Sikkim’s healthcare sector facing major workforce shortage
Gangtok: When Sikkim chief minister Prem Singh Golay in his 73rd Independence Day address at Manan Kendra in Gangtok said, "If I had good resources and sound education as a child, I would have wanted to become a doctor,” it spoke volumes on the importance of healthcare workers in the state.
In his I-Day message to the public, the CM highlighted the key points of 365 recruitments to have taken place in the state’s healthcare sector in the past one year. Health director general Dr Pempa Tshering Bhutia added to it: “365 persons mentioned by the CM include a range of staff from technicians to 261 nurses and 36 medical officers and five super specialists. Bu, it is true, as mentioned by the CM, that there is a need for more workforce in the state’s health sector."
Sikkim reported its first COVID-19 case on May 23, and it took 40 days to cross the 100-mark. In another 42 days (till August 14), the state breached the 1,000-mark with 149 cases reported in a day, which was also the single-day biggest spike. The current state tally as on August 20 is 1,290 with 460 active cases, 827 cured and discharged and three fatalities.
The major part of this COVID-19 surge has been on the health workforce with an average of 45 health workers being exposed to COVID-19 positive patients every week. These include six doctors on an average. That is merely in the state's premier government hospital Sir Thutob Namgyal Memorial (STNM) Hospital in Sochyaghang, Gangtok.
STNM stands as the only devoted COVID-19 hospital in the state. It is also the go-to hospital for every other ailment. But will the hospital’s workforce be able to take such a large-scale increase in COVID-19 cases in the future. Also, what happens to other ailments then?
Months ago, when the first COVID-19 patient was cured, even the state’s health minister Dr MK Sharma asserted on taking up the duty as a doctor away from his role as a minister, if Sikkim faces any shortage of workforce. Now, healthcare workers, especially the nurses and technicians, are already on their second phase of COVID-19 duties after having completed their first run from the end of May.
Doctors and nurses from the hospital were initially allowed a week of COVID-19 treatment followed by two weeks of isolation or quarantine. The same procedure followed for almost 11 weeks since the first COVID-19 case was reported, with 11 batches following the protocol. But a health department notification on August 1 asserts that the health workers will be allowed only a week of quarantine period. If they test negative, they must continue with their services from the eighth day. On being questioned about the change in protocol, many senior doctors and nurses claim that STNM Hospital and the entire state of Sikkim will inevitably face workforce shortage, if the COVID-19 cases continue to surge in the state.
Why is STNM Hospital so important?
STNM Hospital is a state heritage, dating back to as early as 1905 at the heart of Gangtok. Hundred years later in 2018, the new nine-storey state-of-the-art STNM Multi Super Speciality Hospital was inaugurated along with a large premises with subsidiary buildings for expansion.
The hospital was deemed as second only to AIIMS in sheer size for a government hospital. All services in the hospital have been declared free for those that qualify as the citizens of the state, ranging to about six lakh in population with valid residential proofs. The only addition to free treatment involves economically unsound patients under central government schemes but changes have been made on the same with COVID-19 protocol.
However, most officials in the hospital, including health director general Dr Pempa Tshering Bhutia and STNM’s medical superitendent Dr CS Sharma have admitted that the hospital and the state as a whole could face shortage of workforce, if the COVID-19 surge continues. Two of the five super specialists had to be devoted for COVID-19 treatment and more could follow. The nurses in the hospital are already in their second phase of COVID-19 duty after their initial run in May.
Since the outbreak of novel coronavirus, STNM Hospital has been contained twice, with a doctor testing positive in the emergency ward at the end of July. It led to emergency ward being sealed and all emergency services being shifted to CRH Manipal for over a week. But, even CRH Manipal’s emergency ward had to be contained following COVID-19 patients being reported from the ward. Yet again, STNM has faced the concern on August 16, when a patient in the gynaecology ward tested positive, leading to the entire ward and the 6th floor of the hospital being declared as a containment zone.
Dr CS Sharma highlighted STNM has five super specialists, 92 specialists with additional six from the periphery districts (transferred owing to COVID-19), 23 medical officers (MBBS-level doctors) and 446 nurses. The hospital is spread across 22 sub-departments. Equipment and infrastructure wise, the hospital is largely termed to be one of the best in the entire Northeastern region.
Health director general Dr Pempa Tshering Bhutia
Speaking with EastMojo, Dr Pempa Tshering Bhutia said, "There are many places where the doctors and health workers are not sufficient especially in the district hospitals. We have previously pulled in additional workforce of employees belonging to the Group C and D such as peons and clerks from other departments, to aid us in the health sector and now even government teachers are brought for screening at the borders and quarantine facilities. But, we cannot pull doctors and nurses from other sources, hence we are aiming at recruitment of more. We want to protect the health workers, as the treatment and services not merely delve on COVID-19 treatment but also non-COVID services, as well. If need be even those in bureaucracy currently, such as myself have to take up our duty as doctors and specialists".
Referrals from District Hospitals
The referral within the state is another major concern, as most patients from the district hospitals have to be shifted to the STNM or CRH in Gangtok almost every day. The shortcoming is seen in how the district hospitals are infrastructure wise and workforce wise. "We have MBBS doctors who work on an ad hoc basis, they agree to come to the STNM but refrain from going to the district hospitals like Geyzing, Mangan or Namchi," stated the health director general.
On August 16, Geyzing District Hospital had to be declared as a containment zone with only emergency services taking place, as six new cases were reported from West Sikkim district. A positive case was also reported from the hospital among them, leading to the shutting down of all services, except emergency. Similar issues have engulfed the Namchi District Hospital last month, when a positive case was reported from paediatric ward, leading to services being shut.
The district hospitals have a huge burden to handle with minimum facility and workforce. Take Geyzing District Hospital, as an example, it has to cater to patients from as far as the foothills of Mt Kanchenjunga in North-West Sikkim, and bordering the extreme Nepal borders and reach as far as Jorethang in South Sikkim, bordering the Darjeeling District in West Bengal. Similarly, East Sikkim District Hospital in Singtam has to cater to patients from as far as Dzongu in North Sikkim and Ben near Rabongla in South Sikkim, who opt for the hospital due to proximity to Singtam.
In early 2019, an apolitical body from West Sikkim - Sikkim Progressive Youth Forum - led a foot march from Geyzing, West Sikkim to Gangtok in East Sikkim highlighting the concern of Geyzing District Hospital. Their argument then was "Geyzing District Hospital had been overlooked by the State government over the years, churning away its workforce for a more populated East District Hospitals and PHCs and even to the new STNM Hospital after its establishment. There is lack of facilities such as a simple X-Ray procedure, to even concerns about the blood bank and MRIs and CT Scans do seem to be out of question. Along with it technicians, radiologists and others were taken away from the hospital or have never been recruited." They made people aware across the state how the district hospitals need attention.
Meanwhile, North Sikkim District Hospital in Mangan saw its own form of protest in 2018 by the public from Mangan, Chungthang, Lachung and Lachen, among others. The structure of the hospital is very old which was damaged by the 2011 earthquake. It has been considered for reconstruction, but the work is yet to complete and may start fully functioning only by 2021.
Currently, it is functioning from other adjoining buildings and AYUSH Hospital, while places like Lachung and Lachen and even Chungthang have to resort to PHCs. "The facilities are minimum with just an X-ray, even for ultrasound, as is the requirement for Obstetrics and Gynecology, all pregnant women from the district have to rush to Singtam Hospital or STNM. Same goes for accident victims, as emergency cases needing more attention and surgeries, need to be rushed to STNM or CRH. The count of medical officers in the districts is also very less, with 10-13 doctors being present in the district currently who have to run to different PHCs in Dzongu, Chungthang, Lachen, Lachung and places beyond it. The district is so big, starting from the borders of Gangtok and reaching as far as Gurudongmar Lake, there is desperate need for more doctors", stated a doctor from North Sikkim district.
The district hospital in Singtam for East Sikkim is considered substantially better, but a senior doctor mentioned: "The new wave for Singtam Hospital began only in the last few years, for someone who has worked here for over a decade, the changes are encouraging now. We have almost all the facilities here for a district hospital with departments ranging from de-addiction centres close by, to psychology department and even Geriatric Ward. Yet, the workforce from Singtam Hospital had to majorly cater to the initial process of screening at Rangpo and Melli borders, when the influx of stranded people to Sikkim was very high a few months ago."
Recently, the Geyzing District Hospital initiated a dialysis centre while Namchi District Hospital also has the facility. The person leading the charge on haemodialysis is Dr BN Sharma, who lent his expertise on the procedure to the doctors, nurses and technicians. But, sadly, he is not a nephrologist, he is a specialist in medicine, who opted to aid the state for the lack of a nephrologist for years.
Elsewhere, the state government has considered on opting for Mobile Village Clinics with three-day services every week by doctors who will reach every village on specified days of the week. Along with it, one other promising act of the state government has been to include Super Specialist District Outreach Program, wherein Super Specialists from the State will visit the districts to carry out important treatment, operations and surgeries every 15 days. Chief minister Golay also asserted on the claim, stating that the report for feasibility of the equipment and infrastructure has been submitted to the government by the super specialists in the state.
CRH Manipal has lost workforce to govt sector
CRH Manipal was sealed following a COVID scare with positive cases reported from the hospital on Thursday.
Central Referral Hospital, which has been the state’s backbone in generating doctors and other health workers through Sikkim Manipal Institute of Medical Sciences and its Nursing Institute, has its own troubles of workforce.
Among the 524 nurses that were recruited by the State Health Department in 2018-19, majority of the nurses were graduates from Manipal’s Nursing Insitute, who were initially working at CRH Manipal. Add to that, the 40 odd doctors and technicians who have shifted to the government health sector, leaving CRH to face shortage of staffs in technicians, radiologists and others. There are 200 odd doctors, with 100 plus specialists and a collective strength of 700 odd health workers in CRH Manipal, which does seem as an exaggeration from the private hospital.
CRH medical superintendent Dr Gautam Dey
Speaking with EastMojo, CRH medical superintendent Dr Gautam Dey stated, "With most of the non-COVID patients coming to the hospital , it is difficult to handle such rush of patients. Now we have to take care of COVID patients as well. Psychiatry, medicine, accident victims make the most of our patients, now our ICUs are also getting filled. We are in a soup, but we have to take patients. Expertise is not a problem, beds and workforce and resources are a problem."
On the loss of health workers to the government health sector, Dr Dey stated,"Anyone who wants to go to the government sector we cannot stop them. If the person gets the government job, he will go for security. We are in crisis, and to fill such positions will also take time. We will try our best, will see how far it is practical but we are not considering on taking in students for help."
Not letting the state government down was the assertive stand of the CRH MS. "Staff are resenting, especially the non-doctors on the increased number of patients and the COVID threat engulfing now more than ever. We are trying to counsel them, it is natural concern for them but it is also a national emergency. If the state health department shifts health workers from PHCs and Urban PHCs, they may take time to co-adjust to our professional dealings in the hospital and that will be a problem in the case of emergencies. The quality of work has to be there," he stated.
COVID has barred inter-state referrals
The ideal case for Sikkim’s health sector before the new STNM Hospital was referrals from outside the State. With COVID-19 blocking inter-state travel with referrals, many patients have suffered or died within the state. Economically-unsound people had been suffering even without COVID protocols, as they could not find the needed doctors in the state. A major problem is seen on the absence of and a nephrologist at STNM Hospital. While one neurosurgeon works at CRH Manipal whom the state is trying to hire, there is no nephrologist that the state health department has been able to find.
Even the chief minister in his Independence Day address highlighted how Delhi and other states are flooded by Sikkimese patients and their relatives, with most needing dialysis and kidney transplants. Time and again, he has asserted on opening of a dialysis unit in every district hospital and even in subdivisions like Soreng, or closer, Jorethang in South Sikkim. Dialysis centres have been functional in Geyzing and Namchi away from STNM, with Geyzing District Hospital initiating the service just last week.
A senior doctor from STNM Hospital, requesting anonymity, stated, "STNM is carrying out dialysis without a devoted nephrologist. It is being done by Dr. BN Sharma and Dr. Phur Lhamu Sherpa, who are specialists in medicine. They are trained for the same, but nothing beats having a nephrologist as kidney transplants is also a necessity if STNM has to live up to its name of being a super-speciality hospital.
These two doctors are certainly working very hard, but even their services are getting hampered with COVID. Dr Sharma had to take up the COVID duty for a whole week followed by two weeks of quarantine just last month. So imagine, how straining it would have been to Dr Sherpa to handle the surge of dialysis patients in the state.
There has been a humongous number of patients coming to the state for dialysis, since they returned home with COVID fear. The slots are filled for the entire week, with 300-500 patients in the waiting list and dialysis are mostly weekly or bi-weekly or even more depending on the severity of the patients.
Anurag Sharma from Rumtek, East Sikkim whose father was in need of dialysis revealed, "My father was in need of dialysis, so initially we reached Manipal where he was consulting with a Nephrology doctor there. But, despite my father being his patient, he had to reject a dialysis for my father as the slots in Manipal were also filled. He has a private dialysis centre but even that was filled. So he suggested us to back on STNM. Initially, even STNM rejected us, but using our contacts, we were finally able to get emergency dialysis for about 3-4 times, now finally after two weeks, we have got the slot. But there is one certainty that the patient count is more, facility for more slots is hampered, and we do not even have a devoted Nephrologist in the biggest hospital in the State".
On the need for a neurosurgeon, a resident of Rabong in South Sikkim revealed, "About a month ago, my cousin had met with an accident and had brain haemorrhage. She was a health professional herself, but despite that we could get her the treatment that was required to save her life. In that panic situation, we rushed to district hospitals, Manipal and STNM and finally took her to SIliguri, but were unable to save her. That was when we realized how terribly the State is in need for a Neuro Surgeon, if we had, maybe we could have saved my cousin. About time, the state looked upon such concerning matters, than making unnecessary political appointments."
What has the state done?
Over the course of last two years since the establishment of the new STNM Hospital, 40 doctors and specialists joined it through the Sikkim Public Service Commission (SPSC), most of whom are from Manipal. In the posts that were created, some 10 specialists declined serving the state due to less pay.
Up to 261 nurses were appointed in 2018, and 263 the following year. They have been a big addition to the state’s health sector, given how COVID-19 has taken over. In 2019, five super specialists joined STNM of the nine posts created through SPSC, the remaining declined owing to less pay and their existing services in the better paying private sector. Specialists are many, but super specialists are hard to procure as it is tougher to clear an expensive study without a scholarship or state government’s aid and takes at least 3-4 years, meaning most doctors relinquish further studies after their MD degree.
STNM Super Speciality only in name?
Super Speciality is termed as 'end of the line' treatment. Meaning, no referrals need to happen outside the state and the treatment meted is final. The famous five super specialists cater to the departments of Cardiology, Gastroenterology, Pediatric Surgery, Plastic Surgery and Urology. But no Super Specialist Neuro Surgery which is in high demand with so many accident cases needing emergency surgery. Similarly a Specialist in Nephrology for kidney transplant and dialysis patient numbers being very high. The claim was backed even by the Health Director General.
On being asked why is it so hard to procure a super-specialist, one of them mentioned, "It is only after nine years of study and practice that we are eligible for Doctorate in Medicine (DM) or Masters in Surgery taking 3-4 years to perfect. Without a scholarship or government aid, the cost of the entire medical study privately could cross Rs 60 lakh. But once we graduate, we get offered above Rs. 5 lakhs to work in a private facility which is better paying. Our own colleagues in Siliguri, are making close to Rs. 15 lakh per month. So when they are offered government’s salary and package, it does not suffice. Being a super specialist in private hospital is a big money earner, so they opt to work private and refrain from joining the government sector."
The work cut out for a super specialist is hours of consultation and surgery which stands as their primary service, for any ailment. When we take STNM into account, perhaps it is only cardiology department led by Dr DP Rai to be one of the finest in the state. A major part of the work for the establishment of the cardiology department as a state of the art facility, was partly because Sikkim had a former health secretary Dr Kumar Bhandari, a cardiologist, leading the charge at new STNM for the establishment of the cardiology facility. It has multiple medical officers or MBBS doctors, but the same is not the case for other super speciality facility.
"Despite the claims of having a super speciality, there is one doctor who has to attend to morning rounds of the in-patients, he has to consult with out patients coming, divulge in surgeries and operations, and sometimes for plastic surgeons and pediatric surgeons, they have to cater to patients outside their own department as well, and that is not justified. What we need is more MBBS graduates or junior residents, who can take away the workload from the Super specialists, with help in the morning hours or a night watch or preparation of patients before the surgery,and that is not possible until we hire more MBBS doctors," stated a super specialist.
Most of the super specialists also assert on the stand that nephrologists and neurosurgeons are the need of the hour. "Nephrologist in Sikkim may still seem like a distant dream with one probable candidate yet to finish his DM. Another has a devoted clinic in Siliguri and has previously refrained from working in the State owing to low pay scale. Others in contention for nephrologists may have found better alternatives in the private sector. Coming to neurosurgeons, there is one local super specialist working in CRH Manipal, and the state government is desperately trying to bring him to the government sector. Let's see how that works out. But, without a devoted team to support him or any other super specialist with MBBS level doctors, workforce or junior residents, and even infrastructure like devoted ICUs and Super Speciality Centre, STNM will be a super speciality only in name," added a super specialist.
A specialist from STNM
In between political stand and public demand, it is clear that there is the lack of economy to set up a super-speciality. "No one from the private sector are willing to work at the amount of salary we get. Respect won’t get you paid, we spend years in the service, our colleagues in other services reach higher than us. There is so much dissatisfaction among doctors", stated another doctor.
Another senior specialist from STNM, begged to differ. "When each of the super specialist will start expecting Rs 5 lakh, how will the state start paying salaries? It has set the precedence that if they are offered anything less than Rs 5 lakh, then they may not agree to come to STNM or the government sector. That was a mistake made by the previous government, now it is something current government will have to continue. What is lacking in the hospital, is a perspective to what more needs to be done. It equates the demand of the public along with what must be a multi-super-specialty hospital. They want everything here in STNM but it cannot be Medanta or Apollo level treatment in a government hospital, as the public expectation is too much and that too for free," the specialist added.
There is a need for recruitment that needs to come from the medical officer level, that is where the lacking of workforce begins from. "Even some departments such as plastic surgery can ideally be referred outside the State. It is cheaper to refer a patient out then to recruit a plastic surgeon. With the super specialty tag and with the public and political demand there are so many more requirements, but it is impossible. One nephrologist being taken in will not solve the problem, the political stand on dialysis unit is every subdivision and even PHCs must have a dialysis centre, but where to find such a workforce. For nephrology just getting the equipment will not solve the issue, you need labs and technicians to follow," stated another specialist.
Does a super specialist need to be involved in COVID-19 treatment?
If the patient is asymptomatic, does it require a super specialist handling the treatment? A super specialist, requesting anonymity, admitted, "COVID fear is among the people, but what people fail to understand is that the treatment to be meted to a asymptomatic patient is nothing more than observation and flu medicine. There is no big treatment or operation to be carried out, but fearing many crucial departments could face shortage of doctors for treatment inevitably, even the super specialists who otherwise must head only their respective department must be put under the COVID duty. It directly puts many other treatment at risk for non-COVID patients."
To counter the ever-surging need for more health workers, the state government constituted a Steering Committee in the end of July. It is led by Finance and Planning Department Secretary VB Pathak with three other Secretaries from departments such as Department of Personnel and Health with Dr Pempa serving as the Member Secretary including the Chief Medical Officers and the District Magistrates from all four districts.
The Committee is planning to create 37-40 more posts for Medical Officers (MBBS doctors) along with one Neuro Surgeon from CRH Manipal whom they are trying to hire. "There are 37 doctors who have previously given a written examination through SPSC, so we are focusing on recruiting them. We are also trying to permanently hire Ad-hoc doctors, as most don’t agree to work on an adhoc basis, much worse they decline from going to District Hospitals on adhoc basis but agree for STNM", stated Dr. Pempa.
With the lockdown, procurement of Super Specialist from other States is not possible, the State might have to incline on the existing Sikkimese doctors who are working in other parts of the country or those working within and in close proximity like Siliguri in West Bengal even if they are practising private, informed the officials. "There is a neuro surgeon in CRH Manipal who is a local.
State is trying to bring him in as Super Specialist but it depends on the package he will be offered which has to be at par with other Super Specialist as a precedence for the same has been laid at around Rs. 5 lakhs per month. A local nephrologistis currently pursuing his MD in Delhi, so that might have to wait. But there are few nephrologist who practise privately in Siliguri but are earning so high around Rs 15 lakh per month that State may not be able to afford his services, if he asks such a salary. Those doctors working on an ad hoc basis may have to be regularized just so that additional workforce can be generated," stated another doctor requesting anonymity.
The Cadre System among doctors and specialists
In 1990s, Sikkim’s Doctors went through a change in cadre with every doctor be it an MBBS graduate or a MD graduate, was clubbed into one category as 'Medical Officers' holding the same designation with minimum difference in the pay scale. The system carried on till 2019, until Super Specialists had to be hired as under Sikkim State Specialist Wing of Sikkim State Health Service on different grades of pay scale. A Medical Officer holds the designation equivalent of gazetted officer in the State, but with the change in cadre, a specialist may rise to the designation equivalent of a deputy secretary in the State’s bureaucracy. There are handful of doctors who rise higher than the designation unless he directly serves the State’s bureaucracy, specifically with their expertise in the Health Department. There are some who have gone on to become the Secretaries of the Department, while some even shifted to other departments away from Health sector.
CM Prem Singh Golay
"Before it used to be just medical officer designation doesn't matter if you have done specialization or not, now the same has been streamlined. If there was no cadre no one would have joined last year, when 40 odd doctors joined the government sector. Since they were already working here in private sector or even those coming from outside the State are not willing to join district hospitals, if they don’t get facility, or good salary. The win-win situation was only a few super specialists getting the salary as they were promised. Doctors have ample opportunities, if they are settled outside of the State, they will think 100 times before coming to Sikkim. It is not feasible even for the government", stated a specialist doctor recruited last year.
Need for Government Medical College
With the establishment of Government Nursing College in STNM Premises, another need has been felt for a Government Medical College, the same was mentioned as a primary concern even by CM Prem Singh Golay in his Independence Day address. While the establishment of the same could take years, a super-specialist broke the concern claiming, "With a devoted medical college, Super Specialists and even Specialist Doctors can train young medical students and graduates. We can have our own Junior Residents, who will have hands on training on working on a surgery or other needs. If we take 100 odd students every year, 80 odd would qualify as doctors, each of them would go for Specialist learning, and 40 odd would opt for Super Speciality as in DM or MCH, with that we may be able to create a super-specialist for each department. Currently, STNM is Super-Speciality only for name sake, but this does seem like a fruitful solution to inculcate what has been long termed as medical tourism in Sikkim".
It stands true in every essence, the likes of Christian Medical College in Vellore where people from Sikkim frequent, is firstly a medical college and later a hospital catering not only to its own State but people from across the country and even those from abroad. Closer home, CRH Manipal in the State has Sikkim Manipal Institute of Medical College along with its Nursing Institute, catering as a feeding ground for doctors, nurses and technicians in the Hospital. But, with it being a private, students from the State cannot afford on a large scale. The resulting solution as meted by the Chief Minister Golay in his Independence Day address was on setting up a Government Medical College and reservation of around 50- seats for locals in SMIMS for MBBS.
Forensic Medicine in STNM Hospital has only one doctor in Dr. OT Lepcha who was instrumental in handling the first COVID death in the State. Another senior Forensic Specialist has not been working owing to his political inclination, it is said he takes his salary but doesnt come to work, a shortage in forensic department is felt.
"STNM Hospital, alone may need 2-3 forensic expert while each district hospital could be needing one forensic expert at least. Sections such as Medicine Specialists are quite many, but the concern also is on emergency level doctors who are freshly out of MBBS. MBBS doctors are a requirement both in CRH Manipal and STNM Hospital. STNM or CRH Hospital are huge structures with many facilities, with workforce shortage," stated another doctor. Radiology is another department that is seen as a major concern in state with only one doctor devoted for the same as a specialist. MRIs, CT Scan are all under the specialist, meaning more recruitment could follow for a Radiologist as well
It is clear that Sikkim’s health sector needs more attention than any other form of recruitment, perhaps COVID 19 has exposed the same about the state. Perhaps the state needs to pay attention to all these concerns over any other.