Rs 390 crore loss over expired drugs; Shortage of hospital beds, Staff: CAG Report flags health sector concerns in Telangana

Hyderabad: The Comptroller and Auditor General of India (CAG) has raised serious concerns regarding the public health infrastructure and management of health services in Telangana. The key issues include a critical shortage of medical staff, reported irregularities in the replacement of expired medications resulting in considerable financial losses, and an inadequate doctor-to-population ratio.   

This report of the CAG on the State Health Finances for the year 2022-23 was released on August 2 for submission to the Governor of Telangana under Article 151 of the Constitution of India, for being laid before the Legislature of the State. It provides an overview of the finances, budgetary management and quality of accounts, financial reporting practices and other matters relevant to State Finances.  

The Report contains significant results of the Performance Audit on Public Health Infrastructure and Management of Health Services in Telangana State, covering the period 2016-17 to 2021-22. 

Also read- Shortage of doctors, Irregularities in drug procurement in Chhattisgarh: CAG Report

The Performance Audit was carried out to assess the adequacy of funding for health care, the availability and management of healthcare infrastructure and the availability of Drugs, Medicine, Equipment and other consumables. 

The report, which captured the State’s financial health for 2022-23, reveals that Telangana’s total outstanding liabilities, including off-budget borrowings, have reached a staggering Rs 4.68 lakh crore.

Low doctor-to-population ratio 

As per the World Health Organisation (WHO) norms, one Doctor is to be available for every 1,000 persons. The CAG report highlighted that the availability of doctors showed an increasing trend from 2017-18 to 2021-22 and stands at one doctor for every 881 people. 

Audit observed that there were huge gaps between sanctioned posts and the actual persons in positions of healthcare staff. As of March 2022, the Directorate of Medical Education recorded the highest vacancy rate at 56%. This was followed by the Institute of Preventive Medicine with a vacancy rate of 54%, the Department of AYUSH at 51%, the Telangana Vaidya Vidhana Parishad at 43%, the Directorate of Public Health at 40%, the Commissioner of Health and Family Welfare at 35%, and the Drugs Control Association at 34%.

The shortage is particularly evident in the institutions operating under the administrative control of Telangana Vaidya Vidhana Parishad (TVVP), which are responsible for providing primary and secondary healthcare services to the population. the audit showed significant staffing shortages in Telangana Vaidya Vidhana Parishad (TVVP), with over 60% vacancies for doctors, 56% for auxiliary nurses and midwives, 46% for paramedical staff, 21% for nursing staff, and 25% for other support staff.

Similarly, health institutions under the administrative control of the Director of Public Health (DOPH) are also facing a shortage of staff. Shortage of staff is comparatively less in DOPH. It revealed 10% vacancies for medical officers, 35% for CHO/PHN, 70% for Multi Purpose Health Educators (MPHE), 15% for nursing staff, 75% for Para-Medical, 56% for Pharmacists and 24% for other support staff. 

"Government in its response stated (August 2023) that, massive recruitment drive had been taken up by the State Health Department and that regular recruitment had commenced for over 12,000 posts and would be completed soon. It was also stated that new Medical Colleges were proposed to be established in all Districts and hence all the District Hospitals are converted to Government General Hospitals/Medical Colleges. Further, the process of reorganistion was taken up in secondary level hospitals and adjustments of doctors and staff would be done as per IPHS norms. 

Acute shortages of teaching staff were observed in nine Medical Colleges with overall vacancies in the cadre of Associate Professors (48 per cent) and Assistant Professors/Tutors (40 per cent). Vacancies in the positions of Associate Professors and Assistant Professors have an impact on the quality of medical education.

There was no increase in the number of Colleges and seats under AYUSH stream. Huge vacancies were noticed in the Department of AYUSH in the cadres of Doctors (42 per cent), Nurses (53 per cent), Pharmacist (60 per cent) and Para-Medical & other staff (53 per cent). Besides these, vacancies were also observed in the cadre of Professors (52 per cent) and Lecturers (63 per cent) which impacted the quality of medical education imparted under AYUSH. Yoga instructors and ANMs have not been posted in any of the 421 upgraded HWCs.

Outpatient services

Due to a shortage of registration counters in four out of nine test-checked hospitals, each counter per hour was faced with an increased patient load. Thus, the patients were forced to wait a longer time for registration. Non-provision of some Specialist out-patient services was observed in the District Hospitals, Area Hospitals and Community Health Centres. Out of 394 health facilities where AYUSH facilities were available, AYUSH Medical Officer was not available in 204 health facilities. 

The post of Pharmacist was lying vacant in 124 health facilities. Thus, the provision of AYUSH services has not been done fully in the State. Patient Satisfaction Survey for evaluation of the services provided in OPD through certain outcome indicators for Quality assurance was not done in all health institutions. 

Maternity services

The performance of the state with regard to maternity services like ANC received in the first trimester and consumption of Iron Folic Acid tablets has improved in 2019-20 as compared to 2015-16, while it had not shown any improvement in respect of pregnant women receiving at least four ANC.

According to the audit, there has been improvement in the institutional births, institutional births in public health facility. However, Home Birth by Skilled Health Personnel has declined.

Diagnostic services

As per IPHS, District Hospital Laboratory shall serve the purpose of a public health laboratory and should be able to perform all tests required to diagnose epidemics or important diseases from the public health point of view. From the data collected, it can be seen that none of the District Hospitals had diagnostic services relating to ENT, Oesophagus, Stomach, Colonoscopy, Bronchoscopy, Arthroscopy, and Hysteroscopy. Similarly, except in DH, Kondapur, Pulmonary function tests were not available in the remaining 13 DHs. Audit observed that Dental X-ray was not available in both the AHs Golconda and Malakpet and the CHCs Amberpet, Wardhannapet and Badepally.

On August 2, 2024, 7,828 samples were collected from 305 centres. The daily count of samples collected is around 8,000 at the central hub. In 2023, over 71 lakh samples were collected in all, of which 50 lakh were from 30 districts and 20 lakh from two central hubs — the other one being in Rangareddy. The laboratory also received accreditation from the National Accreditation Board for Testing and Calibration Laboratories (NABL) for its quality testing services in 2023.

Medical Equipment

Imaging equipment available with District Hospital Bodhan, Hyderabad, Jogulamba Gadwal, Medak, Medchal Malkajgiri, Narsampet, Utnoor and Yadadri Bhuvanagiri did not have the requisite Licence from AERB authorities. Thermo Luminescent Dosimeter (TLD) badges, a protective device indicating permissible radiation levels were not provided to personnel working with the X-ray unit in 10 DHs. Pathology services were also not available in 11 out of 14 DHs. Microbiology services were not available in any of the DHs except DH Narsampet.

Blood banks were not available in DHs Gajwel and Medchal Malkajgiri, AHs Golconda and Malakpet. DHs Hyderabad, Kondapur and Medchal Malkajgiri did not have the services of mortuary. 

Drugs availability

The Government had set up Telangana State Medical Services and Infrastructure Development Corporation, as a Centralised Agency in 2014 to procure and manage drugs & medicines and equipment & instruments at fair and reasonable prices for all the Government Medical Institutions. However, it has been found that TSMSIDC did not maintain a comprehensive database of the available equipment and its details.

Although the Corporation was to get the Essential Medicines List (EML) and Additional Medicines List (AML) reviewed and updated once in two years, it was observed that the review of EML/AML was done only twice i.e., in 2015 and 2019 till date.

Drugs and Medicines (706 numbers) worth Rs 17.13 crore have a leftover shelf life ranging from 1 to 89 days and were issued by Central Medicine Stores to 1,259 health facilities during the period 2016-22. Contrary to the agreement conditions, the Corporation issued 19 Purchase Orders beyond the agreed Rate Contract (RC) resulting in an excess payment of Rs 1.65 crore to nine suppliers.

As per e-Aushadhi data, expired drugs valued at Rs 390.26 crore were not replaced timely with the suppliers causing huge monetary losses to the Government. Out of the 39,258 batches of drugs/ surgical/ CTS items, the Corporation had not sent 2,392 batches for Quality Check, (6 per cent) not being tested for their quality. 

Availability of Beds

Against the requirement of 35,004 beds for the population as per Census 2011, available beds in Government hospitals were only 27,996 beds which resulted in a shortage of 7,008 beds. Except for the Districts of Adilabad, Hyderabad and Hanumakonda, a shortage of beds was noticed in all the other Districts. 

Shortage of Health centres

Shortage in the number of Community Health Centres (CHCs), Primary Health Centres (PHCs/UPHCs) and Sub-centres/Basti Dawakhanas (SCs) available in the State, as against the prescribed population norms was nearly 69 per cent, 25 per cent and 29 per cent respectively. There were no CHCs in the Districts of Jangaon, Rajanna Sircilla and Hanumakonda. In majority of the Districts, the number of persons who are being served by PHCs and SCs was not as per norms.

Health and Medical Infrastructure

The envisaged 50 bedded Integrated AYUSH Hospitals had not materialised in any of the three Districts, viz., Vikarabad, Siddipet and Jayashankar Bhupalpally and the State also lost central funding of Rs 7.20 crore.

The Academic Building at Osmania Medical College (OMC) constructed and handed over in October 2016 was not put to use as of April 2022, for want of required equipment and furniture. Thus, the expenditure of Rs 17.35 crore incurred on the construction remains unfruitful.

The completed Nursing School building at Nizamabad (other than the additional items) was not handed over to the user Department till June 2022, resulting in an unfruitful expenditure of Rs 14.44 crore. Due to non-completion of the work of the Nursing College, Jagtial, Nursing College is functioning in an incomplete building, since July 2019 and also without providing hostel facilities to the students.