Challenges & Opportunities

Healthcare Delivery in J&K


According to the 2001 census the size of Jammu and Kashmir’s population is 10,069,917 i.e., 0.98 per cent of the all India figure of 1,027,015,247. Its geographical area is 222,236 sq. km. and accounts for 6.76 per cent of the country’s size. Only 54.46 per cent of the population is literate. The national literacy rate for the same period is 65.38 per cent. Jammu district tops with 71.95 per cent literacy followed by Kathua with 62.64 per cent. Surprisingly, Srinagar district falls at the bottom. Jammu and Kashmir is one of those states in the country where both the demographic situation and level of socio-economic development remains far from satisfactory. It is important to note that both social and economic development and demographic situation are actually multi-dimensional processes and each dimension of development as well as demographic change has its own specific determinants.
The population growth rate in the state has been consistently high. The population is expected to grow to 12031825 in 2015 and to 13809601 in 2025. An increasing population in the face of already scarce resources and land can only result in diminishing returns in the absence of increase in other factors such as capital, better-trained labour and technological innovation. Higher level of the necessary investment is essential to achieve a given average output. More capital will be required to support, even at the subsistence level, an increased number of mouths to feed. A rising population decreases the ability of the state to save, as the dependency ratio is high. The rate of growth of the population has important implications for the health services. Increased number of hospital beds will be needed to maintain the same bed/1000 population ratio. A similar problem is faced in respect of doctors, nurses and pharmacists. The cost of such an expansion therefore is naturally very high. Moreover, the demand for medical services depends on the age composition as well as the size of the population. In the state, more than 5 per cent of the population is above the age group of 60 years. Therefore, in order to ensure that the standard of health remains good, an investment in preventive and related social services including housing and education will be essential.
The social infrastructure falls behind most of the developed states in India. The social indicators here are literacy rate, infant mortality rate, death rate, birth rate, status of children and women and level of poverty and rural development. In terms of literacy, J&K ranks third from bottom at 54.46 per cent. The Total Fertility Rate is 2.3, the Infant Mortality Rate is 51 [All India 55], Crude Birth Rate is 19.0 [All India average: 23.1]; Crude Death Rate: 5.8 [All India: 7.4]; and the Sex Ratio is 892 (All India:933). Estimated Death Rate 5.8 ((All India: 7.4), and Life expectancy at birth 65 (All India: 65.8). [SRS 2008]

Health Infrastructure
In J&K, Government institutions are overloaded: 91% in-patients load is on the Public sector against 41.7 % at national level. State needs 1666 Sub centres (1907 in position), 271 PHCs (375 in position), 67 CHCs (85 in position), 238 Allopathic Dispensaries, 2282 Multipurpose Workers (existing 1794), 1907 Male Health Workers at Sub centres, 375 Female Health Assistants (in position 27), 375 Male Health Assistants (in position 89), 85 Gynaecologists (28 in position), 85 Physician Specialists (44 in position), 65 Pediatricians (17 in position), 340 total specialists (135 in position), 85 Radiographers (59 in position), 460 Lab Technicians (396 in position) and 970 Nurses (403 in position). (Source: RHS Bulletin, March 2008, Ministry of Health, GOI). Moreover adequate number of Anaesthesiologists has to be posted at District and Sub-District Hospitals. Blood Banks have to be made fully functional and responsive to the needs of population. Appropriate Laboratory facility including trained manpower is a necessity.
At present the state has 3400 health institutions, over 5800 doctors, 12855 hospital beds in the government institutions and private aided institutions, including 4 Medical Colleges, 22 District Hospitals, 2 Ayurvedic hospitals, 273 Ayurvedic dispensaries, 2 Unani hospitals, 235 Unani dispensaries.. On an average one medical institution has to serve 3127 persons. 111 hospital beds and 48 number of doctors/vaids/hakims put together are available per lakh population. Community Health Centre (CHC) is a 30 bedded hospital/Referral Unit of 4 PHCs with specialised services. Primary Health Centre (PHC): A referral unit for 6 sub-centres, 4-6 bedded manned with a Medical Officer in-charge and 14 subordinate paramedical, Sub Centre: Most peripheral contact point between Primary Health Care System and community manned with one MPW(F)/ANM and one PMW (M)/or Pharmacist.
Health Institutions Average Rural Area (sq.Km) covered by a Health Intuitions Average Radial Distance ( Kms) covered by a Health Institutions
  J&K All India 
Sub Centre 117.21 21.47 6.111 2.61
Primary Health Centre 591.67 139.40 13.72 6.66
Community Health Centre 2766.07 770.90 29.67 15.66
Average Rural Area & Average Radial Distance Covered By Primary Health Institutions.

Impediments to Growth:
Low density population, difficult terrain (problem of accessibility), poor road connectivity, limited presence of private sector/NGOs and private sector largely owned/operated by in-service doctors.
The slow growth of the state can be attributed to various factors. The civil unrest in Kashmir during the past two decades has been a major factor. Low productivity in agriculture and allied sectors has impeded employment and income generation. Poor industrial infrastructure along with the poor investment climate has left the industrial sector in its infant stage. There has not been a suitable strategy for the potential sectors to achieve higher economic growth. Lack of sound fiscal management has also been responsible for the poor economic growth of the state.

Challenges and opportunities
As a state with unique features and a strategic location, the speedy development needs an integrated approach. Sound policy and good governance can lead the state to a faster development path. District and Sub-district hospitals must be strengthened. The infrastructure of the hospitals: buildings, space, technology, latest biomedical equipment (like CT scan machines, ultrasound machines, X-ray equipment, Autoanalysers, etc) has to be upgraded. The problem of shortage of manpower should be addressed. A scientific human resource development program must be a top priority.  Qualification and experience need due consideration while recruiting technicians, nurses and other staff. Patients should be looked after by appropriately qualified nurses and paramedics and not by unskilled persons. Facilities need to be provided to the district and Sub-District hospitals so that they remain functional 24x7. Emergency Medical Services are essential part of healthcare delivery. Functional Emergency Department (Casualty wards) should be set up at all the district hospitals. There is a need to streamline the functioning of the Out Patient Department’s. Residential facilities to doctors should be provided at the district hospitals so that they remain available 24x7. The bed strength of the District hospitals has to be increased. Mental Health has been neglected for far too long. It needs our urgent attention. Birthing Centres at strategic locations must be provided to take care of mother and child.
Doctors working in far flung areas should be given incentives like rural service allowances. Government must invest reasonably in imparting hands-on training to doctors and paramedics by arranging regular aggressive Continuous Medical Education Programmes both at district and state levels which will help them to enhance their knowledge and skills. Competencies of Health Professionals have to be continuously enhanced. Only proficient staff can provide quality care.  Special attention must be given to the training of doctors and nurses in Critical care including Trauma management. All training programs (Symposia, Conferences, Workshops, Seminars) must fetch Credit Points to those who attend it. Earning of credit points should be made essential for professional growth of doctors.
District Hospitals should be made a hub of health care activities and designated as teaching centres for doctors and nurses so far Internship and Residency programmes are concerned. These hospitals should be managed by professionally qualified Hospital Administrators. Quacks that are playing havoc with the lives of poor and vulnerable populations must be brought to book. Drugs should be dispensed by the chemists against a proper prescription by a qualified doctor. Deviations by the chemists need to be dealt under rules.
A proper Referral System must be in place to treat the Right patient at the Right Place at the Right Time. The system needs regular monitoring by higher authorities. Referring institutions/doctors must be made accountable for it and performance determined with proper feedback from referral centres to the referring doctors (two-way). Arrangements can be made to make CHCs functional round-the-clock and PHCs can work in two shifts.
Quality Assurance must be at the heart of all health facilities. Mechanisms have to be in place to measure the outcome of interventions in accordance with principles of Evidence Based Medicine. Clinical Audit is a necessity for improvising patient care.
A robust Health Information System including Electronic Medical Records is an inescapable necessity for planning, policy making and continuity of care. Networking of healthcare facilities by combining all the three levels of care through Telemedicine is required.

Staff expectations
The impact of service standards rests to a great extent on how staff work and how they are facilitated in what they do. A changing workplace: Healthcare professionals expect the organisations they work for to provide high-quality care. They want healthy and efficient workplaces that enhance the well-being of patients as well as themselves, allowing convenient and rapid access to medical expertise. Innovation in delivery: While acute hospitals offer increasingly sophisticated and effective treatments, there is also a policy drive to shift less demanding care closer to the home, and to integrate it with other community services. Improving staff recruitment, retention and effectiveness: the impact of workplace design is significant enough to affect productivity, attachment to the workplace and levels of staff retention. Research into the therapeutic effect of environments shows how their design can affect health outcomes for patients and improve the performance of staff.

(Prof. Syed Amin Tabish (FRCP, FACP, FAMS, FRCPE, MD (AIIMS) is the HoD Hospital Administration, Medical Superintendent and Chairman, Accident & Emergency Department at Sher-i-Kashmir Institute of Medical Sciences, Srinagar)

Lastupdate on : Mon, 27 Dec 2010 21:30:00 Makkah time
Lastupdate on : Mon, 27 Dec 2010 18:30:00 GMT
Lastupdate on : Tue, 28 Dec 2010 00:00:00 IST

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