The carpenter makes furniture and goldsmith, jewellery, not vice versa. The barber cuts the hair and makes it stylish, not the mason. That is common sense. It involves no rocket science.
But the irony is such conventional wisdom is grossly lacking in the public health structure in most States. Specialists are not available in the so-called “referral hospitals.”
In case of a road accident, the public hire a taxi or an autorickshaw and rush the victims to the nearest taluk or sub-divisional hospital only to realise that there is no surgeon or orthopaedician. The post is vacant for so many years! To their utter disgust, the relatives find that there is in fact an orthopaedician but posted in a Primary Health Centre (PHC) supervising immunisation and family planning programmes as the Medical Officer!
The same is the fate of many pregnant women — especially those with complications — reaching many Community Health Centres (CHCs) identified as the First Referral Units (FRUs) or Comprehensive Emergency Obstetrics and Newborn Centres (CEmONC). They are supposed to be saved by an obstetrician, anaesthetist, and paediatrician team. At times, all of them are absent or only one is present which is not effective. The result is such patients have to be taken to the medical colleges or district headquarters hospitals for any meaningful life-saving intervention and care.
During an official visit to Nizamabad district in Andhra Pradesh in 2006, I found that many identified FRUs did not have the combination of anaesthetist-obstetrician-paediatrician. At the same time, five specialists were wasting their time as MO-PHCs or as in charge of public health programmes. This was immediately brought to the notice of the then Principal Secretary and Commissioner of Health and Family Welfare.
Can't we relocate the specialists within the district, region or State for better utilisation of their skills?
This proposition is not a theory of probability, but a feasible option demonstrated by Vikas Sheel, Health Secretary, Chhattisgarh. The State has rationalised the deployment of the available specialists with the firm principle that “no specialist doctor will be posted at the PHC level in order to ensure the filling up of all specialists in the district hospitals and community health centre as per norms.” They could identify 26 specialist doctors and nine doctors with short-term skill training in life-saving anaesthesia and emergency obstetric care, who were serving as general duty medical officers in the PHCs. They were compulsorily transferred to the district hospitals or CHCs.
Additionally, when the Public Service Commission was about to complete the selection of doctors for the PHCs, there were 61 doctors with post-graduate qualifications in different specialities. The government took a proactive step of appointing all of them in district hospitals and the CHCs and they were not sent to a PHC which would have been their normal entry point to government service.
Out of the 9,856 doctors appointed till September 2010, under the rejuvenation effort of State health systems in the country by NRHM, 1,572(15.9%) were specialists. It is worthwhile to evaluate whether they are posted in the right places giving the best output?
There are ENT surgeons and radiologists managing malaria and leprosy control programmes in some districts and ophthalmologists are posted as epidemic and diarrhoeal disease control officers. Is it not absurd?
There is a shortage of specialists for many reasons. Agreed. But who asked you to fritter away whatever specialists you have? That is unpardonable. If there is some accountability to the people, you will wisely deploy them. Such a professional challenge will be in the interest and career progression of the specialists too. They will get motivated to serve the public health system longer rather than quitting when and where they pick up a good private practice on the sly.
Otherwise, they lose their skills and society loses them too. During 1997-2001, I came across many paediatricians in Uttar Pradesh, who could not intubate and resuscitate a newborn as they were not using those skills in a PHC or rural setting for many years. At a State-level workshop facilitated by Sight Savers International, it came to light that only 39 out of about 70 ophthalmologists in government service could do cataract surgery. The rest were “non-operating eye specialists” doing administrative jobs and managing the PHCs!
Unfortunately, specialists are not produced as per the country's needs. They are generated as per the prescribed capacity and norms of training available in medical colleges and speciality training centres. So there are historical production lags vis-a-vis the need for anaesthetists, ophthalmologists, obstetricians, paediatricians and qualified Public Health specialists, for example. At the same time, we find many postgraduates qualified in anatomy, physiology, or forensic medicine earning a living by doing general practice as the posts in teaching institutions for those branches are exhausted. If the available posts in a particular speciality are saturated, why spend public funds in training doctors in such a speciality? Why dangle a deceitful carrot to low-ranked candidates in the postgraduate entrance test? Can't we have a need-based moratorium on intake in post-graduate medical studies?
Alluring jobs in super-speciality centres in the country as well as abroad make the newly qualified doctor specialists close their eyes to the acute shortage of their breed in the public health system of their State. The numbers available are small and precious.
It is all the more reason for searching for them individually rather than through a bureaucratic procedure — notification for an interview with deadlines, catering for their personal choices of posting like place and time and special needs like joint postings for husband and wife and opportunity for teaming up with compatible friends of different specialities in one location, etc.
It is high time the Secretaries and the Directors of Health Services got their act together like high level human resource managers approach good colleges for campus placement in a competitive manner.
(The writer is a former Health & Nutrition Specialist for UNICEF and former Director, State Health Resource Centre, Chhattisgarh. His email id is krantony53@gmail.com)
