Audit Reports

Jharkhand

Overview

The Audit Report of the Comptroller and Auditor General of India on District Hospital Outcomes in Jharkhand, Government of Jharkhand for the year ended 31 March 2019, prepared under Article 151 of the Constitution of India and Section 19A of the Comptroller and Auditor General’s (Duties, Power and Conditions of Services) Act, 1971 was submitted to the Governor of Jharkhand on 27 December 2021. The report was presented to the State Legislature on 15 March 2022.

The Performance Audit of District Hospital Outcomes in Jharkhand, covering the period 2014-19, was carried out during 2019-20 with the objective of assessing the quality of medical services and patient care being provided by DHs in the State.

Keeping in view the goals laid down in the National Health Policy and expected outcomes of Sustainable Development Goal 3 at the global level, evaluating the outcomes has become crucial for timely and systematic corrections. This Report aims at identifying the areas that require corrections and improvement.

In this outcome based audit, focus is on patient care received at the DHs in the State. Various services like Out-Patient and In-Patient Services, Maternity Services, Diagnostic Services, Infection Control and Drug Management have been assessed on the basis of pre-determined criteria in the sampled DHs. Pre-determined outcome indicators were used for assessing In-Patient Services.

Policy framework for healthcare services

Audit observed that the Department did not formulate its own standards/ norms to ensure availability of all types of resources and services in adequate quantum in DHs in respect of out-patient and in-patient services, pathology investigations and human resources. As a result, a methodical gap analysis was not carried out. The absence of standards/norms would, and has, impacted the availability of resources and services in the hospitals.

Out-Patient services

The patient load in the Out-Patient Departments (OPDs) had increased by 57 per cent in 2018-19 in the test-checked DHs compared to 2014-15. Despite increase in the number of patients in OPDs, each OPD clinic was being run by a single doctor leading to increase of patient load per doctor per day. Heavy patient load per doctor per day in the six test-checked DHs, especially in general medicine OPD (between 79 and 325 patients), in gynaecology OPD (between 30 and 194 patients) and in paediatrics OPD (between 20 and 118 patients) adversely impacted consultation time which was less than the suggested minimum consultation time of five minutes. Despite high patient load and consequently low consultation time, test-checked DHs did not deploy more than one doctor in these OPDs for giving better health care services. Less consultation time is directly linked with patient’s dissatisfaction with the consultation process.

Waiting times for patients were also impacted since the number of registration counters were not commensurate with the increase in the daily patient load, exacerbated in some of the test-checked DHs by a lack of suitable seating facility and toilets and an overall weak grievance redressal system.

Diagnostic services

Diagnostic services, both radiological and pathological, were deficient in terms of availability of functional equipment, consumables and human resources in the test-checked DHs. A majority of the test-checked DHs did not have the requisite range of X-ray machines. Ultrasonography (USG) facility was not available in two DHs and Computed Tomography (CT) scan was not available in any of the test-checked DHs.

There were serious gaps in the availability of essential pathological investigations in all the test-checked DHs; whereas the functions of in-house pathology services were marred by shortage of lab technicians and essential equipment.

Owing to lack of monitoring of the time lag between receipts of samples and reporting of results of investigations to the patients, minimum efficiency standards in pathology services remained a challenge.

In-Patient services

There were significant deficiencies in the availability of in-patient services such as Burn ward, Ear Nose and Throat (ENT), Accident and trauma ward as well as indoor services for Psychiatry in the test-checked DHs.

In-patient services in the different DHs also varied in terms of the availability of resources.

• There was shortage of doctors ranging between 19 and 56 per cent in the six test-checked DHs. The test-checked DHs also had shortage of 9 to 18 specialists. Further, none of the test-checked DHs had specialists of AYUSH, Dermatology, Microbiology and Forensics.
• In the six test-checked DHs, shortage of paramedics ranged between 43 and 77 per cent whereas that of staff nurses ranged between 11 and 87 per cent.
• Operation Theatres (OTs) for ENT and Orthopaedics were not available in any of six test-checked DHs whereas OTs for emergency services was not available in five DHs. There was shortage of equipment and drugs in all the OTs of the test-checked DHs.
• Out of six test-checked DHs, records of OT procedures were maintained only in DH East Singhbhum. While three DHs (Deoghar, Palamu and Ramgarh) did not maintain any records, it was partially maintained in DHs, Hazaribag and Ranchi.  In the absence of or partial maintenance of surgical safety checklist, pre-surgery evaluation records and post-operative evaluation records for OTs, it was not ascertainable whether safety procedures in OTs were adhered to in the test-checked DHs.
• Intensive Care Units (ICUs) were established only in nine[1] DHs between July 2016 and May 2017 out of the 23 DHs in the State. Further, shortage of equipment and drugs were noticed in ICUs in the six test-checked DHs. Thus, critical care to patients was not adequate and they were likely to have been referred to higher government health facilities.
• Separate Accident and Trauma ward for providing better care to patients were not available in five test-checked DHs except DH, Hazaribag and patients were referred to the nearest higher government health facility.
• Though prescribed in IPHS, none of the six test-checked DHs had a system for quality testing of the diet provided to in-patients.
• Disaster Management Plan (DMP) was prepared only in one (East Singhbhum) out of six test-checked DHs. Thus, five DHs[2] lacked proper plan in case of any kind of disaster.
• Desired Bed Occupancy Rate (BOR) of more than 80 per cent was not achieved by the test-checked DHs except for two DHs (Palamu and Ramgarh) which achieved the same in some months. However, improvement in BOR was visible in May 2018 with respect to May 2014 in all the test-checked DHs except DH, Palamu where it decreased to 50 per cent in May 2018 from 54 per cent in May 2014.
• Bed Turnover Rates (BTR) of two DHs (Deoghar and East Singhbhum) was much lower compared to BTRs of the other test-checked DHs which indicated comparative inefficiency in these hospitals.
• Leaving Against Medical Advice (LAMA) Rate was high in three DHs (Deoghar, Hazaribag and Palamu) which indicated that the quality of healthcare services in these hospitals was poor.

Maternity services

Significant deficiencies were observed in all the four major components of facility based maternity services - Antenatal care, Comprehensive Abortion Care (CAC) services, Intra-partum care or delivery care and postpartum care:

• Out of 1.30 lakh pregnant women (PWs) registered in the six test-checked DHs during 2014-19, 51,526 (40 per cent) PWs were not provided the complete cycle of ANC. Of the registered PWs, 77,762 (60 per cent) PWs were not provided first tetanus toxoid (TT) injection, 85,743 (66 per cent) PWs were not provided second TT injection and 54,539 (42 per cent) PWs were not provided iron and folic acid (IFA) tablets. This is an area of concern as lack of adequate ANC services are directly linked with increase in the number of stillbirths and children with low birth weight.
• Essential drugs were not available in maternity IPDs which included Hydralazine in all the six test-checked DHs; Dopamine/Methyldopa in five test checked DHs except in Ramgarh; Adrenaline, Calcium Gluconate and Diazepam in four DHs except in East Singhbhum and Ramgarh; Ampicillin in four DHs except in East Singhbhum and Ranchi and Gentamycin in three DHs (Hazaribag, Palamu, and Ranchi).
• Essential consumables like draw sheets, identification tags and threads for sutures were not available in the test-checked DHs. Baby wrapping sheets were not available in two DHs (East Singhbhum and Hazaribag) and Nasogastric tubes were not available in three DHs (Deoghar, Hazaribag and Palamu).
• Test-checked DHs did not have essential equipment in maternity IPDs. Partographs, which enable the birth attendant to identify and manage complications of labour promptly, were not plotted in most of the cases in the test-checked DHs.
• Purchase of equipment for twelve bedded Special Newborn Care Units (SNCUs) was under process as of June 2020 at three test-checked DHs (East Singhbhum, Ramgarh and Ranchi).
• In the six test-checked DHs, it was observed that 77 to 89 per cent of mothers were discharged from the hospital within 48 hours of delivery and as such immediate management of post-partum complications was not ensured.
• Out of 362 test-checked cases during 2016-19, 310 eligible beneficiaries were paid cash assistance under Janani Suraksha Yojana (JSY) after one month of delivery including 97 beneficiaries who were paid after more than six months. Further, eight beneficiaries were not paid as of March 2020. Delay/ non-payment of cash assistance defeated the objectives of Scheme.
• Stillbirth rate was between 1.08 and 3.89 per cent in the six test-checked DHs during 2014-19. In three DHs (Palamu, Deoghar and Hazaribag), stillbirth rates were high (ranging between 2.09 and 3.89 per cent) which was significantly higher than the average State rate of one per cent and the average national rate of 0.7 per cent.

Infection control

Infection control practices were not sufficiently embedded in the functioning of DHs. DHs lacked standard operating procedures (SOPs)/checklists for hygiene and infection control; disinfection and sterilisation of medical tools, instruments and equipment etc. Infection control practices were mostly limited to boiling and autoclaving. DHs also lacked liquid chemical sterilisation and high-level disinfection facilities.

• SOPs for housekeeping were not available in five test-checked DHs except at East Singhbhum. Despite outsourcing, cleaning services were not of a satisfactory level in the test-checked DHs indicating lack of oversight on the part of the hospital administration in ensuring adequate decontamination of functional areas of DHs.
• Only two to four types of linen comprising mainly of bed sheets and blankets were available in sufficient numbers in the test-checked DHs. There was shortage in two to 11 types of linen that included table cloths, OT coats, overcoats etc., whereas six to 17 types of linen comprising bedspreads, draw sheets, overshoes pair etc., were not available in the test-checked DHs. Laundry services were also highly inadequate as washing of linen was not done through mechanised laundry in the premises of test-checked DHs as envisaged under guidelines of “Kayakalp”. Absence of covered trolleys to carry dirty linen from wards was also noticed. Further, there were no almirahs or covered racks to keep the washed linen safely in the wards of the test-checked DHs thereby increasing the vulnerability of patients to hospital acquired infections.
• Liquid chemical waste was being discharged directly into drains without pre-treatment in violation of the Bio-Medical Waste Management Rules, 2016.

Drug management

Drug procurement process in the State was marred with systemic problems as well as non-adherence to the stipulated procedures viz., delays in testing resulting in expiry of medicines, non-adherence to quality assurance of supplied drugs, non-procurement of Essential Drugs etc.

• Jharkhand Medical & Health Infrastructure Development & Procurement Corporation Limited (JMHIDPCL) could not utilise State funds amounting to ₹ 87.85 crore (88 per cent) out of ₹ 100.31 crore on procurement of drugs which was refunded (June 2020) to the Department. Further, only ₹ 40.54 crore (79 per cent) was spent out of available NHM funds for purchase of drugs during 2016-19 and the balance of ₹ 12.24[3] crore was lying in the bank account of JMHIDPCL.
• Test-checked DHs procured medicines from local vendors without quality testing in the absence of centralised purchase of medicines by JMHIDPCL.
• Only 11 to 23 per cent of essential drugs were available with the test-checked DHs during 2017-19. The available drugs also became out of stock for a considerable period due to less procurement of drugs as compared to requirement.
• Test-checked DHs did not adhere to norms for storage of drugs which were directly linked with loss of efficacy and shelf life of drugs. Prescribed safety norms were also not followed for storage of dangerous drugs.

Building infrastructure

To deliver quality health services in the public health facilities, adequate and properly maintained building infrastructure is of critical importance. The Performance Audit, however, revealed several inadequacies and deficiencies in the availability and creation of hospital building infrastructure:

• Shortage of required beds in the test-checked DHs ranged between 61 and 88 per cent and 57 and 86 per cent respectively during 2014-15 and 2018-19. Shortage was due to non-sanction of additional beds with the pace of increase in the population.
• Government decided (August 2007) to construct a 500 bedded hospital building for DH, Ranchi. However, midway stoppage (July 2013) of construction work and failure to attract private partners to operate the hospital on PPP mode after completing the balance work led to the 500 bedded hospital remaining non-functional even after more than 12 years of commencement of building works.
• A new 100 bedded hospital building was sanctioned (June 2008) by the Department at a cost of ₹ 4.89 crore for DH, Ramgarh. However, construction work was stalled (June 2013) after incurring expenditure of  ₹ 3 crore due to corruption charges against the officials engaged in the construction work. The work was not resumed (June 2020) and DH, Ramgarh was functioning in the building of Mother and Child Health Centre since April 2016.
• Construction of 10 bedded burn units with supply of furniture and equipment in all 24 districts were sanctioned (August 2014) at a cost of ₹ 1.35 crore each. Of these, four units were dropped (January 2016) and 20 units were completed at ₹ 12.40 crore (between September 2015 and January 2017). However, the completed units could not be made functional due to non-procurement of equipment.

Download Audit Report

• Inner Cover
• Table of Contents
• Preface
• Executive Summary
• Chapter 1 - Introduction
• Chapter 2 - Out-Patient Services
• Chapter 3 - Diagnostic Services
• Chapter 4 - In-Patient Services
• Chapter 5 - Maternity Services
• Chapter 6 - Infection Control
• Chapter 7 - Drug Management
• Chapter 8 - Building Infrastructure
• Chapter 9 - Recommendations
• Appendices