The 294 page long report of the Comptroller and Auditor General (CAG) of India with regard to Performance Audit on Public Health Infrastructure and Management of Health Services, Government of Bihar was tabled on November 28, 2024. It was sent to the government on October 28, 2024. The report is signed by Raj Kumar, Principal Accountant General (Audit), Bihar and countersigned by Comptroller and Auditor General (CAG) of India.
The relevant part of Article 151 reads: "The reports of the Comptroller and Auditor-General of India relating to the accounts of a State shall be submitted to the Governor of the State, who shall cause them to be laid before the Legislature of the State." Article 148 of the Constitution makes a provision for CAG of India, It reads:"There shall be a Comptroller and Auditor-General of India who shall be appointed by the President by warrant under his hand and seal and shall only be removed from office in like manner and on like grounds as a Judge of the Supreme Court." Article 149 of the Constitution deals with the duties and powers of the CAG. It reads: "The Comptroller and Auditor-General shall perform such duties and exercise such powers in relation to the accounts of the Union and of the States and of any other authority or body as may be prescribed by or under any law made by Parliament and, until provision in that behalf is so made, shall perform such duties and exercise such powers in relation to the accounts of the Union and of the States as were conferred on or exercisable by the Auditor-General of India immediately before the commencement of this Constitution in relation to the accounts of the Dominion of India and of the provinces respectively." Article 150 of the Constitution deals with the "Form of Accounts of The Union and of The States." It reads: "The accounts of the Union and of the States shall be kept in such form as the President may, on the advice of the Comptroller and Auditor-General of India, prescribe." CAG's performance audit report on Public Health Infrastructure and Management of Health Services was prepared for submission to the Governor of Bihar under Article 151.
The news channels, newspapers, news sites and social media reported the decay of the Bihar's Health Department recorded in the CAG's audit report.
The Hindu says, CAG reports highlights glaring deficiencies in Bihar health infrastructure Out
of budget provisions of ₹69,790.83 crore made during FYs 2016-17 to
2021-22, Bihar spent only ₹48,047.79 crore (69 %), leading to
non-utilizations of ₹21,743.04 crore (31%).
Indian Express has reported that As Bihar’s healthcare system crumbled and doctor shortage persisted, state failed to spend its full health budget for years, CAG finds. According to the CAG, "between the financial years of 2016-17 and 2021-22, the state spent only Rs 48,047 crore (69 per cent) of total budget provisions of Rs 69,730 crore".
National Herald reports Huge gaps in Bihar's medical facilities, says CAG report
Facility of diagnosis and management of cases of cardio-vascular
disease, cancer, myocardial infraction and stroke facilities were not
available in any of the test-checked district hospitals.
The Times of India has reported that Bihar's healthcare system in shambles, says CAG report
Press Trust of India and The Print has reported that CAG audit report finds acute shortage of doctors in Bihar
Swastha Bharat says, बिहार में स्वास्थ्य व्यवस्था भगवान भरोसे
ABP reports CAG Report For Period 2016-22:बिहार के स्वास्थ्य सेवा क्षेत्र पर भारत के नियंत्रक एवं महालेखा परीक्षक की रिपोर्ट में पाया गया है कि राज्य में चिकित्सकों और पैरामेडिकल स्टाफ की भारी कमी है.
New Indian Express has reported that Bihar faces acute healthcare crisis: CAG report highlights severe shortage of doctors, staff, and equipment The CAG report also scrutinized procurement data from the Bihar Medical Services and Infrastructure Corporation Limited (BMSICL).
The important findings relating to human resources of the healthcare infrastructure and services are as under:
•There were 49 per cent vacancies across the offices of the department i.e., Directorate of Health Services, State Drug Controller, Food Safety wing, AYUSH and Medical College and Hospitals (MCHs).
• In Bihar, against the projected population of 12.49 crore as of March 2022, 1,24,919 allopathic doctors (1:1,000) were required to fulfil the recommendation of World Health Organisation (WHO) against which, only 58,144 (1:2,148) allopathic doctors were available as of January 2022.
• Shortage of staff nurse against sanctioned strength varied from 18 per cent (Patna) to 72 per cent (Purnea). Shortage of paramedics against the sanctioned strength ranged from 45 per cent (Jamui) to 90 per cent (East Champaran).
• There was significant staff shortage in all the cadres ranging from 35 per cent to 81 per cent, in AYUSH health care facilities.
• The Human Resource agency hired for recruitment of required manpower, at different levels of healthcare services published (October 2019-January 2021) advertisements for 82 types of 24,496 posts. However, recruitment of 35 types of 13,340 posts was pending as of January 2022.
The findings relating to Healthcare Services are as under:
• Basic amenities such as drinking water, fan, separate toilets for males and females, chairs etc., were deficient in the Out-Patient Department (OPD)/registration areas of the test-checked healthcare facilities (four SDHs, two RHs, four CHCs and 10 PHCs).
• As per Indian Public Health Standards, emergency OT was to be made available in each SDH, but it was not available in all the test-checked four SDHs. Besides, accident and trauma care services were also not available in any of the test-checked SDHs (except Mahua (Vaishali)).
• Out of 20 test-checked healthcare facilities, Antenatal Care (ANC) facility was not available in SDH, Udakishunganj, PHC, Bihta and Noorsarai. In the remaining 17 healthcare facilities, whenever a registered pregnant woman turned up for ANC, a new number was being allotted to her. Besides, one per cent to 67 per cent of the registered pregnant women were not supplemented with full course of IFA tablets during 2016-22.
• Out of 24 cases of maternal deaths reported in 16 test-checked healthcare facilities, during FYs 2016-22, maternal death review had been conducted in only one case, in PHC, Goraul.
• In test-checked 68 healthcare facilities of different levels (from HSC to SDH) required number of diagnostic test facilities were not available from 19 per cent to 100 per cent and diagnostic facilities were not available beyond OPD hours except CHC, Kako and PHCs Ratni Faridpur, Sikariya and Shankarpur.
• In test-checked healthcare facilities, shortages of Lab Technicians (LTs) ranged from nil to 100 per cent (on average) against the sanctioned strength during 2016-22.
• Joint physical verification of 25 ambulances showed that none of the ambulances had required equipment/medicine/consumables as per the agreement. The shortages ranged from 14 per cent to 100 per cent.
• Six test-checked blood banks operated without valid license, for a period ranging between three years to 21 years. This depicts lack of monitoring control on the part of SDC.
• None of the test-checked 10 SDHs, RHs and CHCs had functional Blood Storage Units (BSUs). In eight healthcare facilities, BSUs were non-functional due to the non-availability of manpower and authorisation certificates issued by the State Licensing Authority even when the equipment and consumables were available.
The findings relating to Availability of Drugs/Medicines, Equipment and Other Consumables of the healthcare infrastructure and services are as under:
• For providing necessary medicines to the patients free of cost at all health care facilities, the department had prepared an Essential Drugs List (containing up to 387 number of drugs during 2016-22), but the nodal agency i.e., BMSICL, had executed rate contracts with suppliers for only 14 to 63 per cent drugs, during the period, resulting in non-availability of such medicines.
• During 2016-22, BMSICL received 197.38 crore units of drugs/ surgical items valuing ₹ 1,290.39 crore, against 13,440 purchase orders. The received drugs/surgical items had remaining shelf life from 35 per cent to 74 per cent of their total life against the required minimum 75 per cent.
• In test-checked healthcare facilities, non-availability of essential drugs for Out-Patient Departments ranged between 21 per cent to 65 per cent and for In-Patient Departments, the non-availability was 34 per cent to 83 per cent, during 2016-22.
• In Darbhanga Medical College and Hospital (DMCH) and Government Medical College and Hospital (GMCH), Bettiah, it was observed that 45 per cent to 68 per cent drugs were not available during FYs 2019-21, due to short/non-supply of drugs by the BMSICL.
• State Ayush Society, Bihar, could not purchase essential drugs prescribed by Government of India (GoI), though grants of ₹ 35.36 crore for this purpose were provided during FYs 2014-20.
• In Government Tibbi College & Hospital, Patna, 55 drugs costing ₹ 22.33 lakh, purchased during October 2018 to October 2019, without assessment of their requirement, could not be utilised and had been kept idle in stock, and the shelf-life of 20 medicines had already expired.
• Acute shortages of equipment were noticed in the departments of each of the test-checked medical college and hospitals. The shortages, against the required number of machines and equipment, ranged between 25 per cent and 100 per cent, 33 per cent and 94 per cent and 50 per cent and 100 per cent, in DMCH, PMCH and GMCH, respectively.
• Out of available 132 ventilators in test-checked healthcare facilities, only 71 (54 per cent) ventilators were found functional. Four ventilators were non-functional and 57 (43 per cent) were lying idle, due to non-availability of technician and non-functional ICU.
The findings relating to Healthcare Infrastructure are as under:
• There was significant shortage of healthcare facilities, from Health Sub-Centre(HSC) level to Referral Hospital (RH)/Community Health Centre (CHC) level. Further, Sub-Division al Hospitals (SDHs) were not available in 47 sub-divisions.
• Government of Bihar had not prepared any comprehensive health policy/plan, aligned with the National Health Policy, 2017, to address the gaps of infrastructure/equipment in every healthcare facility.
• Health Department accorded (March 2007 to February 2010) sanction for upgradation of 399 out of 533 Primary Health Centres (PHCs) into CHCs but the executing agency i.e., Bihar State Building Construction Corporation Limited had completed construction work of buildings in only 191 PHCs, as of March 2022.
• The Department provided (April 2011 to November 2015) funds of ` 257.02 crore to Bihar Medical Services & Infrastructure Corporation Limited (BMSICL), for upgradation of 198 PHCs into CHCs but work was started at 93 places and only 67 works for construction of buildings could be completed.
• Out of total 1,932 Primary Health Centres/Additional Primary Health Centres (APHCs), 846 (44 per cent) were not functioning on 24X7 basis. Further, only 566 (29 per cent) had labour room, 276 (14 per cent) had Operation Theatre (although mandatory as per guidelines) and only 533 (28 per cent) had at least four beds, against the requirement of six beds.
• It was observed that only 4,129 (52 per cent) Health and Wellness Centres (HWCs) were in existence, as on March 2022, against the target of 7,974 in the State and several deficiencies such as non-availability of toilets, drinking water, waiting space facilities were found in the test-checked HWCs.
The findings relating to Financial Management of the healthcare infrastructure and services are as under:
• Government of Bihar (GoB) made budget provisions of ₹ 69,790.83 crore during financial years (FYs) 2016-17 to 2021-22. Out of these provisions, only ₹ 48,047.79 crore (69 per cent) were spent by the Department, leading to savings of ₹ 21,743.04 crore (31 per cent).
• The savings were mainly attributable to: (i) the absence of gap analysis for raising demands for the budget and (ii) non-receipt of indents/demands from districts, on time.
• The percentage of expenditure on healthcare against the Gross State Domestic Product (GSDP) ranged between 1.33 per cent and 1.73 per cent only, whereas the percentage of healthcare expenditure against the Budget of the state, was between 3.31 per cent and 4.41 per cent, less than the required 2.5 per cent and 8 per cent of the GSDP and State Budget, respectively.
• In all the test-checked three Medical College and Hospitals (MCHs), during FYs 2016-22, 100 per cent persistent savings were noticed, in certain heads of expenditure viz., Training, Publishing and printing etc. However, the Department kept releasing funds, which remained unutilised and were surrendered on the last day of that financial year.
The finding relating to Implementation of Centrally Sponsored Schemes of the healthcare infrastructure and services are as under:
• There were delays in payments (31 to 60 days in 17 per cent, 61 to 180 days in 18 per cent and more than 180 days in six per cent cases) made to sampled 2,378 Janani Suraksha Yojana beneficiaries, covered in nine test-checked healthcare facilities during financial years 2016-22. In 11 per cent cases, no payments were made.
The findings relating to Adequacy and Effectiveness of the Regulatory Mechanisms of the healthcare infrastructure and services are as under:
• Only 27 to 42 per cent of sellers could be inspected by the Drug Inspectors during FYs 2016-22 (up to November 2021) and due to inadequate number of inspections, it could not be ascertained that provisions of the Act/Rules were being complied and quality drugs were being provided to the patients.
• There was acute shortage of manpower in State Drug Controller (SDC) establishment (100 per cent on the post of Deputy Drug Controller, 26 per cent in Assistant Drug Controller and 36 per cent in Drug Inspector), as of December 2021. This was one of the important reason for less inspections leading to ineffective monitoring mechanism.
• Out of 1,350 samples collected for quality test, only 17 per cent samples could be analysed within the stipulated time and remaining were analysed with delays of 61 days to 540 days. Due to delays in analysis, it could not be possible to take timely action, in case the drugs were found of sub-standard quality.
The findings relating to Sustainable Development Goals of the healthcare infrastructure and services are as under:
• As per SDG India Index Report (2020-21) of NITI Aayog, Bihar scored 66, out of 100 SDG index score for SDG-3.
• Achievement of Bihar in respect of key health indicators (like MMR, NMR, TFR etc.) was far below the SDG target, as well as average national achievement during 2020-21.
The CAG's Audit Report recommends that the State government ought to ensure:
1. that adequate number of healthcare personnel are deployed in healthcare facilities, according to relevant norms/benchmark.
2. that waiting time for registration is reduced, by adding registration counters and registration staff etc.
3. availability of maternity services (Antenatal Care, Intra-partum care and Post-partum care) to every pregnant woman/mother.
4. that radiology and Ambulance services are operational in the designated healthcare facilities, with the required manpower and equipment.
5. preparation of Comprehensive plans for Bio-Medical Waste management.
6. segregation of Bio-Medical Waste and proper disposal thereof, as also the establishment of Effluent Treatment Plants in all healthcare facilities.
7. that Fire Safety Plan is prepared by the Health Department and fire extinguishers
are installed in every healthcare facility.
8. at healthcare facility level there is a defined and established system for grievance redressal mechanism for beneficiaries.
9. BMSICL executes rate contracts, prepare annual procurement plan for procurement of equipment, to ensure their timely availability and distribution thereof across healthcare facilities.
10. terms and conditions of the supply contracts are adhered to, for ensuring the timely supply and adequate shelf life of drugs.
11. that drugs and surgical items are stored at the prescribed temperature and moisture standards, to help preserve their shelf life.
12. that required equipment and drugs as per EDL, are available in all the healthcare facilities.
13. carrying out quality tests of each batch of drugs and surgical items. Further, proficiency tests of drugs are conducted, to ensure random cross-checking of the quality of test results.
14. to provide the required equipment and make them functional in healthcare facilities, in accordance with MCI/NMC norms.
15. proper utilisation of idle ventilators through deployment of adequate manpower.
16. that Health Department conducts a proper review of all civil works, for their timely completion, through the concerned agencies.
17. to prepare a comprehensive health policy/plan, to bridge gaps in infrastructure, in the existing healthcare facilities.
18. that budget provisions of the Health Department are prepared on a realistic basis, considering the demands raised on the basis of gap analysis, at the district level.
19. timely finalisation of tenders and completion of projects, so that available funds are utilised effectively.
20. adequate allocation of funds for primary healthcare, as well as enhancement in healthcare sector spending, in line with the National Health Policy, 2017.
21. that available funds are utilised in line with time bound targets, as framed under the guidelines of NAM.
22. that arrangements are made to ensure timely payment to the beneficiaries under the Janani Suraksha Yojna.
23. periodic inspections of manufacturers’/sellers’ establishments.
24. deployment of sufficient and qualified manpower in the offices of the State Drug Controller and State Drug Controller (AYUSH), for their effective functioning.
25. timely testing of Allopathic and AYUSH drugs, to mitigate the possible risks of spurious/NSQ drugs.
26. upgradation of training infrastructure to ensure regular training to technical staff, for updating their skills.
27. proper maintenance and regular updation of records relating to Application, Renewal, Cancellation and Grant of licences, to Manufacturing Units and Blood Banks.
28. that District Registration Authorities monitor clinical establishments under their area and enforce the provisions of the Clinical Establishments Act.
29. that Maternal and child healthcare services are provided according to the relevant norms and standards, to achieve the desired SDG target, related to maternal and child health.
30. phased targets are outlined for all districts, in line with the overall targets, as outlined in the Bihar SDG Vision document.
31. district-wise status of SDG health indicators is prepared and monitored regularly.
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