Public Health Watch

Rajasthan is trying to fix staff shortages at health facilities – but that’s creating other problems

The state has privatised the management of some its primary health centres. But the low wages have prompted many qualified staff to quit.

Lalita Malviya is a lady health visitor at a primary health centre or PHC in Ambirama village in Pratapgarh district of Rajasthan. Her job involves supervising three sub-centres, within the area served by her PHC. For the residents of the area, these facilities are their first point of contact with the public health system. A lady health visitor usually has a few years of experience as an auxiliary nurse and midwife, but 25-year-old Malviya had no experience when she started the job last year. Having just completed a diploma degree in nursing, she was hired after the Rajasthan government handed over management of the Ambirama PHC to the non-profit organisation WISH Foundation.

It was one of 41 PHCs that the state government allotted to private organisations early in 2016 in public private partnerships. Rajasthan said that this arrangement was necessary to overcome the staff shortages that had arisen at PHCs across the state because doctors and other medical personnel were unwilling to serve in rural areas, especially in the state’s desert and tribal regions. Private organisations running PHCs have been filling vacancies by hiring less experienced personnel like Malviya.

In addition to being relatively inexperienced, staff at these privately-run PHCs are often paid less than their counterparts in PHCs that are still run by the state government. As a consequence, staff attrition at privately manages PHCs is also high. This month, for instance, six PHCs run by Geetanjali Hospital and Medical College lost 11 employees and PHCs run by the Chitransh Education and Welfare Society lost 13.

“The staff at PHCs run on PPP keeps changing,” said Dr OP Bairwa, chief medical health officer at Pratapgarh. “So there is no continuity of medical services. People do not trust them much then.”

But despite such complaints by block and district level health officials, the state health department recently conducted a partial evaluation of the programme and declared it a success.

An Auxillary Nurse Midwife conducts a health check at a primary health centre in Rajasthan. Photo: Menaka Rao
An Auxillary Nurse Midwife conducts a health check at a primary health centre in Rajasthan. Photo: Menaka Rao

The inexperience and rapid turnover of the staff at many of Rajasthan’s privately-run PHCs have diminished their efficiency. PHCs treat minor health problems and refer more serious illnesses to larger health facilities. But PHCs also play a crucial role in healthcare and promoting good health practices. For this, health workers need to develop trust in the communities they work with, which requires both experience and time.

For instance, said Dr Sanjeev Tank, chief medical officer of Udaipur district where six PHCs are run in public private partnerships, an auxiliary nurse and midwife with significant field experience is more effective in boosting preventive and promotive health services like immunisation programmes.

Little money

The gap between the wages of staff in privately run PHCs and government facilities can be significant. Malviya in Ambirama earns about Rs 10,000 a month, less than a third of what a lady health visitor employed by the government gets.

Kuldeep Joshi, a laboratory technician at the PHC at Achnera village in Pratapgarh run by Chitransh, earns Rs 6,000 a month – even as a government employee doing the same job would earn a little more than Rs 20,000. Ironically, Joshi had to take a salary cut last year. When WISH Foundation ran the PHC, he was paid Rs 10,000 a month.

At most privately-run PHCs, general nurses, pharmacists and lab technicians get paid only Rs 10,000 to Rs 12,000 per month.

Why do private operators pay their staff so little? The operators that the government does not give them enough money to increase salaries. The government pays private organisations between Rs 22 lakh and Rs 35 lakh per PHC per year, depending on how much the operator had bid to get the contract.

In a petition in the Rajasthan High Court, the health network Jan Swasthya Abhiyan asked that the public private partnership arrangement be discontinued. The petition pointed out that this amount is grossly insufficient to run a PHC and its sub-centres, so private operators compromise on delivery of healthcare and underpay their staff. The public private partnership agreements do not specify whether the salaries of staff hired by the private operators should adhere to government standards.

“The government is paying for staff [at the privately-run PHCs] at the fresher level,” said Dr RN Meena, the state’s joint director for hospital administration. “When we continue this for 5-10 years, these people will get promoted and earn more money.”

Anil Mathur who runs Chitransh said that the organisation cannot afford to pay employees at the same levels as government salaries. “Our employees are social workers,” he said. “We pay them honorarium, not salary.”

Kuldeep Joshi works as a laboratory technician in Achnera PHC. Photo: Menaka Rao
Kuldeep Joshi works as a laboratory technician in Achnera PHC. Photo: Menaka Rao

Underpaid medical personnel do not stay long at these privately-run PHCs.

Rajesh Singh, chief operating officer of WISH Foundation, said that the organisation’s PHCs have a staff shortage of about 40%. “We have been paying more salary to doctors in remote areas,” he said. “If we give them below par salaries, they will run away. We try to incentivise their stay by arranging for accommodation sometimes.”

He claimed that the organisation spends nearly 45% more money on running the PHCs than what the government gives them. The additional money comes from donors, he said.

Not all private providers can afford to pay higher salaries to their staff. “We try to manage with as much money as is given to us,” said Anil Mathur of Chitransh, which runs four PHCs in Banswara, Sirohi and Pratapgarh districts.

Tank said that private operators do not seem to have a plan to address the problem of high attrition. This leads to government health officials having to conduct repeatedly train new personnel.

“We train new recruits again and again but the staff [at privately-run PHCs] does not understand our government programmes well,” he added.

However, Omi Singh of Geetanjali Hospital which runs the six PHCs, denied that the government trains staff at these facilities.

In Karnataka, public private partnerships under the Arogya Bandhu scheme allowed non-governmental organisations to run PHCs. Like in Rajasthan, the private operators paid the staff much less than the government. An evaluation done by Indian Institute of Health Management Research in Bengaluru, found that this resulted in recruitment of less qualified staff. “It is very important to maintain the standardisation in the remuneration for the staff, because it is one of the motivational factors to work in the rural areas,” the institute said in its report.

Tough working conditions

Priyanka Lohar left her job as the lady health visitor at Savina PHC on the outskirts of Udaipur city when she got a contractual government job as an auxiliary nurse and midwife. “In the PPP mode, we do not even get travel or mobile expenses,” she said. “In the government job, at least that will be covered.”

Besides, personnel on government contracts may get permanent well-paying government jobs.

Staff in the PHCs under private management are allowed only one day off a week and do not get any other leave. If a doctor misses work for a day, the government cuts Rs 1,500 from the monthly payment to the private operator. The penalty for a paramedic missing a day of work is Rs 500.

Despite the low salary and poor working conditions Singh, who runs the PHCs for Geetanjali Hospital, believe that the PHC employees get a fair deal.

“Government doctor ke nakhre hote hai,” he said. “They throw tantrums. They take leave often. We do not have that problem.”

Anaemic pregnant women get their doses of iron-sucrose intravenously in Dalot PHC, Pratapgarh district. Photo: Menaka Rao
Anaemic pregnant women get their doses of iron-sucrose intravenously in Dalot PHC, Pratapgarh district. Photo: Menaka Rao

Dr T Sundararaman, dean of the School of Health Systems at Mumbai’s Tata Institute of Social Sciences, said the PHC partnership model works on the flawed expectation that the private player will run the PHC on lower costs and higher motivation. “But this motivation is only at the ownership level,” he said.

Unnecessary shortage?

Why is the government unable to get doctors and other staff to work in rural areas in the first place?

Dr Kishore Murthy, a healthcare researcher in Bengaluru, blames the bureaucratic and inefficient system of filling vacancies. “Some government officials feel the PPP model gives them the freedom to fill posts when necessary,” he said.

Sundararaman said the recruitment deficiency in the public health system has existed for a long time but there are simple ways to fix it. “The government should not wait for vacancies to fill posts and should in fact have a surplus of staff to account for employees quitting or going on leave,” he said.

Doctors are dissuaded from working in rural areas by the lower standard of living there, lack of education opportunities for their children and absence of technology, among other things, argued Dr Vikas Bajpai from the Centre for Social Medicine and Community Health, Jawaharlal Nehru University, Delhi. “All these aspects can only be taken care of by the government, not a non-governmental body,” he said.

The Indian Army Medical Corps is proof that the government can fix this problem, Bajpai added. “I am unable to understand how the government with its reach and logistics is not able to provide for doctors,” he said. “What qualities does an NGO have to provide care to people where the government has failed?”

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Swara Bhasker: Sharp objects has to be on the radar of every woman who is tired of being “nice”

The actress weighs in on what she loves about the show.

This article has been written by award-winning actor Swara Bhasker.

All women growing up in India, South Asia, or anywhere in the world frankly; will remember in some form or the other that gentle girlhood admonishing, “Nice girls don’t do that.” I kept recalling that gently reasoned reproach as I watched Sharp Objects (you can catch it on Hotstar Premium). Adapted from the author of Gone Girl, Gillian Flynn’s debut novel Sharp Objects has been directed by Jean-Marc Vallée, who has my heart since he gave us Big Little Lies. It stars the multiple-Oscar nominee Amy Adams, who delivers a searing performance as Camille Preaker; and Patricia Clarkson, who is magnetic as the dominating and dark Adora Crellin. As an actress myself, it felt great to watch a show driven by its female performers.

The series is woven around a troubled, alcohol-dependent, self-harming, female journalist Camille (single and in her thirties incidentally) who returns to the small town of her birth and childhood, Wind Gap, Missouri, to report on two similarly gruesome murders of teenage girls. While the series is a murder mystery, it equally delves into the psychology, not just of the principal characters, but also of the town, and thus a culture as a whole.

There is a lot that impresses in Sharp Objects — the manner in which the storytelling gently unwraps a plot that is dark, disturbing and shocking, the stellar and crafty control that Jean-Marc Vallée exercises on his narrative, the cinematography that is fluid and still manages to suggest that something sinister lurks within Wind Gap, the editing which keeps this narrative languid yet sharp and consistently evokes a haunting sensation.

Sharp Objects is also liberating (apart from its positive performance on Bechdel parameters) as content — for female actors and for audiences in giving us female centric and female driven shows that do not bear the burden of providing either role-models or even uplifting messages. 

Instead, it presents a world where women are dangerous and dysfunctional but very real — a world where women are neither pure victims, nor pure aggressors. A world where they occupy the grey areas, complex and contradictory as agents in a power play, in which they control some reigns too.

But to me personally, and perhaps to many young women viewers across the world, what makes Sharp Objects particularly impactful, perhaps almost poignant, is the manner in which it unravels the whole idea, the culture, the entire psychology of that childhood admonishment “Nice girls don’t do that.” Sharp Objects explores the sinister and dark possibilities of what the corollary of that thinking could be.

“Nice girls don’t do that.”

“Who does?”

“Bad girls.”

“So I’m a bad girl.”

“You shouldn’t be a bad girl.”

“Why not?”

“Bad girls get in trouble.”

“What trouble? What happens to bad girls?”

“Bad things.”

“What bad things?”

“Very bad things.”

“How bad?”

“Terrible!!!”

“Like what?”

“Like….”

A point the show makes early on is that both the victims of the introductory brutal murders were not your typically nice girly-girls. Camille, the traumatised protagonist carrying a burden from her past was herself not a nice girl. Amma, her deceptive half-sister manipulates the nice girl act to defy her controlling mother. But perhaps the most incisive critique on the whole ‘Be a nice girl’ culture, in fact the whole ‘nice’ culture — nice folks, nice manners, nice homes, nice towns — comes in the form of Adora’s character and the manner in which beneath the whole veneer of nice, a whole town is complicit in damning secrets and not-so-nice acts. At one point early on in the show, Adora tells her firstborn Camille, with whom she has a strained relationship (to put it mildly), “I just want things to be nice with us but maybe I don’t know how..” Interestingly it is this very notion of ‘nice’ that becomes the most oppressive and deceptive experience of young Camille, and later Amma’s growing years.

This ‘Culture of Nice’ is in fact the pervasive ‘Culture of Silence’ that women all over the world, particularly in India, are all too familiar with. 

It takes different forms, but always towards the same goal — to silence the not-so-nice details of what the experiences; sometimes intimate experiences of women might be. This Culture of Silence is propagated from the child’s earliest experience of being parented by society in general. Amongst the values that girls receive in our early years — apart from those of being obedient, dutiful, respectful, homely — we also receive the twin headed Chimera in the form of shame and guilt.

“Have some shame!”

“Oh for shame!”

“Shameless!”

“Shameful!”

“Ashamed.”

“Do not bring shame upon…”

Different phrases in different languages, but always with the same implication. Shameful things happen to girls who are not nice and that brings ‘shame’ on the family or everyone associated with the girl. And nice folks do not talk about these things. Nice folks go on as if nothing has happened.

It is this culture of silence that women across the world today, are calling out in many different ways. Whether it is the #MeToo movement or a show like Sharp Objects; or on a lighter and happier note, even a film like Veere Di Wedding punctures this culture of silence, quite simply by refusing to be silenced and saying the not-nice things, or depicting the so called ‘unspeakable’ things that could happen to girls. By talking about the unspeakable, you rob it of the power to shame you; you disallow the ‘Culture of Nice’ to erase your experience. You stand up for yourself and you build your own identity.

And this to me is the most liberating aspect of being an actor, and even just a girl at a time when shows like Sharp Objects and Big Little Lies (another great show on Hotstar Premium), and films like Veere Di Wedding and Anaarkali Of Aarah are being made.

The next time I hear someone say, “Nice girls don’t do that!”, I know what I’m going to say — I don’t give a shit about nice. I’m just a girl! And that’s okay!

Swara is a an award winning actor of the Hindi film industry. Her last few films, including Veere Di Wedding, Anaarkali of Aaraah and Nil Battey Sannata have earned her both critical and commercial success. Swara is an occasional writer of articles and opinion pieces. The occasions are frequent :).

Watch the trailer of Sharp Objects here:

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This article was published by the Scroll marketing team with Swara Bhasker on behalf of Hotstar Premium and not by the Scroll editorial team.