Healthcare in Tamil Nadu: where less meets more

Between 2021-2022 and 2024-2025, the average daily outpatient (OP) numbers in Tamil Nadu’s public tertiary health facilities increased by 49%. The bed capacity grew by 37%. As patient volumes swell and infrastructure expands, human resources become central to sustaining services. This raises a crucial question: has the State’s health workforce grown proportionately to meet this rising demand? In other words, do government hospitals have enough doctors, nurses, and other health staff to sustain the system’s expansion?

Over the years, the State’s health infrastructure has grown substantially. It now has over 11,000 government health facilities, including 2,336 primary health centres (PHC), 8,713 health sub-centres (HSC), 299 government hospitals, and 36 government medical college hospitals. The addition of new multi-and super-speciality hospitals, upgrades to existing government hospitals, and the rollout of numerous health schemes have improved public access to healthcare. However, while the State government has spent heavily on infrastructure, investment in human resources is lacking.

Health administrators insist they are working toward “zero vacancy” in the Health department, but many in the workforce argue that this overlooks the bigger picture. There are simply not enough personnel, especially doctors and staff nurses, not only due to long-standing unfilled vacancies, but also because no new positions have been created in proportion to the rising patient load and newer facilities/schemes.

At the same time, certain “flawed” policy decisions proved both expensive and damaging. One such decision was a restructuring exercise introduced through a Government Order by the previous government, which resulted in the reduction of nearly 500 doctor posts. Critics argue that this led to reduced manpower, a decline in the quality of services, and increased workload for doctors in government medical colleges. Now, a similar “misstep” is being repeated through the redeployment of doctors, with 572 junior resident (JR) posts already reduced — a move that, they warn, could affect the workforce in more than one way. Contractual appointments, instead of permanent appointments, have also become very common in the health sector.

Instead of evaluating on-the-ground realities, the department has lately been diverting, redeploying, or redistributing staff, and creating new posts by surrendering existing posts, justifying these moves using the National Medical Commission’s (NMC) minimum standards meant for medical education, not patient care, A. Ramalingam, secretary, Service Doctors and Post Graduates Association (SDPGA), said.

This approach is evident in a series of recent Government Orders. New facilities and services have been approved without a corresponding increase in sanctioned manpower, relying instead on redeployment or surrendering of posts from existing institutions.

No new posts

In a Government Order dated November 3, approval was granted to create 59 new posts to strengthen cancer care across 16 tertiary care hospitals by surrendering an equal number of posts from various medical institutions. Earlier this year, the State government approved the establishment of 617 new HSCs in rural areas and 25 in urban areas, specifying that no new posts would be sanctioned; instead, Auxiliary Nurse Midwives from existing PHCs were redeployed to staff the new HSCs. Similarly, 78 medical officers were redeployed from existing upgraded PHCs for 50 new PHCs.

Likewise, no posts were sanctioned for the newly opened Government Pentland Multi Super Speciality Hospital, Vellore, and peripheral hospitals in Sholinganallur, Salem, and Tirunelveli. These hospitals are made functional by redeployment or diversions from nearby medical college hospitals, doctors said.

Some of the Government Orders specifically state that new or upgraded facilities should be operated with existing workforce and no additional manpower has been granted. “There have been so many new health-oriented schemes and programmes, such as Makkalai Thedi Maruthuvam and Innuyir Kappom-Nammai Kaakum 48, and upgrading of hospitals but no consequent increase in workforce. In fact, for the Kalaignar Centenary Super Speciality Hospital (KCSSH) in Guindy, many posts were diverted from existing medical college hospitals rather than creating new posts. Wouldn’t this affect the quality of work in both places?” a government doctor asked.

At the core of the staffing issue lies the State’s growing insistence on adhering to the minimum standards prescribed by the NMC — a move that many government doctors view as reflecting a “narrow, convenient interpretation of the regulatory framework”.

“NMC’s minimum standards apply only to teaching requirements. For instance, institutions with 250 MBBS seats such as Madras Medical College, Stanley Medical College, and Madurai Medical College are required to have an outpatient inflow of 2,000. In reality, these colleges handle nearly three times that number. NMC standards do include a provision allowing manpower to be increased proportionately in line with the patient load,” K. Senthil, president of Tamil Nadu Government Doctors Association, contended.

The State, he added, has nearly 22,000 sanctioned doctor posts, including about 800 service postgraduates. However, roughly twice this number is required to meet the demand, he said.

A physician at a hospital in Chennai paints a familiar picture: for years, government hospitals have been bustling with activity, often overcrowded, with patients waiting in long queues. “One major reason for this is that the staffing patterns for doctors and nurses have remained the same for the past several years. No new posts have been created. Doctors and nurses are not recruited on the basis of the number of outpatients,” he said.

The paramedical workforce is almost entirely absent in Tamil Nadu healthcare. “The role of physician assistants for documentation, nursing assistants, research assistants, insurance managers, public relations, health educators, data entry operators are donned by doctors, postgraduates, and nurses. This frustrates many, resulting in poor concentration on the actual work of clinical care,” he added.

While Dr. Senthil describes the current scenario as among the best in the past two decades, with most doctor vacancies filled and only about 1,000 to 1,200 remaining vacant, he makes a key observation: “This addresses only vacancies. The doctor-patient ratio has remained inadequate for decades. The government should stop focusing solely on new hospitals and buildings, and instead proportionately increase manpower. This is not only for doctors but also paramedical staff, especially nurses. Older medical college hospitals are severely understaffed with nurses,” he stressed.

Shortage of nursing staff

The shortage is not limited to doctors and is acute among the nursing staff. In a communication dated December 12, the Directorate of Medical Education and Research requested heads of medical college hospitals at Karur, Nagapattinam, and Pudukottai to depute the prescribed number of staff nurses — 30, 20, and five respectively — to Mahatma Gandhi Memorial Government Hospital, Tiruchi, on rotation basis. This was to address shortage of staff nurses at the hospital.

When the Government Peripheral Hospital, Periyar Nagar, was upgraded as a 300-bed hospital, the creation of 375 posts of various categories (109 regular and 266 contract) was approved. What irked a section of nursing staff is that 20 staff nurses were redeployed from the Tamil Nadu Government Multi Super Speciality Hospital, Omandurar Estate, and Institute of Obstetrics and Gynaecology, Egmore, and 156 nursing posts were taken on contract pay. This, when some 8,000-odd nurses recruited through the Medical Services Recruitment Board on consolidated pay are demanding regularisation of their services.

Both doctors and nurses frequently stress the need to have manpower in line with the Indian Public Health Standards recommendations. For example, it recommends one staff nurse for every six beds in a general ward and a one-to-one nurse-to-bed ratio in the Intensive Care Unit. However, these recommendations are far from being implemented.

N. Subin, general secretary, Tamil Nadu Nurses Empowerment Association, highlighted the shortage of nurses. “In a city hospital, a single staff nurse handles a 12-hour shift in the ICU. In some hospitals, it is common for one nurse to manage two wards, each with 30 patients, during a shift. At times, they even manage an entire floor,” he said. In fact, a senior surgeon added that there have been situations when one staff nurse had to manage three floors.

“A minimum of 10,000 regular nursing posts should be created immediately, and the 8,000-odd nurses recruited through MRB on consolidated pay should be regularised for these posts,” Mr. Subin said.

Secondary care institutions worst-hit

Doctors agree that the many institutions under the Directorate of Medical and Rural Health Services are the worst-hit. One of them noted that a number of district headquarters hospitals, taluk, and non-taluk hospitals run with skeletal staff.

P. Saminathan, SDPGA’s president, said that the previous AIADMK government upgraded 11 district headquarters hospitals into medical colleges and the nearby taluk hospitals were re-designated as district headquarters hospitals without a corresponding increase in doctors, staff nurses, and paramedics posts. Going back a little further, during 2004-2005, the Comprehensive Emergency Obstetrics and Newborn Care (CEmONC) centres, a significant milestone in improving maternal and child healthcare, came up with no extra posts for doctors. It remains the same to date.

CEmONC centres in certain GHs, which were conducting around 80 deliveries per month in 2005, account for nearly 300 deliveries now but run with the same number of sanctioned posts of doctors — four obstetrician-gynaecologists, four paediatricians and two anaesthetists, said Dr. Saminathan.

“A number of GHs are inadequately staffed. The Valliyur District Headquarters Hospital in Tirunelveli district has five doctors. The non-taluk GH at Pulicat has four sanctioned doctor posts and is run 24x7 by diverting doctors from nearby hospitals at Avadi and Ponneri three days a week,” he said.

Dr. Saminathan added that GHs are upgraded on paper with no increase in human resources, resulting in an exploited and overworked manpower. This impacts patients as they are made to believe that these are new facilities and speciality services will be available.

He said that hospital administrations have no options but to employ paramedical staff, including nurses, on an outsourcing basis using funds generated through the Chief Minister’s Comprehensive Health Insurance Scheme.

Another doctor who worked at a DMS hospital said that most facilities largely manage because of Non Service Post Graduates posted there during their bond period. “Once their tenure ends, the hospitals face severe understaffing until the next batch arrives,” he said.

“No new posts were created for the recently-opened District Headquarters Hospital in Tambaram. Those from other hospitals were redeployed. There are some 30 doctor posts at the facility, while at least 80 are required,” he added.

Strain on healthcare delivery

A doctor in a newly-established hospital in Chennai said the patient footfall was huge. “In fact, people from middle income groups are seeking services here. Patients expect that all speciality services will be available on a full-fledged basis. But on the ground, departments such as general medicine and general surgery are inadequately staffed. Ophthalmology and pulmonology departments have only one doctor each,” he said.

There are doctors who have completed postgraduation and have entered government service through MRB and there are NSPGs on bond period, another doctor said, adding: “What is the point of posting an obstetrician-gynaecologist in a PHC, a plastic surgeon in a GH with no equipment, a nephrologist in a GH with no dialysis facility, and a neurosurgeon where there is no CT scan? In many places, qualified manpower is being wasted. This has to be rationalised,” another doctor added.

“When the government is willing to invest ₹200 crore in new buildings and ₹50 crore in equipment, why is it reluctant to create new doctor posts?” an assistant professor asked. “These deputations and redeployment are essentially cost-cutting measures,” he added.

A senior surgeon posed a question: “If pilots have stipulated flying hours because fatigue can endanger passengers, what about doctors? Most government medical institutions, including the one I work in, are severely understaffed. Patient loads are overwhelming, and we often push ourselves to work even when we are extremely unwell or exhausted. More posts must be created to ease the workload and reduce stress on doctors.”

‘Will create new posts’

Health Minister Ma. Subramanian said though not regular posts, the government has created several posts, including those created through the National Health Mission, Tamil Nadu, and District Health Society. “In certain places, there is uneven distribution of workforce, and so we have been redeploying staff. Nearly 17 to 18 new District Headquarters Hospitals are coming up, for which are in the process of creating new posts,” he said.

Many State governments, he said, are recruiting staff on consolidated pay without having permanent posts. “In Tamil Nadu, more patients are turning to the government hospitals for healthcare services. We are also taking efforts to fill nearly 400 specialist posts and 1,100 doctor posts through MRB. We are aiming for a ‘zero vacancy’ position for the first time in the Health department, and will achieve this in January. In the future, we will take measures to create new posts based on the patient load,” he said.