There is a shortage of 22,845 healthcare workers across institutions due to unfilled sanctioned posts.
New Delhi: A recently released report by the Comptroller and Auditor General of India on public health infrastructure and management of health services in Madhya Pradesh, which is based on the audit done from 2017-18 to 2021-22, has brought out in public how officials and public representatives failed to do their job.
The 350 pages plus audit report, tabled in the state assembly on 18 December, has revealed glaring shortcomings, including the presentation of a false certificate to claim that a centrally funded medical center was completed when, in reality, the construction was still ongoing.
Among others, the report has found that there is a shortage of 22,845 healthcare workers across institutions due to unfilled sanctioned posts, particularly in Primary Health Centers (PHCs), Community Health Centers (CHCs), and Sub Health Centers (SHCs). Trauma care centers are not operating in 26 districts. Key outpatient (OPD) and inpatient (IPD) services are unavailable or incomplete in multiple hospitals. Essential OPD services are missing in hospitals, and there is a critical shortage of medical equipment, including X-ray machines, diagnostic tools, and surgical instruments. Drugs and consumables are either in short supply or mismanaged. Essential drugs for respiratory, cardiac, reproductive, and emergency care are missing in several District Hospitals (DHs).
Similarly, it found that while India made significant progress in reducing the Maternal Mortality Rate (MMR), achieving a 45.51% reduction from 178 in 2012 to 97 in 2020, Madhya Pradesh lagged behind significantly, reducing its MMR by only 24.78% during the same period, from 230 to 173.
In terms of child health, India set a target to reduce the under-five mortality rate to at least 25 per 1,000 live births by 2030. However, in Madhya Pradesh, this rate stood at 49.2 per 1,000 live births in 2020-21.
Additionally, the state government failed to achieve 100% vaccination coverage for newborns, with the vaccination rates for Measles and DPT standing at just 13% and 0.12% respectively between 2017-2022. As a result, the target of full immunization for children under five years was not met, as even zero-day immunization for newborns was not fully accomplished.
Due to non-functioning of outdated machines, more than 27,000 cancer patients could not get treatment of Cobalt therapy in government run hospitals in state capital Bhopal.
The state during this audit period was headed by Shivraj Singh Chouhan and then Congress’s Kamal Nath as the Chief Minister who served as the CM from December 2018 to March 2020.
The shortcomings highlighted in the audit report are largely attributed to long-term neglect and inefficiency. These issues stem from the actions or lack thereof of those in positions of power, specifically the health ministers, bureaucrats, and the Chief Minister prior to the audit. Union agriculture minister Shivraj Singh Chouhan, served as the Chief Minister of Madhya Pradesh from December 2008 to December 2023, with the exception of a 15-month period when Kamal Nath was in office.
One of the most glaring examples of how the babus and netas have swindled public money can be seen from how regarding an ongoing project in Trauma Care Center (TCCC) at the Gajra Raja Medical College (GRMC) in Gwalior, Madhya Pradesh. As per the Project Implementation Unit completion date of TCCC was mentioned as 17-09-2020, however, the work had yet to be completed. Further during joint physical inspection (June 2022), the audit noticed that civil work for the establishment of TCCC was not completed.
During the audit, records maintained at the Directorate of Health Services (DHS), Directorate of Medical Education (DME), National Health Mission, AYUSH (Ayurved, Unani, Siddha and Homeopathy) and Madhya Pradesh Public Health Service Corporation Limited (MPPHSCL) were examined. Records of three Government Medical Colleges and its attached hospitals, 10 CMHOs, 10 DHs, 10 District Health Societies, Eight CHs, 20 CHCs, 20 PHCs, five Government Ayurvedic Colleges, 10 District AYUSH Offices (four District AYUSH Hospitals and 39 dispensaries), Government Autonomous Homoeopathic College and Hospital, Bhopal and Hakim Saiyad Ziaul Hasan Government Autonomous Unani College and Hospital, Bhopal were also examined. Further statistical information was also collected from all the 51 districts of the State.
The CAG held its exit conference with the state government officials on 2 November 2023 with the Additional Chief Secretary, PH&FWD, Medical Education Department and Commissioner, Department of AYUSH wherein the audit findings were discussed with the Government and replies of audit observations were sought. The Public Health and Family Welfare Department furnished a partial reply while the AYUSH Department did not share any response with the CAG.
KEY FINDINGS
- Staff Shortage
The Madhya Pradesh government had adopted Indian Public Health Standards (IPHS) norms 2012, but it did not depute human resources as per IPHS norms. Shortage of 22,845 healthcare workers in healthcare institutions (HIs) was noticed due to not sanctioning 182 posts as prescribed in IPHS guidelines. Further, against sanctioned posts, 11,535 healthcare workers were less deployed in 1,775 health care institutions.
Similarly, the state government did not post the doctors/specialists according to the sanctioned strength.
There was a shortage of doctors ranging between 6% and 92% in District Hospitals (DHs), 19% and 86% in Community Hospitals (CHs), and in Community Health Centers (CHCs), Primary Health Centers (PHCs), and Sub Health Centers (SHCs), it ranged between 27% and 81%. There was a shortage of staff in all cadres of healthcare, ranging between 27% and 43% in Medical Colleges, and it ranged between 28% and 59% in the AYUSH (Ayurveda, Yoga & Naturopathy, Unani, Siddha, and Homoeopathy) department.
In the nursing cadre, there was shortage of nurses ranging between three and 69 per cent in DHs, between four and 73 per cent in CHs and between two and 51 per cent in CHCs, PHCs and SHCs against the sanctioned strength.
Further, there was a shortage of nurses up to 27 per cent in Medical Colleges and up to 59 per cent in healthcare institutions under the AYUSH department.
There was a shortage of paramedical staff ranging between 10 and 80 per cent in DHs, between seven and 75 per cent in CHs and between five and 67 per cent in CHC, PHCs and SHCs against the sanctioned strength. Further there was a shortage ranging between 14 and 100 per cent in Medical Colleges and it was 28 per cent in healthcare institutions under the AYUSH department.
Due to the non-availability of Anaesthetists, Surgeons, Operating Theatre (OT) Nurses, and OT Technicians, the quality of Operating Theatre (OT) services in nine District Hospitals (DHs), four Community Hospitals (CHs), and eight Community Health Centers (CHCs) out of 38 selected health institutions was adversely affected. Further, due to the shortage of nursing staff, quality healthcare to patients in Intensive Care Units (ICUs) and Special Newborn Care Units (SNCUs) of 10 selected District Hospitals (DHs) was compromised.
In 26 districts, Trauma Care Centres (TCCs) were not functional due to not deputing the staff as per sanctioned strength. Regular training of doctors and paramedical staff as envisaged in IPHS norms were not conducted.
Deficiencies in Outpatient and Inpatient Services, Diagnostic Equipment, and Emergency Care
Total 14 types of Outpatient Department (OPD) services as required in District Hospitals (DHs), AYUSH, Directly Observed Treatment (DOT), Integrated Counselling and Testing Center (ICTC), Psychiatry, and ENT (Ear, Nose, and Throat) services were not available in 25, 14, 12, and seven District Hospitals (DHs) respectively out of 51 District Hospitals (DHs). Further, out of the required 12 OPD services in Community Health Centers (CHs) and six OPD services in Community Health Centres (CHC), a full range of OPD services was not available in any of the test-checked Community Health Centers (CHs) and Community Health Centres (CHCs).
Minimum number of OPD patients required for students were not available in five out of seven AYUSH teaching hospitals.
Out of 10 selected DHs, eight CHs and 20 CHCs, full range of IPD services were not available in eight DHs, and in any of the selected CHs and CHCs.
OT for elective major surgery was not available in five CHs and OT for emergency surgery was not available in four CHs out of eight CHs. Out of 20 tests checked CHCs, OT was not available in 12 CHCs.
Against required 12 surgical procedures, tracheotomy, intestinal obstruction and haemorrhage and Nasal packing were not available in eight, four and two DHs respectively.
Out of 51 DHs of the State, an emergency unit was not available in two DHs. In 20 DHs resuscitation units and in 16 DHs, advanced life support ambulances were not available for transportation of referred patients.
Two doses of Tetanus Toxoid were not provided to all the pregnant women registered for AnteNatal Care. Further, 32 per cent (29,90,817 out of 93,88,418 women) were not registered in first trimester of pregnancy due to which 23 per cent (21,85,122 pregnant women) did not get all the required four or more ANC checkups during pregnancy. Out of total institutional deliveries, 10 per cent (6,69,619 out of 64,82,236) women were discharged within 48 hours after delivery which was against the norms.
There was a shortage of radiological and imaging equipment. 60 MA X-Ray Machine in 13 DHs, 100 MA X-Ray Machine in 11 DHs, 300 MA X-Ray Machine in seven DHs, 500 MA X-Ray Machine in 13 DHs, Dental X-Ray Machine in 18 DHs and Colour Doppler machine in 18 DHs were not available. In Pathological investigation, maximum shortage was noticed in Microbiology Investigation. Waiting period for USG in Jaya Arogya Hospital of GRMC Medical College, Gwalior, was 16 to 24 days.
Due to non-functioning of outdated Cobalt-60 machines, 27,894 cancer patients could not get treatment of Cobalt therapy in Hamidia Hospital, Bhopal. Patient specific diets such as diabetic, semi solid and liquid diet were not provided in 35 DHs. Quality of food provided to patients was not checked by competent authorities on regular basis in 40 DHs
Out of 10 selected districts, the trauma care centres were functional in three DHs. In four districts, trauma centre buildings were not available. Further, in three districts, despite availability of trauma care centre building, trauma care centres were not functional due to non-deployment of specialist doctors, trained manpower and non-availability of equipment. Thus, the aim of reducing the preventable deaths due to accidents as per SDG-3 objectives got defeated.
- Shortage of drugs
Availability of Drugs required for the treatment of respiratory and Cardiac patients were not ensured in ICUs of 10 test checked DHs. Shortage of respiratory drugs ranged between 11 and 16 drugs whereas, for cardiac disease treatment, it ranged between seven and 23 drugs. The shortage of drugs for Reproductive Tract Infection (RTI) treatment in selected DHs ranged between 28 per cent and 85 per cent. The highest shortages of drugs for treating RTI patients was noticed in DH Gwalior (84.62 per cent) and Chhatarpur (81.54 per cent).
Due to non-availability of consumables/reagents, six types of tests were not conducted in GMC Bhopal during 2017-18 to 2021-22. In CIMS Chhindwara, Arterial Blood Gas machine was also non-functional from April 2020 to March 2022 due to non-availability of cartridge and reagents.
Out of ten selected DHs, shortage of vital equipment in four DHs ranged between five and 16 per cent whereas in the remaining six DHs, shortage ranged between 22 and 48 per cent. Out of eight selected CHs, there was no OT in CH Teonthar. In three CHs (Berasia, Sendhwa and Hazira) no essential OT equipment was available. In the other four selected CHs, the shortage of essential equipment ranged between 50 and 88 per cent.
Due to mismanagement of stock, 263 types of medicines amounting to Rs 108.11 lakh expired in three hospitals attached to Medical Colleges.
In 20 test checked Health and Wellness Centres, out of 95 medicines required to be available, there was shortage of medicines ranging between 24 and 100 per cent (HWC Tikariya, District Mandla). Further, out of 65 equipment required, there was a shortage of 38 to 59 equipment.
Due to lack of administrative effectiveness in eight DHs out of 10 selected DHs, new equipment worth Rs 1.20 crore remained uninstalled and previously acquired equipment worth Rs 2.90 crore remained non-functional due to non-repairing/ maintenance.
Similarly, Indent Executing Agency (IEA), supplier agency of equipment for Medical Colleges of Madhya Pradesh government failed to supply 738 equipment costing Rs 19.77 crore ordered during 2017-22.
Corporation did not fix timelines for finalisation of tenders. In 30 tenders, the Corporation took six to 12 months for finalization of the rate contract.
Against the purchase orders issued for drugs and medicinal items, the supply was made with delay of one to 1550 days in 39 per cent supply orders and against the purchase orders issued for injections, supply was made with delay of one to 2088 days in 40 per cent supply orders.
In the case of 564 drugs/medicinal items during 2017-22, DDOs/purchasing authorities ignored the available central rate contract and made purchases amounting to Rs 8.57 crore in excess of the central rate contract.
For acquiring Ayurvedic medicines, 81 to 96 per cent of expenditure was incurred to procure medicines from Laghu Vanopaj Sangh.
Similarly, Government Unani Pharmacy was also unable to achieve the target due to shortage of human resource. In seven test checked teaching hospitals of AYUSH department, shortage of equipment in OPD ranged between 28 and 77 per cent and in IPD it ranged between 10 and 60 per cent.
3. Functioning without license
Out of eight selected CHs, only three CHs (Sendhwa, Kukshi and Badnagar) had valid authorization for operating blood storage units. Out of 20 selected CHCs, only two CHCs (Badnawar and Majholi) had a blood storage unit facility. Blood bank in JAH Gwalior was running without license during 2017-22 as their license had expired on 31.12.2016.
Out of 38 selected health institutions (10 DHs, eight CHs and 20 CHCs), 16 HIs were operating different types of X-ray machines without license/ renewed license. Out of 51 DHs of the State, in 17 DHs, the Effluent Treatment System was not established. In 12 DHs, air swab samples were either not collected or not sent for reporting. In 14 DHs, a yearly report regarding disposal of various categories of bio-medical waste was not sent to the State Pollution Control Board.
Out of 38 healthcare facilities (10 DHs, eight CHs and 20 CHCs), no beneficiary survey of OPD patients was conducted in 35 healthcare facilities (except DH Jabalpur, DH Ujjain and CH Rani Durgawati Hospital, Jabalpur) during the period 2017-22. Similarly, OPD and IPD survey was not conducted during 2017-22 in three hospitals out of four hospitals attached to three selected Medical Colleges. No complaint register was maintained, and no complaint redressal committee was constituted in the hospitals attached to two medical colleges GMC, Bhopal (Hamidia and Sultania Zanana Hospital) and GRMC, Gwalior (JAH, Gwalior) during 2017-2022. Against the requirement of 10 meetings, only one to three meetings of the General Council of AYUSH Department were held.
- Pregnancy, infant related discrepancies
Gynaecologist or CAC trained Medical Officers were not posted in seven out of 20 selected CHCs and Medical Termination of Pregnancy (MTP) was carried out by untrained staff, thereby putting lives of patients at risk. C-section deliveries were performed with non-availability of 31 types of drugs prescribed in JSSK Guidelines, 2011 in seven test checked DHs and six CHs. Maximum shortage of C-Section medicines was noticed in CH Badnagar (14 drugs).
Provision of Rs 46.63 crore was made in State Programme Implementation Plans for procurement of Haemoglobinometer during 2018-22. These meters were to be procured for 76 lakh Hemoglobin (Hb) test of Pregnant Women and 176 lakh Hb test for children up to 19 years of age. NHM accorded approval for procurement of 12,700 haemoglobin meters in 2019-20 for next two years, however, it could not be procured due to non-availability of Rate Contract with MPPHSCL and PH&FW Department.
The percentage of home deliveries decreased from the year 2017-18 onwards and it almost remained constant during the year 2018-21.
- No effort to build required hospitals and medical centers
Number of CHCs, PHCs and SHCs established in the State were not in accordance with the IPHS population norms and there was shortage of 249 CHCs (41 per cent), 1,147 PHCs (48 per cent) and 4,904 SHCs (32 per cent) as of March 2022.
The Madhya Pradesh government has not made sincere efforts to expand the AYUSH hospital services since the last 40 years. Consequently, 26 districts were not having facilities of AYUSH hospitals.
In five selected DHs waiting time for registration was much higher as data indicates that in one counter per hour 20 to 45 patients were arriving for registration. There was a shortage of drug dispensing counters in JAH, Gwalior, and in Hamidia Hospital, Bhopal.
Out of 51 DHs of the state, in 33 DHs, there was a shortage of 5,345 beds against the required 19,024 beds as per IPHS norms. Major shortage was noticed in 18 DHs which ranged between 31 and 88 per cent with 4387 beds.
ICU beds were not available in the DH Betul, Indore and Umaria. Shortage in ICU beds ranged between 50 per cent and 73 per cent in nine DHs. In SNCUs of 10 selected districts, except in three districts, the shortage of SNCU beds ranged between one and 22 beds. Further in CIMS Chindwara shortage of SNCU beds ranged between two and 14 beds. Out of 2,436 SHCs targeted to be upgraded as HWCs, only 2,175 SHCs were upgraded, out of which in 209 HWCs, Community Health Officers were not posted.
- Under-utilization of central money
Ministry of Health & Family Welfare (Government of India) implemented a Central Sector Scheme “Human Resource Development for Emergency Medical Services” wherein, medical colleges were provided grant-in-aid of Rs 2.90 crore for setting up NELS skill Center and thereafter impart training in emergency life support to doctor, nurses and paramedics, medical personnel of state Health Departments. A memorandum of understanding (MOU) was signed (July 2018) between MoH&FW, Government of Indiaand Medical Education Department of Madhya Pradesh government for setting up a skill center in GRMC, Gwalior. As per the MOU, the skill centre was to be set up within a period of six months from the date of signing of MOU. Skill Centre was not started even after the lapse of three years from the date of signing of MoU.
Government of India accorded (July 2013) administrative approval for establishment/ strengthening of Multi-Disciplinary Research Units (MRUs) in GMCs and Research Institutions during 12th Five Year Plan.
GoI allotted (September 2018) Rs 1.25 crore as 1st installment to GMC, Bhopal with instructions that release of 2nd and 3rd installments would be subject to the achievements with reference to the laid down markers/milestones of the scheme.
Against the allotment of Rs 1.25 crore, equipment of Rs 61.56 lakh only was purchased during the year 2021-22. Non-fulfillment of conditions given by Government of India resulted in the non-eligibility for 2nd and 3rd installments. The equipment purchased for MRU lay idle till May 2022.
GRMC, Gwalior received Rs 1.25 crore in March 2020 for the establishment of MRU but no amount was spent till March 2022.
GoI, Ministry of Social Justice & Empowerment, Department of Empowerment of Persons with Disabilities, approved (November 2018) the Central Sector Scheme for establishment of State Spinal Injury Centre (SIC) for the comprehensive management of spinal injuries at Gandhi Medical College and Hamidia Hospital, Bhopal and released (November 2019) Rs 2.82 crore. Out of Rs 2.82 crore received from GoI, GMC, Bhopal transferred (December 2019) Rs 45.49 lakh to PIU-2 unit of Public Works Department, Bhopal for infrastructure work and purchased equipment amounting to Rs 38.90 lakh only and Rs 1.98 crore remained unspent. However, SIC was not established (May 2022) due to which patients related to spinal injury were deprived of special treatment.
The Madhya Pradesh government allocated a budget of Rs 52,068.83 crore for the health sector (PH&FWD, MED and AYUSH Department), out of which expenditure of Rs 45,326.05 crore (87 per cent) was incurred during the period 2017-22. Thus, there was a saving of Rs 6742.78 crore (13 per cent). The reasons for saving could not be ascertained as the copies of sanction letters of budget were not furnished to audit. The total expenditure on the health sector including share of Government of India vis-à-vis Gross State Domestic Product (GSDP) ranged between 0.94 per cent and 1.05 per cent which was less than the target of 2.5 per cent under NHP.
- No effort to meet the goals set by the center
As per NHP, the expenditure on the health sector was to be increased to more than eight per cent of the State budget by 2020. However, total allotment from the State budget and Government of India itself was less than eight per cent and it ranged between 3.61 and five per cent during the period 2017-22.
The target of two third (66.67 percent) expenditure on primary healthcare as envisaged in NHP, 2017 was not achieved by the Madhya Pradesh government as the actual expenditure on primary healthcare ranged between 12.60 and 17.76 per cent of the total expenditure during 2017-22. Under National Health Mission (NHM), out of total available funds of Rs 12,419.36 crore, there was unspent balance of Rs 3,116.63 crore during 2017-22. During the above period, unspent funds ranged between four per cent (2018-19) and 42 per cent (2021-22).
No provision for committed expenditure was made in the State Programme Implementation Plan (SPIP) but Rs 89.10 crore and Rs 173.95 crore was released against which expenditure of Rs 41.29 crore and Rs 124.54 crore was spent during the year 2019-20 and 2020-21 respectively. Similarly, in the year 2021-22, against the provision of Rs 12.05 crore in SPIP, Rs 294.86 crore was released and Rs 221.08 crore was spent which was unauthorized.
State Health Society (SHS) was required to approve the State Programme Implementation Plan by 15th January every year which was to be received in the Ministry of Health and Family Welfare (GoI) by the third week of January. SHS approved SPIPs with delay ranging between 34 days and 52 days during 2017-22.
The NHM provisioned Rs 36 crore in SPIP for procurement of screening tools for District Early Intervention Centre (DEIC) and Early Childhood Development (ECD) during 2017-18 to 2021-22 under Rashtriya Bal Swasthya Karyakram. However, NHM released only Rs 12.30 crore, out of which only Rs 9.96 crore was spent on procurement of equipment.
Fund of Rs 26.04 crore was kept at State level for issuing it on demand from the district offices, however, demand from the districts was not found in record. Total Rs 2.69 crore was released to test checked districts out of which Rs 2.24 crore was spent on procurement of equipment. No fund was released during 2020-21 and 2021-22 to districts.
Government of India allotted Rs 146.49 crore out of which only Rs 87.64 crore (59.83 per cent) could be expended during 2017-22 on procurement of IFA syrups and tablets and programme implementation. Thus, the funds were not fully utilised for implementation of the programme.
The District Health Action Plan (DHAP) was not prepared by four districts (Jabalpur, Mandla, Rewa and Ujjain) at district level. Similarly, nine District Health Societies (DHS) indicated that the Block Health Action Plan was not prepared. Thus, due to non-preparation of DHAP and BHAP, a bottom-up approach for planning was not followed. State Health Society (SHS) approved SPIPs with delays ranging between 34 days and 52 days.
Under Anaemia Mukt Bharat (AMB), haemoglobin (Hb) levels of all the Pregnant Women (PW) and school going children between 10 and 19 years of age in Government Schools and Government aided schools were to be checked by digital haemoglobinometer. Due to delay in procurement of haemoglobin meters, the screening of Anaemia in different age groups could not be done during 2018-19 to 2021-22.
- AYUSH fails
Public Health Outreach Activity (PHOA) was to be undertaken to focus on increasing the awareness about AYUSH’s strength and a Community Based Surveillance System (CBSS) was to be established for early identification of the disease outbreak and to increase the accessibility of AYUSH treatment and a health education team was to be constituted in every panchayat, education institution, etc. for conducting health education classes. However, the State had neither established any CBSS nor constituted any health education team in any of the test-checked districts. AYUSH Gram was a concept wherein one village per block was to be selected for adoption of method and practice of AYUSH way of life and interventions of health care. Financial assistance of Rs 9.60 crore was given to the State during 2018-22. It was found that only 75 villages in 58 blocks of 32 districts were identified as AYUSH Gram against 313 blocks in 51 districts of MP. As per National AYUSH Mission framework, School Health Programme (SHP) is one of the core activities of AYUSH services for addressing the health needs of school going children. The Madhya Pradesh government did not implement this programme.