National Health Systems Resource Center September 2012 Jharkhand: Issues and Challenges
1 I. OVERVIEW OF PUBLIC HEALTH WORKFORCE Jharkhand has a population of 32.96 million, 28% of which are tribal and the following public health infrastructure in its 24 districts: Health Facilities Present Required District Hospitals 21 24 (Required in East Singbhum, Bokaro & Dhanbad) Sub Divisional Hospitals 10 Community Health Centers 188 (149 under construction) 329 (if taken as one per lakh population) Primary Health Centers 330 1684 (@ 1/20,000 population) Sub Centers 3958 10968 (@ 1/3,000 population) *The entire report is for the purpose of clarity premised on existing facilities. Suitable extrapolation should be done for additional facilities that need to be created. The healthcare workforce (inclusive of contractual) availability in the state is as follows: Sl. Name of Staff Lab. X-Ray Medical ANM LHV Pharmacist No. District Nurse Tech. Technician Officers 1 Bokaro 270 47 7 22 27 8 71 2 Chatra 193 22 0 37 16 5 47 3 Deoghar 304 26 12 17 17 4 65 4 Dhanbad 334 31 10 22 34 5 84 5 Dumka 566 77 10 24 35 7 74 6 E. Singhbhum 379 20 4 27 0 1 75 7 Garhwa 136 13 2 9 12 3 56 8 Giridih 299 29 0 18 16 7 60 9 Godda 305 17 11 11 13 1 50 10 Gumla 443 51 18 34 43 3 57 11 Hazaribagh 248 21 6 11 23 5 85 12 Jamtara 250 23 5 12 19 2 51 13 Khunti 203 33 3 10 13 8 48 14 Koderma 59 7 0 2 5 3 43 15 Latehar 206 16 4 9 17 4 35 16 Lohardga 163 24 0 9 7 3 46 17 Pakur 213 19 6 10 18 1 34 18 Palamau 286 19 7 20 27 6 98 19 Ramgarh 83 4 0 5 6 3 41 20 Ranchi 703 21 2 14 34 10 174 21 Sahebganj 335 25 9 6 17 2 61 22 Saraikela 351 21 2 15 18 5 56 23 Simdega 377 31 7 4 26 4 30 24 W. Singhbhum 641 37 0 13 13 9 78 Jharkhand 7347 634 125 361 456 109 1519
2 The healthcare workforce in the state can be broadly classified into 3 categories: regular government employees, state contractual employees (paid through the treasury route) and NRHM contractuals. Jharkhand: Public Health HR Profile - 2012 Regular Appointment State Contractual NRHM Contractual 39% 43% 18% 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Jharkhand: Break-up of Health Care Worker - Regular, Contractual (NRHM & State) - 2012 73.4 2.8 58.5 23.9 27.4 X RAY TECHNICIAN 14.0 30.7 STAFF NURSE 48.9 44.5 20.4 LAB TECHNICIAN 16.2 39.3 26.0 42.1 31.9 3.3 21.7 75.0 ANM PHARMACIST MEDICAL OFFICER 0 4 96 LHV Regular Employee State Contractuals NRHM Contractuals
3 II. HUMAN RESOURCE FOR HEALTH POLICY Since its statehood, Jharkhand has been following the Bihar Service Code and wanting to have its own HR policy. During March 2011, the Jharkhand Public Service Code for Health, Medical Education and Family Department (only for Medical Officers) has been published, which defines norms for remuneration, recruitment, promotion & posting etc. The state is in the process of having similar codes for the paramedical workers Issue: The State does not have a specialist cadre, which makes it difficult for the planners in identifying Medical Officers with post-graduation and posting them in the identified FRUs The Medical Officer Cadre is managed by the health secretariat and the establishment for paramedical workers is located at the medical directorate. Since the inception of NRHM, separate cells for human resource and training/capacity building has been set up to manage the huge contractual workforce as well assist the state machinery. III. GENERATION OF HUMAN RESOURCES The current availability of government training institutes in the state is as follows: Sl. No. Name of the Institute No. of Seats Remarks Medical Colleges (3) 1 Rajendra Institute of Medical Sciences (RIMS), Ranchi 90 150 (Proposed) 2 Mahatma Gandhi Medical College (MGM), Jamshedpur 50 100 (Proposed) 3 Patliputra Medical College & Hospital, (PMCH), Dhanbad 50 100 (Proposed) Total 190 BSc Nursing College (1) 1 College of Nursing (RIMS Campus), Ranchi 50 Basic 30 Post Basic Total 80 GNM Schools (3) 1 Rajendra Institute of Medical Sciences (RIMS), Ranchi 50 2 Mahatma Gandhi Medical College (MGM), Jamshedpur 30 3 Patliputra Medical College & Hospital, (PMCH), Dhanbad 30 Total 110 ANM Training Schools (10) 1 ANM TC, Ranchi 60 2 ANM TC, Simdega 60 3 ANM TC, Deoghar 60 4 ANM TC, Dumka 60 5 ANM TC, Giridh 60 6 ANM TC, Jamshedpur 60 7 ANM TC, Chaibasa 60 8 ANM TC, Hazaribagh 60 9 ANM TC, Dhanbad 60 10 ANM TC, Palamu 60 Total 600 Local Area Selection criteria is a must for ANM Training Centers
4 Nursing Training Institutes in the private sector are as follows: Sl. No. Name of the Institute Location Annual Intake ANM Training Schools (12) 1 Mahadevi Birla Nursing School Ranchi 40 2 Panchvati Nursing School Ranchi 40 3 Sirdaul Nursing School Ranchi 200 4 Raj Nursing School Ranchi 30 5 Shine (Apollo) Ranchi 20 6 Gurukul Nursing School (MIB) Ranchi 20 7 Vananchal Nursing School Garhwa 45 8 St. Ursuline Lohardaga 25 9 Mohulpahari Nursing School Dumka 30 10 Ambedkar Nursing School Godda 50 11 Holy Cross Koderma 20 12 Navjeevan Hospital, Satbara Palamu 20 Total 550 GNM Schools (3) 1 Shine School of Nursing (Apollo) Ranchi 40 2 HEC Plant Hospital, Dhurwa Ranchi 20 3 Nightingale School of Nursing (Apollo) Ranchi 40 4 SDA School of Nursing Ranchi 20 5 St. Barnabas Hospital Ranchi 20 6 Holy Family, Mandar Ranchi 20 7 Mohulpari Dumka 20 8 BCCL Dhanbad 30 9 BGH Bokaro 25 10 Jeevan Jyoti Jamshedpur 40 11 Nightingale School of Nursing Jamshedpur 40 Total 295 BSc Nursing College (2) 1 Shine College of Nursing Ranchi 40 2 College of Nursing, SDA Ranchi 20 Total 60 To meet the HR Gap in the public health facilities, the state intends to increase annual intake in its 3 Medical Colleges and operationalize 7 more ANM Training Centers during 2012. Process is also underway to set up new Medical Colleges by upgrading DH at Ranchi, Hazaribagh, Saraikela, Dumka and Daltonganj, to be made operational by 2015-16. Expression of Interest (EOI) has also been issued for Public Private Partnerships (PPP) Sl. No. District Hospital Current Bed Strength Projected Bed Strength 1 Ranchi 50-60 (currently operational - renovation going on) 500 2 Hazaribagh 100 300 3 Saraikela 100 300 4 Dumka 100 300 5 Daltonganj 100 300
5 IV. RECRUITMENT, SANCTIONED POSTS & VACANCIES Irregular recruitments for regular posts have led to vacancies in critical healthcare workforce positions, in spite of provisions under NRHM to appoint contractual service providers. % of vacancies in regular positions against sanctioned posts -Jharkhand 2012 100% 80% 64% 70% 79% 85% 60% 40% 34% 37% 51% 20% 0% Medical Officer ANM Staff Nurse X Ray Technician Percentage of Vacancy LHV Pharmacist Lab Technician A. Regular employees: 1. Medical Officers & Specialists: No recruitment was done from 1993 till 2009. The Jharkhand Public Service Commission (JPSC), which does recruitments for regular doctors, through a process of written examination and interviews, recruited 977 doctors in 2009, the first time since statehood. But gaps still existed and attempts were made to mitigate the gap through contractual employees. There has been another round of recruitment in March 2012, which took about 6 months (from advertisement to appointments) and appointment letters have been issued recently. *The figures do not include the recent round of appointments Sl. No. District Regular Medical Officers Sanctioned Vacant 1 Bokaro 83 35 2 Chatra 56 16 3 Deoghar 62 11 4 Dhanbad 67 3 5 Dumka 107 41 6 E. Singhbhum 65 10 7 Garhwa 62 19 8 Giridih 96 52 9 Godda 69 29 10 Gumla 96 43 11 Hazaribagh 98 24 12 Jamtara 59 15 13 Khunti 48 15
6 *The figures do not include the recent round of appointments Sl. No. District Regular Medical Officers 14 Koderma 44 12 15 Latehar 46 22 16 Lohardga 48 14 17 Pakur 46 18 18 Palamau 107 37 19 Ramgarh 36 5 20 Ranchi 119 16 21 Sahebganj 68 19 22 Saraikela 57 17 23 Simdega 61 32 24 W. Singhbhum 135 80 Jharkhand 1735 585 2. Paramedical & Nurses: There has been no recruitment for regulars since statehood. All those serving were transferred from Bihar and vacancies arising from retirements have not been filled as well. This has resulted in large-scale vacancies, as is evident from the table below. *The state is finalizing policies for recruitment, posting & transfers. The Staff Selection Commission will be responsible for the recruitments. Sanctioned (S) and Vacant (V) Paramedical Posts Sl. No. District ANM Staff Nurse Pharmacist Lab. Tech X-Ray Tech S V S V S V S V S V 1 Bokaro 178 98 16 16 31 29 28 24 4 1 2 Chatra 108 60 9 9 21 3 14 12 2 2 3 Deoghar 210 100 14 14 19 13 18 12 2 1 4 Dhanbad 182 20 2 2 12 7 12 5 5 Dumka 353 74 46 46 30 26 35 29 5 1 6 E. Singhbhum 292 78 37 37 14 0 7 Garhwa 117 51 12 12 16 11 33 27 4 1 8 Giridih 233 101 24 24 32 26 29 27 4 2 9 Godda 207 90 17 17 21 15 19 15 3 3 10 Gumla 304 131 14 14 0 6 0 7 3 2 11 Hazaribagh 166 54 20 20 25 23 26 22 2 0 12 Jamtara 162 60 8 8 15 14 18 17 1 1 13 Khunti 122 54 6 6 6 6 7 5 2 0 14 Koderma 81 22 9 9 2 0 10 5 3 0 15 Latehar 92 19 8 8 14 14 15 11 2 2 16 Lohardga 91 52 14 13 17 15 2 1 17 Pakur 147 80 8 8 11 8 14 14 5 4 18 Palamau 239 119 10 10 33 30 17 16 2 0 19 Ramgarh 69 28 7 7 8 8 9 7 1 1
7 Sanctioned (S) and Vacant (V) Paramedical Posts Sl. No. District ANM Staff Nurse Pharmacist Lab. Tech X-Ray Tech 20 Ranchi 389 57 20 17 25 13 1 1 21 Sahebganj 165 53 12 12 14 14 20 18 3 2 22 Saraikela 206 117 3 3 12 6 11 11 1 1 23 Simdega 185 61 13 13 13 9 13 12 2 2 24 W. Singhbhum 319 152 54 54 48 43 62 62 19 19 Jharkhand 4617 1731 349 349 431 341 452 386 73 47 Since there has been no regular appointment, contractual ANMs, meant for SCs (many times, to be the 2 nd ANM) are posted at higher facilities to fill vacancies, leaving Sub Centers without ANMs e.g. in the designated FRU at Ghatshila (E. Singhbhum), there is only 1 SN supplemented by 17 ANMs, leaving 7 SCs in the block (total: 33) being managed by a single ANM B. Contractual Service Providers: Recruitment for contractual staff takes place at two levels: state and district. All appointments are given one-year contracts to be renewed annually after performance appraisal. 1. Doctors & Specialists: At the state level, there is a Selection Committee headed by the Mission Director, which recruits Medical Officers (mainly specialists), Consultants for Disease Control Programs. The committee also comprises of an expert panel drawn from the medical colleges and recruitment is done through walk-in interviews. Recruitment of doctors takes place 2-3 times in a year and the entire process from the time of advertisement to joining is completed within a time frame of 2 months. Main recruitment is for Specialists, although during 2008, 112 Lady MOs were recruited. 19 of them are still in service, whereas the rest have been absorbed in the regular services. For the first time, approval has come for hiring contractual AYUSH MOs. The recruitment will be done at the district level and these MOs will be paid a salary of 20,000/- per month Issues: The major hurdle is in finding specialists willing to join and serve in the designated FRUs. For the 108 posts were advertised in August 2012, only 34 turned up for the walk-in interview. This can be attributed to the fact there are very few post-graduate seats in the medical colleges and many of the pass outs prefer private practice (private practice is not allowed for govt. employees) the state plans to set to new medical colleges to address this issue 2. Nurses & Paramedics: Recruitments are done at the district level, with the District Collector heading the selection panel. Vacancies are communicated from the state and selection done at the district level - entire process takes about 3-4 months. In East Singbhum (district visited), 134 ANMs, 20 SN and 1 X-Ray Tech. have been recruited under NRHM so far. Local-Area criteria are taken into account along with same-block posting.
8 V. DEPLOYMENT OF HUMAN RESOURCES The state does not have any specialist cadre and the state HR Information System (ihris) tried to capture the post-graduate qualification of Medical Officers serving in all the 24 districts. 100 18.4% Specialty-wise break-up of Medical Officers in Jharkhand - 2012 20.0 90 18.0 80 70 60 50 40 30 13.9% 12.8% 12.2% 7.9% 7.5% 5.6% 5.2% 16.0 14.0 12.0 10.0 8.0 6.0 20 3.3% 2.7% 2.1% 2.1% 4.0 10 0 1.0% 1.0% 0.8% 0.8% 0.4% 0.4% 0.4% 0.4% 0.4% 89 67 62 59 38 36 27 25 16 13 10 10 5 5 4 4 2 2 2 2 2 0.2% 1 0.2% 0.2% 2.0 1 1 0.0 Numbers Percentage of total specialist Though 52 health facilities have been designated as First Referral Units (FRU), only 17 of them are conducting Caesarian Sections. The following table details the lack of specialists in the designated FRUs, where caesarian sections not being conducted District Designated FRUs not Lacking Specialist FRUs conducting LSCS Anesthetist-A, Pediatrician-P, Obstetrician-OG BOKARO 2 - - CHATRA 1 DH Chatra 1-P DEOGHAR 3 Madhupur 1-A Sarwan 1-A, 1-P DHANBAD 1 - - DUMKA 2 DH Dumka - CHC Saryahat 1-A, 1-P, 1-OG E. SINGHBHUM 2 Ghatshila CHC 1-OG, 1-A Behragoda CHC 1-P, 1-A GARHWA 2 SDH Nagarutari 1-OG GIRIDIH 3 RH Rajdhanwar 1-A RH Dumri 1A, 1-P, 1-OG GODDA 3 RH Thakurgangati 1-P GUMLA 2 RH Basia 1-P HAZARIBAG 3 CHC Badkagaon 1-A, 1-P
9 District Designated FRUs JAMTARA 2 KHUNTI 2 KODERMA 2 FRUs not conducting LSCS Lacking Specialist Anesthetist-A, Pediatrician-P, Obstetrician-OG DH Jamtara 1-P CHC Nala 1-A, 1-P SDH Khunti - RH Torpa - DH Koderma 1-P RH Domchanch 1-A, 1-OG LATEHAR 1 DH Latehar 1-P LOHARDAGA 2 CHC Kuru 1-P DH Pakur 1A, 1-P, 1-OG PAKUR 2 CHC Litipara 1A, 1-P, 1-OG PALAMU 2 CHC Hussainabad 1A, 1-P, 1-OG RAMGARH 2 CHC Patratu 1-A, 1-P RANCHI 4 SDH Bundu 1-P RH Silli 1-A SAHIBGANJ 2 Rajmahal 1-A SARAIKELA- KHARSAWAN SIMDEGA 2 2 DH Saraikela - RH Rajnagar - DH Simdega 1-A RH Thethaitangar 1-A DH W. Singhbhum - W. SINGHBHUM 3 SDH Chakradharpur - CHC Manoharpur 1-A, 1-P Total Specialists 52 35 45 (19-A, 18-P, 8-OG) According to data available at the ihris (State HR Information System), many Medical Officers with the required post-graduate qualifications are still working in PHCs or Clinics Specialist Total Lacking Specialist at FRU No. Posted at PHC or Clinics Anesthetist* 28 19 7 Pediatrician 67 18 9 Obstetric & Gynecologist 89 8 19 Total 184 45 35 *including dual specialization **data source: ihris Rational Deployment of these MOs with necessary specialties from their current postings to the designated FRUs not conducting CS will be helpful in fully operationalizing these FRUs VI. TRAINING & CAPACITY BUILDING The Training Cell has 3 consultants who help the state in planning and implementation of training calendars under NRHM for both the regular and contractual service providers EmOC, LSAS, SBA, IMNCI, NSSK, FP trainings and PG Diploma in Public Health Management etc. A comprehensive and integrated training plan is drawn up every year and the numbers trained so far are as follows:
10 Sl. No. TRAINING Target 2012-13 Achievement 2012-13 till July 2012 Cumulative Achievement till July 2012 1 IMNCI Health Worker Training 2400 (100 Batches) 415 17720 2 MTC & MTEC on New Module 245 (7 Batch) 191 191 3 Navjaat Shishu Suraksha Karyakram (MO) 96 (6 Batch) 95 1099 4 Navjaat Shishu Suraksha Karyakram (SN) 1056 (44 Batch) 210 1609 5 SBA Health Worker Training 825 (173 Batch) 234 3222 6 LSAS Training - 7 (Ongoing) 91 7 EmOc Training - - 81 8 BEmOC 10 days Training 20 (5 Batch) 8 8 10 Supportive Supervision Training for MO (SBA) 120 (4 Batch) 22 222 11 Minilap cum MTP Training 24 (12 Batch) 5 71 12 MTP Training 62 (31 Batch) 12 529 13 Training of Service Provider in CU IUCD 375 144 (6 Batches) 58 58 14 PPIUCD Training 54 237 15 NSV Training 32 (8 Batch) 2 24 16 ARSH District Level Training 600 (24 Batch) 167 1501 VII. REMUNERATION The medical officers have to appear in a Departmental Examination for proficiency in hindi language and accounting procedures after which they are eligible to become Drawing & Disbursing Officer (DDO) as well as annual increment of Rs. 1500/- Issue: There is huge disparity in the salary of regular and contractuals, which serves as a demotivating factor. Contractual ANMs have had only one increment since their joining and get a salary of Rs. 8000/-, in comparison to regular ANMs who start with Rs. 9 10,000/- per month with periodic increments. A regular ANM whom we met in the Sub Center currently gets a monthly remuneration of Rs. 35,000/-. Among Staff Nurses, contractuals get 12,000/- whereas regulars draw a salary of around 42,000/- Salary revision of all categories of contractual staff is subject to annual performance appraisal, but irregular appraisals have led to stagnant salary structure for these workers. Healthcare workers get preferential posting in District Hospitals after serving in remote areas. However poor working conditions including improper residential facilities has resulted in unwillingness to work in these areas reflected by high attrition rates among contractual specialists out of 250 specialists appointed in 4 rounds during last 2 years, only 66 are still working. VIII. RETENTION STRATEGY Issue: Under the Jharkhand Swasthya Protsahan Yojana, the state government had proposed financial incentives for both regular and contractual staff for serving in remote areas, linked with performance. But the proposal was not approved by the central government
11 Interaction with service providers reveal that financial incentives will go a long way in ensuring their extended stay in remote areas. Jhantijharna PHC is a hard-to-reach facility located in the naxalite belt. The PHC building has not yet been handed over and is currently functioning in the panchayat building. Due to lack of basic infrastructure including residential quarters, the staffs stay in Ghatshila (block headquarter), about 50 kms away. Every visit to the PHC, mostly on motorcycles, incurs an expenditure of 250-300 on fuel. The service providers feel that monetary incentives for serving in these remote areas will be helpful and even translate into increased frequency and reach of service delivery IX. HEALTH HUMAN RESOURCE INFORMATION SYSTEM Under the ihris, the state has computerized information of Medical Officers in all the 24 districts. The database includes information regarding the personal, educational, training and service history. This exercise has been completed recently and the state plans quarterly update of information. This information is being used for HR Planning and rational deployment. Technical assistance is provided by Vistaar (USAID), backed by NHSRC & HISP India. Servers have been procured by the state. Issue: Handholding of concerned state officials is lacking. They also need to be given access to the database X. WORKFORCE MANAGEMENT A. Regular Employees: The transfer & posting for medical officers is overseen by the health secretariat and that of the regular paramedical staff by the medical directorate but there is no clearly defined transfer & posting policy in the state. ACRs and length of service form the main criteria for promotion of medical officers. B. Contractual employees: There is no scope for promotions. They are given one-year contacts, to be extended after a process of annual appraisals against their terms of reference (TOR), which are held at state and district levels. The increments are also to be decided during these appraisals. Issue: Apart from the fact that contractual ANMs have so far received only one increment, the more worrying part is the irregular payment of salaries. Interaction in the field revealed that NRHM ANMs have not received salary for the last 2 months, while the RCH ANMs haven t been paid in more than 5 months Terms of reference, defining job responsibilities, for all categories of contractual workers, including program management staff are available in the state. They have also designed a detailed format for performance evaluation, to be used during the annual appraisal. In the district level the appraisal is done at 4 levels: 1 st level: MO I/C; 2 nd level: DPM/RCHO; 3 rd level: Civil Surgeon; 4 th level: District Collector.
12 Issue: Even though a very robust system of annual appraisal has been defined, this process has been conducted only once (for appraising 09-10 performance) at the state and district level - and there has been no block level appraisal. Though these workers have been getting their salaries, there have been no increments. XI. MANAGEMENT CADRE A. Regular Management Cadre: At the state level the Director-in-Chief heads the directorate and every division or national program has individual Program Officers. These divisions also have Additional & Deputy Directors. The Chief Surgeon manages at the district level, aided by a team of Program Officers. Issue: All these are regular posts, to be filled by officers from the cadre of government medical officers, promoted on the basis of their seniority and annual confidence reports. However, the existing practice has to be studied B. Contractual Management Cadre: To help and support the state and district machineries, NRHM has instituted program management support units at the state, district & block levels. The State Program Management Support Unit (SPMSU) has a State Program Manager (SPM) supported by Consultants looking after various aspects of the program e.g. IEC, Sahiyya, Finance, HR, Infrastructure, Training, M & E, Family Planning etc. The District Program Management Support Unit (DPMSU) has District Program Manager (DPM), District Accounts Manager, District Data Manager and District Program Coordinator (Sahhiya); while at the block level, there is a Block Program Manager (BPM) and a Block Accounts Manager. The State Selection Committee (headed by the MD NRHM) does recruitment for the SPMSU & DPMSU is done by and the BPMSU staff is recruited by a selection panel of the District Health Society (headed by the DC). While all the 24 DPMSU is fully staffed, there is a high attrition rate in the BPMSU. Out of a total of 194 Blocks, 46 BPM and 24 BAM posts are lying vacant. Advertisements for filling these vacancies have already been published. XII. PARA-STATALS A. Institute of Public Health (IPH): The IPH is led by a Director and there are 2 Deputy Directors. These are regular posts and filled from the Medical Officer Cadre. Currently, the other positions are contractual 7-8 program associates, training coordinator etc. But a proposal for creation of regular posts for these positions has been submitted to the government. B. State Health Resource Center (SHRC): Currently there is 2 staff and recruitment for the other posts is underway. C. Village Health and Sahhiya Resource Center (VHSRC): At the state level - 1 Sahhiya State Program Coordinator, 1 Sahhiya Training Coordinator and 1 State Finance Officer. Apart from the District Program Coordinator (DPC) placed in 24 districts as part of the DPMSU, there are 422 BTT placed at the Block level who support and handhold the Sahhiya and Sahhiya Sathi.
13 ACTION POINTS A. IMMEDIATE 1. Urgent release of salaries to contractual service providers who have not been paid for many months 2. Process for contractual appointments of specialists, doctors, nurses & paramedical staff to be with the districts and states should recruit only when districts are unable to find candidates 3. Ensure all obstetricians, anesthetists, pediatricians and EmOC & LSAS trained MOs are posted in designated FRUs 4. Ensure all MOs with PG qualifications are posted in CHCs, block PHCs or higher centers 5. Create adequate number of contractual (3 year term) posts in IPH, SHRC & VHSRC as well as in SPMSU and organize recruitments on an urgent basis outsource recruitment if required. Follow through with twinning each of these institutes with an external institutional mentor, so as to build capacity and improve their functioning 6. Accelerate implementation of incentive program for difficult areas. Notify all difficult PHCs on declared criterion 7. Sustain and build on ihris an excellent initiative B. MEDIUM TERM (with respect to rules) 1. Till vacancies in regular posts are filled monthly recruitment held in each region, after advertisement. This must be for regular appointments 2. Preferential admission from under-served areas in the nearest ANM / Staff Nurse Training Schools 3. Creation of a specialist cadre 4. Faculty development program & quality assurance in nursing schools 5. Decrease salary gap between contractual and regular staff C. LONG TERM 1. Creation of adequate number of regular posts for health facilities existing & to be created 2. Creation of adequate number of health facilities