FUNCIONALIDADES DE LA HERRAMIENTA ACTUAL USADA POR LA LINEA DE

Picture 4.4: CHC Sandasu, Chirgaon Block, Shimla District

Sufficiency of Budget for MOs (in %) 0 10 20 30 40 50 60 70 80 90 more than sufficient sufficient insufficient by far insufficient n = 20

The interviewed MOs, BMOHs and SMOs were all male. The mean for service in the public health system is more than 14 years, at the current location officers were placed for more than 3 years. BMOHs have longer experience in the public health sector (mean 18.4 years) than MOs (mean 6.8 years). The duration of their stay in their current location is also longer (mean 3.4 years).

Medical Officers are supposed to be shifted every 3 years. However, the interviews revealed that shifting practice depends on political connections. Doctors in urban locations or close to cities are not willing to change their service areas to more remote areas. Hence, the longest stay for MO encountered was 7 years and for BMOH more than 10 years. Since the participants were not asked why their stay was prolonged, it is unclear whether they wanted to stay in the location or not. Nevertheless, shifting practice came up often in the discussions and was a major point of critique from the MO side towards government policies. It was not possible to find out from the interviews, who was responsible for replacements and on what grounds the decision was made. Hence, transparency of decision-making in personnel matters is low in the public health system. Finance is the first function to be looked at in the map of decision space. Since all sources of revenue come from the central and state government the range of choice is narrow. Furthermore, the health officials feel that the financial resources decline (CMOH 07.10.2003). The CMOH does have a free budget of only Rs. 50,000 per year22_{, which}

he/she can dispense on needed equipment or others. But the prices for equipment are high, an x-ray machine costs ten times the budget. A contingent revolving fund of Rs. 1,000 is available at the BPHCs and CHCs for emergencies; they can even get funds up to Rs. 5,000 from the district (SMO 08.10.2003). Information on the use of this money was not available. From the district health administrations down to the SCs all receive allotted budgets with little decision space to manoeuvre.

Figure 4.9: Sufficiency of Budget for MOs in Shimla and Kangra

For each programme and each activity within the programme a certain amount is fixed. The amounts are very low, for example Rs. 25 per school for school AIDS education are given (BMOH meeting 24.09.2003). Most MOs (95 %) find the budget insufficient or by far insufficient for all the tasks they have to carry out (see Figure 4.9).

Service fees are decided at state level. Outpatient services are free of costs at all public health facilities, only a nominal registration fee of Rs. 0.25 is collected. The service fee does not remain in the health facility, but is transferred to the state. No contracts can be given to private organizations due to lack of funds. In cases of repairs this particularly hinders the service. MOs will call up their superiors to report the case. In half of the cases the superior will take all the following actions and in the other fifty percent advices the MO what to do. The Public Works Department (PWD) is responsible for maintenance of health facilities and also for equipment. It is not under the supervision of the health department. The majority of MOs calls the PWD when something is broken. The response of PWD is not satisfactory for the MOs. Repairs may take many weeks or months if they are carried out at all. Most PHCs and BPHCs were in desolate condition. The discussion shows that the range of choice for all financial functions is narrow (see Table 4.3).

The indicators for the function service organization also offer a narrow range only for decision space (see Table 4.3). Autonomy for hospitals is defined by law but it recently opened up and requested the formation of hospital societies (see 2.3.4.). One rural hospital (CHC) was visited during a field trip which had formed a hospital society back in 1979. The MOs at the hospital found the society very useful. They were able to hire a private cleaning service, the society bought equipment when needed and further helped to improve the facility (SMO 30.09.2003). The hospital was remarkably clean and well- organized compared to the BPHCs. The hygiene and sanitation standards in the other BPHCs and CHCs visited also offering inpatient services were very low (see Picture 4.5). The BMOHs have no autonomy to make decisions involving funds or the management of the BPHC, it is all defined by laws and regulations. Furthermore, it was discouraged or even negatively reviewed to be proactive (SMO 08.10.2003). In one case the MO of one CHC run out of outpatient treatment slips. He went to a local copy shop, got them printed and paid it out of his own pocket. For this action he later received negative remarks from his superiors (Ibid.). Local health programmes follow the central norms. The targets for the National Health Programmes are rigid and depend on population numbers. Local demand is not taken into account. One example is the allocation of funds for malaria control but Himachal Pradesh being a mountainous state has malaria only in some districts and could rather use the funds elsewhere (NGO group discussion 22.09.2003).

Lack of Personnel (in % of all answers) 0 10 20 30 40 50 60 70 80 90 100 Service Personnel Nurses MPW MO Specialist n = 26 Figure 4.10: Lack of

Personnel in Health Facilities in Shimla and Kangra

The human resources function is concerned with salaries, contracts and civil service. The salaries are defined by law and are the same in all states. A Medical Officer starting his service receives Rs. 10,000 per month as a basis salary. In Himachal Pradesh he/she also receives a non-practising allowance of 25 % of the basis salary for not engaging in private practice. The most senior officer met receives a salary of Rs. 25,000 per month after 29 years of public service. However, three quarters of all MOs felt that the salary was sufficient. One reason could be that living costs in rural areas are low. Contracting non- permanent staff is not possible; all jobs at the health facilities are assigned by the state and district authorities. The lack of staff for all designations is a serious problem in the two districts. Nearly 90 % of all facilities do not have the required staff. Most wanted are specialists like gynaecologist, followed by service personnel and MOs (see Figure 4.10). While the lack of specialists in rural areas leads to long travel distances for patients - for one block visited the next available gynaecologist was in Shimla which means 12 hours by bus - the lack of service personnel especially affects the conditions and the maintenance of the health facilities. All facilities visited, except one PHC, were not fit to correspond to any hygienic standards. Operation theatres still containing bloody bandages from three days ago, plaster falling from the wall on sterile instruments, mould on the walls, and dusty indoor departments were recurring aspects (see Picture 4.5 and 4.6). It was not only the lack of sweepers, but also the attitude of the doctors contributing to these situations. Often the BPHC or PHC had a sweeper but he/she was not present or there was no soap available or other excuses were made. Since BMOHs or MOs have no authority to hire or fire staff, they have little influence on their workers. Furthermore, the lower-level staff coming from the local areas may have political connections and influence the doctor might lack. Hence, complaints about subordinate staff hardly occur and are not handed up to the district level either. Responses or actions as follow-ups are rare.