The purpose of upgrading Government Medical Colleges (GMCs) was not achieved as all the Super Specialties had not been fully established. And the same fact proved costly for Jammu and Kashmir during the COVID year.
When Ayushman Koul’s grandfather developed respiratory issues on November 27, 2020, his family immediately called a compounder from a nearby healthcare facility for a quick checkup.
After his blood pressure and other parameters were examined, it was found the condition was severe with some respiratory clog, as liquid had filled up his lungs.
“We were told we had to admit him as soon as possible,” Koul, 22, recalls.
The family was advised against shifting the ailing 83-year-old man to Batra Hospital, a prime private hospital in the city – pertaining to their alleged personnel shortage. Sarwal Hospital – another government setting – was told to avoid.
Trying to waste no time in reaching about the necessary place, they rushed him to the emergency ward in GMC – or Government Medical College – a premier government hospital in Jammu, also declared as one of J&K’s dedicated COVID-19 hospitals by the J&K administration in May 2020.
At around 7:30 in the evening upon admission, when his health card and admission brochure in the hospital was made, a doctor advised an immediate Rapid Antigen Test to determine whether his grandfather had tested positive for the deadly virus or not.
The reports yielded a negative result within 15-20 minutes or so.
However, since the oxygen levels in his body were detected to be low, his family was told to admit him without delay.
“After a round of tests, scans and medication, nana ji became unconscious, fidgeting and unstable,” recalls Koul.
“At around 7 am the next day, on 28, a CT Scan report revealed he had contracted pneumonia.”
The concerned doctor, however, was uncertain whether it was regular pneumonia or COVID pneumonia – and recommended an immediate RT-PCR test (Reverse Transcriptase – Polymerase Chain Reaction), the most sensitive technique of mRNA detection. The sample for the same was taken at 2:15 pm in the afternoon.
Another test revealed that his grandfather had accumulated urea in his kidneys, because of excessive protein called creatinine in them. This made the old man’s urination difficult.
Immediately, the hospital staff recommended a dialysis, for which he had to be shifted to the Super Specialty Hospital (SSH).
“We became apprehensive as to how we’d transport him there. He was unconscious. We were scared he would experience jerks and the lung problem would make it worse,” Koul explains.
Owing to the unhygienic conditions of the hospital, he wanted to shift his grandfather to a private hospital nearby.
“They agreed, but only on the account that we were responsible and liable for the same. We were told they couldn’t discharge him without the necessary formal documents, and needed an undertaking for it.”
Wasting no time, Koul called up his acquaintances at the Batra hospital.
“The hospital, however, had one contraption I was told,” he says. “While COVID patients do have a space to isolate, they aren’t taken into dialysis. And dialysis is done only for the patients who’re negative or normal.”
However, because the RT-PCR report results were yet to come, the private names in the game refused to admit.
“My acquaintances at Batra, too, recommended that either we shift him to Narayan or elsewhere, or outside J&K. I called up Narayana hospital and they demanded an RT-PCR to admit as a precautionary measure before admitting, which we didn’t have as the result takes about 12 hours to arrive.”
As uncertainty loomed over the family, they couldn’t decide the next step.
“This is my major grievance with the GMC,” says a rather furious Koul. “If they admitted him at 7:30 pm on the 27th and immediately took a Rapid Antigen Test, whose results are often dubious – they could’ve taken a sample for RT-PCR at the same time – which has more accurate results but takes longer to determine.”
“And if he was positive, there is scope for lesser patients to contract or further infect.”
When left with no option, the family had to ‘settle on’ SSH. The hospital, however, later took the sample at around 2 pm on the 28th, and the old man was taken to SSH from GMC in an ambulance with an oxygen cylinder.
“The cylinder would barely last halfway,” Koul recalls.
“The dialysis was done at the nephrology department at the SSH. I requested them if nana ji could be shifted there. But we were told to take him back to GMC.”
At around 5-6 in the evening, the deceased was brought back.
Next morning, at around 10 am, the RT-PCR report revealed he was tested positive. Post which, he was shifted to a COVID isolation ward at GMC.
“But, when they should’ve immediately sanitized the bed and the surroundings the patient was in – they didn’t. Nor did they give us PPE kits so we could easily transfer him. Even the oxygen cylinder we were given lasted halfway.”
Around 10 am on November 29, Koul’s grandfather was admitted to the isolation ward, where he passed away at 7:05 pm in the evening. The body was shifted to the mortuary, where it was kept for the night. Next day, at 4 pm in the evening – the body was handed over to the family.
“We were told since he is a COVID patient, cremation will only be done post 3 pm the next day. He was cremated at Jogi Ghat at the Shakti Nagar Shamshan Ghat.”
Koul is apprehensive and fails to understand why the GMC did not conduct the rapid as well as RT-PCR tests as soon as the patient had arrived.
“I couldn’t shift him to a private hospital solely because the RT-PCR test wasn’t done at the same time. I got the report after 36 hours, when the man passed away in 48,” he adds furiously.
“Any patient who arrives post 9 pm, isn’t given the rapid test,” he continues. “Staff is practically invisible around the time. Sanitization isn’t maintained, PPE kits aren’t given. Half the staff roams about without masks. It’s functioning as if everything is like the normal days. A nurse told me half the staff is tested positive. What should we expect? There are barely a total of 20-30 ventilators in the emergency. Very few doctors, and the ones present have immense workloads. Would they see over administration or the medicines? Senior doctors should make at least 3 or 4 rounds, whereas the one concerning GMC makes only in the morning.”
Koul had even taken to Twitter to express his grievances.
I was in GMC Jammu from 27th Nov to 30th Nov alongwith my maternal grandfather. Emergency section in GMC is the COVID hotspot. They are neither sanitizing stretchers used by corona patients who are shifted from emergency to isolation ward after testing positive nor the ward. 1/n
— Ayushman Koul (@ayushman_koul) December 3, 2020
“In the emergency ward,” he says, “it’s possible we could have contracted COVID because of him. I was roaming in the hospital getting tests done. There are 20 people standing with one patient. Either give everyone PPE kits, or at least create a buffer space between two patients arriving on bed in the emergency ward.
“My grandfather’s death was a failure of J&K’s health system.”
Interestingly, as reported by the Economic Times, New Delhi had finalised two sites—one at Vijaypur in Samba district in Jammu region and the other at Awantipora, Pulwama, in Kashmir region—for setting up AIIMS in the wake of a row in the erstwhile state last year with people in Jammu demanding the tertiary care institution be set up in that region.
“Sufficient funds are available under Pradhan Mantri Swasthya Suraksha Yojna (PMSSY) to take up the project,” Minister of State for Health Faggan Singh Kulaste told Rajya Sabha in a written reply.
While amid the surge of COVID-19 cases, GMC has time and again stirred controversies and created paranoia in both staff as well as citizens over lack of oxygen, availability of beds as well as PPE kits for the frontline health workers despite the J&K administration in May declaring it as a dedicated COVID hospital, the pandemic interestingly has pinpointed the systematic inadequacies.
However, a 2017 report clearly makes the GMCs in J&K ill-fit to handle the COVID crisis.
The report published by CAG India on Social, General and Economic sectors for the year ended 31st March 2017 (Sec 3.6) – under the Pradhan Mantri Swasthya Suraksha Yojana (2003), reveals the purpose of Upgradation of GMCs was ‘not achieved’ as all the super specialities had not been ‘fully established’.
Some medical services/ facilities installed had not functioned and remained out of order rendering expenditure of Rs 8.57 crore incurred thereon unfruitful and Rs 3.12 crore wasteful, it notes.
“And out of 592 medical equipment procured for two GMCs (both in Jammu and Kashmir), 336 medical equipment (57 per cent) costing 40.97 crores were not traceable/non-available, not installed, non-functional or had got damaged in floods,” it reveals.
“There were shortages of trained specialist doctors and nursing and paramedical staff/ technicians in both the super speciality hospitals.”
Under the Pradhan Mantri Swasthya Suraksha Yojana (PMSSY) – in Jammu & Kashmir, GMCs in Jammu and Srinagar were approved for the upgradation programme under Phase-I of the scheme and covered three aspects: construction works, procurement of medical equipment and providing workforce.
According to the report, the civil works for construction of Super Specialty block of GMC Jammu and for Institute of Traumatology (Super Specialty block) of GMC Srinagar had been executed by the Central Public Works Department (CPWD), while the medical equipment was procured for the hospitals both by the CPWD and M/s HLL Life Care Limited.
The report said that GMC Jammu and GMC Srinagar were taken up for Upgradation under PMSSY each at a cost of Rs 135 crores with Government of India (GoI) share of Rs 115 crores and state share of Rs 20 crores.
The Central share was released directly by the Ministry of Health & Family Welfare, GoI to the CPWD and M/s HLL Life Care Limited.
Out of which against an amount of Rs 197.99 crores was released during 2007-08 to 2016-17 under PMSSY for GMC Jammu and GMC Srinagar, an expenditure of Rs 165.41 crores was incurred by the CPWD.
Further, an expenditure of Rs 78.10 crores was incurred by M/s HLL Life Care Limited for procurement of medical equipment and furniture (GMC Jammu: Rs 35.92 crores and GMC Srinagar: Rs 42.18 crores) directly released by the Ministry.
Out of total State share of Rs 40 crores, an expenditure of Rs 26.29 crores was incurred by the State Government whereas Rs 13.71 crores were released to CPWD for procurement of medical equipment under the Scheme during the period 2007-08 to 2016-17.
Non-Functional CSSD Equipment
The figures revealed that an expenditure of Rs 1.41 crore was incurred by the Executive Engineer, Central Division-II CPWD Satwari, Jammu on the installation of CSSD equipment at GMC Jammu.
However, the audit in the report noticed that the Principal GMC, Jammu intimated (July 2015) the Chief Engineer, CPWD Jammu that CSSD equipment was out of order and could not be maintained due to non-availability of Annual Maintenance Contract (AMC) and other related documents which were lying with the firm.
Further, it was noticed in the report that a load of sterilisation of various equipment and linen of the Super Specialty block was taken by the Medical Superintendent, GMC Hospital, Jammu due to non-functioning of CSSD equipment and the Hospital incurred an expenditure of Rs 0.13 crore on procurement of two sterilisation equipment in March 2017.
The purpose for which the CSSD equipment had been installed was thus not achieved, rendering the entire expenditure of Rs 1.41 crore incurred thereon unfruitful, besides, resulting in extra avoidable expenditure of Rs 0.13 crore.
The matter was brought to the notice of the Principal GMC, Jammu in June 2017, who constituted (August 2017) a Committee of officers for providing detailed replies on the Audit observation but the reply was awaited (December 2017).
Non-Maintenance of Inventory Medical or Non-Medical Furniture
According to Rule 8-23 of Jammu and Kashmir Financial Code, all materials received should be examined, counted, measured or weighed as the case may be, when delivery is taken, and they should be taken in charge by a responsible Government servant who should see that the quantities are correct and their quality is good, and record a certificate to this effect.
However the Executive Engineer, Central Division-II CPWD Satwari, Jammu incurred an expenditure of Rs 1.66 crores on the supply of furniture during 2010-13.
Audit noticed that no stock entries of these furniture items were recorded, neither had these articles been inventoried nor their stock records maintained by the hospital management.
Further, according to Rule 8-28 of J&K Financial Code, physical verification of all stores must be made at least once every year under rules prescribed by the Head of the Department.
However, such physical verification of these medical and non-medical furniture articles had not been done, according to the report. The hospital management was ‘not in a position to explain’ the factual installation of medical and non-medical furniture in various sections/ wings of the Hospital and their actual status was also not known.
Status of Medical Equipment
The CAG report further reveals that out of 315 medical equipment valuing Rs 45.51 crores supplied, only 189 equipment (60 per cent) were installed in various sections/departments of GMC Jammu and SSH Jammu.
“65 equipment worth Rs 5.24 crore had not been installed (June 2017) rendering expenditure incurred thereon unfruitful,” it mentions.
“Out of 189 medical equipment installed, 36 equipment (19 per cent) valuing 2.03 crore were non-functional/out of order. 61 medical equipment valuing Rs 2.77 crores were not traceable in the hospitals.”
“Out of 252 medical equipment valuing Rs 48.10 crores supplied, 43 medical equipment (17 per cent) valuing Rs 23.89 crores were damaged in the floods of September 2014.”
“82 medical equipment valuing Rs 4.04 crore supplied during 2008-09 to 2012-13 were not traceable in various departments/hospitals of the GMC Srinagar.”
It was also noticed that 24 medical equipment (10 per cent) valuing Rs 0.71 crores supplied by M/s HLL Life Care Limited and CPWD though installed were non-functional/ out of order.
Failure to renew the licenses of the Nursing Homes/ Clinical establishments and recover the licenses renewal fee resulted in unauthorised functioning of these establishments and non-recovery of revenue of Rs 0.44 crore.
Human Resource Management
The report said that the purpose of upgradation of GMC Jammu was not achieved as trained specialist doctors were not posted in full strength in all the departments which were further marred by shortages of nursing and paramedical staff along with technicians. For filling of vacant posts, adequate steps were not initiated.
The matter was brought to the notice of the Principal GMC, Jammu in July 2017, but the reply was awaited.
The State Government accorded (April 2010 and April 2012) sanction for creation of 821 posts for the Super Specialties at GMC, Jammu for upgradation under PMSSY.
However, an effective position of staff during 2013-14 to 2016-17 was between 46 per cent and 52 per cent of the sanctioned posts.
During 2014-15 to 2016-17, the shortfall of specialist doctors together with the registrars and assistant surgeons ranged between 22 percent and 100 percent.
A shortfall of nursing and paramedical staff/technicians was between 37 per cent and 42 per cent during 2013-17.
In GMC Srinagar, the purpose of upgradation was not achieved as there were shortages of trained specialist doctors and nursing and paramedical staff.
For filling of vacant posts, adequate steps were not. The matter was brought to the notice of the Principal GMC, Srinagar in August 2017, but the reply was awaited (December 2017).
The State Government accorded (April 2010 & April 2012) sanction for creation of 949 posts for Institute of Traumatology and Allied Super Specialities for upgradation under PMSSY.
However, the effective position of staff against these posts (as of March 2017) was only 549 (58 per cent).
Shortage of specialist doctors including professors, associate professors, assistant professors and lecturers was 84 per cent whereas 90 posts (50 per cent) of registrars, demonstrators and assistant surgeons were vacant.
Further, 203 posts of nursing and paramedical staff (33 per cent) and 20 posts of administrative staff (44 per cent) remained vacant vis-a-vis sanctioned posts.
Clearly, as the CAG report reveals, the purpose of upgrading GMCs was not achieved as all the Super Specialties had not been fully established.
And therefore, today, among other things, Ayushman Koul holds this medical scam and sham responsible for his grandfather’s demise.
“My grandfather’s death,” he reiterates, “was a failure of J&K’s health system.”