Doctors' license renewal due! CAG tells Himachal Medical Council to maintain data

Kullu: Altogether 2,779 doctors in Himachal Pradesh failed to renew their registration as of September 2022 and despite this, they did not face any action by the State Medical Council (SMC), revealed a recent report on the healthcare system by the Comptroller and Auditor General (CAG).

The report highlighted that even though the Himachal Pradesh Medical Council Act, 2003 requires doctors practicing modern medicine to mandatorily register with the Council, not all the employed doctors in the State were registered with the Council. It also noted that no mechanism was adopted by the Council to track such non-registered employed/non-employed doctors.

Doctors Practicing with Expired License: 

Rule 15(7) of the Himachal Pradesh Medical Council Act, 2003 says that no person though qualified in modern scientific system of medicine, shall practice in the State of Himachal Pradesh without having a certificate of registration. Any person serving or practising modern scientific system of medicine in Himachal Pradesh shall be registered with the Council under this Act.

However, the CAG report mentioned that the State Medical Council did not develop any procedure to de-register or cancel the names of doctors who had expired or migrated to other States or stopped practicing in the State.

Further, the CAG report alleged that the SMC had not published the list of all registered practitioners in the public domain on yearly basis. However, it was stated in the report that the Council maintained a list of registered medical practitioners manually and quarterly reports were sent to the National Medical Commission (NMC).

Registration of Clinical Establishments Operating in the State: 

The report also highlighted the lapses in the State Health Department's efforts to register all clinics across the State and monitor rule violations. Audit observed that though directed by the Union Government in 2016, there was no mechanism put in place for permanent registration of the clinical establishments. The process of permanent registration had not commenced till date (January 2024), the report mentioned.

Further, it noted that the Clinical Establishments Act and the Himachal Pradesh Clinical Establishments (Registration and Regulation) Rules, 2012, did not provide for the specific number of regular inspections of establishments with provisional registration. Therefore, due to the lack of proper monitoring provisions, clinical establishments were operating without provisional registration or without renewal of provisional registration. When the Department was questioned about this, it admitted the facts and stated that most of the clinical establishments were being inspected only on complaint basis.

In this regard, the CAG report observed that there was no mechanism in place for the State Health Department to track and monitor the clinics running without registration or with unqualified staff.

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Regarding the issue of anomalies found in the process of how private clinics and hospitals were operating in the State, the report revealed that altogether 3,610 clinics were provisionally registered in Kinnaur, Solan, and Kangra districts between 2016-2017 and 2021-2022.

During joint physical verification of 23 private clinical establishments in the selected districts, it was noticed that 11 clinics/hospitals were running without renewal of their provisional registration and one clinic was not registered at all.

At this outset, the report noted that Health Department in the State had not developed any mechanism to track and monitor the clinics running without registration, closed clinics, clinics running with unqualified staff etc.

Referring to Kinnaur, Solan and Kangra districts, the CAG report mentioned that no notices were issued by the DRAs to the clinic who were not renewing their registrations.

Treatment Cost and Storage of Essential Drugs: 

As per the operational guidelines for private clinical establishments, rates for procedures and services to be charged by the private clinics/hospitals were to be determined by the Central Government from time to time in consultation with the State Government. However, in Himachal Pradesh, Audit observed during joint physical verification that as the State Government did not prescribe any rates to be charged by the private clinics/ hospitals, the rates were fixed by the owners themselves.

"Hence, there is every possibility of overcharging by private clinics, nursing homes, etc. entailing more financial burden on the patients. The guidelines further prescribed that the private clinics should display the details of charges at a conspicuous place. During joint physical verification of 23 private clinics, it was noticed that charges of treatment were not displayed in 18 clinics," mentioned the CAG report.

Besides, the CAG report also mentioned how the State health institutes lacked storage of essential drugs as per the Essential Drugs List (EDL) prescribed by the Indian Public Health Standards (IPHS), which prescribes that 493 essential drugs should be available in the hospitals.

Despite such guidelines, the district hospitals of Kinnaur, Solan and Kangra had a shortage of essential drugs ranging between 20% and 58%, revealed the report.

The CAG found that general medicines for blood pressure and hypertension, contraceptives, anaesthetics, and oxygen were available during the inspection. Similarly, the civil hospitals and community health centres also lacked the essential drugs.

Referring to these issues and highlighting the non-availability of essential drugs, the report mentioned "Thus, the required drugs and consumables as per the EDL were not available in all the selected health institutions. There was shortage of drugs and consumables against EDL at secondary level and primary level health institutions. Further, patient surveys revealed non-availability of drugs in both OPD and IPD. Non-availability of essential drugs deprived patients of the intended healthcare as a result of which they would have been compelled to purchase medicines from the market, thereby increasing out-of-pocket expenditure on healthcare."

Inspection of Clinics including Ultrasound Clinics: 

Further, the report revealed that the State health authorities did not inspect ultrasound clinics regularly, even though the rules demand that health officials inspect the ultrasound clinics at least once in three months.

Regarding this, the report mentioned that in between the period from 2016 to 2022, there was a shortfall ranging from 30.11 per cent to 66.34 per cent in conducting inspections of the ultrasound clinics in the State.

"Thus, shortfall in inspection of ultrasound clinics could be a major contributing factor towards low child sex ratio in Himachal Pradesh in 2015-16 (919) to 2019-21 (929) as per the data of NFHS-4 and NFHS-5 respectively and demands attention," mentioned the report.

Apart from this, the report also noted the shortfall in targets of lifting drugs and cosmetics samples, delay in lifting samples and also delay in analysis of samples.

"Consequently, drugs declared ‘not of standard quality (NSQ)’ were already issued to the patients, putting their health at risk," noted the report adding that the new drug testing laboratory at Baddi was yet to be completed and the only drug testing laboratory in the State at Kandaghat was short-staffed.

"In Himachal Pradesh, some manufacturers were charging higher prices of medicines than the notified prices. NPPA had issued show cause notices to different firms for overcharging of medicines. Price approval was not being taken by manufacturers for a new drug. Blood Banks and x-ray machines were running without licenses. Health institutions had not obtained SPCB authorisation for generation of bio-medical waste," concluded the audit.

Recommendations: 

The CAG has recommended the Government to ensure the following:

• State Medical Council maintains the data of all registered medical practitioners in the State in electronic form.

• SMC develops a communication mechanism with the Government as well as private health institutions to check the existence/updation of the registration of the doctors.

• The process of permanent registrations of clinical establishments is initiated and regular inspections are conducted.

• Maximum number of drug samples are lifted and testing capacities of the laboratories are increased so that the test results are obtained within the stipulated time frame.

• Overpricing of drugs by the manufacturers is checked.

• Timely action for obtaining license from concerned authorities for running various facilities is taken.

• A mechanism is put in place to ensure that all Health Institutions have proper authorisation from State Pollution Control Board (SPCB) for generation, storage, treatment/disposal and handling of bio-medical waste.

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