The document analyzes determinants of doctor performance in public health systems in three states of India. It finds that all three states have significant doctor vacancies, with Jharkhand filling only 30-95 of 96-131 positions across different districts. Rajasthan has 8,162 doctor positions but 745-658 new positions per year, leaving 2,991 vacancies. Uttarakhand has 946 doctors against a sanctioned 1,922 positions. Peripheral health facilities generally lack adequate doctors, medical infrastructure and support systems. Recruitment challenges, contractual uncertainties and lack of promotions contribute to poor retention of doctors in rural areas.

1. Determinants of performance of Doctors in the Public Health Systems (Preliminary Observations from three States of India) Shiv Chandra Mathur Executive Director, RHSRC-NRHM, Jaipur and Thamma Rao D. Advisor, NHSRC-NRHM, New Delhi

2. Issues Human Resource is the most critical component in a Health Facility Competence and morale of the Doctors as Leader of Peripheral Health Facilities determines the quality and effectiveness of health services

3. Objectives Process of Recruitment/ Deployment Workforce Management Issues Compensation Package/ Incentives Support System Gaps between Provisions/Expectations

4. Methods Interviewing State Level Officers including Secretaries and Directors Jharkhand Rajasthan Uttarakhand Dumka Palamu Ranchi Bikaner Bharatpur Jhalawar Sirohi Hardwar Dehradun nagar DH 1 1 1 1 1 1 1 1 1 1 CHC* 5 5 5 3 3 3 3 5 5 5 PHC 10 10 10 6 6 6 6 10 10 10 MO 30 29 32 10 10 10 10 30 29 32 Spel’s 10 11 8 10 10 10 10 10 11 8

5. Do Peripheral Health Facilities have sufficient Doctors?

6. Doctors in Jharkhand Out of 131 positions in Dumka, 95 were filled up Only 30 available against 96 positions in Palamu 29 vacancies out of 101 positions in Ranchi

7. Doctors in Rajasthan 8162 positions of Doctors in the Health Systems (200-11) 745 and 658 positions of Generalists were announced in budget in 2009-10 and 10-11 respectively 2991 vacancies – 1390 positions sent to RPSC, contractual appointments against the existing vacancies DPC for Senior positions

8. Uttarakhand Sanctioned Positions of 1922 GDMO and 259 SMO 946 GDMO and 195 SMO available 976 GDMO and 64 SMO vacant

9. HRH Density Non- availability of adequate HRH is the constraint in High Focus States - WHO recommends HRH of 25 per 10,000 - in India variance in States is too wide - 10 in Bihar to 38 in Kerala

10. Recruitment/ Deployment Filling up vacancies is a consistent challenge PSC selection is a long procedure Contractual System accepted albeit insecurity continues Postings and Transfers is always uncertain Gradual acceptance to ISM at PHF Deploying Specialists is now receiving attention

11. Promotions/Grievances Limited scope of Promotions for Generalists Subjective Appraisals Grievance handling is lethargic

12. Compensation/Incentives Comparative Anomalous Pay structure Rural/Difficult Area Allowance Perks: Telephone/Mobility/Insurance/LTC Non Practicing Allowance Residence/Security

13. Physical Facilities Water supply - 24 Hours Electricity-24 Hours Generator/Inverter Ambulance Operation Theater Telephone Computer with Internet

14. Equipments Functional Delivery & Episiotomy Functional OT light Functional OT table Boyle's Apparatus (for Anesthesia) Instruments for Surgery Sterilizer/Autoclave

15. Training Induction versus In-Service Training In-Service versus CME Lack of Training Policy Exclusive project based training Several compartments

16. Diagnostic/Therapeutic Facilities Laboratory Services X- Ray Machine Ultrasound Machine Medicines Blood Storage/Banking Facilities

17. How far IPHS is a reality? Ranchi Jharkhand Estimated Population in 2010 35,02,364 3,40,75,853 PHC (Actual/IPHS) 28/175 330/1103 CHC (Actual/IPHS) 14/44 194/265 Medical Officers (Actual/IPHS) 72/350 1710/2205 Specialists (Actual/IPHS) 2/306 188/1852

18. Striking a Balance Sub-Centers loaded with female staff Male Workers extinction Job responsibilities to be defined PMU reaching to the block Referral linkages required Balancing the National Health Program Review UG Medical Teaching

19. Thank you