Sarin Committee Report and the Recommendations

Dr. S.K. Sarin Committee, formed by the High Court of Delhi, submitted an interim report on April 1, 2024, following the court’s order on February 13, 2024. Tasked with improving medical services in Delhi, the committee, chaired by Prof. S.K. Sarin and comprising five additional members, was given eight specific Terms of Reference (ToRs) by the court. Due to the complexity of the task, they enlisted additional experts for technical support, including Prof. M.K. Daga, Prof. Vivek Gupta, and Prof. Dhiraj Shah.

To fulfil its mandate, the committee took several vital actions: it identified issues using data from the Department of Health and Family Welfare, engaged with the Government of NCT for support, collaborated with the DGHS, MCD, and NIC for software development, and held meetings with Medical Directors and Superintendents from 38 hospitals to understand challenges. The committee gathered first-hand information on hospital staffing, equipment, and infrastructure, solicited input from hospital heads on priority areas, and conducted on-site inspections. Throughout the process, they maintained communication with stakeholders through 13 virtual meetings.

In its findings, the Committee highlighted critical deficiencies requiring urgent action from the government, particularly in human resources. Key issues identified include:

1. Urgent filling of vacancies across various staff categories, including faculty, resident doctors, nurses, and technicians.
2. There is a critical shortage of faculty, such as radiologists, anesthesiologists, critical care specialists, and neurosurgeons, particularly during regular and emergency hours.
3. New posts are needed to address current and future workloads in critical care and medical/surgical services.
4. There is a need for more staffing for operation theatres and rioritizin pediatric and adult services.
5. Needs to be more efficient in filling vacant posts, whether on a contract or regular basis.
6. There is a need for qualified hospital administration and management staff to manage operational tasks effectively.
7. A dedicated engineering and infrastructure maintenance team for health services is needed.
8. Inadequate training facilities for critical care, trauma management, and Advanced Cardiac Life Support (ACLS) for medical and paramedical staff.
9. A need for collaboration between district administration and hospital management to provide timely administrative support and promote the right to health.

The Committee highlighted critical issues related to infrastructure and medical services in Delhi hospitals, particularly in emergency and trauma care:

1. Inadequate Emergency Services: Trauma and accident emergency centres in each district’s major and medium-sized hospitals are needed.
2. Insufficient ICU Facilities: Hospitals with fewer than 500 beds should have 5-10% of beds designated as ICU beds, while those with more than 500 beds should allocate 20%. Currently, there are 1,058 ICU beds in Delhi hospitals, necessitating an increase to 2,028 by adding 1,046 beds.
3. Lack of Operation Theaters: More operation theatres and adequate pre- and postoperative facilities must be needed.
4. Essential Equipment Shortages: Hospitals lack critical equipment, including ultrasounds, CT and MRI scanners, and anaesthesia machines.
5. Poor Equipment Maintenance: Maintenance of essential equipment, including life-saving devices and patient transport systems, needs to be improved.
6. Delays in Equipment Installation: Installation delays often occur due to a lack of site readiness by the Public Works Department (PWD); the Committee suggests adopting turn-key and built-operate models for procurement.
7. Limited Procurement Authority: Heads of Institutes have restricted powers regarding the purchase, repair, and maintenance of equipment.
8. Non-computerized Services: OPD, lab, and pharmacy services are not computerized, impacting operational efficiency.
9. Lack of ACLS Ambulances: There is a shortage of Advanced Cardiac Life Support (ACLS) ambulances in hospitals and emergency services.

Additionally, hospitals are facing a persistent shortage of essential medicines and supplies due to the inefficiencies of the Centralized Procurement System (CPA), leading to challenges in operating emergency services and often necessitating patient referrals to other centers, especially during nights and holidays. The referral system in the government health sector is unstructured, causing hospital overcrowding and suboptimal care for patients in need. There is no centralized control room or helpline to direct patients to the nearest healthcare facility, worsening health emergencies.

In response, the Committee prioritized improving efficient emergency healthcare services and developed recommendations for each of the eight Terms of Reference (ToRs). These are organized in a phased and time-bound manner, with expected financial and administrative support from the GNCTD. Timelines for task completion are categorized as follows:

• Immediate: within 30 days (subject to Model Code of Conduct)
• Short-term: within 31-90 days
• Intermediate term: within 91-365 days
• Long-term: within 1-2 years.

TOR 1

To suggest ways for the prioritizing of existing resources in the various hospitals located in Delhi, which are either owned by the Government of NCT, including Delhi Government autonomous hospitals or MCD

Immediate measures.

• Redistribution of consultants: Institutions where non-teaching specialists/experts are available but are not optimally rioriti due to lack of machines or infrastructure may be asked/ allowed to be posted or visited on designated day(s) to Institutions where such facilities are available.

• Extension of tenure/ reappointment of specialists: The age for faculty positions permitted by the National Medical Commission is up to 70 years. The age for superannuation in the Delhi Govt. hospitals for clinical staff should be enhanced to 7p0 years. While such a change can be implemented, it would be prudent to extend the tenure of the serving clinical specialists and reappoint those clinicians who have superannuated to carry out the required services in the Govt. hospitals.
• Hiring/Empanelment of Consultants from the private sector: Engagement of the private sector is urgently needed, and specialists should be empanelled/ hired where there is non-availability or shortage of regular specialists. This can be done by proper advertisement, and appropriate remuneration. These consultants should be given respectable designation and infrastructural support to provide the required services. A three-member committee could prepare service conditions for appointing consultants from the private sector.

1. Proper utilization of Equipment

In institutions where equipment remains unused due to a lack of technical manpower, efforts should be made to either ensure that qualified personnel are available to operate such equipment or transfer it to other institutions where the necessary technical expertise exists. Additionally, instruments requiring repair must be prioritized for operational readiness and should be made functional within the next 30 days, with specific instructions issued to the PWD or relevant agencies to complete the repairs in compliance with ECI guidelines. Furthermore, all medical equipment should be made operational and available for patient care 24/7, with appropriate provisions and service models, including public-private partnerships (PPP), being explored to support this initiative.

TOR 2

To suggest ways and means to devise a mechanism for the establishment of a control room that will enable the provision of real-time information concerning the availability of ICU / HDU beds in the various Hospitals and their timely availability for patients in need thereof.

Immediate and Short-term measure

Control Room Establishment:

The Committee recommended the establishment of a Centralized Command and Control Room (CCR) by the IT Department of GNCTD, staffed with trained executives and medical professionals available 24/7. This control room should feature live screens displaying the locations of available emergency and ICU hospital beds, medical services (such as CT/MRI and operation theater facilities), and ambulance service availability. A geo-mapping system of all Delhi hospitals with dynamic facility details should also be implemented.

Each hospital will designate a referral coordinator responsible for updating a dashboard linked to the CCR at least three times daily. A reliable company should maintain the CCR to ensure uninterrupted service, akin to the Delhi Fire Service or Police Help Line. The NIC has indicated that a functioning dashboard is already active in Delhi Government hospitals and can be upgraded swiftly. Additionally, a 24/7 call center facility should be integrated into the CCR setup.

As an intermediate measure, an app providing timely information about emergency health services in Delhi hospitals should be developed for citizens. Furthermore, to enhance emergency care, Delhi should maintain at least five Advanced Cardiovascular Life Support (ACLS) ambulances per district, available around the clock, which could be outsourced temporarily.Top of Form

TOR 3:

To suggest ways and means to ensure the availability of infrastructure, medicines, and adequate manpower in the Hospitals for operating / managing high-end medical equipment / critical care units in the various Hospitals.

Immediate measures:

15% of the vacant posts in all categories to be filled within 30 days.

1. Manpower
2. Permitting hiring of the doctors on a contract basis as academic faculty/ consultants by the Director/MS of the Institution. The salary and perks of contractual doctors should be at least same as of regular employees.
3. Private doctors should be empanelled as Visiting Consultants, especially in radiology, anaesthesia, and any other speciality. The emoluments may be paid per patient/procedure basis. Empanelment can be for durations ranging from 2 hours to 4 hours, 8 hours to 12 hours, and for night calls every day, Sundays, and holidays.

iii. For nursing staff and para-medical staff, outsource agencies to be engaged on Quality-cum-Cost Based Selection (QCBS) and immediate deployment should be done.

1. Adequate clinical and paramedical staff should be made available at the primary and secondary health facilities throughout Delhi Govt. institutions.
2. Equipment

Immediate and short-term measures:

• Implement Public-Private Partnership (PPP) model for CT scan and MRI services by identifying successful bidder for implementing the same. Currently, at the Janakpuri Super-Specialty Hospital (JSSH) and PGI Rohtak a PPP model is running successfully. In all hospitals where CT/MRI scan or radiologist is not available, the aforesaid model can be adopted and implemented, especially in Level 3 & 4 hospitals.

1. Provision to get equipment on lease from concessionaires, by announcing expression of interest.

iii. Rate Contract of any Central Govt. Hospitals in Delhi and AIIMS Delhi should be allowed to be used by the Delhi Govt. Hospitals, if the Delhi Govt has no Rate Contract for the said equipment(s). Rate contracts should be made for longer time (say – for useable life of the equipment, subject to requirement) instead of the prevailing system of contract for one to two years.

1. Decentralization of Financial Powers—The Powers of HOD (MD/MS) are limited at present. It is recommended that the heads of major hospitals consider financial powers of up to Rs. 5 crores to purchase equipment and appropriate enhancements in the powers of other categories of hospitals.

Intermediate-term measures:

Install CT / MRI / PAT scan / Accelerator, etc. and other required equipment to run emergency services in all hospitals on the PPP Model.

3. Other diagnostic and Laboratory equipment:

Immediate and short-term measures:

PPP model or leasing models for procuring various equipment like ultrasound machines, dialysis machines, ventilators, lab diagnostic machines, ICU and cardiac monitors, ABG machines, etc. should be done.

4. Medicines and consumables Immediate measures:

The recommendations for improving the inventory and supply chain of medicines and consumables in hospitals are as follows:

Immediate Measures:

1. Inventory Maintenance: Hospitals should maintain a minimum inventory of essential drugs and consumables for two months, with ready-made rate contracts to meet up to 50% of annual demand. This will ensure a secure supply line for the next six months.
2. Delegation of Financial Powers:
   • Financial powers should be delegated to Heads of Departments (HoDs) to maintain at least 25% of the required supply and inventory, capped at ₹5 crores per annum.
   • Additional financial limits for daily purchases should be established, effective immediately:
     • For hospitals with over 1000 beds: ₹10 lakhs per day
     • For hospitals with 501-1000 beds: ₹7.5 lakhs per day
     • For hospitals with 300-500 beds: ₹5 lakhs per day
     • For hospitals with fewer than 300 beds: ₹3 lakhs per day
3. Jan Aushadhi Kendras: Establish Jan Aushadhi Kendras in each hospital for emergency procurement of medicines to prevent shortages.
4. Supply Assurance: Ensure an adequate supply of medicines and consumables at primary and secondary health facilities.

Short to Intermediate-Term Measures:

1. Pharmacy and Storage Facilities: Provide adequate and standard storage space for pharmacy and consumables at all hospitals, rioritizing implementation.
2. Inventory System: Implement a system to maintain a two-month inventory of drugs and consumables in hospitals, alongside six-month rate contracts to prevent shortages.

Long-Term Measures:

1. Strengthen Central Procurement Agency (CPA): Enhance the CPA’s accountability for providing uninterrupted and quality medicines and consumables to all healthcare facilities.
2. E-Governance Implementation: Bring the entire procurement system under e-governance through the Hospital Management Information System developed by NIC.

TOR 4:

To suggest ways and means to maintain functional high-end medical equipment in various hospitals.

Maintenance of high-end equipment

1. All equipment should be purchased including five years of comprehensive management contract (CMC) with provision of extending CMC for further 5 years. Provisions should also be there to extend the CMC till the useful life of the equipment.
2. A penalty clause should be included in the purchase contracts to compensate for the down time, in case the equipment repair is going to take long time. An in-built mechanism of provision for an immediate replacement equipment should be ensured.

TOR 5:

To suggest ways and means to reduce the stress on referral hospitals by strengthening the peripheral hospitals located in the various districts of Delhi.

Immediate Measures:

15% of the equipment requirements and the man power requirements should be met within the next 30 days.

Short and Intermediate term measures:

The Committee recommended the following measures to strengthen small (100-bedded) and district hospitals:

1. Enhance manpower, equipment, and diagnostic services to ensure round-the-clock emergency, ICU, operation theatre, and maternal/child services.
2. Ensure the availability of medicines and consumables at all hospitals by delegating financial powers to the heads of departments (MD/MS).
3. Rotate Senior Residents from larger hospitals with medical colleges to district hospitals to meet staffing needs. This includes pooling Senior Resident posts from smaller hospitals with those of larger ones and conducting regular walk-in interviews for non-academic Senior Residents. A committee of MDs/MSs from three major hospitals should oversee the selection and rotation process within two weeks.
4. Provide standard diagnostic facilities (blood tests, labs, radiology) at primary and secondary health centers, with the option to outsource services if necessary for efficiency.

TOR 6:

To suggest an end-to-end mechanism for ensuring uninterrupted supply of medicines, injections, and consumables in government hospitals.

Immediate measures:

To address the availability of injections and consumables in government hospitals, the Committee recommended the following immediate measures:

1. Strengthening and fully operationalizing the CPA (Central Procurement Agency) to ensure a continuous supply of medicines and consumables (action by H&FW, GNCTD).
2. Enhancing financial powers delegated to hospital MDs/MSs to maintain a two-month stock of medicines at all times (action by GNCTD).
3. Ensuring adequate storage space in all hospitals, with priority given to this need (action by PWD).
4. Opening Jan Aushadhi Kendras in each hospital, allowing procurement of medicines during emergencies to prevent shortages.

TOR 7:

To address the immediate shortage of specialists, medical officers, and paramedics in Delhi hospitals, the Committee proposed filling 15% of vacant posts using the following methods:

1. Contract-based recruitment of teaching and non-teaching specialists, or hiring consultants from the private sector to fill vacancies.
2. Empowering the Medical Superintendents (MS) and Directors of institutions to form committees, advertise vacancies, and conduct interviews to select candidates. Specialists’ tenures can be extended up to the age of 70.
3. Ensuring that contractual staff receive salary and perks equivalent to regular employees. Hospitals can have both teaching and non-teaching specialists.
4. Empaneling private doctors as part-time or full-time Visiting Consultants, particularly in high-demand specialties like radiology, anesthesia, neurosurgery, and orthopedics. They should be paid on a per-patient or procedure basis, with payments not lower than CGHS rates.

Key short-term and intermediate measures recommended by the Committee to improve Delhi’s hospital services include:

Streamlining and expediting the selection process for hospital staff through UPSC and other channels.

Addressing the shortage of pharmacists and data entry operators to improve medicine distribution and reduce long queues at OPD registration counters. This includes urgent recruitment or outsourcing of data entry operators and implementing the NIC’s Hospital Management Information System.

Creating additional manpower cadres:

Hospital Operations Staff: Hiring qualified hospital administrators and managers to handle operations, procurement, and administrative tasks, which are currently managed by senior doctors, detracting from patient care. The proposal includes appointing one to two managers for level 2 and 3 hospitals and two deputy managers for level 4 hospitals.

Resident Medical Officers (RMOs): Hiring MBBS graduates with three years of experience to manage emergencies, ICUs, and essential services, relieving pressure on senior residents.

Junior Residents: Allowing MBBS graduates to work for up to three years, providing continuous service and future eligibility to become RMOs.

Recruiting additional specialists such as intensivists, phlebotomists, and physiotherapists to enhance care in critical areas.

TOR 8:

The Committee proposed a range of immediate and short-term measures to enhance medical services in Delhi hospitals:

The Committee proposed the following measures to improve medical services in Delhi:

1. Emergency Services Inclusion: Integrate Emergency Services into the Delhi Arogya Kosh (DAK) for quick online approvals within four hours.
2. Aadhar-based Cashless Services: Establish cashless emergency services for Delhi residents in private hospitals at CGHS rates, mandating private hospitals to provide these facilities.
3. Full-time Medical Superintendents: Appoint dedicated full-time Medical Superintendents or Directors for all hospitals to ensure effective management.
4. Telemedicine Services: Involve teaching faculty in offering telemedicine services to district hospitals to improve regional healthcare delivery.

For intermediate to long-term improvements, key recommendations include:

1. Achieving NABH accreditation for all Delhi hospitals by December 2024.
2. Initiating telemedicine services to expand healthcare access.
3. Launching teaching programs for doctors, nurses, and paramedics at society-based and district hospitals.
4. Appointing dedicated Chief Engineers from PWD to enhance infrastructure management in hospitals.
5. Hiring non-medical HR professionals to oversee ministerial and ancillary services.
6. Yearly enhancement of the Delhi health budget to meet increasing healthcare demands, including establishing at least one medical college per district by converting 300-bed hospitals into teaching institutions.
7. Encouraging the private sector to establish medical colleges and specialty hospitals in Delhi.
8. Providing at least five ACLS ambulances in each district, available 24/7, connected to a Central Control Room for emergency care.

The Court directed the Chief Secretary and the Principal Health Secretary of GNCTD to implement the immediate measures within 30 days and to outline a roadmap for intermediate and long-term measures, with an action taken status report due in four weeks.  The Court emphasized that these recommendations are critical for saving lives and should be supported by the Model Code of Conduct. The Committee is also permitted to file a supplementary report within four weeks, and the order will be shared with the Election Commission of India. The next hearing in this matter was scheduled for May 24, 2024.