DNB Courses in District Hospitals: Experiences & Lessons Learnt

Best Innovative Practice: Introduction of DNB Courses in District Hospitals: Experiences & Lessons Learnt

Experiences & Lessons Learnt

Dr Sathyanarayana, MBBS, DHA, MPH, PhD

Public Health Foundation of India-Bangalore campusdrsathya1@gmail.com,

9535450999

Overview

• Introduction

– Health System framework, -HR issues

• Health workforce/specialist issues

• DNB courses in district hospital as potential • DNB courses in district hospital as potential solution

• Experiences of DNB courses promotion

• Findings from feasibility study

• DNB courses scaling up framework

Principles of Public health policy

There few core public health policy principles on which DNB being contemplated , promoted

I. Policy drivers1. Scientific credibility

2. Financial feasibility2. Financial feasibility

3. Operational stability

4. Political viability

5. Implementers acceptability

II. Identification of low cost, organizational, managerial and technical solutions

III. Develop sustainable, replicable and operable models

Introduction: Health Environment in India

• Large population

• Limited resources

Population

• Health human Resource shortages

• Big Disease burden

Physician workforce

Disease Burdenwww.worldmappers.org

Introduction

Health Workforce Imbalances

• Imbalances between HR management practices and national policy objectives

• Mismatches of numbers: Shortage/surpluse

• Qualitative disparity: resulting from gaps between the training programs and the requirements of the country’s health policy

• Unequal distribution of workforce: b/w Geographical areas, • Unequal distribution of workforce: b/w Geographical areas, professions and categories, health establishments and specialities.

Challenges: SIZE, COMPOSITION, DISTRIBUTION

The key issues in HRH

• There is in specialists an estimated 10% migration and a large and increasing private sector preference.

• Available pool does not necessarily translate into public sector recruitment- more so if the into public sector recruitment- more so if the expansion is in the private sector.

• Growth in the private sector is particularly haphazard and of very poor quality..

• There is often no match between skills required and skills imparted

Poor Quality of In- service Capacity Building …

• Multiple short duration fragmented training programmes. • Little evaluation of training and no

evaluation of whether training led to evaluation of whether training led to improved service delivery outcomes and increased capacities to deliver services.• Human resource planning for

training institutions faulty.

Medical specialist gap-a serious issuePercentage of Sanctioned Posts of Specialists Vacant

Source: (Laveesh Bhandari., 2005) Ministry of Health and Family Welfare

Specialist gap…• The figure shows nearly 50% of specialist

gap in India. This translates to approximately 13794 medical specialist gap in community health centers (CHCs)/block in community health centers (CHCs)/block hospitals and District hospitals in India(GOI-HFW, 2011).

• The gap may be up to 23000 if we include other specialist other than specialist mentioned in the figure for entire country.

• For instance Karnataka alone has gap of more 1000 specialists’ gap in the public sector hospitals when compared to sanctioned posts. posts.

• Nationally, there is a requirement and in position gap of 2682 gynaecologists and 3029 pediatricians alone. These two specialists account more than 5000 in requirement.(

Bajpai, Dholakia, Vynatheya, Sa, & Paper, 2013)

The whys?• Why was HR NOT planned along with infrastructure…

• Why this very uneven growth of professional education?

• Why are we unable to make USE of DNB courses in District Hospital?

Basic question• Is it possible to use district hospital for DNB courses as a • Is it possible to use district hospital for DNB courses as a

vehicle to address the SPECIALISTS Gap? Could we use it to maximise gains within available policy boundaries.

• What are the “boundary conditions” which determine the choice for making the DNB courses possible to conduct in public sector hospitals, which is – more effective, more efficient/WHAT ARE DNB PROMOTION POLICY ENABLERS

Policy Enablers

Court order

Gazette of India -2012

Different views

• Health systems, human resources: despair and crisis

• Innovation and new process: excitement and hope

Education: Critical Solution

Underlying health workforce crisis is failure to train and retain enough

Entry points to increase equitable availability of specialists

Increase Entrants Reduce Losses

Improve Distribution Improve Productivity

Rationale for proposal of DNB courses in district hospitals

• Necessity of human resource innovation to bring Universal Health Coverage

• Dearth of medical specialists in government hospitals/More than 50% vacancyhospitals/More than 50% vacancy

• Cost effective, efficient way of training in specialists

• To make government medical jobs attractive

Challenges of attracting and retaining specialist in govt hospitals

Illegal Capitation fee in private medical schools

• The illegal capitation fees range from Rs.50 lakh to Rs.1-2 crore for a MBBS seat/PG seat

• Salary• Salary

• Working environment

• Work load

• Transfers/quality life

Medical education black market

Conservative estimate of DNB Seats/year

S.no particularsNumber of

unitsNote

1 Number of states in India 30 676 districts

2Number of states having more than 20 districts

21

3District hospital DNB seats projection

DNB seats/district hospital/year 202 DNB seats per speciality *10 specialities=20 DNB candidates/district/yearcandidates/district/year

DNB seats/state/year 200 DNB seats for 10 districts per state*20 seats per district per year

Number of DNB Seats in 21 big states

4200 DNB seats for 21 BIG states*10 districts per state*20 seats per dist

Number of DNB seats in 9 small states

360DNB seats for 2 districts/9 SMALL state*20 seats/year

Total number of DNB seats/year 4560

Number of DNB passes out candidates for next five years

22800

Experiences: DNB Courses Policy Promotion Promotion

Journey continued

Experiences• We initiated DNB Policy advocacy in 2010

• Prepared concept note and detailed report

• Frequent change/transfer of health secretaries/commissioners/Director health

– Health secretaries -6,– Health secretaries -6,

(Madan gopal, Ramana reddy, Shivashilam, Atul tiwari, Laxminarayan, Shalini)

-Health Commissioners -7

-Director health -6

(Thangaraj, Dhanya, Ramesh, Vamdev, vimala, Renuka)

• Frequently missing DNB proposed file

Experiences…

• Had meeting with health secretaries –no institutional memory

• 2012, 2013, 2014, Sent email and hard copy courier to all state health secretaries and courier to all state health secretaries and director health services-minimal response

• 2013-Meeting with health/medical education minister-no action

• 2014 meeting with Ms Chakrapani D, Center for Innovation in Public Systems (CIPs)

Experiences……….

• 2012 done DNB courses feasibility study.

• Written draft peer review draft paper related to DNB promotion in district hospitalhospital

• Developed FAQs to answer most of the common questions.

• DNB Courses policy advocacy through SOCIAL NETWORK by the health secretaries for the health secretaries.

Network with key stakeholders

• DNB executive director and chairman

• Secretaries of health all state governments

• CIPS/DGHS

• PHFI• PHFI

Summary of Experiences: DNB Courses Policy Promotion

Systematic analysis of Human resources gaps for sustainable Health System

Lack of health policy analysts/health policy advocatesadvocates

Limited institutional memory

and lack of POLICY Limited relevant Evidence and lack of POLICY MAKERS focus on long term sustainable

solutions

Limited health system innovations

GAPS

Findings from Feasibility Study of DNB courses in District Hospitals-

Karnataka stateKarnataka state

QUOTES FROM INTERVIEWSBenefits of DNB courses at district hospital• “If we start DNB courses, the infrastructure of the hospital will improve, people will

get better services. We will get extra funds, equipment and human resources.”[District health officer, 57 years/ female]

• “I have worked with DNB candidates. They are as good as MD/MS” [A specialist, 47 years/ male]

• “Usually district hospitals have enough beds and infrastructure, and we have specialists. We need not start a new setup. With less expenditure we can manage”[A specialist, 47 years/ male][A specialist, 47 years/ male]

• “Our hospitals have variety of patients. The students will get exposure in all aspects.” [A specialist, 47 years/ male]

• “A great change will occur! Providing services to the public will improve.” [Medical superintend/ District Surgeon, 59 years/ female]

• “We will have better indicators. We can offer better services. Patient input will increase. Even the doctors may come forward to work in government setup” [Medical superintend/ District Surgeon, 59 years/ female]

Study findings………Problems because of lack of specialists

• “Lack of specialists affects the services in the rural areas causing unnecessary referral and increased out of pocket expenditure to the patients.”

• “In emergencies, there will be an opportunity lost to treat at the golden hour, leading to mortality and morbidity.”

• “The specialty services are offered in team concept. The lack one service may affect the other specialty services.”

Principles of Public health policyThere few core public health policy principles on which DNB being contemplated , promotedI. Identification of low cost, organizational,

managerial and technical solutionsII. Develop sustainable, replicable and operable

modelsmodelsIII. Policy drivers

1. Scientific credibility2. Financial feasibility3. Operational stability4. Political viability5. Implementers acceptability

DNB courses scale-up framework

GOAL: Sustainable specialist workforces

Incremental improvement in DNB courses teaching faculty, library and

other services

PRIORITIZED Specialist Courses

INDICATOR: INDICATOR:

“Initiate DNB Courses at DistHospitals in each state”

Use Existing teaching/infra capacity Develop new infra/ faculty program/capacities

FINANCIALPOLITICAL TECHNICAL

- Resources- Incentives- Partnerships

- Supportive environment

- Leadership- Commitment- Legislation- Policy- Partnerships

- Training- Institutions- Infrastructure- Connectivity- Partnerships

Critical success factors for scaling upCritical success factors for scaling up

Critical factors identified:

• Political commitment and good governance– Sustained high level support,

• Enabling environment– Multi-sector participation, Good information systems, effective management – Multi-sector participation, Good information systems, effective management

and leadership

• Workforce planning– Plan long term, act short-term and update regularly, commitment to

production / appropriate skill mix integrated teams, needs based, expansion of courses

Time to build institutions and the health workforce!health workforce!