A detailed performance audit by the Comptroller and Auditor General (CAG) of India on Maharashtra's public health infrastructure and services has revealed that the country’s second-most populous state makes for shocking reading. It reveals that the system is  under strain, with shortages in medical personnel, inadequate facilities, and delays in the completion of critical healthcare projects.

The report was tabled in the legislative assembly on Saturday. Covering the period from 2016-17 to 2021-22, the CAG 2024 report assessed the availability of human resources, medicines, equipment, and the overall quality of healthcare services, highlights several areas that require urgent attention.   

Severe Shortages of Healthcare Workers

The CAG report reveals alarming shortages in Maharashtra’s healthcare workforce. The Public Health Department faces a 22% shortage of doctors, 35% of nurses, and 29% of paramedical staff in primary and secondary healthcare. Women’s hospitals are similarly understaffed, with 23% fewer doctors and 19% fewer nurses than required. The Medical Education and Drugs Department is also struggling, with 37% fewer doctors, 35% fewer nurses, and 44% fewer paramedics than necessary.

The report calls for the state government to fill these vacancies urgently and to increase the sanctioned strength of doctors in line with national standards to ensure adequate care for the population.

Overburdened Healthcare Institutions and Delayed Projects

Maharashtra’s healthcare institutions are overwhelmed, with many facilities serving more patients than recommended by Indian Public Health Standards (IPHS). The audit found that 70% of new healthcare institutions and 90% of planned upgrades under the state’s master plan were still incomplete by September 2022. One notable example is the Super Speciality Hospital in Amravati, which, despite costing ₹31.91 crore, has remained unused for over three years.

Additionally, 433 healthcare projects have been delayed due to land acquisition issues, with the report urging the government to expedite land identification and ensure timely completion of these projects to meet the rising healthcare demands.

Healthcare Spending Falls Short of Targets

Despite an increase in healthcare spending, the state’s budget remains insufficient to meet the needs of its population. The healthcare budget grew from ₹10,723.82 crore in 2016-17 to ₹21,067.33 crore in 2021-22, but healthcare expenditure still accounts for only 0.66% of Maharashtra’s Gross State Domestic Product (GSDP).

The audit also found that up to 76% of the funds allocated for urban health missions were left unused during the audit period. The CAG report calls for improved financial planning and better fund utilization to avoid last-minute spending.

Delays in Medicines and Equipment Procurement

The audit reveals significant inefficiencies in the procurement and distribution of medicines and medical equipment. During the 2016-17 to 2021-22 period, ₹2,052 crore worth of inventory remained unutilized. The delays were attributed to inefficiencies within the state-run Haffkine Biopharmaceutical Corporation, which is responsible for procurement. The report also pointed to poor storage practices that led to the wastage of essential drugs and supplies.

The CAG recommends streamlining procurement processes and ensuring timely delivery of medical resources to healthcare facilities.

Gaps in Private Healthcare Oversight

The report highlights regulatory gaps in Maharashtra’s private healthcare sector. The state has yet to implement the Clinical Establishments Act, 2010, leaving many private hospitals and clinics unregulated. This lack of oversight could lead to substandard healthcare services and exploitation of patients.

Additionally, the audit found inadequate monitoring of bio-medical waste management in private facilities, posing environmental and health risks. The CAG recommends the immediate adoption of the Clinical Establishments Act and stricter enforcement of bio-waste management rules.

Inadequate Patient Services and Safety Concerns

The audit also pointed out several shortcomings in patient services. In rural hospitals, 93% had only one registration counter, despite IPHS guidelines requiring two. Some doctors were attending to more than double the recommended number of patients, and specialist services, including general medicine and dental care, were missing in many district and women’s hospitals. Radiology services, such as X-rays and ultrasonography, were also unavailable in several healthcare institutions.

The report also raised concerns about food safety and fire hazards in healthcare institutions. A third of the hospitals did not provide patient-centric diets, and many failed to test food supplied by contractors. Widespread non-compliance with fire and electrical safety standards puts both patients and staff at risk.

Procurement Failures and Budget Shortfalls

The audit uncovered inefficiencies in the procurement of medical supplies, with Haffkine Biopharmaceutical Corporation failing to meet the demands of healthcare institutions, leaving 71% of requested items unsupplied between 2017 and 2022. The report urges the government to improve procurement processes and ensure timely delivery of medicines and equipment.

Maharashtra’s healthcare budget has also been underutilized, with savings of ₹22 crore from 2016-17 to 2021-22. The capital expenditure on health remained low, ranging from 4.68% to 7.97% of total health expenditure. The CAG report calls for better fund utilization and an increase in the health budget to address the state’s growing healthcare needs.

Regulatory and Environmental Concerns

The audit pointed to several regulatory lapses, including the lack of a state-specific health policy and the non-adoption of the Clinical Establishment Act, 2010, which has led to unregulated private healthcare facilities. Additionally, the Maharashtra Medical Council failed to renew the registration of nearly 40% of doctors, and local authorities did not conduct regular inspections of private nursing homes.

Environmental concerns were raised about the improper disposal of bio-medical waste in healthcare institutions. The audit urges the government to enforce stricter adherence to bio-medical waste management rules.

Alignment with Sustainable Development Goals

The audit also found that Maharashtra’s health budget is not aligned with the Sustainable Development Goals (SDGs), particularly SDG-3, which focuses on good health and well-being. The state government has not set targets for many health indicators under SDG-3, and its performance in several key areas remains below national standards.

Key Findings:

Key Recommendations

To address these challenges, the CAG has outlined several recommendations:

• Formulate a State Health Policy: Maharashtra must develop a comprehensive health policy to address regional disparities and align with national standards.

• Strengthen Human Resources: Filling vacant positions and creating a robust recruitment pipeline are essential.

• Complete Infrastructure Projects: Expedite pending projects and resolve land-related issues.

• Optimize Fund Utilisation: Ensure efficient and timely use of allocated resources.

• Enhance Oversight: Regulate private healthcare providers and enforce compliance with waste management rules.