CAG Report on Health Exposes 'Delhi Model' of Arvind Kejriwal

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CAG report in Delhi Assembly Reveals Acute Doctors’ Shortage in Hospitals

By Raisina Correspondent

New Delhi, February 28: The CAG report on Health was finally tabled in the Delhi Assembly. The report revealed that the Delhi hospitals faced acute shortages of doctors and paramedic staff.

The CAG report also stated that Delhi government between 2016-17 and 2020-21 could create just 1357 new hospital beds against the promise of 10,000. Also, the CAG reports stated that the Delhi government could not utilize land given for constructing new hospitals.

Human Resource

As of March 2022, there was a shortage of 21 per cent staff in Health and Family Welfare Department of GNCTD. There was overall shortage of 30 per cent in the category of teaching Specialists, 28 per cent in non-teaching Specialists and 9 per cent in Medical Officers category in respect of 28 Hospitals/Colleges covered in this performance audit. Shortage in the cadres of Nurses and Paramedic staff was 21 per cent and 38 per cent respectively.
There was 36 per cent shortage of staff for implementing the National Health Mission (NHM) schemes in the NCTD.
Absence of promotion and career progression opportunities and unchanged salary structure in teaching faculty resulted in shortage of super specialist doctors in two test checked hospitals viz. Janakpuri Super Specialty Hospital (JSSH) and Rajiv Gandhi Super Specialty Hospital (RGSSH)

Healthcare Services in GNCTD

There was high workload in registration counters in test checked hospitals namely Lok Nayak Hospital, Rajiv Gandhi Super Specialty Hospital, Janakpuri Super Specialty Hospital and Chacha Nehru Bal Chikitsalaya. The average consultation time per patient was less than five minutes in Medicine Department and Gynaecology Department of Lok Nayak Hospital (LNH).
Due to shortage of pharmacists, patient load per Pharmacist/counter in LNH was high and medicines were not distributed on the same day. Shortage of essential medicines and equipment was also observed in ICU/ emergency departments of two test checked hospitals (LNH and RGSSH).
Waiting time for major surgeries in the Surgery Department and Burn & Plastic Surgery Departments of LNH was 2-3 months and 6-8 months respectively and at the same time, six out of 12 modular OTs in RGSSH and all the seven modular OTs in JSSH were found lying idle due to shortage of manpower.
Many Ambulances of Centralised Accident and Trauma Services (CATS) were running without essential equipment and devices.
While huge waiting time was observed for radiological diagnostic services in LNH, radiological equipment were found underutilised in the other three hospitals (JSSH, RGSSH and CNBC) due to shortage of manpower.
Atomic Energy Regulatory Board guidelines were not fully adhered to in these hospitals for ensuring the safety of staff and patients.
Dietary services were not available in Janakpuri Super Specialty Hospital (JSSH) and RGSSH. Periodic inspection was not conducted by the dieticians and quality of food was never checked.

Availability of drugs, medicines, equipment and other consumables

Essential Drugs List (EDL), the list of drugs that should be available at all times in Hospitals and other health facilities, was not prepared annually and was prepared only thrice during the last ten years.
Central Procurement Agency (CPA) which was entrusted with the duties of procurement of drugs and equipment for GNCTD hospitals was not functioning optimally as Hospitals had to procure 33 to 47 per cent of essential drugs from local chemists for meeting their day-to-day requirements during 2016-17 to 2021-22. Out of 86 tenders floated for procurement of equipment by CPA, only 24 (28 per cent) were finally awarded.
Audit also noticed procurement of medicines from blacklisted and debarred firms by CPA. There was also short supply/shortage of injections for rare/fatal diseases like Haemophilia and Rabies.
There were delays in empanelment of drug testing laboratories by CPA.
There were also instances where drugs supplied by the CPA were later reported as inferior quality by the laboratory. In some cases these inferior quality drugs were consumed in the hospitals due to the time gap of two to three months between receipt of drugs and receipt of test reports.

Availability and management of healthcare infrastructure

Against the proposed addition of 10,000 hospital beds (Budget speech 2016-17), only 1,357 beds were added during 2016-17 to 2020-21. The Department was unable to utilize any of the 15 plots acquired (June 2007 and December 2015) at a cost of ₹ 648.05 lakh for establishing hospitals and dispensaries, despite having possession for period ranging between six to 15 years.
Out of the eight new hospitals under construction during the audit period, only three hospitals were completed.
Janakpuri Super Specialty Hospital (JSSH) and Rajiv Gandhi Super Specialty Hospital (RGSSH) could not provide Super Specialty tertiary care as envisaged in the Memorandum of Association due to weak monitoring and failure to develop a viable business model.
There was also delay in completion of various building and infrastructural projects in test checked Hospitals.

Financial Management

There were unspent/savings ranging from 8.64 per cent (2021-22) to 23.49 per cent (2016-17) against the budget allocated by GNCTD on Health sector during 2016-17 to 2021-22 and ranging from 13.29 per cent (2021-22) to 78.41 per cent (2018-19) against the budget for healthcare infrastructure during 2016-17 to 2021-22. Delhi State Health Mission (DSHM) could not utilize the funds released under National Health Mission as ₹ 510.71 crore was lying unspent in the bank accounts of Delhi State Health Society and its 11 Integrated District Health Societies (March 2022).

Outcome of selected Centrally Sponsored Schemes

Reproductive, Maternal, New-born Child and Adolescent Health (RMNCH+A) is the most important component/programme under National Health Mission (NHM) for improvement of Maternal and Child Health care. During 2016-17 to 2021-22, 57.79 per cent of total funds available for RMNCH remained unutilised.
There were shortfalls in providing Ante Natal Care, Tetanus Toxoid (TT) shots, Iron folic acid tablets to pregnant women (PW) and also testing them for HIV and Sexually Transmitted Infection/ Reproductive Tract Infection (STI/RTI).Coverage for providing free diet and other facilities (free diagnostic) to pregnant women under Janani Shishu Suraksha Karyakram (JSSK) was also inadequate as only 30 per cent PW had availed the benefits.
Only 10 per cent Medical Officers and 16 per cent Auxiliary Nursing Midwives/health workers were given training for Prevention and Control of Cancer, Diabetes, Cardiovascular Diseases and Stroke.

Adequacy and effectiveness of the regulatory mechanisms for ensuring quality healthcare services

Delhi Nursing Council was not reconstituted regularly by holding elections and notifying fresh members after three years. Only 20 out of 37 Nursing Training Institutions functioning in Delhi were inspected, that too, with delays of seven to 41 months.
Pharmacy Practice Regulations (PPR) notified by GoI in January 2015 has not yet been notified by GNCTD.
There was overall shortage of 52 per cent staff in different cadres including 63 per cent shortage in key staff of Drug Inspector in Drugs Control Department. There was huge shortfall in the mandatory inspections of drug selling and manufacturing units and Blood Banks by the Drugs Control Department.
Drug Testing Laboratory (DTL) was not accredited by National Accreditation Board of Laboratories (NABL) and did not have modern equipment and manpower. Two test checked hospitals were not accredited by NABH. None of the four labs of LNH/MAMC was accredited by NABL. Two out of three labs were not accredited by NABL in the case of RGSSH.

Achievement of Sustainable Development Goals related to Health sector

The Sustainable Development Goals (SDG) adopted in September 2015 set out a vision for a world free of poverty, hunger, disease and want. Examination of individual indicators however revealed that Delhi lacked under two indicators, viz. case notification rate of Tuberculosis[1] and suicide rate. Audit observed deficiencies in implementation of Revised National Tuberculosis Control Programme (RNTCP) such as lack of creating awareness about TB, non-formation/ delay in formation of District DR-TB Committees, inadequate monitoring of implementation of the scheme, etc.

Implementation of Programmes, schemes/projects/services of GNCTD

All private hospitals which were allotted land on concessional rates were to provide 25 per cent of their OPD facilities and reserve 10 per cent IPD beds for free treatment of patients from Economically Weaker Sections (EWS). Information about the total OPD patients treated by these Identified Private Hospitals (IPHs) were not provided by DGHS. Audit noted that 19 out of 47 Government Hospitals (GHs) in Delhi had not established referral centres to refer EWS patients to Identified Private Hospitals (IPH) even after a delay of 15 years (June 2022).
Audit also observed shortcoming in functioning of Delhi Arogya Kosh (DAK) constituted (September 2011) to provide financial assistance to poor patients. It did not maintain scheme-wise details of beneficiaries, did not regularly seek details of unspent amount lying with government hospitals and also did not implement online Aadhar-based/biometric tracking of patients to ensure proper follow-up and to prevent malpractices. Free surgery scheme of DAK provides for sending eligible patients from Delhi Government Hospitals to empanelled hospitals when the allotted date for a specified surgery is beyond one month or specified surgery is not performed in Government Hospital. DAK did not carry out any assessment to verify the effectiveness of the scheme for sending eligible patients to private hospitals to reduce waiting period for surgeries.
One of the conditions of reimbursement of bill of Medico-legal victims is that the victim is not covered in any insurance scheme. No mechanism was in place to check this before making payment.

AYUSH

Number of IPD and OPD patients visiting AYUSH hospitals had declined during 2016-22. Pathology lab, maternity ward and radiology departments in one of the test checked hospitals were not functional/partially functional. There was also shortage of essential medicines in the test checked hospitals in spite of availability of funds.
There were shortages in the cadres of doctors (51.89 per cent), paramedical staff (55.93 per cent) and nurses (32.21 per cent) in the four Medical Colleges with attached Hospitals (Ayurvedic and Unani Tibbia College, BR Sur Homoeopathic Medical College & Research Centre, Nehru Homoeopathic Medical College and Hospital and Choudhary Brahm Prakash Ayurvedic Charak Sansthan).
Four Equipment (Fully Automatic Biochemistry Analyzer, Hematology Analyzer, Electrolyte Analyzer and Immunoassay CLIA System) costing ₹ 45.98 lakh procured (March 2018) for Pathology lab in Tibbic College & Hospital were not put to use.
GNCTD did not set up a State Ayush Society nor did it submit State Annual Action plan to GoI for availing financial benefit under National Ayush Mission.
Delhi Bhartiya Chikitsa Parishad (DBCP), intended to provide registration of medical practitioners of Indian Systems of Medicines, was not reconstituted since July 2015. Delhi Homoeopathy Anusandhan Parishad (DHAP), constituted to develop and coordinate research in Homoeopathy, was not functional since 2017-18.