Rajasthan: Public Health Workforce – Issues & Challenges

I. Overview of Public Health Workforce Rajasthan has a population of 68.62 million with rural population of 37% residing in the desert

and tribal areas. The state has 34 districts with 1 district (Jaipur 2) recently adding to the list. In

this report, to understand the human resource issues in a better way, 33 districts have been taken

because for the 34th district the data was partially available.

Health Facilities Present Required

District Hospitals 34 34

Sub District Hospitals 12 686 ( per one Lakh population)

CHC 243

PHC 1656 3431 (@ 1/ 20000 population)

Sub Centers 11487 22873 (@ 1/3000 population)

The total availability of health workforce including the contractual staff is as follows:

S.No Name of Districts Nurses LHV ANM Lab tech X ray Tech

1 Ajmer 597 400 115 95 30

2 Alwar 545 643 234 127 29

3 Banswara 329 468 64 54 8

4 Baran 190 241 25 29 11

5 Barmer 327 555 227 59 9

6 Bharatpur 261 500 166 92 21

7 Bhilwara 467 524 159 91 17

8 Bikaner 422 407 144 106 27

9 Bundi 204 221 54 44 8

10 Chittorgarh 231 340 144 59 11

11 Chooru ratan garh 286 470 134 54 10

12 Dausa 175 251 86 52 10

13 Dholpur 148 236 26 32 9

14 Dungarpur 278 418 100 44 5

15 Hanumangarh 164 328 134 47 7

16 Jaipur 2341 741 162 306 84

17 Jaisalmer 76 138 110 25 9

18 Jalor 216 399 103 54 2

19 Jhalawar 202 280 218 38 10

20 Jhunjhunu 321 552 173 85 14

21 Jodhpur 1066 679 238 145 36

22 Karauli 198 255 145 44 10

23 Kota 444 220 136 68 22

24 Nagaur 364 756 134 99 20

25 Pali 429 497 269 80 16

26 Pratapgarh 116 190 109 29 5

27 Rajsamand 172 261 121 49 11

28 Sawai Madhopur 179 249 115 39 8

29 Sikar 442 652 148 101 18

30 Sirohi 104 216 108 31 9

31 Sri Ganganagar 245 410 139 37 12

32 Tonk 199 298 73 60 10

33 Udaipur 871 643 114 118 32

Total 12609 13438 4427 2393 540

Under the two broadly classified categories i.e, Regular staff and NRHM contractual staff,

following bar charts have been made:

II. Human Resource for Health Policy Since 1951, the state of Rajasthan is following its own service code for recruitment, transfer and

deployment of the regular staff. The state is not having as such any HRH policy as such for

contractual staff whose HR issues are dealt by the HR cell which abides by guidelines of

Government of India for contractual manpower under NRHM.

III. Generation of Human resource The current availability of government nursing colleges in the state is as follows:

S.no. Name of the Institution Annual Intake

ANM Nursing Colleges ( Government)

1 A N M Training Centre Govt R R Hospital,Rajsamand 40

2 District Hospital Fhw Trg. Centre, Ajmer 20

3 District Training Centre, Health & Family, Bikaner 20

4 Female Health Workers Training Center, Udaipur 60

5 General Hospital, (Health And Family, Bharatpur 20

6 General Hospital, Alwar 20

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

ANM Labtechnician

LHV MO GNM

32.73

95.61

0

99.86

0

67.27

4.39

100

0.14

100 Contractual

Regular

7 General Hospital, School Of Nursing, Sawai Madhopur 30

8 Govt General Hospital , Sawai Madhopur 20

9 Govt General Hospital, Sirohi 20

10 Govt. General Hospital ,Dholpur 20

11 Health Worker ( Female) Training Centre, Sikar 30

12 Maharao Bhim Singh Hospital , Kota 20

Total 320

BSc Nursing Colleges ( Government)

College Of Nursing J L N Medical College 60

College Of Nursing M B S Hospital, Kota 60

College Of Nursing Maharana Bhupal Govt. 50

Government College Of Nursing S M S 26

Govt College Of Nursing Dr S N Medical 40

Govt College Of Nursing Sardar Patel 100

Rajasthan Medicare Releef Society College 60

Total 396

GNM Nursing Schools ( Government)

Mahatma Gandhi Hospital, Jodhpur 60

G N M Training Centre , Sikar 60

General Nursing Training Centre, Barmer 60

Gnm School Of Nursing , Chittorgarh 60

Govt Rajbhadur Memorial Hospital, Bharatpur 60

Govt. General Hospital , Ganganagar 20

Jawahar Lal Nehru Hospital, Ajmer 50

School Of Nursing, Sawai Mansingh General Hospital,Jaipur 60

Total 430

Msc Nursing colleges ( Government)

Government College Of Nursing, Jaipur 25

Govt College Of Nursing, Jodhpur 20

Govt College Of Nursing ,Bikaner 20

Total 65

Besides this, there are 12 Private ANM nursing colleges with an annual intake of 360 candidates

per year; 115 B.Sc. Nursing colleges with an annual intake of 720 seats; 134 GNM nursing

schools with an annual intake of 6350; 11 MSc nursing colleges with annual intake of 121.

S.no Medical Colleges Annual Intake

1 Dr SN Medical College, Jodhpur Govt. 150

2 Government Medical College, Kota Govt. 150

3 Jawaharlal Nehru Medical College, Ajmer Govt. 100

4 R N T Medical College, Udaipur Govt. 100

5 Sardar Patel Medical College, Bikaner Govt. 150

6 SMS Medical College, Jaipur Govt. 150

7 Jhalawar Medical college, Jhalawa Govt. 100

Total 900

The state is also having 8 dental colleges including government & private with an annual intake

of nearly 80.

Specialty-wise number of Degree colleges in Rajasthan

Obstetrics & Gynecology

No. of Seats

Govt 66

Private 5

Total 71

No. of Colleges

Govt 6

Private 2

Total 8

Anesthesiology

No. of Seats

Govt 64

Private 9

Total 73

No. of Colleges

Govt 6

Private 2

Total 8

Pediatrician

No. of Seats

Govt 52

Private 6

Total 58

No. of Colleges

Govt 6

Private 2

Total 8

The state is facing dearth of specialists although ,there are 226 PG seats (including Private and

Govt. colleges) for the three main specialities required for the proper functioning of an FRU

IV. Recruitment, sanctioned posts, vacancies Erstwhile Rajasthan Public Service Commission (RPSC) was the responsible body for

conducting recruitments. But due to extended time lag taken by RPSC for recruitments, the

charge of recruitment was relegated to Rajasthan University of Health Sciences. With this move,

the state has managed to cut down recruitment time span from around 1 year to 3 months.

State hasn’t done any recruitment since June, 2011 accounting to the ban imposed by Finance

department on 17/6/2011. State plans to regularize its NRHM contractual staff through the

impending 21,000 vacancies to be launched in upcoming fiscal.

Chart showing percentage vacancies against sanctioned posts – Rajasthan 2012

ISSUE- Upon visit to CHC Shahpura, it was observed that 2 specialists’ name were there in

register even after more than 6 months of their not joining or reporting. Regarding this, CHC

administration had apprised the state authorities. But no action has been taken so far and the

specialists’ positions still remain occupied but only on papers.

Regular Employees

1. Medical Officers & Specialists: The state is facing acute dearth of specialists, even more

so in rural and remote areas. An online test followed by the interview is conducted by

RUHS for recruitment of MOs and specialists. These shortages are persistent due to the

delay in processes of recruitments.

ISSUE- Another issue that has cropped up in the state leading to high attrition rate is

lucrative offers in the private sector. Experienced medical staff is shifting towards private

sector due to better salary prospects offered in there.

ISSUE- As per the govt. protocol specialist gets placed preferably at the CHCs as a

PGMO in the beginning, where he neither gets the facilities nor the support staff to assist

in conducting specialist interventions. This is how their skills don’t find proper

deployment and gradually fade off by the time they get posted at any suitable place.

S.no. Name of Districts Specialist MO

Sanctioned Vacant Sanctioned Vacant

1 Ajmer 125 39 207 44

2 Alwar 149 61 273 41

3 Banswara 86 60 176 53

4 Baran 69 37 141 34

5 Barmer 89 62 213 64

6 Bharatpur 96 50 195 26

7 Bhilwara 116 72 217 91

8 Bikaner 64 19 171 16

9 Bundi 63 38 113 27

10 Chittorgarh 98 66 158 61

11 Churu 94 40 204 57

12 Dholpur 37 27 110 36

13 Dausa 61 22 102 16

14 Dungarpur 88 65 159 64

15 Hanumangarh 58 24 111 22

16 Jaipur 211 36 524 30

17 Jaisalmer 50 35 87 35

18 Jalor 56 37 117 30

19 Jhalawar 90 61 142 43

20 Jhunjhunu 100 46 179 30

21 Jodhpur 113 47 319 48

22 Karauli 60 26 104 22

23 Kota 54 7 164 7

24 Nagaur 130 63 236 52

25 Pali 112 56 227 67

26 Pratapgarh 44 32 93 33

27 Rajsamand 79 59 140 56

28 Sawai Madhopur 68 37 112 27

29 Sikar 116 34 209 30

30 Sirohi 49 28 75 19

31 Sri Ganganagar 84 38 156 44

32 Tonk 59 22 120 22

33 Udaipur 109 59 286 70

TOTAL 2877 1405 5840 1317

2. Paramedical staff & Nurses: No hiring of staff has been done after June, 11. Nurses get

recruited through merit calculated based on the marks’ weightage in Higher Secondary

school (12th pass) and Nursing diploma. Nurses join at the level of Nurse Gd II and then

get promoted to Nurse Gd I. The Nurse Gd I are generally posted on the MCH facilities.

S.No Name of Districts Nurse(Gd.I) Nurse (Gd-II) LHV ANM LT X-ray tech

San Vac San Vac San Vac San Vac San Vac San Vac

1 Jaipur 369 34 2050 311 784 77 111 40 304 21 103 21

2 Alwar 101 11 500 45 776 133 108 23 134 12 34 5

3 Sikar 65 20 416 19 723 71 103 44 104 5 26 8

4 Dausa 27 7 188 33 349 98 44 19 51 2 11 1

5 Jhunjhunu 46 18 349 56 641 89 94 9 101 21 18 4

6 Jodhpur 184 19 1216 315 803 124 123 63 182 37 49 13

7 Barmer 45 12 341 47 748 193 86 39 98 39 21 12

8 Jaisalmer 18 9 151 84 198 60 22 14 34 16 12 3

9 Sirohi 24 17 136 39 282 66 34 4 38 10 12 3

10 Pali 71 15 415 42 611 114 98 54 101 23 22 6

11 Jalor 27 9 210 12 483 84 37 28 76 26 10 8

12 Bikaner 142 95 608 233 492 85 56 25 113 11 39 12

13 Sri Ganganagar 58 41 276 48 480 70 58 11 68 31 17 5

14 Hanumangarh 29 19 225 71 394 66 45 11 59 12 11 4

15 Chooru ratan garh 54 37 353 84 532 62 71 13 88 39 16 6

16 Ajmer 164 28 765 304 477 77 62 14 111 18 37 7

17 Bhilwara 73 2 412 16 586 62 80 15 102 16 20 3

18 Nagaur 70 40 481 147 914 158 127 74 126 33 28 8

19 Tonk 32 13 202 22 346 48 62 25 64 4 12 2

20 Kota 90 16 468 98 254 34 39 10 80 16 26 4

21 Baran 43 25 231 59 287 46 39 14 57 28 13 2

22 Jhalawar 49 22 247 72 349 69 39 12 61 25 17 7

23 Bundi 37 5 197 25 266 45 32 5 47 8 13 5

24 Bharatpur 68 14 238 31 536 36 55 8 91 6 22 1

25 Dholpur 30 13 191 60 269 33 29 3 44 12 11 2

26 Sawai Madhopur 39 12 188 36 315 66 31 12 42 7 13 5

27 Karauli 29 5 188 14 335 80 33 6 43 3 13 3

28 Udaipur 170 26 925 198 1125 482 97 17 155 43 46 14

29 Rajsamand 35 18 256 101 287 26 47 7 68 21 16 5

30 Dungarpur 40 4 265 23 709 291 63 10 66 27 14 9

31 Banswara 60 6 321 46 836 368 70 16 73 22 20 9

32 Chittorgarh 55 18 273 79 411 71 54 7 69 15 20 9

33 Pratapgarh 23 9 162 60 312 122 29 13 39 15 11 6

34 E.S.I 39 7 290 55 40 6 0 0 50 9 4 2

Total 2406 646 13734 2885 16950 3512 2078 665 2939 633 757 214

B. Contractual employees Rajasthan government has also come up with a unique policy of regularization of

contractual staff under NRHM, under which around 21,000 vacancies are to be

announced in the next fiscal. For the same, state has also sought financial support from

MoHFW for the entire period of NRHM.

Third Party Agencies for HR recruitment and placement

Since the state has not done any recruitment since 2011, therefore the districts, through

District Health Society (DHS), are addressing their manpower needs by hiring Third

Party Agencies (TPAs) for HR recruitment and placement. The TPAs are selected based

on a bidding process done by DHS. Then the TPA recruits and places their staff with

salary being paid through NRHM to TPA, which further pays it to the staff placed.

Medical Officers: The Selection procedure involves walk-in interviews which are

conducted on weekly basis at the district level. But despite the persistent recruitments,

vacancies still lie considerably.

Nurses and Paramedical staff: Selection is done on merit basis followed by the

interview.

Erstwhile, State Institute of Health and Family Welfare (SIHFW) used to hire contractual

staff with the coordination of medical health department (non-gazetted).

ISSUE- Since the state is not directly involved in hiring the workforce; it lacks the

discretionary control over them. At some places, it was found that the staff hasn’t even

got the appraisals because of the pending performance evaluation.

V. Deployment of Human Resources The state has a special cadre for specialists. Specialists start off as PGMO in a CHC and may

reach upto the level of Director, if get all promotions timely. The cadre wise percentage

distribution of medical officers and specialists are enlisted below.

In Rajasthan, there are 133 facilities designated as First Referral Units, out of which, 33 are DH

hospitals, 12 are sub district hospital, 3 Satellite hospitals and 85 Community health centers. In

these 133 facilities, 49 facilities are not conducting deliveries. The details of the staff in these 49

facilities are enlisted below.

S.no. District Name of Institution Type Specialist lacking Gynaecologist -

G ,Paediatrician - P, Anaesthetist - A

1 Ajmer Bijaynagar CHC 1-A

2 Bhilwara Raipur CHC 1 -A

3 Nagaur Govt. Hospital, Ladnu SDH 1-G,1-A

4 Tonk Malpura CHC 1-G, 1-P

5 Bikaner District Hospital, Bikaner DH -

6 Bikaner Nokha CHC 1-G, 1-P

7 Churu Lunkaransar CHC 1 -A

8 Ganganagar Raisinghnagar CHC 1-G

9 Hanumangarh Rawatsar CHC 1-A

10 Bharatpur Bayana CHC 1 -P

0.00

10.00

20.00

30.00

40.00

50.00

60.00

70.00

SMODental

MO Dental SeniorSpecialist

SMO Juniorspecialist

MedicalOfficer

0.17 1.79 2.50

10.02

21.36

64.17

Percentage

11 Bharatpur Deeg CHC 1-P

12 Dholpur Bari CHC -

13 Dholpur Baseri CHC 1-P, 1-A

14 Karauli Hindon CHC -

15 Karauli Todabhim CHC 1-P, 1-A

16 S Madhopur Khandar CHC 1-A

17 Alwar Behrod CHC -

18 Alwar Kishangarh CHC 1-P

19 Alwar Rajgarh CHC 1-A

20 Dausa Mahuwa CHC 1-P, 1-A

21 Dausa Lalsot CHC 1-A

22 Jaipur1 Shahpura CHC 1-A

23 Jaipur1 Jamwa Ramgarh CHC 1-P

24 Jaipur1 Govindgarh CHC -

25 Jaipur 2 Bassi CHC 1-A

26 Jhunjhunu Udaipurwati CHC 1-G,1-A

27 Sikar Khandela CHC 1-G,1-P, 1-A

28 Sikar Ajeetgarh CHC 1-G,1-A

29 Barmer Dhorimanna CHC 1-G,1-P, 1-A

30 Jaisalmer Pokhran CHC 1-A

31 Jaisalmer Sankda CHC 1-G,1-P, 1-A

32 Jalore General hospital, Jalore DH 1-A

33 Jalore Bhinmal CHC 1-G

34 Jalore Sanchor CHC 1-G,1-P, 1-A

35 Pali Sumerpur CHC 1-P

36 Sirohi Revdar CHC 1-P,1-A

37 Sirohi Abu road CHC 1-P,1-A

38 Baran Chhipabarod CHC 1-G,1-A

39 Bundi Taleda CHC 1-G

40 Jhalawar Aklera CHC -

41 Jhalawar Sunel CHC 1-G,1-P

42 Kota Itawa CHC 1-G,1-A

43 Banswara Bagidora CHC 1-A

44 Banswara Kushalgarh CHC 1-G,1-P, 1-A

45 Chittorgarh Begun CHC -

46 Chittorgarh Kapasan CHC 1-G,1-P, 1-A

47 Dungarpur Simalwara CHC 1-G,1-P, 1-A

48 Pratapgarh Dhariawad CHC 1-G,1-P, 1-A

49 Udaipur District Hospital, Chandpole DH 1-A

Total 49 71 (19-G, 21-P, 31-A)

As per the above data, out of 49 facilities there are 8 facilities which are not having even a single

specialist. The state has although done a redeployment of specialists recently due to which the

numbers of facilities conducting deliveries have increased but the shortages of specialists still

exists.

VI. Training State Institute of Health and Family Welfare looks after the coordination of NRHM training in

the state. Withal that, SPMU has also 1 consultant who looks after the training related issues.

Every year, the training plan with budget is proposed under the PIP, which on approval gets

executed. The current status of training is as follows:

S.no. Training name Target FY12-13

Achievement FY12-13 (till Nov'12)

Cumulative achievement till Mar-12

1 SBA 1280 124 8307

2 BEmOC (MO) 240 86 184

3 EmOC 40 5 56

4 NSSK (SN/ANM/LHV) 750 289 691

5 IMNCI (MO/SN/ANM/LHV) 1700 222 13633

6 F-IMNCI 256 6 54

7 IYCF 420 283 343

9 FBNC -14 days (SN) 150 24 64

11 FBNC - 4 days (SN) 260 0 40

13 RI 1280 642 -

15 Lap. Sterilisation (Spec.) 27 3 267

17 Minilap 68 6 51

19 NSV 10 0 166

21 IUCD (SN/ANM/LHV) 680 203 946

23 PPIUCD 288 92 115

25 LSAS 72 22 136

27 ARSH 360 92 -

29 CAC 100 192 54

31 BSU 50 0 24

33 RTI/STI 1680 289 -

State has 868 delivery points at the level of 24x7 PHCs, CHCs, SDHs and DHs for which it has

only 184 BEmOC trained doctors to handle complicated deliveries.

376 CHCs and other facilities at Sub district level (except DHs) are currently functioning as

FRUs for which requirements are shown as below:

Training Current status Gap in number

LSAS 136 240

EmOC 56 320

FBNC 64 312

At present, 1125 Newborn Care Corners are operational in 1665 delivery points but equipped

with only 691personnel trained in NSSK.

ISSUE- Major training like LSAS and EmOC are given exclusively to the regular MOs, who

often refrain to work in rural and remote areas. The contractual staff who usually gets placed in

such areas remains devoid of such crucial training.

ISSUE- In PHC Dhanota, only 1 staff, i.e. AYUSH MO was trained in SBA training who barely

attends any delivery. On the other hand, the ANM who has been attending deliveries for last

many years was not trained in SBA. This indicates that there is still scope of more rational

planning of training loads.

VII. Remuneration The salaries are released by DDOs at the district level for the regular staff only. For the TPA

hired contractual staff , the salaries are disbursed by the agencies which in turn gets yearly

contracts for providing HR consultancy services.

ISSUE- Huge disparity in the salary of regular and contractual staff was observed. Contractual

ANMs get Rs 7,200 as monthly salary whereas the regular ANMs get the salary of Rs 23,000.

Similar gaps were observed for other personnel categories too.

VIII. Retention Strategies The Government of Rajasthan has proposed different type of incentive schemes for retention of

the human resource personnel. But it is still facing problems in retaining the staff in difficult

areas.

Performance based incentives have been introduced at the PHC levels in the state. These are:

Rs 10000/month to the team at the FRU level, for conducting more than 10 C-sections.

Rs 2000 to the EmOC and LSAS trained doctors for conducting a C- section at the FRU

level.

Besides that the government of Rajasthan is providing hard duty allowances also for the

contractual service providers. The Hardship allowance for Medical officers is Rs 3000 in 350

identified PHCs & CHCs in high focus districts. The ANMs and other paramedics are also

provided with hardship allowances of Rs.1000 in the identified 500 SCs in high focus districts.

IX. Health Human Resource Information System The state does not have any human resource information system because of which, it is not able

to track the real time information on HR tracking.

X. Workforce management A. Regular employees- All recruitments, transfers and posting of the medical and paramedical

staff is overseen by the medical directorate but no transfer and posting policy is being followed

in the state. Promotion depends largely upon the availability of vacant prospective positions and

is done only on one criterion, i.e. length of service.

B. Contractual employees- There are no definite policy for transfer or promotion of the

contractual staff. However, the contractual staff is entitled to get annual pay scale up gradation

based on their performance appraisal. A dedicated HRD Cell under supervision of Project

Director has also been established at SPMU to look after the performance appraisals and has

even worked out with formats. But upon interaction in the field, it was found scarcely

implemented. Appraisals were either automated or dependent upon the mercy of supervisor.

XI. Management Cadre Regular employees-

Director (Public Health) heads the Medical directorate, under which there are 2 Additional

Directors, one looks after the HR related issues of gazetted staff, i.e. Doctors/Specialists and the

other looks after that of non-gazetted staff, i.e. Paramedical staff and Nurses.

Contractual employees

District level committee chaired by the District Collector and CMHO as its Member Secretary

has been formed to do recruitments at the district level through District Health Society. Whereas,

a state level committee comprising MD NRHM (Chairperson), Project Director, NRHM,

Director RCH and other technical specialists does so at the state level.

State Programme Management Unit (SPMU) spearheaded by State Programme Manager under

supervision of MD (NRHM) gets the support from 23 consultants for looking after various

aspects of the programme, like IEC, HR, Training, FRU, AYUSH, MCH, etc.

ACTION POINTS

Immediate

Human Resource Information System (HRIS) is urgently required for real time

information of HR tracking and proper deployment of trained and non-trained staff. State

should get an online HRIS in collaboration with relevant stakeholders/partners as soon as

possible.

Since no transfer policy is being followed, the state may implement a short term strategy

of rotational posting of staff with fixed time frames. This is how state might be able to

address the requirements of health workers in the rural remote areas.

Rural bonding of 2 years should be followed for the critical human resource in the state

especially for the specialists posted in the underserved areas.

Once a specialist joins, he should get posted at a place where his skills could get proper

deployment. A comprehensive clear cut HRH policy with revised posting guidelines

should be framed.

Selection committee should also follow a flexible approach to post the candidates at

preferred location, if possible. It would help in attracting candidates from the neighboring

states of Haryana, Punjab, Gujarat and Madhya Pradesh.

Planning of the training loads should be done rationally based on the HR requirements

not based on who’s available. Major training like LSAS, EmOC should also be imparted

to the contractual staff since the contractual staff is more likely to get the postings in

remote areas. At the FRU level, the dearth of specialists like Gynae/Anasthesist could be

addressed through giving EmOC and LSAS training to the MOs.

Medium term Plans

Increase in the number of Medical colleges and their annual intake by relaxation of state

specific norms in coordination of medical council of India.

Decreasing the gap in the salary structures of contractual and regular staff in the state.

Faculty development program & quality assurance in nursing schools

Long term

Creation of adequate number of regular posts for health facilities

Creation of adequate number of health facilities.