CRISIS IN KERALA HEALTH CARE SYSTEM

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BONDED SERVICE VS. PUBLIC SERVICE:

BONDED SERVICE VS. PUBLIC SERVICE CRISIS IN FRONT OF THE KERALA HEALTHCARE SYSTEM

BONDED SERVICE- A SHORT HISTORY:

Introduced in 2004 vide GO(MS)263/04/H & FWD dated 04/10/2004 Above GO states that bonded service of 1 year is required due to : 1. scarcity of doctors in rural areas in the govt. sector. Listed vacancies remain unfilled. 2.students who have studied at govt. subsidized rates have a social obligation towards the people BONDED SERVICE- A SHORT HISTORY

EVOLUTION OF BONDED SERVICE:

2006 – 6 months optional posting 2007 – 6 months compulsory posting 2008 Jan – 1 year compulsory posting 2008 Oct – 3 year compulsory posting State wide protest against the unscientific policy Consensus made between Govt. and students New GO (MS) 533/2008 passed on 07/10/2008 EVOLUTION OF BONDED SERVICE

GO(MS) No. 533/2008/H&FWD:

Clause 1 – Applicable to all Govt. students /self financing / co-operative medical colleges Clause 10 – cumulative period if 1 year in a lifetime. Those who have completed one year need not do after PG/ Diploma/ Superspeciality . Those who have not have to do the remaining period. GO(MS) No. 533/2008/H&FWD

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2009 – status quo continues 2010 – GO number being removed from the bond document 2012 – senior residents who have completed cumulative period of 1 year being denied their TC and all academic original certificates . A few could not join higher studies due to the reason. 2012 Jan – High Court rules against the Govt. on this issue. Govt. being criticized by the court .

2012 FEBRUARY 16:

GO (MS) 56/2012 passed Bond of 1 year each after MBBS,PG,DIPLOMA,SUPERSPECIALITY (TOTAL 3 YEARS) Previous status of rural service nullified 2012 FEBRUARY 16

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ARE THERE NOT ENOUGH DOCTORS IN GOVT. SERVICE ?

VACANCY STATUS:

DME (5 MEDICAL COLLEGES) 2009 – 127 2010 – 37 2011 – 14 (Source : www.keralapsc.org ) VACANCY STATUS

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DHS (PHC/CHC/W&C/TALUK/ DISTRICT/ GENERAL HOSPITAL) TOTAL 643 CIVIL SURGEON – 71 ASSISTANT DENTAL SURGEON – 11 CONSULTANT – 31 SENIOR CONSULTANT – 3 CHIEF CONSULTANT – 2 JUNIOR SURGEON – 299 ASSISTANT SURGEON – 226 (Source: Answer by Health Minister in Legislative Assembly)

PSC RANK LIST:

SEPT 2010 TOTAL APPEARED : 3940 ADVICE MEMO SENT: 685 GQ + RESERVATION 3300 REMAIN AWAITING ADVISE MEMO ONE AND A HALF YEARS PASSED SOURCE : www.keralapsc.org PSC RANK LIST

IF STILL NOT SATISFIED…:

Loksabha unstarred Q No: 87 dated March 1 2011: List of states with scarcity of doctors PUNJAB ASSAM UP BIHAR IF STILL NOT SATISFIED…

KERALA ?:

No. of doctors at PHC s – - Required – 697 - Existing – 1063 Specialist doctors at CHC s all over India deficiency in all states Least deficient : KERALA (794/904) far ahead of all other states – PSC RANK LIST STILL EXISTS. KERALA ?

STILL NOT SATISFIED ?:

Reason why still there is scarcity even if statistics show sufficient workforce. As per GO (MS) No. 45/2007 dated 13/3/2007 staff pattern set in 1961 has not been amended over the last 50 years. Population increased 3 times. Doctor patient ratio decreased by 3 times. STILL NOT SATISFIED ?

STATUS UNDER DHS:

Total number of hospitals – 1255 P H C – 660 24 X 7 P H C – 175 C H C – 230 Taluk Hospital – 80 D H & G H – 26 Others – 65 Sub centre – 5403 Source (state (3)41230/12/DHS & Twelfth five year plan 2012-17dated 7/12/2011) STATUS UNDER DHS

NUMBER OF DOCTORS WE NEEDED ?:

P H C – 660 X 2 doc = 1320 24 X 7 P H C – 175 X 7 doc = 1225 C H C – 230 X (4 specialty cadre ie Med, Paeds , OBG, Surg , Anaes + 7 asst. surgeon) = 2530 Taluk Hospital – 80 X (7 asst. surgeon/ casualty m o + 14 specialty cadre ( ie 2 X Med, Surg , OBG, Paeds , + 1 ortho , ENT, Anaes , Dermat , Psychiatry, Ophthal ) = 1680 NUMBER OF DOCTORS WE NEEDED ?

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D H & G H – 26 X (7 asst. surg / casualty m o + 24 specialty ( ie 3 X Med, Surg , OBG, Paeds , Anaes , ortho + 1 X ENT, Opthal , Dermat , Psych, R T, Chest) + 3 super sp.( ie Nephro , Cardio, Neuro ) = 884 Others – 65 X 2 = 130 Total needed = 7769 Create an administrative cadre above the level of PHCs – 364 (336 CHCs, T H, D H & GH + 14 DMO + 14 ADMO) Now total needed = 8133 Total asst. surg /casualty M O = 4477 Total specialty cadre = 3292

ACTUAL STATUS IN DME (ref:G16011/2012/DME dated 28/03/2012) :

Total vacancies – 322 Professor – 7 Associate – 56 Assistant professor – 71 Senior lecturer – 188 ACTUAL STATUS IN DME (ref:G16011/2012/DME dated 28/03/2012)

WHAT IS HAPPENING?:

14 Vacancies for doctors remain in 2011 against which 40 advice memos have been sent. Approximately no vacancies available. Or no vacancies being reported. Transfer hustle during IMC inspections points towards this. Senior residents are also being shown in IMC inspections and they too are transferred. WHAT IS HAPPENING?

CRS – a FAILURE, WHY?:

Govt offered PG entrance weightage - not getting (GO 533/2008 dated 07/10/20080 Salary for CRS is 20,000 , while that of assistant surgeon is 38,000 and temporary M Os 32,000 (ADHOC) & 34,000 (NRHM) Govt offered quarters – not getting Not at all attractive CRS – a FAILURE, WHY?

INFERENCE:

EXISTING VACANCIES IN DME ARE EITHER FILLED OR ARE NOT BEING REPORTED. SENIOR RESIDENTS IN MEDICAL COLLEGES ARE SHOWN AS FACULTY, FURTHER JUSTIFYING OUR CLAIM THAT VACANCIES ARE NOT BEING REPORTED. PRIMARY HEALTH CARE SYSTEM IN KERALA HAS SUFFICIENT DOCTORS, AT LEAST ON PAPER. NO POST CREATION BEING DONE IN THE LAST 50 YEARS. BONDED SERVICE IS BEING USED AS A TOOL TO COVER UP THE GOVT. RELUCTANCE TO CREATE PERMANENT POSTS FOR DOCTORS IN THE KERALA HEALTH SERVICE INFERENCE

DOCTORS HAVE NO RIGHT TO CONCEIVE?:

DOCTORS HAVE NO RIGHT TO CONCEIVE?

RESIDENCY SYSTEM :

Implemented to achieve better health care by GO (MS) 20/09/H&FWD dated 13/01/2009 Resident doctor will be a temporary employee of the institution Resident doctor is the junior most staff member to provide service to patients Govt offered family quarters, medical leave, maternity leave, reasonably good stipend What we got – only maternity benefits, but…. RESIDENCY SYSTEM

MATERNITY BENEFITS:

Woman residents are eligible for maternity leave for a period of 120 days with full stipend during maternity leave and extension period by GO(MS)380/09/H&FWD dated 31/10/2009 The maternity benefits of woman residents are lifted by GO(MS)574/11/H&FWD dated 22/12/2012 Average age of woman resident is 25 – 32 Why this discrimination? MATERNITY BENEFITS

DOCTORS ARE MADE FROM TAXPAYERS MONEY:

DOCTORS ARE MADE FROM TAXPAYERS MONEY - FACT OR MYTH ?

KERALA BUDGET 2011 – 12 source: www.finance.kerala.gov.in:

Medical education – 414 crores University education – 1500 crores Primary and Secondary education – 7600 crores Technical education – 396 crores Sports and youth welfare – 102 crores Art and culture – 102 crores Agricultural education – 182 crores KERALA BUDGET 2011 – 12 source: www.finance.kerala.gov.in

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Medical education – 4 % of money allocated for education, 0.8 % of total budget Medical education includes MBBS,PG,Superspeciality,Nursing,BDS,MDS , MLT,B Pharm,M Pharm,DMLT,DRT,Ophthalmic assistant,X ray technician,DOTT etc. Budget allocated for five medical colleges - Rs. 52 crore

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According to a journal published in www.indmedica.com for 50 bedded subdistrict hospital in 2000 approx.- 1.54 crore required per annum Total bed strength in kerala medical colleges approx. 7000 so total minimum required as per above journal – 215 crore How can 52 crores meet this expense ? We seriously doubt the above amount being met with the budget allocated for medical education (414 crores )

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Money spent on teaching staff forms the major chunk of the money allocated for medical education. Teaching staff in medical colleges spends less than 5% time for teaching, The major work they do is for the patients. Residents spend less than 5 % time for academics.

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Only two departments in the medical colleges namely Physiology and Pharmacology is solely for students. The rest (34) of the departments is primarily patient oriented.

FEE STRUCTURE IN MEDICAL COLLEGES:

MBBS – Rs 25,000 PG – Rs 50,000 Superspeciality – Rs 70,000 All of the above mentioned fees are the HIGHEST IN INDIA. Approximate income from fees – 50 crores Still residents are not provided with residence and the major bulk are staying outside. FEE STRUCTURE IN MEDICAL COLLEGES

SO IN FEE KERALA STANDS:

SO IN FEE KERALA STANDS

EXAM FEE STRUCTURE IN MEDICAL COLLEGES:

EXAM FEE STRUCTURE IN MEDICAL COLLEGES M G CALICUT KUHS M B B S 600 600 2500 P G DIPLOMA 600 600 3100 P G DEGREE 900 750 6100 SUPERSPECIALTY 900 750 16100

THESIS FEE STRUCTURE IN MEDICAL COLLEGES:

M G 500 KUHS 2000 + 2000 + 2000 THESIS FEE STRUCTURE IN MEDICAL COLLEGES

INFERENCE:

Money spent per medical student is too meagre than what is speculated. Money spent on hospital functioning and patient care is claimed to be spent on students. INFERENCE

BOND SYSTEM IN OTHER STATES:

Presently bond system exists in Maharashtra and Tamil Nadu. Maharashtra – Post MBBS bonded service planned to be lifted as per statement from Dr. Vijaykumar Gavit , the state medical education minister. Specialist doctor requirement in MH is 1504 versus an existing 439.A deficit of more than 1050. BOND SYSTEM IN OTHER STATES

TAMIL NADU:

– No bond for post MBBS 2 yr bond as service MO (with all allowances) for post PG students. Deficit of speciality doctors in CHC s in TN is 1024 Source : Rajya Sabha starred Q# 87, dated March 1,2011 Deficit of 1000 specialist doctors each in these states justifies bond system, while in kerala the deficit is as small as 100 ( psc rank list remains) TAMIL NADU

BOND SYSTEM IN PRIVATE SECTOR:

As per GO(MS) 533/2008 bond system is also applicable to self financing and co-operative colleges. The honourable High Court ruling in writ petition (E)No. 2500 0f 2007 states that even students who studied using their own money ( paid seats) have social obligations towards the community to serve in rural areas. BOND SYSTEM IN PRIVATE SECTOR

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Still the govt. has not shown any interest in calling the students from self financing / cooperative medical colleges (even those who have studied in Govt. quota) for counselling or rural postings. This action on the part of the Govt. clearly favors the private sector.

BOND SYSYTEM IN OTHER PROFESSIONAL COURSES:

Bond system was only applicable to medical students and nursing students till date. Students from IIT,IIM, engineers, advocates etc. are exempted. Govt. does not insist them to work in Govt. sector nor does it insist them to work in their mother country. BOND SYSYTEM IN OTHER PROFESSIONAL COURSES

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Recently the Indian Nursing Council as per circular F. No.1-5/GB-CIR/2011-INC dated Aug 29, 2011 states that taking service bond from students and retaining their original certificates is an unethical practice. The Govt. Of Kerala as per GO ( Ri ) No. 3006/2011 has lifted the bond for nursing students.

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Even in such circumstances the Govt. insists on bonded service for doctors. Why this paradoxical treatment ?

BONDED SERVICE – IMPACT ON PUBLIC HEALTH:

BONDED SERVICE – IMPACT ON PUBLIC HEALTH

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In this respect no scientific studies has been conducted by the Govt. A few inferences from the above presentation are stated below: CRS/Senior residency stands as a hindrance for effective post creation and proper vacancy filling. The concept of permanent doctor/ family doctor is on the path of extinction.

WHAT DOES W.H.O. SAY ?:

Compulsory service program are a mechanism for staffing and reinforcing the health workforce especially in areas where access to primary and essential health care services and systems is weak(certainly not in the case of kerala ). Compulsory service may not be able to provide a permanent answer to capacity development, nor guarantee the development of a permanent workforce for underserved communities. (source: www.who.int/bulletin/volumes/88/5/09-071605/en/index.html) WHAT DOES W.H.O. SAY ?

RECENT TRENDS IN KERALA HEALTH SYSTEM:

Kerala is losing its index position in health care system in recent times. This is attributed to two reasons: 1. Lack of permanent staff in health care system hindering policy implementation 2. Health expenditure is far less than similar health care systems. America spends 16 %, Australia 7%, Cuba 11 % of their respective GDPs while India just 1.5 % of the GDP and in Kerala only 4 % RECENT TRENDS IN KERALA HEALTH SYSTEM

WHAT CAN BE DONE ?:

1. FILL ALL THE EXISTING VACANCIES FROM THE EXISTING PSC LIST. 2. IMMEDIATE ABOLITION OF BONDED SYSTEM WHICH IS UNLAWFUL AND IS CAUSING DEPRIVATION OF PERMANENT DOCTORS. 3.CREATION OF POSTS SO AS TO MEET THE INCREASING POPULATION’S NEEDS. 4. INCREASE GOVT. ALLOCATION OF FUNDS IN HEALTHCARE SYSTEM. 5.TO CONDUCT SCIENTIFIC STUDIES TO UNDERSTAND THE HEALTHCARE NEEDS OF THE PUBLIC. WHAT CAN BE DONE ?

NOW WE NEED :

Withdraw 56/2012 H & FWD dated 16/02/1012 Fill all vacancies immediately Create a medical recruitment board to facilitate appointments under health sector (Recommendations to improve health & allied specialties by Dr. B. Ekbal 2007) Abolition of bonded system which is causing deprivation of permanent doctors Maternity benefits of Junior & Senior Residents should be similar to that of other temporary staff in Govt. services - 180 days P G & U G fee structure should be similar to that of other universities There should be a centralized counseling and allotment process for the posting of senior residents (bond) for the current year NOW WE NEED

THANK YOU:

THANK YOU