partnerships -Private specialists were contracted in on call basis to
provide specialty health care services in the public health facility where regular
government specialist posts were vacant. For example, specialists were paid Rs. 1500
9
per caesarean section or were paid on a part time basis for providing services in public
health facilities for two hours each day.
Union and State Public Service Commissions in India
The Union Public Service Commission (UPSC) and its state level counterparts were
established under Article 315 of the Constitution of India. The Commission consists of a
Chairman and ten members. The major role played by the Commission is to select
persons to man the various central civil services, posts and the services common to the
Union and states. The terms and conditions of service of the Chairman and members of
the Commission are governed by the Union Public Service Commission (Members)
Regulations, 1969. The UPSC has been entrusted with the following duties and role under
the Constitution:
1.
2.
4.
5.
6.
Recruitment to services & posts under the Union through conduct of competitive
examinations
Recruitment to services & posts under the Central Government by selection
through interviews
Advising on the suitability of officers for appointment on promotion as well as
transfer-on-deputation
Advising the government on all matters relating to methods of recruitment to
various services and posts
Disciplinary cases relating to different civil services
Miscellaneous matters relating to grant of extra ordinary pensions, reimbursement
of legal expenses
Exemptions: In order to exempt some posts which for reasons of national security or
some other reasons may not be required to be referred to the Commission for their advice,
the Union Public Service Commission (Exemption from Consultations) Regulations were
issued on September 1, 1958. under Article 320(3)(a) and (b) of the Constitution. These
Regulations are amended or revised as and when the need arises-
However, both these strategies could not meet the requirements. Retention was a problem
with contractual appointment. Unsure of their annual extensions, staff would leave the
moment they got alternative employment. When contracting in specialists, the desired
combination of three specialists - pediatrician, obstetrician and anesthetists was never
available at one time thereby undermining the functionality of providing referral and
10
emergency care for maternal and child health. Therefore the focus shifted to finding a
way of being able to give permanent appointments to professionals without going
through the long recruitment process of HPSC.
Changing recruitment policies
At the meeting of State Health Mission, held on 7th Aug 08 under the Chairmanship of
Chief Minister of Haryana, facts depicting large number of vacancies and the routine
lengthy recruitment process through HPSC were shared by the Health department. A
quick decision then followed for recruiting to regular posts of doctors and specialists out
of the purview of HPSC. An immediate formal approval for the same was granted by the
state Assembly on 8th August, 2008. The anticipated resistance from the HPSC did not
arise and consent was given on 25th August, 2008.
As per No. G.S.R. 7/ Const./ Art. 320/2009 - in exercise of the powers conferred by the
provision to clause (3) of article 320 of the constitution of India that allows the state to
take certain category of posts out of the purview of public service commission, the
Governor of Haryana made the amendments in the HPSC (Limitations of Functions)
Regulations, 1973. These regulations would be called as HPSC (Limitation of Functions)
Amendment Regulations 2009. A clause (q) - Initial appointment to the post of Medical
officer in the Haryana Civil Medical Services - II in the Health Department, was added
after clause (p) of HPSC (Limitation of Functions) Regulations, 1973, in part - II
Limitations, in regulations 3.
A mutual decision was then taken by the Directorate of Health Services to take 630
regular posts out of the purview of the HPSC. Recruitments for other regular posts which,
like those of Senior Medical Officers and Dental surgeons, are still being done by the
HPSC. Recruitment - into permanent government services, thus became an on-going
process under which applications are entertained round the year for posts of generalists
and specialists. As remarked by the senior state official, “It was not the question ofpower
for the State department of Health and HPSC, but ofpublic interest”.
The state has also sanctioned an increase number of specialist posts raising it from 8 to 26
at the level of the district hospital. The Indian Public Health Standards promoted by the
National Rural Health Mission, helped to justify these norms to the finance ministry.
Thus in total 424 additional posts of doctors were sanctioned out of which 359 posts were
of specialists.
A Departmental High Powered Selection Committee of experts in the field of medicine
and state health officials was formed for conducting the interviews and offering regular
appointments to the selected candidates. The Health Directorate advertised the posts of
doctors at the level of CHCs in September 2008. For the first round of interviews over
1750 applications were received for 620 posts at CHCs. First preference was given to
11
based on the grade or category of difficult area. Highest package is of Rs. 60,000 per
month for serving in Grade I difficult area, followed by Rs. 50,000 per month for Grade II
and Rs. 40,000 per month for Grade III areas. Six additional increments have also been
introduced for post graduate degree specialists and three for diploma post graduates
working in difficult areas.
(iv) Difficult area allowance - Out of 91 Community Health Centers(CHCs) and 427
primary health centers (PHCs), 10 CHC and 50 PHCs are identified as located in difficult
area where doctors are by in large reluctant to work. To encourage and attract critical
professional service providers to these areas, special incentives were introduced under
NRHM for specialists, MBBS doctors, staff nurses and paramedics. The range of difficult
area allowance is in accordance to the remoteness/backwardness (Grade I, Il & III) of the
area of posting. MBBS doctors staying at PHC head quarters are entitled to an additional
payment of Rs 5000 per month and this rises to Rs 10,000 per month for PHCs in Mewat
and Momi hills. AYUSH doctors posted in CHC in Mewat region receive an additional
Rs. 8000 per month. Specialists in the field of Medicine, Gynecology, Pediatrics,
Anesthesia, Orthopedics and Surgery get Rs 15,000 per month for serving in difficult
rural areas and Rs. 25,000 per month for Mewat and Momi hills. Staff nurses receive an
incentive of Rs. 3000 per month while Paramedical staff receives Rs. 2,000 per month for
any difficult area
Medical
officers
Specialists
Difficult Area CHCs(10)
Contractual
Staff Nurses
Para Medical
3000
2000
3000
2000
1500
Difficult RuralPHCs(50)
5000
MORN1 (PHC)
10000
MEWAT PHC/CHC/ G
10000
25000
Source - State PIP 2009-10
Outcomes
One of the major and explicit achievements of these innovative strategies is the massive
reduction in the number of vacancies of doctors at public health facilities of Haryana. 825
doctors including 525 specialists were appointed during the year 2008-09. Currently state
authorities are able to state claim that there are no vacancies of specialists in the state.
This was unthinkable two years ago. As of April, 2009 319 MBBS doctors and 231
Specialists have joined on regular posts through the new recruitment process. In the
course of implementation of the new recruitment policy, the Health Directorates realized
the importance of developing strategies with a focus on retention of human resources .
14
The entire gamut of workforce management policies and a fast recruitment process for
regular government posts has made government service attractive for the doctors. This is
evident from the consistently increasing number of applications received for every new
round of interviews. In total about 3,000 applications were received by the Directorate of
Health Services in response to the advertisements of 1,044 posts in different rounds.
Has increased presence of skilled human resources in the facilities, led to improved
access and utilization of services? Though there is no formal evaluation that has been
done, early reports in the review meetings are encouraging. Bed occupancy at public
health facilities has increased to 100 % from 40 % in the last one year. Outpatient and in
patient attendance of patients has also increased. Comparing the period January to April
2008 with the same period in 2009, we note that there has been an 11% increase in
outpatient (OPD) cases, a 20% in the number of deliveries conducted at the public health
institutions and a 25% and 24% increase in the number of major and minor
gynecological surgeries, respectively.
Not all of this can be attributable to increased human resources alone. Other processes of
strengthening public health systems proceeded in parallel- these include the distribution
of free medicines to all patients at the public health facilities, the introduction of surgical
packages at subsidized and fixed user fees. Earlier user fees were liberal.
Conclusions
In the entire discourse on health sector reform of the nineties and even contemporary
discourse, the failure to recruit or retain or ensure performance of skilled professionals in
the public health system has largely been treated as evidence of the inherent non-viability
of public health delivery and the need to search for partnership alternatives. Yet this often
ideologically driven discourse almost completely left out simple measures needed to
make the public health system viable, and overcome the constraints to its growth.
Haryana’s simple yet audacious reform of dispensing with the cumbersome process of
Public Service Commission recruitment, and its dispensation with the whole logic of
contractual appointments has solved one of the most intractable problems of the state
health systems. But it has done more; it has cleared the cobwebs of the mind and helped
us to think out of the box about how to make the system work. One notable feature of the
Haryana programme was the persistence with the approach and the political steer. It
would be impossible for the administration to have moved through such a basic reform, if
it had been unable to carry the political good will along with it, or if there had not been
the readiness to take a political decision to change the system at such short notice. In
many states the early failure of this policy where many recruits failed to join would have
been enough justification for scrapping the reform. Instead Haryana went in for building a
package of measures to address retention of services providers recognizing that such a
15
package was needed to complement the moves they had made to attract doctors. They
have also introduced a system to monitor individual service provider’s outputs and
performance and innovatively linked it up to providing them more role in decision
making - instead of projecting it only as a disciplinary control.
No doubt, it will still be a challenge to sustain utilization and build on performance, and
though they are on the right track, such advances are fragile, and too easily reversed. Also
this is but one small step in all the processes that lead to improved health outcomes. The
main learning from Haryana was that some of the most basic problems of crafting
credible health systems lend themselves to easy solution, given some administrative
imagination and political will.
16
ANNNEXURE - CASE STUDY 1
17
Annex 1: District wise comparison of service utilization (Jan - April 2008 and Jan - April 2009)
No. of Outpatients
No. of Inpatients
Inst. Deliveries
2008
180595
247132
118178
57164
112726
136124
126228
170922
116485
183461
137503
133822
81300
126749
34549
118703
156963
40267
89495
150594
34352
2553312
2008
27845
31328
13974
0
8496
8980
7632
11870
3546
8610
4037
14376
3132
6502
4428
23660
2995
3214
7806
6452
6601
205484
2008
1491
1056
2675
1080
1632
2732
1772
1886
1072
1744
1863
504
1639
1639
1106
232
3858
275
3450
1062
644
33412
District
Ambala
Bhiwani
Faridabad
Palwal
Fatehabad
Gurgaon
Hisar
Jind
Jhajjar
Kamal
Kaithal
KKR
Mewat
Narnaul
Panipat
Panchkula
Rohtak
Rewari
Sirsa
Sonepat
Y.Nagar/Jagadhari
Total
Increase
%
2009
175717
271574
122842
68620
114787
153230
109403
182736
118044
254379
138525
158163
104145
140645
45929
159947
171369
46803
113495
174466
41894
2866713
313401
11
2009
23673
26074
12820
0
8605
16111
4182
13240
4328
11050
4707
14704
3771
7518
8910
26022
5882
5164
16613
8562
5902
227838
22354
10
18
2009
1615
1970
3163
1396
2089
2843
1860
2935
1151
2899
2210
1045
1320
1848
1139
824
4640
370
3142
2524
1040
42023
8611
20
Gynecological surgeries
Major
2008
2009
68
30
117
137
24
231
129
73
94
158
55
60
1
137
30
144
46
1
75
22
66
26
124
32
343
5
31
138
98
213
1637
140
44
516
22
66
151
100
87
2197
560
25
Minor
2008
2009
261
48
4
1
611
6
292
80
142
0
9
532
63
3
174
94
2320
5
335
69
8
84
66C
125
493
100
144
166
2
65
547
65
3
183
3061
741
24
CASE STUDY - 2
Chhattisgarh’s Experience with 3-Year Course for Rural Health Care
Practitioners: A Case Study
Shomikho Raha1, Dr. T. Sundararaman1, Dr. Garima Gupta1, Dr. Kamlesh
Jain 2, Dr. K. R. Antony2, Krishna D. Rao 3
1 National Health Systems Resource Center, New Delhi
2State Health Resource Center, Chhattisgarh
3Public Health Foundation ofIndia, New Delhi.
19
Chhattisgarh’s Experience With 3-Year Course for Rural Health Care Practitioners
Situation analysis
The state of Chhattisgarh was carved out of south-eastern Madhya Pradesh (M.P.) in late
(November) 2000. With regard to key socio-economic and health indicators (including IMR
and MMR), this state lags behind the rest of the country. Although geographically the ninth
largest state, covering 135,194 sq.km, its rank by population size would be much lower as its
population of 20.83 million (2001 Census) is dispersed with a population density which is
half that of the national average (154 for the state as against 312 per sq.km for the country).
One thirds of its population is tribal, the highest amongst large states and 40% of the land
areas is classified as forest lands. Of the 18 districts of the state, 12 are classified as remote,
tribal and extremist affected areas.
Providing health care is a human resource intensive activity, and in Chhattisgarh state the
shortage of trained health care providers is among the most acute in the entire country. The
state has 4692 sub-centers sanctioned and of these almost one-third do not have even a single
ANM, though they are expected to take on two ANMs. Only 540 staff nurses are available
against the 1344 required by IPHS norms for working in primary and secondary public health
facilities in Chhattisgarh (National Health Systems Resource Centre (NHSRC) and Academy
of Nursing Studies, 2009). The shortfall for doctors both MBBS graduates and Specialists is
about 72%, with 1455 medical officers posted at PHC against the posts of 1737 and only 247
specialists available against the sanctioned 637 posts (State PIP 2009-10). The shortfall in
doctors is even more severely felt as the vast majority of the inadequate numbers that do exist
are located in urban or semi-urban areas, with certain large tracts of rural and tribal areas
almost devoid of even a single doctor-( with MBBS qualification).
At the time of its bifurcation from the state of Madhya Pradesh,, Chhattisgarh had no
government nursing college and only a single private college of nursing admitting 30
students for a four year BSc Undergraduate degree course. . Four years after the creation of
the state, the Government College of Nursing started functioning at the state capital, Raipur,
with an annual intake of 33 students. At present there are 2 colleges that offer postgraduate
programmes in nursing (M.Sc), 10 colleges that offer undergraduate degree courses in
nursing and 4 that offer diplomas in nursing (GNM) all of which are in the private sector. In
2000, there was a single medical college in the entire state admitting 100 students, and even
this was considered one of the least favored medical colleges by students in undivided
Madhya Pradesh. This was because it was relatively poorly staffed and a limited reputation
for quality and outcomes. This college had to be strengthened after the creation of the state,
and a second medical college opened in August 2002, got recognition in 2006 and a third
was initiated in July 2007. Two further medical colleges remain in the pipeline. Though for
a state these are rapid strides forwards, it would be quite some time before this would
translate into increased recruitment in public sector recruitment. The immediate impact of a
new states was a stagnation or even a small drop in the number of doctors in 2006 as
compared to eailier (see table 1) which could be due to the fact that the rapid urban and
industrial development of the state could support a larger number of doctors in private
practice. In the year 2001 only 516 medical officers were available at PHC level out of total
of 1455 sanctioned posts. By 2571 it had increased to 1345 but this was still only about half
the number of sanctioned posts. As the numbers of facilities rise to meet the national norms,
20
and as the number of posts rise to meet the IPHS norms the gaps between what is posted and
what is needed would become even more. For example the table below shows that 6470 posts
of ANM and LHV are sanctioned- but if the second ANM as mandated by IPHS is sanctioned
that would push up requirement by another 4692 ANMs.
Table 1: the Changing HRH situation in Chhattisgarh State
In year 2002-03
Sanctioned
Facility
______
In year 2006-07
With
sufficient
infrastructure
and facilities
Sanctioned
In year 2002-03
_________
With sufficient
infrastructure
and facilities
In year 2006-07
Sanctioned
In
position
Sanctioned
In
position
5729
4667
6470
5275
3785
3121
4467
3149
1455
516
2571
1345
291
103
1006
291
Cadre
_____
Sub
centers
PHCs
3818
1458
4692
1853
513
327
717
400
CHCs
114
34
133
70
District
Hospitals
6
6
16
14
ANMs +
LHVs
MPW +
supervisor
Medical
Officers
Specialist
Source: -SHRC, Raipur
As evident from the table above, since the formation of Chhattisgarh, the largest challenge
the state government has faced in the health sector is the human resources challenge.
Chhattisgarh had one of the lowest human resource denisities in India, and perhaps one of the
lowest anywhere in the world. To address the challenge with respect to physicians, one of the
options that the state government considered was the option of a three-year course to train
medical professionals or three year doctors as it was then popularly known to serve in rural
areas.
The policy options in Chhattisgarh4
The initial idea of a 3-year diploma course for training a health care practitioner for rural
areas stemmed from the new Chief Minister’s office and was a result of his direct
intervention. The initial logic was that if candidates from rural areas are brought into a 3year diploma programme, they would be more likely to return and serve in such areas. Their
opportunities for urban private sector employment would be less. Another rationale that was
articulated was that a formally trained skilled provider in the
underserved areas of
Chhattisgarh would serve as a better than to the “jhola chaap^ doctors practicing in these
4 This Case Study is a result of information collected through extensive interviews with key
informants representing different stakeholder interests within government and outside,
including a focused group discussion with over 40 graduates from the 3-year courses and 12
‘Rural Medical Assistants’ (RMAs) currently in government employment. In addition, all
published documentation related to the 3-year course or to the RMA postings has been drawn
on. Finally, the Case also contains primary data collected and expressed here for the first
time. The authors are grateful to all who participated in this study, in providing or facilitating
information on this case.
21
regions. This is a term that derisively refers to the unqualified practitioners of modem
medicine that has mushroomed over the villages.
Given the fact that the outcomes from new medical colleges would take over six years to be
visible, a three year course would yield results within the political lifespan of the government
of the time. Moreover, starting new medical colleges, conforming to guidelines of the
Medical Council of India (MCI) required significant capital investment from the government
and recruitment of human resources. Even if the financial resources were to be found, the
human resources would be difficult, for even the existing state college in the state capital was
facing shortages of key faculty members.
The implementation process of the 3-Year course
Formation of the Chhattisgarh Chikitsa Mandal (CCM)
From early 2001, when discussions to the three yp^r course began, opposition from the
Medical Council of India, the professional council regulating medical education, was
anticipated. In discussions shared among the Health, Law and General Administration
Departments, it was agreed that the powers of recognizing the council which would approve
the three year course should be given to a body created for the purpose through an Act passed
in the Chhattisgarh state legislative assembly. The MCI would thus not have to approve the
course. Such a State Act could be passed by the state without requiring the approval of the
central/federal government or the president. MCI was however contacted and they formally
rejected this course, even without going into any discussion of objectives or course content.
The Chhattisgarh government however proceeded, using existing precedence of West Bengal
having briefly implemented such a course and with the knowledge that in Maharashtra and
Karnataka, where similar courses had been implemented. The operationalization of the plan
was given great urgency by the political leadership. Within days of the decision, a committee
was fonned in the Health Department. Within the month, a committee of senior secretaries
presided by the Chief Secretary forwarded a letter of approval to the Chief Minister (CM).
Still within the same month, the CM signed for the legislative assembly to meet to consider a
proposed bill. The very next month the assembly met and passed the act. The notification
rules were drawn out and printed as an extraordin ary Gazette on 18 May. The state assembly
accepted these rules four days later and the e Chhattisgarh Chikitsa Mandal (CCM) came into
existence.
One important reason for such a quick process was the clearance or no objection from the
Finance Department. The principal reason for quick clearance by the Finance Department
was the explicit understanding that the CCM would be an autonomous body with no financial
burden to the state government. The CCM was expected to raise its own finances through
fees charged from private agencies in return for being given permission for starting institutes
which would run these 3-year courses and later to be supplemented by through registration
fees charged to graduating three year doctors. Private managements of these institutions were
expected to recoup these losses and make a profit through tuition fees. The costs to the
government of running the CCM were expected to be minimal with a total of only three
officials linked to the new registration body; all of whom were already on government
payrolls and were being seconded for the task. The CCM comprised the Director of Health
Services as President, the Dean of the Medical College in the state capital as Vice-President
22
and a district chief medical officer to be seconded in as Registrar. With such limited initial
capital and human resources in CCM, the new registration body was a limited institution.
The powers that the CCM was authorized with, however, were not so limited. It was initially
given several responsibilities: (i) to inspect private bids made for starting the new institutes
for the 3-year courses, (ii) to be the nodal authority in-charge of the admissions process of the
students to these institutes, (iii) to have power to change the syllabus of the course, (iv) to fix
norms and guidelines for charging tuition fees for the 3-year course, (v) to be the authority
charged with undertaking the examinations process as well for this course; and (vi) to be the
registration body for graduates from the 3-year course. These were far more powers than the
state medical council had and even more than the Indian medical council had for its
regulation of medical courses..
Opening of the Institutes
Since the 3-year course was not going to be public funded, the institutes for imparting this
education were all planned to be private. The locations proposed were in rural/tribal districts,
but with access to a large government hospital usually the district hospital to make it possible
for clinical teaching and internship. Fifteen applicants responded to an expression of interest
advertisement by the government. It is notable that although the CCM was charged with the
responsibility of initially inspecting the infrastructure and facilities available for the first year
of non-clinical teaching alone, the final selection of the initial three institute locations was
solely with the state government. First three colleges were inaugurated in October, 2001 at
Ambikapur, Jagdalpur and Pendararoad. At this stage, the syllabus for the remaining two
years was still not prepared. Three further institutes at Kwardha, Katghora and Ranker
opened a year later in end 2002, with two of these going to two owners of the first batch of
institutes opened. Although initially it was decided that each institutes would have maximum
of 100 students, all the six institutes were allowed to admit 150 students per year. The student
admission was in three categories:
1. 50 % free merit seats - 75 seats,
2. 35% payment merit seats - 53 seats
3. 15% NRI seats - 22 seats.
There was only a 20-day period for applications to the first three institutes, but even in this
short time there were approximately over 9,000 applicants who applied for admission to these
three institutes in the first year. Admissions happened for three years before the course was
stopped. For the first year, CCM conducted the admissions as per the provisions of the Act.
In the subsequent years when the institutes took the lead through an association they formed
called the “Three Year Medical Institute Association of Chhattisgarh” (TYMIAC). The cut
off for the admissions of the first batch was 75% in the required the school-leaving
examination, with inclusion of Biology being compulsory. In the first two years, eligible
candidates were called for interview in the order of their scores in the school leaving
examination, and given the seats in the institutes of their choice, against vacancies that
existed at the time of their appearance- a process that has of late being called counseling though in fact no counseling occurs. This counseling was centralized and held at Raipur. In
the third year of admissions, even this centralized counseling was given up and admissions
were directly done at each institute. For entry to the third batch, there was a significant fall in
23
the number of interested applicants as compared to the first batch. The reasons for both these
developments are explained below.
The influence of legal issues on the Name and Content of the Course
The Indian Medical Association (IMA), representing largely private doctors, opposed the
idea of a 3-year course of medical education as a dilution of the standards of the medical
profession. Not surprisingly, therefore, the IMA filed a case questioning the legality of the
Chhattisgarh three year course almost immediately after the CCM Act. Even though there
was no verdict in favor of the IMA, the state government’s engagement with the three year
course was almost exclusively dominated by its having to survive this legal challenge and to
find the legal space to start and continue with this course. Such primacy to legal sanction, did
manage to keep the legal space open, but it came, at the expense of attention to other issues
that were equally important, if not more, to the actual functioning and to the institutional
support the course may ideally have had. Above all, there was very limited clarity on three
vital issues- the syllabus, the exact identity of the graduating students, and institutional
provisions related to standards and the transparency of process - especially admissions,
hiring of faculty and maintenance of quality in certification.
The first influence of the pending legal battle over the 3-year course was the change in its
name, even before the course formally started. At the time of the CCM Act, the 3-year
diploma course was to create a “Practitioner in Modern Medicine & Surgery”. Three months
later, however, the course was re-titled “Diploma in Alternate Medicine”. This was a direct
response to the legal concerns with the use of “Surgery” and modem medicine in the title,
both of which attracted clearance from the medical council of India which had not been
consulted. To justify this claim to “Alternative Medicine”, there were subjects introduced to
the syllabus that had not been considered before - viz. biochemic medicine, herbo-mineral
medicine, acupressure, physiotherapy, magneto-therapy, yoga, and Edward Bach flower
remedies and acupuncture indeed every possible alternative medicine name that could be
thought off.
Institutional hurdles faced and created: Speedy implementation at a cost?
The unusually rapid progress in setting up these courses, despite legal hurdles related to the
strong political will - in the form of the chief minister’s personal and explicit priority for this
scheme. Internally there was administrative reluctance to rush through such a course. The
IAS officei who was secretary to health was relieved of this task and the task was handed
over to a faculty member of the preventive and social medicine department who was
designated as an officer on special duty” reporting to the health minister directly and with
many of the powers of the secretary. The ostensible reason was that the health secretary has
several tasks whereas the OSD brought from outside the career civil services was appointed
explicitly to deliver on the 3-year course. The health secretary, not being the reporting
authority for the OSD, had no reason to be involved with this 3-year program henceforth.
The Director of Health Service, while the officiating President of the CCM, is a senior career
government official mandated to oversee much more than the CCM and has an important
working relationship with the IAS health secretary to preserve. In contrast, the post of OSD,
perceived to be a ‘temporary political appointment’, commanded far less compliance from
the Director of Health Services and other senior career officials compared with the authority
of the health secretary. This resulted in a working environment where the OSD had limited
24
cooperation within the government - and there was little sharing of information and a lack of
ownership of this course. It is also within this strained working environment with other key
health officials that the OSD sought to bring important ‘corrective’ changes. After the first
year of the course had already begun, it was decided to affiliate the private institutes to the
established universities in Chhattisgarh and to bring the exams under the purview of these
universities instead of the CCM as stipulated in the May 2001 Act. It was also decided that
the authority responsible for admissions to the 3-year diploma course be transferred from the
CCM (as under the Act) to the private institutes. The underlying rationale driving both these
midstream changes was a revised assessment of the CCM aimed at reducing its powers. The
CCM created through the May 2001 Act was no longer deemed a legitimate body, in this
revised perspective, to conduct examinations; instead the universities were expected to better
facilitate recognition for the course. These changes again had unintended but deleterious
effects on the course. First, the attempt to link the course to the universities delayed the firstyear examinations by nearly half-a-year and became the initial cause for the course getting
derailed in its schedule (see Table 2). Second, the CCM or any single independent nodal
agency was far less directly involved in the admission of the second batch to the diploma
course and indeed for the admission of the third batch in 2003, many seats were “filled on the
spot” without Counseling, with no quality standards on an almost walk in basis.5
As part of this revised perspective on the CCM, the name of the 3-year course was changed
yet again to “Diploma in Holistic Medicine and Paramedical Course” in March 2003 through
an internal government order. The thinking behind this change was that the change of name
would pave the possibility for graduates of this course to be registered with the State
Paramedical Council and not under the CCM. The state paramedical council would be less
likely to be legally challenged than would the CCM as it would be clearly outside the
purview of medical councils and associations. The name change, however, struck a problem
from another quarter, this time the students. The students launched an agitation declaring that
the term “paramedical” was a dilution of the status of the course, away from the medical
profession to which they desired affiliation. The name of the course instead was revised
again following the July 2003 student strike to “Diploma in Modern and Holistic Medicine”.
Therefore, legal and political issues, rather than any dialogue over the aims and purposes of
the course, governed the decisions to change the name of the course several times and with it,
its stated curriculum. Lacking clarity in objectives from the very beginning, these changes
only added to the confusion.
The legal and political turns and twists also led to constant redefing of the syllabus of the 3year course. The initially designed syllabus for the 3year course was a scaled down and
trimmed version of the MBBS curriculum with some additional subjects of AYUSH( the
indigenous steams), alternative medicine and public health added in to justify the term
“Alternate” and thereafter “Holistic”. Two Inspection committees in 2004 and 2005
examined the syllabus and recommended changes in syllabus to make it more appropriate for
the epidemiological needs of the rural and tribal population- but these were not carried out.
The only modifications made related to alternative and holistic medicines and was done to
justify the new names of the course.
The change in the state government after the November 2003 elections brought all
issues of course objectives and identity of the graduates into a fresh review. The new
5 Moreover, anecdotal evidence suggests that the vacant free and management seats were
converted into NRI seats with a fee structure of 1.5 lakh per year.
25
political regime, dropped officer in-charge of the 3-year course (the OSD) as a political
and irregular appointment, The health secretary who had been pushed aside to make
way for the OSD was brought back to re-formulate policy on the course after a gap of
almost two years. The government was now willing to define the course objectives more
clearly, but they faced a situation because the courses were in an advanced stage with
three batches studying and students resorting to agitation to safeguard both their
identify as doctors and to gain employment prospects from the government.
Delayed Clarity: Student Agitations and closure offurther admissions
At its inception and when the course was initially for training a “Practitioner in Modem
Medicine & Surgery”, it was not clear whether the 3-year course would be a “diploma” or
“certification” course. The precedence in West Bengal that influenced the making of the
course in Chhattisgarh was a diploma program. There exists also an, instance of a 3-year
certificate courses, such as the one run by the national AIDS program of the country..
At the time of admissions, almost all the students were given to understand that they would
graduate as a three year trained doctor with a high likelihood of government job in rural and
tribal areas due to the significant vacancies that exist in primary health centers (PHCs). This
belief was based on media statements and coverage and on verbal assurances of the state
government, but no order to this effect had ever been issued. As the verbal assurances failed
to be followed up and as students had enrolled, some of them after paying fairly high tuition
fees or in some cases capitation fees, the students became restive. There were several
agitations of students, promoted by institution owners and supported by political interests of
districts in which the institutions were located and from where the students came. In total
there were three major strikes.
The main reason for the first strike of students in January 2003 was a demand to change the
name of the course from “Alternative Medicine” and to secure guaranteed government jobs.
The name of the course was changed following this strike.
The second major agitation was in July 2004 for change of the name from “Diploma in
Modern and Holistic medicine” to “Practitioner in Modem and Holistic medicine” and in
order to increase the duration of internship from 6 months to one year. Students also sought a
stipend for the period of internship (much like MBBS students get), security of a government
job and recognition of the course by the State Medical Council. This led to the change of the
name for the final time and an increased duration of internship to one year.
The longest strike lasted one month in December 2006 with the main demands remaining the
same, including recognition of the course by State Medical Council in order to practice
allopathy.
All these agitations of students led to further delay of the annual exams and further derailed
the course schedule. The legal and political issues along with the various strikes of the
students also contributed towards the growing unpopularity of the course in the state, which
led to far decreased numbers of applications especially for the entry of the final 2003 batch.
The entry requirement of 75% percentage for the first batch dropped to 65% and 40% for the
second and third year batches, respectively. There were also around 809 dropouts from the
six institutes out of total 2200 admissions made.
26
Faced with this scenario, the new state government which anyway did not have to own the
moral responsibility of this adventure, found it opportune to immediately stop any further
admissions to the course. Managing three batches of students- a total of 1391 students was
complex enough and it had no appetite for more. Thus on 1st September 2008, the course was
officially ended. Attention now shifted to the question of what should be done with these
1391 students.
Table 2: Derailed Timeline for the Different Batches admitted to the 3-Year Course
Admission
Ist-Year
2nd-Year
3rd-Year
Exam
Exam
Exam
Length
of
delay
in
completion
1
year, 2
months
First Batch
Nov 2001
Mar 2003
Oct 2004
Jan 2006
Second Batch
Nov 2002
Oct 2004
Dec 2005
Feb 2007
1
year,
months
Third Batch
Nov 2003
Mar 2005
Sep 2006
Oct 2007
11 months
Source: CCM, Raipur and corroborated in interview with students of different batches, 23 May 2009.
Iterating to a solution: The birth of the RMA
The May 2001 state Act created the CCM as the only deemed body to register the 3-year
course graduates, which allowed the course to legally begin even though it was not
recognized by MCI. The creation of CCM, however, did not facilitate the legal status of the
graduates as practitioners of allopathic medicine. Education is constitutionally in the
Concurrent List (subjects shared between Centre and states). This implies that if there is a
central Act already in existence, states cannot contradict the central Act without legal
violation. As per the MCI Act (1956), MCI and state medical councils have the sole
authority to allow the registered physicians to practice allopathy. With the Chhattisgarh State
Medical Council having no role in the registration of the three year graduates, and with no
likelihood of their being able to recognize this course, the students cannot legally, practice
modern medicine. This became clearly stated in a Supreme Court (SC) Ruling of February
20036. This particular ruling noted a precedent7 when by virtue of such qualifications as
prescribed in a State Act being registered in a separate State Medical Register with the State
Medical Council a person was “entitled to practice allopathic medicine under Section
15(2)(b) of the 1956 [MCI] Act.”8 The CCM Act was a state act, but since this qualification
was not registered with the state medical council, it could not confer the rights to practice
allopathic medicine.
6 Supreme Court of India decision on Subhashis Bakshi v.West Bengal Medical Council (Civil Appeal No. 152 of
1994)
7 Cited as Dr. Mukhtiar Chand v. State ofPunjab, (1998) 7 SCC 579.
8 SC decision on Subhashis Bakshi v. West Bengal Medical Council, pp. 287-288.
27
3
One response to this situation was to allow them to practice as paramedicals under the
paramedical act. The paramedical act specifies that the paramedic could provide that
medicine or that care which he or she was trained to provide- and this could have provided
the cover needed. But the problem with this was that the graduates of the three year course
aspired to be called doctors and medical professionals and would not settle for the term
paramedicals or even alternative medicine. The government therefore had to define what they
could be allowed to practice, which did not fall under the MCI Act but yet would be medical
enough to manage this situation.
With the clarity that no legal independent practice in allopathic medicine was possible for
these students, a bipartisan high powered committee was tasked to find a viable employment
for these students. One suggestion that this committee considered was to revive the post of
Assistant Medical Officer (AMO), an earlier posts which had been abolished in 1976. The
post had been occupied by the three year Licensed Medical Practitioner (LMP) of West
Bengal and the Registered Medical Practitioner (RMP) of Maharashtra. The proposal in
Chhattisgarh was to create a third post of AMO in addition to the 2 MOs that had been
already sanctioned per PHC. This proposal however was rejected by the Finance Department
on grounds that such an increase in health personnel expenditure was not justifiable.9 The
next option considered was to post them as Block Extension Educators (BEE). This is a post
financed by the central government and which has duties not only of health education but of
assisting the block medical officer in management tasks. Being a centrally funded post, it
would create no additional financial burden on the state exchequer. The post of the BEE, was
higher than a field supervisor but immediately under the medical officer which would be a
positioning in the hierarchy that would be acceptable. However this was rejected by the
students who were not ready to accept any post without the word “medical” in it. And at any
rate the center would fund only about 250 BEEs and many of the posts were not vacant.
The current decision is to appoint Rural Medical Assistants in leu of the second MO post
which was kept in abeyance. The government thus saves half the salary of the second MO-Rs
8,000/-against Rs.l5,000/-to MBBS doctor by this measure. The RMAs were sanctioned
selectively in the PHCs classified as remote or tribal in districts with the most acute shortage
of doctors. By the letter of the law they are not to be posted where there is no medical
officer, for they are only assistants, and therefore they would not contravene the law.
However in practice medical officers would not join in many PHCs and these RMAs may
have to function independently which is acceptable. Already pharmacists and nurses and
AYUSH doctors do the same. Government employment with medical functions thus becomes
possible, but private independent practice by these graduates is still not permissible. The IMA
finds this truce acceptable and so do the students who have got the title of ‘medical’ in their
designation and government job- two key demands of theirs. The funds are from the central
9 The process of sanctioning 2 MOs per PHC had already taken two years (2004-6) to get budgetary approval.
Interview with Dr. D.K. Sen, 22 May 2009.
28
government through the NRHM mechanism and therefore the state finance department finds
it easier to accept- though in the long run it would have to take this over.
Most important of all, over half of the State’s 700 odd PHCs were languishing for the lack of
a doctor and at one go, all of them are not having a doctor in place- even if legally he is an
RMA, to the public he or she is a doctor!! The state has sanctioned two doctors per PHC in
2005 and this is in accordance with IPHS norms. It was barely able to fill the PHCs with even
one doctor and was had used AYUSH doctors to fill in over 200 posts. Now with 1391
RMAs potentially available, most PHCs could be made functional. It seems to be a win-win
situation all around, even if this solution was arrived at after a prolonged iterative process.
Recruitment of RMAs in rural postings
There has been overwhelming positive response to recruitment of RMAs to the most rural
and tribal PHC postings, where previously no trained physician existed; RMAs are stipulated
to work under supervision of the first Medical Officer. However, this does not translate
always into direct supervision as RMAs are present in PHCs where usually no other MO is
willing to accept a posting.
RMAs in non-tribal areas are supposed to get an honorarium of Rs. 8000 per month
(significantly less than the salary of a MBBS-trained doctor) and those in tribal areas are
appointed on honorarium of Rs. 9000 per month as per approved NRHM PIP. But the
government had appointed them on uniform salary of Rs.8000 per month. Appointments are
contractual and for a period of 2 years. In 2008, the CCM conducted the first round of
interviews for 398 sanctioned posts of RMAs in the identified 12 with large tribal and remote
rural areas. About 225 candidates were selected and posted. Preference was given to their
native districts if that ‘home district’ was among the 11 districts selected for RMA postings.
The scope of practice of RMAs is summarized in Box 1 and detailed in Appendix C below.
The remaining 173 posts were re advertised in 2009 and 529 applications received and
another 78 were recruited. About 303 out of 398 RMA posts are filled. The 95 posts of
RMAs which were not filled fall under the SC/ST category. They remained vacant, not
because of a dearth of interested applicants, but due to the absence of adequate numbers of
SC/ST students ever trained in these institutes. The reservation rules at the time of admissions
were either insufficient or poorly implemented. These first RMAs have been posted in the
most remote and difficult areas of Chhattisgarh to provide health services.
29
I able 3: Postings of RMAs in First & Second Recruitment Drive
District
‘Sanctioned
Posts
Bijapur
13
Narayanpur
Jagadalpur
Jashpur
7
55
32
Surguja
77
Koriya
27
Positions
filled Positions
filled In
during the First during the Second Position
recruitment round recruitment round in
in 2008
Feb.2009
3
5
8
7
7
33
9
42
18
4
22
54
1
55
12
10
22
Ranker
28
12
15
27
1
Korba
31
29
2
31
0
Raigarh
47
31
31
16
27
12
19
303
6
12
5
95
Rajnandgaon 33
20
Dantewada
24
2
Kawardha
24
4
Total
398
225
Source: CCM, Raipur and SHRC, Raipur
7
10
15
78
Vacant
5
0
13
10
22
5
Table 4 Postings of RMA after Third Recruitment Drive
1
2
3
4
5
y ii Positl
:
\
,(CHC
10
Bijapur
Narayanpur
Jagadalpur
Jashpur
Surguja
Koriya
Ranker
Korba
Rai garb
Rajnandgaon
11
Dantewada
30
14
7
58
31
81
28
34
37
50
47
28
12
13
14
Kawardha
Bilaspur
Dhamatari
Durg
Janjgir Champa
Mahasamund
Raipur
26
84
26
86
48
30
81
858
22
74
23
72
39
26
63
734
6
7
8
9
15
16
17
18
Total
17
9
67
38
98
31
38
41
57
51
Source: CCM, Raipur and SHRC, Raipur
30
3
2
9
7
17
3
4
0
0
0
0
0
0
0
4
0
7
4
0
0
2
0
4
10
3
14
9
4
18
124
0
0
0
0
0
0
0
0
In light of this positive experience of posting RMAs in underserved remote areas and existing
740 vacancies of Medical officer, the state has recently increased the total RMA posts to 858.
With the policies of contractual appointments of MBBS doctors and recruitment of
contractual AYUSH doctors at the post of MOs, only 1407 posts could be filled out of total
MO posts of 2147. Therefore to make up the gap, in a recent order, the state government had
introduced one RMA post at all PHCs and an additional post for Lady RMAs at CHC level in
all the 18 districts of Chhattisgarh irrespective of the difficult, rural or tribal status of the
districts.10 About 74 RMAs who had joined in the second round of recruitment also appeared
in the third counseling seeking change of posting location. Thus 629 posts were filled through
the counseling sessions conducted by CCM from 1st - 8th Oct, 2009. Thus of the total 1
sanctioned posts of 858 RMAs, 229 were recruited from earlier two rounds and 629
recruited after the third round. At the time of this documentation, those selected from the
third round are joining. Even if all do not join, the historic nature of this achievement cannot
be diminished. For the first time, probably since independence, a way has been found to fill
up all these vacant posts.
Differences between the 3-year course and MBBS graduates: In training and
aspirations
The 3 year diploma course was justified as an effort to prepare skilled health care providers
for the underserved areas. Locations of the six institutes were selected to be in rural areas.
Unlike for MBBS graduates, the one year of internship for these three year students has a
significant exposure to rural public health system with 1 month of training at Sub-Health
Centre, 3 months at PHC, 4 months at Community Health Centre (CHC) and 4 months at
District Hospital (DH). At the DH, there are rotational postings in the departments of
Surgery, Medicine, Obs & Gyn, as well as orthopedics and pediatrics for 20 days each and
for 10 days each in the Orthopedics, ENT, Ophthalmology and Casualty departments. This
gives to the students, field-based learning of the public health systems and enables them to
develop skills to provide health care services even with limited availability of equipments and
facilities. The MBBS graduates, on the other hand, are taught in urban settings focused
around a tertiary care hospital. Their rural posting is often in their own outreach center, which
is not a sufficient exposure to the public health system. They have tended to therefore
develop an urban orientation and preference to practice in a tertiary care n set up, rather than
in rural areas.
It is also significant that in our focal group discussions and interview, the 3-year course
students expressed their role models to be doctors working in the PHC, CHC or DH where as
for MBBS students the role models have most usually been their professors in medical
colleges.8 It has been well documented that the vast majority of MBBS graduates aspire
almost singularly on further specialization through post-graduate studies. Although the
10 Interview with Chhattisgarh Health Minister, Shri Amar Agrawal, Raipur, 22 May 2009.
The Minister expressed a vision of recruiting all the current 1391 graduates from the 3-year
courses in the coming years and hoped that their successful posting in such remote and tribal
areas would provide the necessary evidence to restart such a course at some later date.
31
curriculum for the 3-year course and MBBS are similar, it is still the graduates from the 3year course who are more likely to serve in rural and tribal areas, as compared to MBBS
graduates. This difference in the aspirations of students is attributed mainly to the design and
pattern of the courses.
In terms of performance the difference between MBBS and the three year doctors is being
studied using the sample of the first 50 RMAs who have joined public service.
Box 1: Scope of the Rural Medical Assistants (RMAs)
■ Assist in implementation of all National and state level health programs
■ In case of any emergency situation, RMAs have to provide primary health care services and then refer
the patients to higher level of public hospitals based on the requirement.
■ Provide preventive health education and measures to attain good health.
■ Provide limited primary level treatment for some of the conditions.
■ Provide basic maternal and child health care, conduction of Delivery, Basic management of
complications of pregnancy and childbirth, Suturing of first degree Perineal tears.
■ Perform simple operative procedures - repair of small wounds by stitching, drainage of abscess; burn
dressing, applications of splints in fracture cases, application of tourniquet in case of severe bleeding
wound in a limb injury
■ Provide primary level treatment for 5 - 7 days only if the improvement is visible in the health of the
patient else they should refer the patient to the nearby CHC for further treatment.
■ Permission from the High Court and Supreme Court to dispense certain Over The Counter (OTC)
Drugs
■ Linkages with communities to increase the service delivery.
■ Regular meeting with the peripheral staff.
■ Follow up in treatment diseases initiated by Medical Officers of CHC and PHC
■ Follow up of all National Health Programs in Coordination with the BMO.
8
•
1 Discussions with a group of 30 graduates from the three year course.
Lessons from the case
The 3-year course was a response to a major crisis in human resources for health that the
newly formed state of Chhattisgarh faced. The state responded to this crisis in multiple
ways- and it is interesting to look back now on what was tried and what was not tried and
why this was so and what were the outcomes of different efforts.
One effort was to open up new medical colleges. Two colleges have been successfully
opened and two more including a centrally sponsored one is planned. The other was nursing
schools and ANMs schools. These two have opened up and though less in numbers and
slower to start off than could be asked for they are progressing well. A third was the Mitanin
programme, a community health volunteer programme of a woman health activist in every
hamlet that is doing relatively well. It has survived and grown and it is exploring new
directions of growth. A fourth, very little discussed and even less documented is a major
effort to train village RMPs, or quacks in less polite usage, to provide rural care. These
informal medical practitioners had only to be nominated by the panchayat and sent to the
32
?
10
district hospital, where they would then get a six month training and a certificate and then be
sent back. About 1100 persons were so trained and state considered providing two of them
with government employment in each panchayat and then gave it up, preferring them to be
market driven. This by all reports failed to make any impact and has disappeared from public
consciousness, but is worth digging up, if not for anything, at least to not repeat it. The fifth
bold experiment and the most curious of the lot is this three year course. It ran three years and
then stopped by the government, but in a final spin seems to have come up as a winner with
fresh possibilities.
Some officials interviewed for this study have suggested that the entire problems are due to
the speed with which initial implementation of the 3-year course occurred. It did not allow
time for substantial consideration of the various aspects which were later noted as
weaknesses. Such a reading is only partially true for even the haste was part of the design. A
better analysis of what happened and the lessons therein would be from a stakeholder
analysis. Each stakeholder had a differing programme theory- a different interpretation of the
context, of the objective, of the way various mechanisms were supposed to work and the
outcomes these mechanisms would deliver. There were also many different expectations of
the programme. Let us reconstruct these programme theories.
One is the programme theory of the political party in power at the time of starting the course,
and with it of the administration, represented then by the OSD, who was willing to implement
then the political mandate. To them the expansion of medical education was the fundamental
political achievement- and the political and social good will they would gain from such an
expansion. Access to medical education is one of the most powerful vehicles for upward
social mobility, and for a political middle class coming into its own with the creation of a
new state this was all the more important. This had to happen in the here and now and in
large enough and dispersed enough measure to secure the good will in time for political
mileage and social recognition. Medical college expansion would be too slow and too
cumbersome and affect too few. If a large number of graduates are thrown into the market
and they are less competitively placed as compared to 5 year doctors, they would have to
gravitate to the rural areas and thereby the rural shortage of doctors would be achieved. The
main barrier to this is the restrictions imposed by the medical council, which have to be
legally and administratively circumvented and haste is part of the process of doing so. To the
students one has to promise a regular medical education, for that is the main attraction of the
course, but simultaneously to the legal front one has to project it as alternative medicine.
Is this an unfair portrayal? Were not the architects of this programme serious about the rural
human resource gap and trying to address it- primarily. Certain reasons that question this are
the following: there were no plans explicitly made for public sector employment. There were
no standards strictly followed- for faculty and for students and for clinical teaching as CCM
failed to monitor the set standards. The rules of admission allowed for NRI seats and
management quotas. All the education was positioned in the private sector and none of the
parties had much experience of running any such institution. All of these indicate a lack of
seriousness about the course as a vehicle of creating doctors specially tuned to work in rural
areas. We must also remember one aspect about this context. The government was also trying
similar experiments in the entire educational field. Over 125 universities - all private had
been sanctioned under another hastily planned state law and most of these had to be closed
once the new government came to power. Many of them had no buildings or faculty- but
were sanctioned. Permission to start up professional colleges and universities were one of the
important forms of rent seeking in those days and could have acted as a driver. Note
33
especially the capitulation of more and more functions to the organization of these
institutions and to the hasty increase of students and the picture is complete.
Now consider another programme theory of the medical professional and their institutions. In
this understanding the three year course is nothing but a political stunt that would provide
under-qualified medical professionals who would compete on the market with fully qualified
professionals. Though in theory 5 year medical professionals would be able to command the
market because of better knowledge and skills and because of higher status, in practice, given
information asymmetry, patients cannot be trusted to make the correct choice. The likelihood
of these three year doctors working in remote areas is remote. Also even if they do, they are
less likely to be effective and more likely to make dangerous mistakes than their five year
counterparts. As the programme rolls out, and the three year graduates fight to be called
doctors, and the government fails to post them into remote areas, their fears seem genuine.
Now to consider the students. Many of them saw the course as an opportunity for upward
social mobility into the social and economic privileges of being called a doctor. They
possibly knew that the course was unrecognized and the government job was uncertain but
counted on their collective and individual political influence to swing these two dimensions.
The moment this seemed less likely applicants to the course dropped sharply and it may be
that those who still apply have either a different motivation or are more detennined to
somehow make it into the medical ranks. If they find that there is no career progression from
RMAs and cannot return to the city, and they are stuck there some of them may settle for this,
but most would return to their dissatisfied status. Their acceptance of the current compromise
may just represent a pragmatic judgment that given the forces at work, they should first
secure these two gains, the medical word in their title and the government job for some more
time, before they take up the struggle again.
Now consider another programme theory- one that is current in NRHM circles and also the
way that some of the other architects of the course conceived it. We present this with some
elaboration, given the wisdom of hindsight. That is to plan this only as an approach to putting
in place physician skills at the primary health center - especially in remote and rural areas. If
this indeed be the aim the following corollaries would follow:
a. Allow only public sector institutions to teach this course or at least ensure that all
seats are merit based. There is no role for capitation fee paid management quota,
much less NRI quota. If the institutions are private run, the government may consider
paying the institution for every student who turns out and joins government service. If
students have to pay a high tuition fee for admission that it would tend to select
students who are well off seeking upward political mobility.
b. Allow only as many seats as are needed for filling vacancies in public sector. No role
or space is provided for private practice. This in itself is a powerful way of ensuring
that these candidates staying in the rural posting. Inform students and select students
by their clear willingness to work as RMAs. This would need an interview
counseling process that makes this clear. Do not offer them the option of going into
private practice as doctors or working in urban areas. This will lessen the candidates
who would apply and make it unattractive for anyone to pay capitation fees, which in
turn would make it unattractive for private sector. The government would need to live
with this logic. The entrance examination may be used, but with all its risks, an
aptitude and attitude assessment in the interview would help select students for rural
areas better.
34
c. Reassure the medical professional that this sector is not going to compete with them
in the urban market. If doctors are willing to stay in rural areas, this would be
unnecessary, but till then this is needed.
d. To satisfy in part the aspirations of the political leadership and politically active
groups and the students do offer an up gradation to a regular MDBS after 5 to 10
years of service with a bond to serve another 5 years.
e. Set down standards for admission, for number of faculty and for certification.
f. Define the syllabus carefully, so that it is practice oriented.
g- Choose the institutions to conduct this course carefully. With profit motive ruled out,
few would apply and whether government should take it up or find not for profit
institutions who would.
h. Accredit under the paramedical act, with modifications if needed and ensure that the
upgradation course is recognized by the Medical council of India before it is begun.
i. Build up an institutional mechanism at state and district level to design and implement
this course.
35
The way forward
At the time of writing this case study, the political- administrator position is modified to see
this model as offering a way forward to solve the problem of retention in rural areas. This is
because of four factors- graduates have accepted this arrangement, PHCs vacancies have
been greatly reduced , preliminary reports show patient and public satisfaction with the
arrangement, and finally the professional resistance to this arrangement is muted, if not
altogether absent. An evaluation is ongoing to test whether the professional skills they have
and use is comparable with other alternatives and to formulate strategies of improving this.
The preliminary reports are positive and the clinical gaps appear remediable in-service.
Currently the Ministry of Health is also thinking of upgrading the Health Sub-centers to an
independent, fully functional curative care unit in addition to the hither to preventive and
health promotive roles like the one being implemented in China. In this context, RMAs are
the best option to be placed in such Health Sub Centers in addition to the ANMs considering
the cost factor and availability of such human resource in remote areas.
When the Urban Health Mission is rolled out, there will be shortage of qualified medical
personnel to man the Urban Health Centers providing better curative services than the
unqualified practitioners normally the urban poor and the slum dwellers resort to. Here the
three year course graduates may also prove to be a good option.
There are thus calls to re-start the course. Assam has also started up a similar programme,
and this reinforces a trend. This case study is meant to remind ourselves of the history of how
it worked, so that we learn from the past. There could be a trend to just declare it is working
and go back to an unregulated, hasty market based education model. Only this time it would
not be as easy to absorb the graduates in the public health sector as earlier. Moreover both
legal and professional resistance would be more, for it would not be able to tell the courts or
the profession that this is about alternative medicine, and not allopathic medicine. Students
also, given the past experience of a successful agitation would be more persistent. There is a
potentially useful role to play for this three year course, but only if it is highly focused as a
strategy of providing access to professional skills in rural and remote areas, and it
consciously shies off from other stated and unstated objectives. The conditions by which this
focus on rural retention is maintained, does not lie in only its three year nature, it lies also on
which sort of students are selected for the course, the number of students who are selected for
the course, who conducts the course, how the sy'labus is oriented, and whether at all the
graduates are allowed to do private practice in urban areas, or for that matter anywhere, and if
not how they would be restricted.
There is nothing wrong with imposing such restrictions- indeed that is precisely what would
make it acceptable to all stakeholders. World over creating professional skill sets that have
limited acceptability in private markets and in international migration, and are by policy kept
off public markets, has been an useful device to make professional skills available where they
are needed. But for this to work, the other policy corollaries have to be part of an essential
package- with some good on the job support and training too, if we need health outcomes in
addition to user satisfaction. Also a career path that provides for long term sustainability of
the option. Thus we need a professionally competent long term plan- not one designed for the
immediate alone.
36
Chhattisgarh has been able to achieve a set of immediate objectives through a process of
iteration, including the cancellation of errors, some hard negotiation and some good luck.
Despite this, the sheer historic scale of this public health achievement should not be lost on
us. For the first time, perhaps since Independence , it has been possible to post a person with
medical skills in all the PHCs of this region. However this Chhattisgarh’s past approach to
generating RMAs cannot be the basis of policy for re-starting the three year medical course in
Chhattisgarh or the terms of its replication. The three year course could be re-started, and
other states can consider its replication, only after a policy decision on all these aspects is
taken and the support mechanisms needed to sustain this process are put in place.
37
ANNEXURE - CASE STUDY 2
38
Appendix A
Time line
Events
2000
January 2001
Committee of 3 members - Professors of Medical college - Design of 3 yr
diploma course was proposed
Proposal of 3 year diploma medical course
February 2001
Proposal for formation of Chhatisgarh Chikitsa mandal
2nd March 2001
Refusal of MCI to recognize the course
2nd March 2001
Approval for the CCM from Law
2nd March 2001
Approval from Finance department
2nd March 2001
Nomination of 3 members of the CCM - President - DHS, Vice President Dean Medical Colleges, Registrar - 1 Nominated Gazetted officer
3rd March 2001
Formation of a Committee with DHS, DME and Senior Secretaries as members
27,h March 2001
Meeting of Chief Secretary, Addditional Chief secretary, Principal Secretary,
Secretary GAD, Principal Secretary Law, Secretary Health
29,h March 2001
Approval of the proposal
17th April 2001
Proposal approved in the Cabinet meeting and the
Name of the course - Diploma in Modern Medicine and surgery
16th May 2001
Proposal approved and signed by Governor
18th May 2001
Formation of CCM and Gazette notification printed
22nd May 2001
Minimum standard guidelines for Private colleges prepared and EOI floated
31s1 may 2001
IMA Bilaspur filed a petition against the course at Bilaspur High Court
24th August 2001
Name of the course changed to Diploma in Alternative Medicine , Chhattisgarh
Chikitsa Mandal act - amended
29th August 2001
Gazette Notification with new the name of Diploma in Alternative Medicine
September 2001
Inspection of colleges by inspection committee - DHS, Joint DHS, 1 CMOH
nominated by Govt., Registrar CCM, District CMOH
2"d Oct 2001
3 colleges - Jagdalpur, Ambikapur , Pendraroad were inaugurated by CM.
39
Appendix B
Total Stu
Balgangadhar Tilak Institute, Jagdalpur
308
Anusha Memorial Medical Institute, Pendra road, Bilaspur
264
Ma Bambleshwari Medical Institute, Kwardha
229
Mahrishi Ashtang Medical Institute, Sarguja
210
Biken Institute of Medical Science, Ranker
200
Shri Kedarnath Institute of Medical Science, Katghora, Korba
180
Total
Source: CCM, Raipur and SHRC, Raipur
1391
40
Ml
Appendix C
DISEASE THAT CAN BE TREATED BY A RURAL MEDICAL ASSISTANT
DISEASES TO BE TREATED BY A RURAL MEDICAL ASSISTANT
Acute bacterial infections, febrile illness, diarrhoea, dysentery, viral infections, malaria, amoebiasis, giardiasis, worm
infestations, gastroenteritis, cholera, typhoid fever, vitamin deficiencies, iron deficiency anaemia, malnutrition, upper
respiratory infections, acute bronchitis, bronchial asthma (status Asthamaticus), first aid in ischemic heart disease, peptic
ulcer, acute gastritis, viral hepatitis, urinary tract infection, common skin infections,, scabies, first aid in trauma, and animal
bite.
In children treatment before convulsion, measles, chicken pox, asthma(status Asthamaticus), scabies and other common skin
infections.
Care in pregnancy, child birth and post natal period, family welfare activities.
Follow up in treatment diseases initiated by Medical Officers of CHC and PHC.
OPERATIVE PROCEDURES PERMITTED TO BE CARRIED OUT A RURAL MEDICAL ASSISTANT
Repair of small wounds by stitching, drainage of abscess; bum dressing, applications of splints in fracture cases, application
of tourniquet in case of severe bleeding wound in a limb injury.
Conduction of Delivery , Basic management of complications of pregnancy and childbirth. Suturing of 1st degree Perineal
tears.
Follow up of all National Health Programmes in Coordination with the BMO.
DRUGS THAT CAN BE PRESCRIBED BY A RURAL MEDICAL ASSISTANT
Antacids, H2 receptors blockers, proton pump inhibitors, Antihistaminic,
Antibiotics- cotrimaxazole, trimethioprim, norfloxacin, quinolones, tetracycline, gentamycin, cephalosporin, erythromycin,
nitrofuratoin, metronidazole, tinidazole. Ampicillin
DID Antitubercular- INH, rifampicin, ethambutol, pyrazinamide, Anithelminthics- mebendazole, albendazole
Antimalerials- chloroquine, quinine, primaquine, sulfadoxine- pyrimethamide.
Antileprosy- dapsone , rifampicin, colfazimine
Antiamoebic- metronidazole, tinidazole, dooloxanide furoate
Antiscabies- benzyle-benzoate, gama benzene hexachloride
Topical antifungal
Antiviral
Antocholenergic- Dicyclomine
Antiemetics
Antipyretics and analgesics
Laxatives
Oral rehydration solutions
Hematinics and vitamins
Bronchodilators- Salbutamol, theophyline, aminophyline
Expectorants
Oral Contraceptives
Gentian violet 1% solutions
Miconazole 1% cream
Vitamin A liquid
Vitamin B complex
Folic Acid tab
Xylocaine local
Methylergometrinc tablets
Mehylergometrne- injections ( For PPH)
IMPORTANT
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Certain Emergency drugs can be given before Referral
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Referral of all sick patients after initial management.
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Linkages with communities to increase the service delivery.
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Regular meeting with the peripheral staff.
PROCEDURES NOT TO BE PERFORMED BY A RURAL MEDICAL ASSISTANT
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Medicolegal Cases
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Postmortum
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- Media
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