Since 2018, Tamil Nadu has been ranked at number two on the Annual Health Index that the NITI Aayog and the Union Ministry of Health & Family Welfare prepare. But, doctors from government-run Primary Health Centres (PHCs) are an unhappy lot as long working hours, increase in workload, understaffed hospitals and inadequately staffed medical colleges have resulted in severe stress. 

Dr Shanthi from the Doctors Association for Social Equality (DASE) told TNM that there has been a visible increase in the number of patients who seek treatment at government hospitals since the pandemic. “But the problem is that there has been no proportionate increase in staff,” she said. According to Health Secretary Gagandeep Singh, of the roughly 19,000 posts for doctors in the state, 1,800 posts remain vacant. 

Gagandeep Singh told TNM that the vacancies have not been filled because the Madras High Court, earlier this year, passed an interim stay on the consultation for promotions. “We are trying to ensure the interim stay is vacated since around 1,000 doctors are eligible for promotion as medical professors and associate professors. Once the promotion cycles are complete and the higher posts are filled, we will fill the vacancies at the lower levels,” he added. 

Doctors complain that these vacancies across the Department, clubbed with the recent influx of patients, have severely increased the workload and pressure.

Cascading effect 

Dr Thamarai (name changed), working at a Rural Primary Health Centre (RPHC) in the western region of the state, reacted, “Regular Out Patient (OP) hours are between 8 am and 2 pm. There should ideally be three doctors to attend to the patients. But, two of those posts have remained vacant for more than a year now, and I have to attend to at least 40 patients a day. The department also checks if we attend to all patients by 2 pm. So, I work without taking any breaks so that I can give enough time to my patients to explain their problems before I can prescribe treatment.” She further added that while she works for seven to eight hours at the RPHC, she has to be on phone duty for 16 hours. “I have attended calls in the middle of the night and rushed to the RPHC to check on patients who come in with an emergency,” she said.

A senior doctor from the Obstetrics and Gynaecology wing and member of the Legal Coordination Committee (LCC) for government doctors, Dr Perumal Pillai, said that a similar situation persists in several hospitals. With fewer gynaecologists in the government sector, the pressure on them was tremendous, he said.

“Several doctors who perform clinical duties also teach hundreds of students. So preparing for classes and evaluating students are among the other duties that add to our workload,” Perumal highlighted. 

The existing vacancies in the system have also caused the government to increase their dependency on Post Graduate (PG) doctors. In 2022, the government increased the working hours for PG doctors from six to seven hours (48 hours per week). However, Dr Ajay M, PG doctor and resident of Tamil Nadu Medical Students Association, said, “While on paper we only work 48 hours, PG doctors, especially first years, work for more than 80 hours per week easily. They work for 18 hours at a stretch. The second and third years will work 12-13 hours, which we consider as a concession, but it really isn’t.”

In addition, PG doctors should now mandatorily complete their District Residency Programme (DRP) to reduce staffing shortages in district hospitals. But, given that several medical college hospitals are already depending heavily on their PG doctors, this system is creating an additional burden, PG doctors said. “In Stanley Medical College hospital, there are only 20 PG students, and we attend to almost 1,000 deliveries every month. Next month, eight of us are to go for DRP. The other 12 PG doctors will be even more burdened for a year,” Ajay explained. He added that the only possible solution could be to increase the number of PG medical seats.

In Shanthi’s opinion, utilising PG doctors because of a lapse in the system is a problem. “PG doctors come with bare minimum experience because they come in straight after pursuing their MBBS degree. Ideally, one senior doctor will have to act as a guide for  five to eight PG doctors to ensure that the best care is extended to patients, but this is not possible today in public hospitals,” she said.

Crumbling mental health

Doctors TNM spoke to believed that the state government has stepped on them to climb up the health index table. Thamarai expressed, “Our mental well-being should be prioritised because it directly impacts how we behave or treat our patients. But it seems like the government doesn’t care about us.” Perumal added that the pressure of work equally affects their physical health.

Dr Netra (name changed), a PG student, referred to the recent suicide death of a PG doctor in Kanyakumari and told TNM that the stressful working environment and long working hours didn’t allow them enough time to even call their family or friends. “After the PG doctor's death, we have sought an effective redressal mechanism to report problems through protests and social media. We even highlighted these issues, which can lead to mental stress, but nothing happened,” Netra said.

Government doctors and PG students alike complain of not being compensated adequately for the services that they are extending. “ Health Minister Ma Subramanian announced a hike in stipend for PG doctors recently. We receive around Rs 50,000. But this is the pay for a 48-hour work week, and we are working for more than 80 hours in a week,” Ajay told TNM. He added that in several north Indian states, PG doctors’ stipends are close to a lakh. 

The Kalaignar GO

In 2009, when Dravida Munnetra Kazhagam (DMK) leader Karunanidhi held office, he issued a Government Order (GO) number 354, which assured Dynamic Assured Career Progression (DACP) salary for the state’s doctors. GO 354, or the Kalaignar GO as it is popularly known, was to ensure that doctors are provided increments at par with the rest of the states in India and to avoid stagnation of promotions. While doctors have held multiple protests across the state during both the All India Anna Dravida Munnetra Kazhagam (AIADMK) and the DMK periods to implement the GO, their pay scales haven’t improved in 14 years.

According to the DACP’s Pay Band IV, doctors in the state should be on a pay scale between Rs 37,400 and Rs 67,000. However, they are currently on Pay Band III (Rs 15,600 to Rs 39,100). 

“Due to its lack of implementation, we are losing upto Rs 40,000 per month in our salaries,” Perumal said. In 2023, the Health Department said that in order to implement GO 354, the government will require an additional fund of Rs 300 crore every year. But doctors ask why the government cannot acquire this funding, which will provide them with their rightful pay.