Public Health Workforce Issues and Challenges

JAMMU AND KASHMIR

September 2013

National Health Systems Resource Center, National Rural Health Mission, Ministry of Health and Family Welfare, Government of India

2

Public Health Workforce: Issues and Challenges

I. Overview of Public Health Workforce

Jammu and Kashmir has a population of 12548926 as per the provisional results of the Census

of India 2011. J&K is divided into 2 main divisions which administratively function separately

i.e Jammu and Kashmir. Jammu division has 10 districts i.e. Kishtwar, Kathua, Poonch,

Rajouri, Ramban, Reasi, Samba, Udhampur, Jammu and Doda. Kashmir division has 12

districts namely, Anantnag, Bandipora, Baramulla, Budgam, Ganderbal, Kargil, Kulgam,

Kupwara, Leh, Pulwama, Shopian and Srinagar. The following public health infrastructures are

available in its 22 districts of Jammu & Kashmir.

Table 1: Status of public health infrastructure in JK (Source: State PIP 2013-14)

Health Facilities In-position Required

District Hospitals 22 22 Sub Divisional Hospitals 84 (SDH+CHC) 114 required (SDH+CHC) Community Health Centers Primary Health Centers 637 565 Sub Centers 2265 3772

The healthcare workforce in the state can be broadly classified into 3 categories: regular

government employees, state contractual employees and NRHM contractual employees. The

healthcare workforce (regular) availability across the districts in the 2 divisions of the state is

given in table 2.

Table 2: District-wise availability (in-position) of regular medical doctors

Sr. No.

District Gynae Paed Anes Other specialist

MBBS M.O

Dental surgeon

1 Bandipora 1 0 3 5 44 11

2 Doda 4 2 2 10 74 20

3 Kargil 2 2 2 10 24 1

4 Kishtwar 2 1 2 4 37 8

5 Kupwara 0 2 4 4 105 26

6 Leh 2 2 2 4 35 3

7 Poonch 3 2 3 15 51 12

3

8 Rajouri 5 4 4 14 83 25

9 Ramban 2 2 2 3 35 10

10 Reasi 3 1 3 6 42 11

12 Anantnag 6 4 3 11 93 34

13 Baramulla 4 1 11 15 43 41

14 Budgam 5 3 9 20 154 57

15 Ganderbal 2 1 2 3 46 20

16 Jammu 15 7 9 35 215 49

17 Kathua 7 3 3 14 78 24

18 Kulgam 1 1 2 7 67 23

19 Pulwama 4 3 5 9 81 22

20 Samba 3 3 4 5 56 17

21 Shopian 2 2 1 6 37 13

22 Srinagar 3 2 3 13 81 18

Total 80 50 82 218 1648 467

Table 3: District-wise availability (in-position) of regular skilled health workers

Sr. No.

District SN ANM MPW Pharmacist

L.T X -ray

1 Bandipora 0 53 0 535 11 5

2 Doda 29 123 6 118 32 12

3 Kargil 0 0 0 535 0 0

4 Kishtwar 10 47 5 48 13 10

5 Kupwara 0 196 8 976 37 21

6 Leh 0 0 0 980 0 0

7 Poonch 43 141 10 137 34 18

8 Rajouri 49 209 24 160 37 20

9 Ramban 24 87 2 77 15 7

10 Reasi 24 54 2 60 17 9

12 Anantnag 0 88 17 1126 52 28

13 Baramulla 0 74 12 1156 45 23

14 Budgam 0 73 19 1265 40 24

15 Ganderbal 0 14 1 377 16 8

16 Jammu 68 258 27 140 70 31

17 Kathua 60 166 30 143 45 16

4

18 Kulgam 0 110 19 745 22 13

19 Pulwama 0 43 6 591 20 15

20 Samba 21 94 3 5 18 13

21 Shopian 0 57 7 77 13 8

22 Srinagar 0 30 3 508 23 15

Total 352 2058 205 10137 594 313

Source: Performance Review. 2013 of Department of Health & Family Welfare, Government of JK

Table 4: Status of permissible and the in-position of specialists, medical doctors and

AYUSH doctors under contractual NRHM appointment across the districts in JK as in

March, 2013

Sr. No.

Name of District

Specialists MBBS Doctors ISM Doctors

Per. IP Per. IP Per. IP

1 Kishtwar 0 0 20 20 13 13

2 Kathua 2 2 33 23 31 31

3 Reasi 1 1 18 13 19 19

4 Doda 1 1 28 21 22 22

5 Samba 2 2 14 14 11 13

6 Jammu 2 2 48 41 33 29

7 Poonch 2 2 25 19 22 21

8 Rajouri 2 2 38 36 30 30

9 Ramban 0 0 18 18 14 14

10 Udhampur 3 2 22 19 26 26

GMCJammu 9 5

DHS Jammu 6

Total Jammu Divn. 30 19 264 224 221 218

11 Anantnag 3 3 25 25 26 26

12 Bandipora 0 0 14 14 7 7

13 Baramulla 2 0 30 30 33 33

14 Budgam 2 2 33 33 45 35

15 Gandrebal 2 2 15 15 15 15

16 Kargil 1 0 16 11 4 4

17 Kulgam 2 1 23 23 19 19

18 Kupwara 5 5 35 34 36 36

19 Leh 2 1 33 24 26 26

20 Pulwama 0 0 17 17 17 17

5

21 Shopian 3 3 12 11 9 9

22 Srinagar 1 1 10 6 9 9

GMCSrinagar 12 9 0

DHS Kashmir 4 4

Total Kashmir Divn. 35 27 267 243 250 236

State Total 65 46 531 467 471 454

Table 5: Status of permissible and the in-position of paramedical staffs (staff nurse, L.T, X

ray tech, 2nd ANM, MPW) under NRHM contractual appointment across the districts in JK as

in March, 2013

Sr. No.

District Staff Nurse

Lab. Tech X-ay Tech Second ANM MPWs

Per IP Per. IP Per. IP Per. IP Per. IP

1. Kishtwar 29 29 10 10 4 3 39 39 18 18

2. Kathua 49 20 23 21 10 10 137 122 12 12

3. Raesi 24 22 11 11 6 6 64 59 9 9

4. Doda 39 27 16 11 6 6 75 73 27 27

5. Samba 36 15 14 11 8 8 75 69 3 0

6. Jammu 95 57 36 36 16 15 248 229 10 10

7. Poonch 41 41 17 17 6 6 102 98 10 10

8. Rajouri 53 53 27 35 14 13 140 134 12 11

9. Ramban 26 26 13 13 8 8 39 39 15 15

10. Udhampur 37 34 14 14 4 4 97 94 15 11

GMC Jammu

DHS Jammu

Total Jammu Divison 429 324 181 179 82 79 1016 956 131 123

11. Anantnag 55 55 22 21 10 10 114 114 9 9

12. Bandipora 26 26 11 11 6 6 44 44 3 3

13. Baramulla 55 51 27 20 12 12 128 125 13 13

14. Budgam 63 52 30 29 18 18 115 105 4 4

15. Gandrebal 34 13 15 14 4 4 42 42 1 1

16. Kargil 27 2 11 11 8 3 60 56 59 0

17. Kulgam 46 43 23 22 8 8 81 81 9 9

6

18. Kupwara 65 48 29 28 14 14 141 141 34 34

19. Leh 41 41 17 17 6 6 36 36 70 12

20. Pulwama 37 29 14 14 4 4 74 74 3 3

21. Shopian 24 20 12 10 8 8 52 51 8 3

22. Srinagar 29 11 4 0 2 2 128 128 2 0

GMC Srinagar

DHS Kashmir

Total Kashmir 502 391 215 197 100 95 1015 997 215 91

State Total 931 715 396 376 182 174 2031 1953 346 214

Table 6: Categorization of health workers by type of appointments

Staff category Type of appointment

Regular # State contractual*

NRHM contractual @

Total

Specialists 430 (90.3%) 0 46 (9.7%) 476

M.O (MBBS) 1648 (76.7%) 33 (1.5%) 467 (21.7%)

2148

SN 352 (32.9%) 2 (0.18%) 715 (66.8%) 1069

ANM 2058 (51.3%) 0 1953 (48.6%)

4011

MPW 205 (48.2%) 0 214 (51%) 419

Pharmacist 10137 (99.9%) 1 (0) 08 (0.1%)

10146

L.T 594 (61.2%) 0 376 (38.7%) 970

X-ray tech 313 (64.2%) 0 174 (35.7%) 487

Source: # is from Performance Review, 2013; * is from PIP, 2013-14 and @ is HRMIS for state contractual staffs, March 2013;

The NRHM’s share of contractual employees is substantial for the paramedical staffs like staff nurse, ANM, MPW, LT and X ray technicians as given in table 6 and chart 1. In the state, majority i.e. 90.3% of specialists were regular while 9.7% of them were contractual employees under NRHM. In case of MBBS doctors, the state contractual were 1.5% only while NRHM contractual were 21.7% and 76.7% of them were regular government employees. Majority of staff nurses i.e. 66.8% of the total SNs in the state were NRHM contractual employees while only 32.9% of them belonged to regular cadre.

7

Chart 1: Bar chart showing the distribution of staffs (in absolute numbers) by the type of appointment in the state

II. Human Resources for Health Policy

HR policies for Doctors, nurses, paramedical staff and programme management staff: Since the launch of NRHM in 2005, the state of Jammu & Kashmir initiated systematic policy changes in relation to recruitment, placement and manpower development which have made it possible to staff most of the institutions in focus districts and difficult areas of the state. Recruitment of Medical Officers has been lined with eligibility for Post Graduation and the differential pay structure (with higher monetary incentive to serve in difficult and inaccessible areas) has been adopted besides other positive, enabling HR policies to ensure availability of Medical Officers and specialists in remotest parts of the state. The state has created “specialist” cadre for rational deployment and effective delivery of services across facilities where specialists’ are required. The Medical Officer Cadre is managed by the Health Secretariat and the establishment for

paramedical workers is located at the Directorate of Health Services, JK situated in Srinagar

for the state.

III. Generation of Human Resources for Health

Medical Colleges (New Colleges and Upgradation of existing ones): The state government has taken following steps to upgrade the existing ones. (a) Intake capacity in MBBS seats increased from 100 to 150 in each of the Govt. Medical College of Jammu and Srinagar and b) from 50 to 100 in SKIMS, Medical College, Bemina. The current availability of government and private medical institutes and those of paramedical training institutes in the state is given in table 7, 8 and 9

8

Table 7: Current availability of education institutes and annual intake in JK

Sr. No.

Name of Institute No. of seats Remarks

Medical Colleges (all in government sector)

1.

Government Medical College , Jammu MBBS (100)

MBBS Seats increased from 100 to 150

2. Government Medical College, Srinagar MBBS (100)

MBBS Seats increased from 100 to 150

3. SKIMS, Bemina MBBS (50) MBBS Seats increased from 50 to 100

Total: MBBS (250)

Increased to 400

There are total 12 ANM schools and 12 GNM schools and 4 B.Sc (Nursing) schools in the state

as in march, 2013. The lists of ANM/GNM schools under public sector are given in table 8.

Table 8: List of ANM/GNM Government institutions in Jammu & Kashmir Division in JK

Sr.

No.

Name of Institution District Annual intake

1 ANMT School, Kupwara Kupwara

2 ANMT School, Baramulla Baramulla

3 ANMT School, Anantnag Anantnag

4 ANMT School, Kangan Ganderbal

5 ANMT School, Leh Leh

6 ANMT School Udhampur Udhampur

7 ANMT School Doda Doda

8 ANMT School Rajouri Rajouri

9 ANMT School Poonch Poonch

10 ANMT School Kathua Kathua

11 ANMT School, Kargil Kargil

12 GNM School, Baramulla Baramulla

13 GNM School, Kupwara Kupwara

9

14 GNM School, Anantnag Anantnag

Table 9.1: Lists of private training institutes in Kashmir division of JK

Sr.

No.

Name of institutes District Annual intake

1. Tahira Khanam, Para Medical Institute

Lawaypora

Srinagar

2. Imam Hussain (AS) Bemina Srinagar

3. Classic Para Medical Institute,

Hyderpora

Budgam

4 Mubarik Para Medical Institute

Nowgam

Srinagar

5 Ramzan Para Medical

Institute,Nowgam

Srinagar

6 Ahmeds Institute of Health

Sciences,Nowgam

Srinagar

7 John Bishops Memorial Institute Sarnal Anantnag

8 St.Josephs Hospital Baramulla

9 Royal Para Medical Institute Fristbal,

Pampore

Pulwama

10 Lords Para Medical Institute Anantnag

11 Kashmir Institute of Para Medical

Sciences Hokersar

Srinagar

12 Phonix Institute of Para medical

Sciences

Pulwama

13 Dolphin Institute of Para Medical

Sciences

Pulwama

14 Green Valley Para medical Institute ,

Tangmarg

Dobiwan

10

15 Green Land Para Medical Institute

Hawal

Srinagar

16 Hakim Sonaullah Para Medical Institute

Sopore

Baramulla

17 Guru Institute of Para Medical

Sciences Sopore

Baramulla

18 Kidney Urological Disease Research

and Training Centre ,Sonwar

Srinagar

Table 9.2: Lists of private GNM training institutes in Jammu division of JK

Sr. No.

Name of the GNM schools District

1 Sh. Sain Charitable Trust/ Para Medical Institute Nardani Raipur Jammu

2 B.R. College of Para Medical Sciences, Gangyal Jammu

3 Madre-Meharban Institute of Health Services Jammu Jammu

4 Krishna Memorial Para Medical Training Institute, Miran Sahib, Jammu

Jammu

5 Indian Institute of Technical Training, Bari Brahmana Jammu Jammu

6 Kawa College of Para Medical Sciences, Gurah Brahmana Jammu Jammu

7 Guru Institute of Nursing & Para Medical Sciences Jammu Jammu

8 A.V. Institute of Nursing & Medical Sciences Trikuta Nagar Jammu

Jammu

9 Shri Nanak Medical Insitute of Health Sciences NH Kaluchak, Jammu

Jammu

10 Baba Budhan Ali Shah Para Medical Insittute, Chatha Jammu Jammu

11 MMC Para Medical Insittute, Babliana Jammu Jammu

12 Sovereign Insitute of Para Medical & Health Services Talab Tillo Jammu

Jammu

13 Simmer Insitute of Para Medical Sciences, Kunjwani, Jammu Jammu

14 Jammu College of Nursing & Para Medical Sciences Jammu Jammu

15 S.Sidhartha Para Medical Training Institute Channi Himmat Jammu

Jammu

16 Galaxy Para Medical College Extension Sec. F Sainik colony Jammu

Jammu

17 JK Institute of Nursing & Para Medical Sciences Sanjay Nagar Jammu

Jammu

18 IGES Institute of Nursing & Health Sciences Sunjwan Jammu

19 B.N. Institute of Nursing & Para Medical, Nowabad Sunjwan Jammu

Jammu

11

20 PC Memorial Institute of Para Medical Sciences Jammu Jammu

21 Vinayak Institute of Nursing & Para Medical Sciences, Kunjwani, Jammu

Jammu

22 BMS Institute of Para Medical Sciences, Bishnah Jammu

23 SMS Institute of Medical Sciences, Kalu Cahk Jammu Jammu

24 Shri Mata Vaishno Devi Para Medical Institute, Roopnagar, Jammu

Jammu

25 ST. Jospn Para- Medical Institute Bari Brahmana Jammu

26 Rajiv Gandhi Para-Medical Institute Chack Malwal Jammu

27 B.R. Kohli Institute of Para Medical Sciences, Kathua Kathua

28 Guru Teg Bahadur Para Medical Trg. Institute Kathua Kathua

29 Hem Raj Para Medical Trg. Institute Kathua Kathau

30 R.B. Para Medical College Rajbagh, Kathua Kathua

31 Data Ranpat Dev Institute of Para Medical & Health Sciences, Kathua

Kathua

32 Baba Sidh Gouriya College of Para Medical Sciences Kathua Kathua

33 Taran Para Medical Institute, Kathua Kathua

34 Sidhi Vinayak School of Nursing Kathua Kathua

35 Gupta Institute of Para Medical & Allied Health Sciences, Kathua Kathua

36 Mata Vaishno Devi Institute of Para Medical & Health Sciences, Kathua

Kathua

37 Indian Institute of Para Medical Sciences Nagri Kathua Kathua

38 New Age Education & Research Society, Phinter Kathua

39 Baba Balo Dev Charitable Education Trust & Welfare trust, Kathua

Kathua

40 Rajiv Gandhi Institute of Para Medical Sciences, Kathua Kathua

41 Nightingale School of Nursing Kathua Kathua

42 RDGD Para Medical Institute Samba Samba

43 Iges Para Medical Institute Surankote Surankote

44 Poonch College of Nursing & Para Medical Sciences Surankote Surankote

45 Baba Institute of Nursing & Para Medical Sciences, Rajouri Rajouri

46 Tariq Para Medical Institute Rajouri Rajouri

47 SVS Para Medical College Sunderbani Rajouri Rajouri

48 Akash Para Medical Institute Udhampur Udhampur

49 Narsing Dev Institute of Nursing & Para Medical Sciences, Ramnagar

Ramnagar

50 Ramnagar College of Nursing & Medical Education, Ramnagar Ramnagar

51 Narsing Dev Institute of Nursing & Para Medical Sciences, Ramnagar

Ramnagar

52 Bhaskar Institute of Para-Medical Sciences, Dhar road Udhampur Udhampur

53 Florence Nightingale School of Nursing Udhampur Udhampur

12

54 Apex Para Medical Trg. Institute Doda Doda

The annual intake capacity in existing AMT Schools of GMC Jammu and that of Srinagar has

been enhanced from 510 to 1020 seats. The annual intake capacity in existing ANMT Schools

of the State enhanced from 968 to 2358 seats.

IV. Recruitment, Sanction Posts and Vacancies

A. Regular employees: 1. Medical Officers and Specialists:

The JK Public Service Commission (HPPSC) used to conduct recruitments for regular medical

officers, through a process of interviews, selected on merit based without conducting

screening tests since the notification of the commission in 1971. With the launch of NRHM in

2005, in order to fill up huge vacancies in government medical officer’s posts, the state

government has adopted an alternative method for recruitment of regular doctors. The last

JKPSC was conducted in 2009.

2. Nurses & Paramedical: The recruitment of non-gazetted for nurses, paramedical and

other staffs of the Health Department of JK is guided by the Non-Gazetted Recruitment Rules

of the JK Health Department in which the class, category, designation with grade along with

qualification and mode of recruitment had been enumerated as Annexure “A” under Part-III,

Laws, Regulations and Rules, passed under the GoJK, Civil Secretariate, Health & Medical

Education Department dated Jammu, the 24th February, 1992.

Method of Recruitment: The recruitment to the service, after commencement of these rules

are made by the following method namely- (a) 100% direct recruitment on the basis of merit

from amongst the candidates who have polled the prescribed training, and allotted to the

Appointing Authority; (b) by promotion of the members of the service cadres. As per the

Recruitment Rules, 1992; for recruitment of Junior Nurse, the grade pay is 900-1830 and

he/she should have qualification i.e. matric with diploma in nursing from SMF or any other

recognized institute and to be recruited through 100% by direct recruitment.

Table 10: District wise status of ANM, staff nurse and L.T (in-position against sanction

posts)

S.No. District SN ANM MPW Pharmacist LT

S , IP S, IP S, IP S, IP S, IP

1 Bandipora 0 62, 53 0 547, 535 16, 11

2 Doda 60, 29 123, 123 12, 6 152, 118 33, 32

3 Kargil 0 0 0 631, 535 0

4 Kishtwar 23, 10 69, 47 5, 5 82, 48 15, 13

13

5 Kupwara 0 207, 196 23, 8 1322, 976 48, 37

6 Leh 0 0 0 1833, 980 0

7 Poonch 79, 43 149, 141 11, 10 169, 137 36, 34

8 Rajouri 101, 49 211, 209 25, 24 206, 160 40, 37

9 Ramban 34, 18 97, 87 9, 2 111, 77 15, 15

10 Reasi 41, 24 75, 54 3, 2 96, 60 18, 17

12 Anantnag 0 88, 88 18, 17 1198, 1126 52, 52

13 Baramulla 0 85, 74 17, 12 1442, 1156 53, 45

14 Budgam 0 78, 73 19, 19 1539, 1265 45, 40

15 Ganderbal 0 17, 14 1, 1 512, 377 16, 16

16 Jammu 127, 68 265, 258 35, 27 215, 140 86, 70

17 Kathua 90, 60 207, 166 32, 30 195, 143 48, 45

18 Kulgam 0 128, 110 22, 19 901, 745 31, 22

19 Pulwama 0 43, 43 8, 6 693, 591 24, 20

20 Samba 38, 21 104, 94 3, 3 97, 77 19, 18

21 Shopian 0 69, 57 8, 7 301, 231 20, 13

22 Srinagar 0 32, 30 3, 3 566, 508 23, 23

Total 654, 352 1860, 2058 259, 205 12986, 10137

672, 594

Source: Performance Review, 2013; Dept of H&FW, GoJK

B. Contractual Service Providers:

The recruitment for contractual staff takes place at two levels: state and district.

Doctors & Specialists: The contractual appointment for doctors and specialists is done by the

Rogi Kalyan Samiti /District Health Society based on local criteria. At the state level, there is

a Selection Committee headed by the Mission Director, which recruits Medical Officers

(mainly specialists), Consultants for Disease Control Programs. The committee also comprises

of an expert panel drawn from the medical colleges and recruitment is done through walk-in

interviews.

The recruitment of Specialists (OBG, Aneaesthesia, Pediatrics, Surgery) for difficult areas (as per categorization) is done by offering them additional monetary incentives to serve in these areas. (Incentive paid by NRHM). For the doctors and paramedics engaged on contract basis under Centrally sponsored scheme, certain recruitment rules had been laid down by the State, which highlights the category of post, qualification/experiences, remuneration. The rules has been revised to increase the remuneration and include the age upto certain years, specific qualification along with selection criteria for recruitment to make it more standardized.

14

Issues: The major hurdle is in the non-availability of specialists in the pool, finding specialists

willing to join and serve in the designated FRUs which could be attributed to the fact there

are very few post-graduate seats in the medical colleges– the state needs to develop plans to

set to new medical colleges to address this issue.

2. Nurses & Paramedics: Recruitments are done at the district level with the District

Collector heading the selection panel. Vacancies are communicated from the state and

selection done at the district level - entire process takes about 3-4 months. The local-area

criteria are taken into account along with same-block posting.

3. Programme Managers: The process for the appointment of contractual staff i.e. Block

Programme Managers and Block Accountants to be engaged under NRHM started in April, 2007

through advertisements and walk-in-interviews were conducted for which Selection

Committee got constituted. Emoluments got revised and increment fixed upto 5% on the

basis of performance. There was a job profile of various categories of staff under NRHM.

Vacancies: State Government has fill up its existing vacancies against sanctioned posts, preferably by contract under NRHM primarily. Top most priority in contractual recruitments should be for backward districts and for difficult, most difficult and inaccessible health facilities. A differential payment to serve in the hard and inaccessible areas of the state has helped the state to fill up vacancies of Medical Officers in these areas. These appointments are place specific and rotational after serving for specific period of years as per Transfer Policy, 2012.

V. Deployment of Human Resources

There is shortage of specialists and staff nurses in the state on the whole and this shortage is further compounded when it comes to Focus Districts, difficult and very difficult areas. As on March, 2013, there is not even a single Pediatrician in Bandipora district in the state. There is acute shortage of OBG specialist in Kupwara district of Kashmir division as well. In this light, the state has proposed to appoint Specialists in OBG, Anethesia and Pediatrics on Contract in the FRUs under NRHM in the focus districts of and also at selected places in the difficult areas of Kupwara, Leh, Kargil and Bandipora. The salary of specialist per month is in the range of Rs.36,000-48,000 per month under NRHM contractual appointment though a salary of Rs.50,000 per month has been proposed in PIP 2013-14. The current salary for MO (contractual) is Rs.25,000 per month while the proposed salary is Rs. 30,000 pm. To attract Medical Officers to serve in hard and remote areas, financial incentives are provided to them in addition to their salaries. The JK state had categorized these areas as most difficult (A) and difficult area (B) and incentive is @ Rs. 20,000 per month for category A, Rs, 15,000 per month for category B and Rs. 10,000 for category C. As per state Government SRO, a financial incentive of Rs 8,000/- month is given for regular doctors posted in facility under Category A and (b) Rs. 4,000/-month for regular doctors posted in Category B respectively which has resulted in filling up the posts in these areas in the state.

15

Table 11: Differential incentive norms for different gradient of accessibility of SDH/CHC/PHC/SC (across 121 facilities in the state) for the regular doctors under JKPSC (as per SRO)

Sr. No. Category of Medical Officers

Area categorization

Category A Category B

1.

General Rs.8000/-pm Rs.4000/-pm

Deployment of specialists in FRU: Though 49 health facilities have been designated as First Referral Units (FRU), 33 of them are conducting Caesarian Sections. Table 10 and 11 details the lack of facilities and specialists in the health facilities and designated FRUs, where caesarian sections not being conducted. Table 12 : Lists of institutions with status on availability of specialists and functionality of blood storage and blood bank units across districts

Status as on date (Ending July 2013)

District Name of FRU/CHC/DH

Gynae.(Nos) Paed(Nos.) Anesth(Nos.) Blood Storage

Unit functional (Yes/No)

Blood Bank functional (Yes/No)

R C R C R C

Anantnag DH Anantnag 0 0 0 0 2 0 Yes

MCCH 5 0 2 1 2 0 Yes

Bijbehara 1 0 1 0 1 0 Yes

Kokernag 1 0 1 0 1 0 No

Seer 1 0 0 1 0 1 No

Shangus 0 0 0 0 0 0 No

Dooru 1 0 1 0 1 0 Yes

Bandipora DH Bandipora 1 0 0 0 1 0 No

CHC Sumbal (FRU) 1 0 0 0 2 0 No

CHC Dawar (FRU) 0 0 0 0 0 0 No

CHC Hajan 0 0 1 0 0 0 No

Baramulla DH Baramulla 1 0 1 1 2 0 Yes

Uri 1 0 0 0 1 0 No

Chandoosa 0 0 0 0 1 0 No

Sopore 1 0 1 0 2 0 Yes

Kreeri 2 0 0 0 2 0 No

Pattan 0 0 0 0 1 0 No

Tangmarg 1 0 1 0 1 0 No

16

Budgam DH Budgam 2 0 1 1 2 0 Yes Yes

Charsharief 0 0 0 0 1 0 Yes

Chadoora 1 0 0 0 2 0 Yes

Beerwah 1 0 0 1 1 0 Yes

Khansahib 1 0 1 0 1 0 Yes

Magam 1 0 1 0 1 0 No

Ganderbal DH Ganderbal 1 0 1 0 1 0 No

CHC/FRU Kangan 1 1 1 0 1 1 Yes

kargil DH. Kargil 3 0 2 0 0 0 Yes

FRU/CHC Drass 0 0 0 0 0 0 No

FRU/CHC Sankoo 0 0 0 0 0 0 No

CHC Chicktan 0 0 0 0 0 0 No

CHC Zanskar 0 0 0 0 0 0 No

Kulgam DH Kulgam 1 0 1 0 1 1 Yes

CHC Yaripora 0 0 1 0 0 0 No

CHC D H Pora 0 0 0 0 0 0 No

CHC Qazigund 0 0 0 0 1 0 No

Kupwara DH Handwara 3 0 0 0 1 0 Yes Yes

CHC Kupwara 3 0 0 0 1 2 Yes Yes

CHCSogam 1 1 0 0 0 1 No

CHC Tangdar 1 1 0 0 1 0 No

CHC Kralpora 0 0 0 0 0 0 No

CHC Zachaldara 0 0 0 0 0 0 No

CHC Langate 0 0 0 0 0 0 No

CHC Kralgund 0 0 0 0 0 0 No

Leh DH Leh 5 0 2 0 2 0 Yes

CHC Khalsi 1 0 0 0 1 0 Yes

FRU Disket (Nubra) 1 0 1 0 1 0 Yes

Pulwama DH PULWAMA 2 0 1 0 2 0 Yes

CHC TRAL 0 0 1 0 1 0 No

CHC RAJPORA 0 0 0 0 0 0 No

CHC PAMPORE 0 0 1 0 1 0 Yes

Shopian DH Shopian 1 1 1 0 0 1 Yes

FRU Zainapora 1 0 1 0 0 0 No

FRU Keller 1 0 1 0 1 0 No

Srinagar JLNM 4 0 1 1 4 0 Yes

FRU- Gousia Hospital Khanyar

1 0 1 0 2 0 Yes

Total No. of Yes 16 11

17

Total No. of No 30 1

Grand Total 54 4 29 6 50 7 46 12

Table 13: Lists of identified FRUs and functional FRUs where C-section is conducted across districts

Sr. No District Name of FRU Deployment of Specialists

C-Sections (Yes with no. and No)

1 Poonch CHC Surankote 0G, 0P, 1A Yes -57

2 Poonch CHC Mendhar 0G, 0P, 1A Yes-39

3 Poonch CHC Mandi No specialist No

4 Ramban CHC Batote 1G, 0P, 1A No

5 Ramban CHC Banihal 1G, 0P, 1A No

6 Doda CHC Bhaderwah 0G, 1 P,1A Yes- 134

7 Doda CHC Gandoh 1G, 0P, 0A No

8 Rajouri CHC Sunderbani 1G, 1P, 1A No

9 Rajouri CHC Nowshera 2G, 1P, 1A No

10 Rajouri CHC Kandi No specialist No

11 Rajouri CHC Darhal 0G, 1P, 0A No

12 Reasi CHC Katra 2G, 1P, 1A No

13 Samba CHC Ramgarh 1G, 1P, 0A Yes-68

14 Samba A/H Vijaypur 1G, 1P, 1A Yes-61

15 Kathua CHC Hiranagar 1G, 1P, 1A Yes-101

16 Kathua CHC Billawar 1G, 1P, 1A Yes- 146

17 Kathua CHC Bani 0G, 0P, 1A No

18 Udhampur CHC Ramnagar 1G, 0P, 0A Yes- 32

19 Udhampur CHC Chenani 1G, 1P, 1A Yes- 90

20 Jammu CHC RS Pura 1G, 1P, 1A Yes-30

21 Jammu CHC Akhnoor 2G, 2P, 2A Yes- 618

22 Jammu CHC Bishnah* 1G, 1P, 1A Yes-73

23 Anantnag CHC Bijbehara 1G, 1P, 1A Yes- 109

24 Anantnag CHC Kokernag 1G,1P, 1A No

25 Anantnag CHC Seer 1G, 0P, 0A No

26 Anantnag CHC Shangus No specialists No

27 Anantnag CHC Dooru 1G, 1P, 1A Yes-15

28 Bandipora CHC Sumbal 1G, 0P, 2A Yes- 122

18

29 Baramulla CHC URI 1G, 0P, 1A Yes-1

30 Baramulla MCH SOPORE 1G, 1P, 2A Yes- 544

31 Baramulla CHC KREERI 0G, 0P, 1A Yes-95

32 Baramulla CHC PATTAN 1G, 0P, 1A Yes- 28

33 Baramulla CHC TANGMARG 1G, 1P, 1A Yes-64

34 Budgam CHC Beerwah 1G, 1P, 1A Yes-59

35 Budgam CHC Chadora 1G, 0P, 2A Yes-162

36 Budgam CHC Chasharif 0G, 0P, 1A Yes-71

37 Budgam CHC Magam 1G, 1P, 1A Yes-43

38 Budgam CHC KhaSahib 1G, 1P, 1A Yes-34

39 Ganderbal CHC Kangan 2G, 1P, 2A Yes-131

40 Kulgam CHC D H Pora No specialist No

41 Kupwara CHC Kupwara 3G, 0P, 3A Yes-617

42 Kupwara CHC Kralpora 3G, 0P, 1A No

43 Kupwara CHC Sogam 1G, 0P, 1A Yes-69

44 Kupwara CHC Tangdar 1G, 0P,1 A Yes-75

45 Kupwara CHC Langate No specialist No

46 Pulwama SDH Pampore 0G, 1P, 1A Yes-147

47 Pulwama SDH Tral 0G, 1P, 1A Yes-56

48 Shopian CHC Keller 1G, 1P, 1A Yes-27

49 Srinagar CHC-Gousia Hosital Khanyar

1G, 1P, 2A Yes-160

The district wise classification of designated FRUs which conducts LSCS along with deployment of specialists in these FRUs where C-section does not take place is given in the table 14 below.

Table 14: District-wise classification of designated FRUs against availability status of

specialists and functionality of FRUs (June, 2013)

District Designated FRU

FRU not conducting LSCS

Deployment of specialist in FRU not conducting LSCS (Anesthetist-A, Pediatrician-P, Obstetrician-OG)

Poonch 3 1 NIL (no specialist)

Ramban 2 2 1G, 0P, 1A 1G, 0P, 1A

Doda 2 1 1G, 0P, 0A

19

Rajouri 4 4 1G, 1P, 1A 2G, 1P, 1A NIL 0G, 1P, 0A

Raesi 1 1 2G, 1P, 1A

Samba 1 0 All these designated FRUs are conducting C-section Udhampur 2 O

Jammu 3 0

Kathua 3 1

Anantnag 5 3 1 A, 1 P, 1 OG; OA, OP, 1OG; NIL

Kulgam 1 1 NIL

Kulwara 5 2 3 OG, OP, 1A NIL

Bandipora 1 0 All these designated FRUs conducting C-section

Baramulla 5 0

Budgam 5 0

Ganderbal 1 0

Shopian 1 0

Srinagar 1 0

Pulwama 2 0

Total 26 16

20

Table 15: Categorization of health institutions into A (most difficult) and B (difficult)

areas

Name of District

Name of difficult areas

Name of Health Institution

Sanctioned No. of Doctors

Sanctioned No. of Paramedics

Category A or B

Leh Nobra SDH 13 23 A

Noyama PHC 04 09 B

Kargil Zanskar CHC 14 25 A

Drass CHC 10 11 A

Panikbar PHC 03 10 A

Abran

Ticket AD 02 03 B

Bandipore Dawar SHC 03 23 A

Sheikpora NTPHC 02 09 A

Budugam SHC 01 05 A

Bagtore AD 02 02 A

Burnai AD 01 02 A

Gujran MAC - 01 A

Budwan MAC - 02 A

Kanzalwan SC - 02 A

Hasangam SC - 03 A

Buduab SC - 02 A

Chorwan SC - 02 A

Tarabal SC - 02 A

Wanpora SC - - A

Kupwara Tangdhar SDH 12 18 A

Keran SHC 02 06 A

Machil PHC 03 24 B

Budnumbal area

SC - 02 A

21

Table 16: Types of health institutions categorized under Special category A, category A

and category B in JK

Special Category A

Block Dachan No of Institutions No. of Doctors

Remarks

PHCs 03

08+02=10 Marwah being block PHC has 3 Posts of

Asstt. Surgeons ADs 04 08

Total 07 18

Category A

No of Institutions No. of Doctors

CHCs 00 00

PHCs 20 60

ADs 31 62

Total 53 122

Category B

CHCs 5 70

PHCs 30 93 Includes 3 block PHCs having 12 posts of Asstt.

Surgeons

ADs 25 52

Total 61 213

There are total 121 health institutions coming under these categorizations

(ADs/CHCs/PHCs) and 353 doctors were posted at these facilities.

Transfer policy:

As per GO 210-HME of 2012 dated 13th March, 2012; the Health and Medical Education

Department under Government of Jammu and Kashmir had issued the Transfer Policy in

Health Department in the interest of patient care and smooth functioning of health

institutions especially those located in far flung areas; to be adopted in the manner of

transfers/postings of the employees of Health Department with immediate effect.

The general principles is enumerated as :

It shall be imperative for the department to maintain a database on transfers/postings

of the employees

While effecting the transfers/postings, the qualification of the employees and the

requirements of health institutions shall be given utmost priority

Postings shall be made on rotational basis to sensitive and non-sensitive posts with

identification of these areas by department with approval of Ministry in-charge

Where both husband and wife are in government service, they may be posted

conveniently in the same institution/district as far as possible

22

Physically challenged persons may be posted conveniently, subject to availability of

posts

The calendar for transfer shall ordinarily be ordered in the first month of the financial year.

The transfer for Ladakh region shall be made as per the policy laid down for such transfers by

the Ladakh Affairs Department. Persons returning from leave, training or on revocation of

suspension or on promotion shall be adjusted against the vacant posts.

Tenure of postings: The minimum tenure of a government employee on a post shall be two

years and maximum three years. Pre-mature transfer wherever unavoidable, in the interest of

administration shall be ordered with the prior approval of the Minister in charge, with reasons

to be recorded. A government employee holding any post may be transferred even before the

completion of minimum tenure with approval of the Minister in charge if: (a) the performance

of employee is found to be below job requirement; (b) on ground for initiating enquiry or

disciplinary proceedings against him/her (c) if it is not in the public interest or in the interest

of administration to allow the employee to continue on a post for a full tenure (d) transfer is

sought on health grounds supported by medical certificates issued by duly constituted Medical

Boards.

The GO also detail out the delegation of powers for making transfers/postings and zonal

based transfers/postings of Assistant Surgeons/Medical Officers/ISM &H, Assistant Surgeons

with PG/B-grade specialists. Zonal I comprises of AD (Administrative Department), PHC/ISM

dispensaries while zonal II comprise of CHC/SDHs/Ayush units and Zonal III is DH/Provincial

hospitals, Ayurvedic/Unani hospitals. The health institutions will be divided into three

categories depending upon topography and terrain of district.

Category A: All health institutions whether or not connected by road which remain

inaccessible or cut off for more than four months due to climatic conditions, landslides

located in “Inaccessible areas”

Category B: All health institutions which are not connected by road and are at a distance of

more than 5 km from the road head/located in “very difficult” areas.

Category C: All health institutions which are not connected by road and are at a distance of

less than 5 km from the road head or are connected by road which remains blocked for a

period of more than one month but less than four months in a year due to climatic

conditions/landslides or which are included in the list of areas notified under SRO 201 of 2006

but cannot be classified as “Inaccessible” or “very difficult”

Category D: All other health institutions not covered under category A to C, may be treated

as “Normal”

Issues in promotion: The last promotion of doctors took place in 1998 though the staffs get

salary in time scale promotion

23

VI. Training & Capacity Buildings

The State/regional level training is provided at RIHFW, Dhobiwan, Baramulla as per the training load and requirements and suitability. These trainings are planned, executed and imparted by RIH&FWTC Baramulla as nodal agency at all levels.

The training cell at SHS, NRHM has 1 Deputy Director for training, on deputation from regular

cadre who is responsible for coordinating and implementation of training calendars under

NRHM for both the regular and contractual service providers – EmOC, LSAS, SBA, IMNCI, NSSK,

FP trainings and PG Diploma in Public Health Management etc. He/She is assisted by Assistant

Training. A training plan is prepared by Technical Programme Head of each division and get

compiled/consolidated at district level; which is sent to the division for consolidated at state

level. The integrated training plan is consolidated drawn up every year and the numbers

trained so far is given in table 17 as in April, 2011 to 2012 till March, 2013.

Table 17: Cumulative Training achievements for various training programs in JK (April,

11-12 to March, 2o13)

Cumulative Achievements of Important trainings of J&K State w.e.f April 2010 to March 2013 (3 Yrs)

Name of training programme

Categories of staffs

2011-12 2012-13 Cumulative Achievement April

2006 to March 2013

SBA Staff Nurses 71 142 253

SBA LHV/ANM's 68 184 292

LSAS for MOs at GMC, Jmu/Sgr

MOs 4 0 30

EMOC Training MOs 8 0 30

IMNCI & NSSK LHVs/ANMs/SNs/AWWs

192 143 803

Laproscopic Sterilization Training

Gynaecologist, OT technician,

OT Nurse

5 3 71

VII. Remunerations

The contractual M.O gets Rs.25,000/- PM + incentives (as admissible) and Rs. 36,000-

48,000/- only ( for Specialists i.e. Anaesthesia, OBG, Surgery, Medicine, Ortho, Radiology,

Eye, ENT and Pediatrics) P.M in lump sum plus incentives at the time of joining the

service whereas the regular M.O gets a pay scale of Rs 15600-39100 + Grade Pay Rs 5400

(initial pay of Rs.20,300/-+ allowances which comes around Rs.27,000/-PM in entry level).

The contractual staff nurse, ANM, LT, MPW and AYUSH pharmacist gets Rs. 10,800 per

month.

24

VIII. Health Human Resources Information Systems

The state has developed an in-house a web-based portal which is HRMIS (Human Resource

Personal Management Information Systems) for doctors and specialists (allopathic and ISM)

through which the state has computerized information and records of these personnel working

under health sector (regular/contractual/RKS) across all facilities in all 22 districts of the

state. HRMIS has a comprehensive database for health personnel which has several features

such as e-service records with 12 standardized forms capturing relevant employee’s personal

information, address, education qualification, date of joining, place of joining, training

received and service history, ACR details, employee awards/medals, loan details,

departmental proceedings etc. Each employee is given an ID and they can log in for updating

the relevant details. The information is updated on daily basis as per needs and requirements.

This information is being used for transfer, posting and for rational deployment of staffs

across facilities.

Issues: The database of other category of health workers needs to be developed, updated

and maintained. The updation of the regular doctors and specialists is done once in a year.

IX. Workforce Management

A. Regular Employees: The transfer & posting for medical officers is overseen by the health

Secretariat and that of the regular paramedical staff by the medical directorate and there is

clear cut, well defined transfer & posting policy in the state.

Career progression: State government has notified a policy to regularize the services of the RKS doctors after he / she has put in six years of service as RKS Contract doctor. Induction training, regular orientation/skill up-gradation/ refresher training is organized. A special programme of Rural CME has been started to give an opportunity to the doctors posted in the remote and difficult areas to interact with specialists and to update their skills and also to clarify their doubts. Both clinical and non-clinical (management, accounts, NRHM) aspects are covered in these CMEs. Rational deployment: There is rationalization of doctors and paramedical staffs employed under NRHM as per requirement, locally based preference in rational deployment and also keeping in view the coverage of entire population for the purpose of effective service delivery.

Stability of tenure: The Medical Officers and Staff Nurses are posted to an institution for a period of maximum three years initially and are not transferrable during this period unless on certain grounds laid down in Tranfers/posting policy.

B. Contractual employees: There is no scope for promotions. They are given one-year

contacts, to be extended after a process of annual appraisals against their terms of reference

(TOR), which are held at state and district levels. The increments are decided during these

appraisals.

25

The terms of reference, defining job responsibilities, for all categories of contractual workers

including program management staff are available in the state. There is currently no system

for performance management of these staffs though it has been proposed with design of a

detailed format for performance evaluation, to be used during the annual appraisal along

with general behaviors with supervisors/colleagues etc.

Issues: Though there is no policy for incentivizing the health service provider on the basis of performance. Performance appraisal, renewal of contracts based on performance: Job profile of the Contractual Appointees under NRHM such as District/Block Managers, Consultants, Co-ordinators, District/Block accountant has been notifies and Renewal of Contracts is dependent upon performance. There is currently no standardized system for grading or ranking based on individual or team performance of employees. Incentives for difficult areas: The regular Medical Officers posted in the difficult areas are paid differential incentive (ranging from 4000 to 8000 rupees per month) over and above the monthly salary depending upon the place of the posting. The contractual NRHM medical officers are paid Rs. 20,000 per month, Rs. 15,000 per month and Rs,10,000 per month for postings under category A, B and C respectively.

X. Management Cadre

Regular Management Cadre: At the state level the Director heads the directorate and every

division or national program has individual Program Managers. These divisions also has Deputy

Directors assisted by Superintendents. The Chief Medical officer assisted by teams of District

Programme Officers (D.P.O) manages at the district level and the D.P.O are aided by a team

of Bock Program Officers (B.P.O).

Issue: All these are regular posts, to be filled by officers from the cadre of government

medical officers, promoted on the basis of their seniority and annual confidence reports.

However, the existing practice has to be studied

Contractual Management Cadre: To help and support the state and district machineries,

NRHM has instituted program management support units at the state, district & block levels.

The State Program Management Support Unit (SPMSU) has a State Program Manager (SPM)

supported by Consultants looking after various aspects of the program e.g. IEC, Sahiyya,

Finance, HR, Infrastructure, Training, M & E, Family Planning etc.

The management cadres at state and district levels are supervised and their performances

are appraised by State and respective District Deputy Directors/Programme Managers

deputed from regular cadre to the SHS.

The District Program Management Support Unit (DPMSU) has District Program Manager (DPM),

District Accounts Manager, District Data Manager and District Program Coordinator while at

the block level, there is a Block Program Manager (BPM) and a Block Accounts Manager.

26

The State Selection Committee (headed by the MD NRHM) does recruitment for the SPMSU &

DPMSU and the BPMSU staff are recruited by a selection panel of the District Health Society

(headed by the DC).

XI. Action Points

A. IMMEDIATE

1. Ensure that all obstetricians, anesthetists, pediatricians and EmOC & LSAS trained MOs who

are posted in designated FRUs as per availability of facilities like blood storage units/blood

bank for operationalization of FRUs.

2. Ensure all MOs with PG qualifications are posted in CHCs, block PHCs or higher centers and

to follow through with twinning each of these institutes with an external institutional

“mentor, so as to build capacity and improve their functioning.

3. Sustain and build on HRMIS which is a good initiative so that other staffs (service providers,

administrative and support staffs) are included in the database though it is crucial to ensure

completeness, correctness and timeliness of data entry along with regular updation.

B. MEDIUM TERM

1. Need to fill up the vacant posts for regular staffs

2. Faculty development program & quality assurance in nursing schools

3. Need to develop a standard performance management system for the contractual as well

as regular employees

4. Need to conduct assessment of the incentive scheme for working in difficult areas

prevailing in the state for identifying strengths and weaknesses

C. LONG TERM

1. The state need to frame a policy for regularization of NRHM contractual appointment into

permanent by giving due preference to these candidates having NRHM experience of more

than 3-5 years for sustainability in the coming years.

2. Creation of adequate number of health facilities as per requirements.

3. Development of projected number of medical/nursing and allied professional institutes for

enhanced production of health workers.