UPGRADING SECONDARY LEVEL HEALTH CARE FACILITIES IN THE STATE OF KARNATAKA, INDIA
Item
- Title
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UPGRADING
SECONDARY LEVEL HEALTH CARE FACILITIES
IN THE STATE OF KARNATAKA,
INDIA - extracted text
-
UPGRADING
SECONDARY LEVEL HEALTH CARE FACILITIES
IN THE STATE OF KARNATAKA,
INDIA
FINAL
PROJECT PROPOSAL
FOR
KREDITANSTALT FUR WIEDERAUFBAU
GERMANY
DEPARTMENT OF HEALTH AND FAMILY WELFARE
GOVERNMENT OF KARNATAKA
BANGALORE, JULY 1995
Copied on Rlso & Binded at Project Secretariat - June 1997
FOREWORD
a
As elsewhere in India, health services in Karnataka are being provided by the State at
three levels, Primary, Secondary and Tertiary. Over the years, Primary Health Care has
received considerable attention and resources through the State’s own funding as also
external agencies, through various EPP Projects. The main objective of these projects is
to promote integrated family welfare through strengthening of the health infrastructure
and planned improvement of the delivery system and the quality of health services at the
primary level.
The Secondary Level of Health Care, comprising all rural hospital' of varying types and
magnitude, has not, however, received attention and assistance on a similar scale. There
are also marked disparities in the availability of infrastructure and the quality of services
provided by these hospitals, across different regions in the State. The fact that the broad
network of the secondary hospitals discharging, as they do, the essential first referral
services all over the State, is only a natural and organic extension of the Primary Health
Care system has now been recognized all over the world.
The preliminary project proposal prepared earlier by the Department of Health & Family
Welfare, Government of Karnataka has now become full-fledged. A Workshop held on
Feb. 28-March 1, 1995, has provided a comprehensive set of norms for a wide range of
hospital services and facilities at different levels of Health Care. This was followed up by
setting up a large number of expert Working Groups on various components of the
Project, whose recommendations have been incorporated in this document.
The Project funded by Kreditanstalt fur Wiederaufbau shall aim at identifying and filling
the glaring gaps within our Health Care System. This will concentrate on the upgrading
and renovation of secondary level hospitals in the Districts of Gulbarga Division. This
Division comprises four districts which are socio-economically less developed than most
other districts of Karnataka. It is hoped this project proposal will help not only in
conducting a detailed dialogue with the Kreditanstalt fur Wiederaufbau on the Health
Systems Development project in Karnataka, but once the negotiation is completed, it will
also serve as the basis for implementation of the project itself.
I would like to place on record the Department’s sincere gratitude to Mr. H.C.
Mahadevappa, Honourable Health Minister for his constant support, and leadership. I
would also like to convey my appreciation to the members of the Project Preparation
Committee, our consultant Mr. D.V.N.Sarma and the large number of experts who have
put in tireless efforts to bring this document out in record time. My thanks are specially
due to Mr. Dieter Nassler and the members of the team of Mediconsult Management
Sdn. Bhd., Kuala Lumpur, Malaysia, without whose tireless efforts the project report
could not have been completed in time.
Gautam Basu
Secretary to Government,
Health & Family Welfare Department,
Government of Karnataka
Bangalore, 15, July 1995
i
I
EXECUTIVE SUMMARY
». I
Socio-Demographic and Health Status
The available data shows that the state of Karnataka has more favourable indicators compared to India
in terms of population growth, crude birth and death rates, fertility, age at first marriage and literacy.
There is evidence of improved health status over time as measured by declining infant mortality,
especially post-neonatal mortality in urban areas, increased childhood immunizations, increased
deliveries by trained personnel, (including institutional deliveries), and control of infectious and
parasitic diseases.
However, declines in infant mortality, specifically neonatal deaths, have not continued in recent years,
especially in the rural areas. The factors associated with this need to be identified in order to plan ways
to reverse the trend. For example, raising the capability of small hospitals to control diarrhoeal diseases
and respiratory infections in infants and young children may be one measure. Hospital admissions data
further show that diseases of the circulatory system have increased in relative proportion over time and
injuries continue to feature most prominently. Public health strategies on behavioural and other risk
factors are warranted to prevent these health problems.
In terms of case-fatality, improvements in curative care appear to have occurred for some conditions,
such as neoplasms, but have worsened for others, such as conditions originating in the perinatal period.
It is felt that upgrading skills in neonatal care, especially at first referral level, would contribute to
improving infant survival.
Data on women indicate a need for far greater efforts to alleviate high maternal mortality and reduce
risks of childbearing through antenatal care, safe deliveries, identification of high-risk pregnancies for
referral and reducing adolescent pregnancies. Intervention by medical providers at the first referral
level on high-risk pregnancies and obstetric complications would be needed to reduce maternal mortality
and morbidity. Finally, improving literacy and education attainment among females would have
benefits on the health status of women as well as children.
Strengthening ofSecondary Level Hospitals in Karnataka
Primary healthcare has been advocated as ;a major strategy towards
- achieving
the goals of “Health for
All”. This strategy is based on providing and increasing preventive and basic curative care to the entire
population. The main components are the safe motherhood initiatives (birth spacing, antenatal care,
nutrition supplementation, safe delivery), breastfeeding promotion, childhood immunizations, oral
rehydration therapy and growth monitoring.
The provision of safe water supply and proper sanitation facilities are also important non-health sector
components of primary health care. Primary health care programmes in India have been a focus since
the 1970s with the nationwide Integrated Child Development services (initiated in the mid 1970s) and
the Child Survival Safe Motherhood programme (initiated in the mid 1980s). The Primary Health Care
Sector has also been the recipient of fiscal and technical support from international agencies such as the
However, with the improvements made in the area of Primary Health Care, secondary level healthcare
facilities have not received the same level of attention resulting in imbalances between primary and
secondary levels. The focus of the KfW project will thus be to address the problems of secondary level
ii
health care facilities. The objectives to meet the project goals will entail upgrading and renovation
works of all secondary level hospitals in the 2 phases in the Gulbarga Division.
!
Phase 1 will involve upgrading of 19 Hospitals and renovation works for 7 other hospitals. Upgrading
will involve adding beds to the existing bed capacity and renovation will involve improvements. The
hospitals to be upgraded ;and renovated in Phase 1 require more urgent work while the remaining
hospitals for upgrading and renovation works has been proposed for Phase 2.
¥
Planned Measures by the State Government
The Government assures that increases to the healthcare budget will continue at least in the same
proportion as in preceding years and with external funding will further strengthen the goals of achieving
“Health for .Ml”,
With the physical upgrading of the hospital facilities, the Government of Karnataka will improve the
medical services provided in the hospitals by sanctioning and filling additional doctors/specialists and
other medical staff, and also increase the operating budget especially for maintenance and drugs.
To support the plan to strengthen the secondary health care level facilities, the government is prepared
to improve cost sharing.
Project Components
The project is phased in two stages whereby stage one comprises 26 hospitals out of which 19 hospitals
will be upgraded and 7 hospitals renovated. Additional staff quarters will also be included in the
upgrading process. The total number of additional beds in phase one will be 627 beds. In phase two,
the main emphasis will be on the renovation of district hosptials including the remaining General
Hospitals or Community Health Centres.
The budget that has been allocated to strengthen the secondary level hospitals has been divided into the
following project elements:•
•
•
•
•
•
Construction
Equipment
Vehicles
Maintenance
Cost Sharing Study
Project Management
Carefiil planning and detailed estimates have been included in the overall project plan in order to achieve
the desired results.
Budget
In the following, the summary of all project components is provided. The total project cost amounts to
IR319.67 million which is equivalent to DM15.22 million.
iii
-A
PROJECT ELEMENTS
Construction
Fees for design and engineering
Equipment
Initial supplies
Vehicles
Provision for district hospitals
Maintenance
Cost sharing development
Project management_________
Project cost
Contingency
Inflation
COST (Rs)
149,029,000
12.964,000
60,653,000
2,300,000
8,400,000
35,000,000
8,000,000
4,000,000
_______ 39,320,000
319,666,000
32,334,000
105,000,000
COST (DMf
7,097,000
617,000
2,889,000
109,000
400,000
1,667,000
381,000
190,000
_______ 1,872X30
15,222,000
1,540,000
5,000,000
Sub-total (Total Funding)_____
Contribution of the government
457,000,000
69,700,000
21,762,000
3,319,000
GRAND TOTAL project cost phase 1
* Exchange rate IR:: DM = 21:1
526,700,000
25,081,000
% OF TOTAL
PROJECT COST
47%
4%
19%
1%
3%
11%
2%
1%
12%
100%
The second phase will mainly comprise the renovation of the district hospitals and some of the
remaining general hospitals or community health centres which will be renovated or upgraded. The
final approval of the second phase will depend on the findings of the mid-term review which will be
undertaken in the third year of the project implementation of the first phase.
_________________ ACTIVITY__________
District hospital Bidar
District hospital Bellary
District hospital Gulbarga
District hospital Raichur________________
Sub-total district hospitals______________
Renovation and upgrading of other facilities
Other project components______________
Inflation (30% of Grand Total)
COST IN IR
25,000,000
30,000,000
20,000,000
20,000,000
95,000,000
60,000,000
35,000,000
80,000,000
COST IN DM*
1,190,000
1,429,000
952,000
_________ 952,000
________ 4,523,000
________ 2,857,000
________ 1,667,000
3,810,000
Sub-total (Total Funding) Phase 2
Contribution by the Government
270,000,000
50,000,000
12,857,000
2,381,000
GRAND TOTAL Phase 2
* Exchange rate IR:DM 21:1
320,000,000
15,238,000
The total project funding for first and second phase will be approximately IR727.00 million which is
equivalent to DM34.62 million. The contribution of the Government of Karnataka can be assumed to
be IR119.70 million or DM5.70 million.
PHASE 1
PHASE 2
KFW FUNDING
IR
!
DM
457.000,000 |
21,762,000
270,000,000 |
12,857,000
CONTRIBUTION GOK
IR
!
DM~
69,700,000
3,319,000
2,381,000
50,000,000 |
TOTAL________
DM
___
I?___ 25,081,000
526,700,000
320,000,000 | 15,238,000
TOTAL
727,000,000 !
119,700,000 I
846,700,000 !
34,619,000
iv
5,700,000
40,319,000
ABBREVIATIONS
•’J
ANM
CBR
CDR
CEO
CHC
CSSM
DH
DHFW
DHO
DME
GH
HA
ICDS
IEC
IMR
IPP
IUD
LHV
MCH
MIES
MMR
MO
MS
NGO
NSS
NM
OPEC
PHC
PHU
Sc
SDH
TBA
>-
Auxiliary Nurse Midwife
Crude Birth Rate
Crude Death Rate
Chief Executive Officer
Community Health Centre
Child Survival Safe Motherhood
District Hospital
Department of Health and Family Welfare
District Health Officer
Department of Medical Education
General Hospital
Health Assistant (Male/Female)
Integrated Child Development Services
Information, Education and Communication
Infant Mortality Rate
Indian Population Project
Intra-Uterine Device
Lady Health Volunteer
Maternal and Child Health
Management Infomation and Evaluation System
Maternal Mortality Rate
Medical Officer
Medical Superintendent
Non-Govemment Organization
National Sample Survey
Nurse Midwife
Oil Producing and Exporting Countries
Primary Health (Care) Centre
Public Health Unit
Sub-centre
Sub-District Hospital
Traditional Birth Attendant
TABLE OF CONTENTS
PAGE
Foreword
i
Executive Summary
11
Abbreviations
1.
INTRODUCTION
1
2.
PROFILE OF KARNATAKA
2
2.1
2.2
2.3
2.4
2
2
4
5
3.
HEALTH STATUS
7
3.1
7
7
8
9
12
12
3.2
3.3
3.4
4.
5.
Area and Administrative Divisions
Socio-Economic Characteristics
Demographic Characteristics
Regional Variations
Morbidity
3.1.1 Morbidity Pattern Among Users of Government Facilities
3.1.J2 Death Rate of Inpatients
Mortality
Causes of Death
Maternal and Child Health
ORGANIZATION OF PUBLIC HEALTH CARE SYSTEM
15
4.1
4.2
15
17
Organization at The State Level
Structure of Health Care System
HEALTH FACILITIES IN KARNATAKA AND THEIR USAGE
19
5.1
5.2
5.3
19
19
21
21
23
26
5.4
Medical Practitioners
Hospitals
Usage of Medical Services
5.3.1 Outpatient Service
5.3.2 Inpatient Services
Bed Occupancy
PUBLIC HEALTH EXPENDITURE AND COST SHARING
6.
6.1
6.2
Expenditure on Social Services
Increase in'Recurring Expenditure
6.2.1 Current Status
6.2.2 Current Pattern of User Charges
HEALTH POLICY AND PROGRAMMES
7.
7.1
7.2
8.
Health Policy
Health Programmes
7.2.1 Integrated Child Development Services
7.2.2 Child Survival and Safe Motherhood Project
7.2.3 India Population Projects
HEALTH SECTOR ISSUES
8.1
8.2
8.3
8.4
8.5
8.6
8.7
8.8
8.9
8.10
8.11
8.12
Integration of PHCs and Secondary Hospitals
Resource Allocation
Planning and Management
Quality of Services
Access and Equity
Work Force
Referral System
Management of Communicable and Other Diseases
Bums and Injuries
Chronic Illnesses
Role of Private Sector
User Charges and Sustainability
27
27
30
31
31
32
32
33
34
34
34
37
37
37
38
38
38
39
39
40
40
40
40
41
9.
HEALTH SECTOR DEVELOPMENT STRATEGY
42
10.
STRENGTHENING OF SECONDARY LEVEL HOSPITALS IN KARNATAKA
46
11.
STRENGTHENING OF SECONDARY LEVEL HOSPITALS WITH KFW
ASSISTANCE
48
Project Objectives
Selection Criteria
Project Components
11.3.1 Renovation and Upgrading of Facilities
11.3.2 Improvement on Maintenance
11.3.3 Clinical, Technical and Management Training
11.3.4 Improvement on Sustainability of Medical Services
48
49
50
50
53
53
53
11.1
11.2
11.3
11.3.5 Contribution of the Government of Karnataka
11.3.6 Project Management
54
54
M
11.4
A
i
12.
13.
55
56
57
58
59
PROJECT BUDGET
60
12.1
12.2
12.3
12.4
12.5
12.6
12.7
12.8
12.9
Budget for Upgrading of Facilities
Provision for Sustaining of Services at the District Hospitals
Maintenance Facilities
Improvement of Cost Sharing
Project Management
Summary of Cost of Project Components
Contributions by the Government of Karnataka
Total Project Budget
Project Cash Flow
12.10 Cost Estimation for the Second Phase
60
62
62
62
62
63
63
64
64
65
IMPLEMENTATION SCHEDULE
66
ANNEX 1
4
The Selected Facilities
11.4.1 Bidar District
11.4.2 Raichur District
11:4.3 Bellary District
11.4.4 Gulbarga District
ANNEX 2
ANNEX 3
ANNEX 4
ANNEX 5
ANNEX 6
ANNEX?
ANNEX 8
ANNEX 9
ANNEX 10
ANNEX 11
Minutes ofMeeting - Upgrading Secondary Level Health Care Facilities in
Karnataka
Health Care Expenditure
Demand ofSecondary Health Care Beds
Norms For Health Care Services
Scope For Cost Sharing Improvement
Contribution By The Government ofKarnataka
Scope For Improvement On Maintenance
Project Management
Selection ofFacilities For Upgrading And Renovation
Delegation OfAdministrative And Financial Power
Contact Addresses OfDepartment Health And Family Welfare
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UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVtSION, KARNATAKA
1.
|
INTRODUCTION
The State Department of Health and Family Welfare of Karnataka, India, submitted a
proposal to Kreditanstalt fur Wiederaufbau (KfW) in March 1992 to upgrade secondary level
hospitals. Subsequent to negotiations between the Government of Germany and the
Government of Karnataka, a revised proposal was submitted by the state government in
February 1994. Thereafter, in April 1994, the Government of Germany agreed in principle to
provide financial assistance for the project.
In May 1994, a project concept paper to upgrade primary and secondary health care facilities
in Karnataka was then prepared and accepted by both KfW and the Government of Karnataka.
As per concept paper, this project comprises: (1) expansion of hospital facilities, including
infrastructure, renovation of existing buildings and mechanical and electrical services for
Primary Health Centres (PHC), Community Health Centres (CHC) and General Hospitals
(2) supply of medical equipment; (3) upgrading of maintenance facilities at District and
Division levels; and (4) training to improve knowledge and skills of health care providers.
The Districts to be covered under this project are Bidar, Raichur, Gulbarga and Bellary in the
Gulbarga Division. These constitute the least developed districts in the state, and were
selected on the basis of available health and socio-economic indicators.
During the mission of KfW from 11. - 13. June 1995 the main framework for the project had
been discussed and agreed in principle and this involves funding by KfW for upgrading and
renovation of secondary level hospitals in Gulbarga Division. The project will be implemented
m two phases. Phase one will involve Community Health Centres and General Hospitals or
Sub-District Hospitals. Phase two will involve renovation of District Hospitals and facilities
which have not been covered in the first phase. The respective Minutes of Meeting between
the State Government and KfW is enclosed in ANNEX 1.
Based on the project concept developed in May 1994, the Final Project Report describes the
selection of facilities in each district and defines the specific upgrading needs for each facility.
A team of architects and engineers visited all proposed facilities and elaborated a detailed
status of each facility. Based on the report, the scope for each hospital was defined. This
report will also qualify and quantify the other project elements and the project management
scope in further detail.
Within this project, efforts by the State Government to increase continuously the budget for
health care services, deployment of required staff and the development of a cost-sharing
mechanism will continue.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
1
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
2.
PROFILE OF KARNATAKA
2.1.
Area and Administrative Divisions
Karnataka is located in the South-West part of India and lies between latitudes 11° 5” N and
19 N and longitudes 74° E and 78° E. It is bounded, in the clockwise direction, by the States
of Goa, Maharashtra, Andhra Pradesh, Tamil Nadu, Kerala and the Arabian Sea. The area of
the State is 191,791 sq. km. and constitutes 5.38 percent of the area of the country. The
twenty districts of the State are grouped into four Revenue Divisions with head quarters at
Bangalore, Belgaum, Gulbarga and Mysore.
Table 2.1: Administrative Division of the State of Karnataka
DIVISION
Bangalore
_____________________
DISTRICT
__
Bangalore, Bangalore (Rural), Chitradurga, Kolar, Shimoga and Tumkur
Belgaum
Belgaum. Bijapur, Dharwad, Uttara Kannada
Gulbarga
Bellary, Bidar, Gulbarga and Raichur
Mysore
Chikmagalur, Dakshina Kannada, Hassan, Kodagu, Mandya and Mysore
2.2.
Socio-economic Characteristics
The population of the State in 1991 was 44.98 million and accounted for 5.31 percent of the
population of India. In terms of population, size and area, Karnataka ranks eighth among the
States.
Kannada is the mother tongue of 65.7 percent of the population. There are regional
concentrations of linguistic groups. Tula and Konkani are the mother tongues of 59 percent of
the population of Dakshina Kannada, while Konkani is the mother tongue of 22 percent of the
population of Uttara Kannada. Kodata is the mother tongue of 28 percent of population of
Kodagu. The Telugu speaking population is concentrated in Kolar district (52 percent) and is
also present in sizeable numbeRs in Bangalore, Chitradurga, Tumkur and districts of Gulbarga
Division bordering Andhra Pradesh. Marathi is spoken in the districts bordering Maharashtra
namely, Belgaum (21 percent) Bidar (19 percent) and Uttara Kannada (9 percent). People
with Malayalam as mother tongue are concentrated in Kodagu (22.9 percent) and Dakshina
Kannada (12.9 percent), bordering Kerala. The Tamil speaking population is concentrated in
Bangalore (16 percent), Kolar (9 percent) and Mysore (5 percent). The Urdu speaking
population is distributed in all districts but they form only 5 percent of the population of
Mysore division while in other divisions the Urdu speaking population ranges between 10 to
14 percent.
Hindus, including Jains, Buddhists and Sikhs form 86 percent of the population of the State,
while 11 percent are Muslims and 2 percent are Christians.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
2
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA ~~~~|
In 1992-93, the per capita net domestic product for Karnataka was Rs. 5898 at current prices
which is marginally higher than that for India (Rs 5583). The per capita income varied
between districts. Kodagu district has the highest per capita income of Rs. 10,810 and Bidar
the lowest per capita income of Rs. 3,725.
Table 2.2: Per Capita Income 1992-1993
PER CAPITA INCOME
Over Rs. 9,000
___________________________ DISTRICT
Kodagu (10,810), Bangalore (9,190),
Rs. 6,000 to 9,000
Belgaum (6,2C6),Uttara Kannada(6,339),Mysore (6,400), Bangalore Rural, Dakshina
Kannada (7,203), Chikmagalur (8,065)’
Rs. 5,000 to 6,000
Tumkur (5,045),Dharwad (5,108), Chitradurga (5147), Bellary (5,293), Shimoga
(5,812)________________________________
Below Rs. 5,000
Bidar (3,725), Kolar (4,151), Raichur (4,159), Bijapur (4,414), Gulbarga (4,732),
Mandya (4,827), Hassan (4,924).
In 1991, the literacy rate among those aged seven years and above was 67 percent among
males and 44 percent among females, which is marginally higher than that for the country (64
percent for males and 39 percent for females).
The proportion of workers to total population in 1991 was 53.9 percent among males and
29.3 percent among females. The corresponding rates for 1981 were 54.6 among males and
25.3 among females. There has been a three percent shift away from agriculture and household
industry to other occupations. However, agriculture continues to be the occupation for 63
percent of the male workers.
'w
A requisite to disease control is access to a safe water supply and proper sanitation facilities.
In regards to the former, the majority (70%) of the population in Karnataka now have safe
drinking water (TABLE 2.3) compared to about 34% a decade ago. This substantial increase
has been achieved by a concerted effort by the state authorities to identify and provide bore
wells to communities. The increased coverage is particularly substantial in the rural areas. In
addition, treated water for drinking is also supplied by the municipal council to urban and
some semi-urban areas either directly to homes or to public water tanks. In fact, the increase
in provision of safe drinking water is higher in this state than for India as a whole.
TABLE 2.3: Percentage with Access to Safe Water Supply
•
Urban & Rural
Rural
Urban
•__________ _______________
Karnataka
India
Karnataka
India_____
Karnataka
India
-' ■ ■
[—
SAFE DRINKING WATER
1Q81
1991
33.9
38.2
17.6
26,5
74.4
75.1
DEPARTMENT Or HtALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
71.7
62.3
67.3
55.5
31.4
81.4
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
2.3.
|
Demographic Characteristics
The compound annual growth rate of the population of Karnataka was 1.93 percent in the
decade 1981-91. Th£ decline in population growth rate has been more rapid in Karnataka than
in India. While in Karnataka, the compound annual growth rate declined from 2.40 percent
during the decade 1971-81 to 1.93 percent in 1981-91. that for India declined marginally from
2.23 percent to 2.16 percent.
In 1991, the urban population accounted for 30.91 percent of the population of the State as
compared to 25.71 percent for India. Nearly 30 percent of the urban population of the State
lives in Bangalore Urban Agglomeration and another 35 percent in twenty urban
ag^omera^ons with population over 100,000. The remaining 35 percent of the urban
population live in 233 towns. The rural population is distributed over 27,024 villages.
The sex ratio expressed as the number of females to thousand males declined from 963 in 1981
to 960 in 1991 in the State. Similar decline occurred at the national level (934 in 1981 to 927
in 1991).
The mean age at marriage of females in Karnataka was estimated for the year 1981 at 19.2
years as compared to 18.3 years for the country.
Scheduled Castes and Scheduled Tribes formed respectively, 16.4 and 4.0 of the total
population in 1991.
The Crude Birth Rate (CBR) for Karnataka is estimated at 25.5 for the year 1993. The CBR
for urban Karnataka was 23.1 while for rural Karnataka it was 26.7. Estimates of birth rates by
district for the year 1993 reveal that Chikmagalur had the lowest birth rate of 19.9 and
Raichur the highest birth rate of 35.1.
Table 2.4: Crude Birth Rate (CBR) by District (1993)
CBR PER 1000
POPULATION
______ ___ ___________________ DISTRICT_______________ _______
CBR over 29
Raichur (35 1), Bidar (34.9), Gulbarga (33,3), Bijapur (32 0), Bellary (29 2)
Between 24-28
Kolar (27.2), Dharwad (27,1), Chitradurga (26.9), Belgaum (28.9),
Between 22 to 24
Uttara Kannada (23.5), Tumkur (23.2), Shimoga (22.4) Bangalore (22.3).
Below 22
Mysore (21.6), Mandya (21.0), Kodagu (21.0), Hassan
Kannada(22.3), Chikmagalur (19.9).________________
(20 6)
Dakshina
The crude death rate for the year was 8.5 for the State while it was 6.0 for urban Karnataka
and 9.4 for rural Karnataka. The infant mortality rate estimate for the year 1993 was 67 for the
state, 41 for urban Karnataka and 73 for rural Karnataka.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
4
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UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
Regional Variations
2.4.
As mentioned, the population of Karnataka is distributed in twenty districts and four revenue
divisions. There are wide variations in the demographic characteristics across the four
divisions as may be seen in Table 2.5.
Table 2.5 Demographic Characteristics of Districts
Thousand
Persons
1991
Density
sq. km.
1991
Bangalore
4,839.2
2,210
Annual
Growth
Percent
1981-91
3.31
Bangalore Rural
1,673'2
288
1.43
Chitradurga
2,180.4
163
Kolar
2,216.9
Shimoga
1,909.7
Sex
Ratio
1991
Percent Literate
Scheduled
1991*__
Male
Female Castes Tribes
%of
%of
Total
Total
1991
1991
83.1
69.0
14.7
1.1
Mean Age
at Marriage
1981
Percent
Urban
1991
903
20.2
85.8
950
N.A
18.2
61.1
38.9
19.5
3.0
2.06
944
19.2
67.0
43.5
36.2
19.8
14.6
224
1.53
966
19.1
23.3
63.0
38.1
25.7
6.9
351
1.43
961
20.5
26.5
71.1
51.4
17.7
3.9
Tumkur
2,305.8
135
1.55
959
19.2
16.6
66.6
42.1
17.7
7.3
Bangalore Division
15,125.2
281
2.12
939
19.8
42.6
71.6
51.1
18.4
5.4
Belgaum
3,583.6
498
1.87
959
19.4
23.9
65.5
38.7
11.4
2.3
Bijapur
2,928.0
270
2.00
965
17.3
23.6
70.6
41.3
17.4
1.4
Dharwad
”3,503.2
415
1.75
945
19.2
35.0
71.7
45.5
11.7
3.0
Uttara Kannada
~,220 3
89
1.29
967
21.2
24.2
76.1
56.7
7.5
0.8
Belgaum Division
11,235.0
279
1.80
957
19.0
27.3
69.9
43.5
12 6
2.1
Bellary
1,890.1
116
2.41
957
18.1
29.9
59.3
32.5
19.3
8.8
Bidar
1,255 8
184
2.35
953
17.6
19.5
59.5
31.0
20.7
8.3
Gulbarga
2,582'.2
629
2.18
962
17.5
23.5
52.3
24.9
23.7
4.1
Raichur
2.309.9
281
2.62
978
17.5
20.8
49.7
22.3
17.2
7.8
Gulbarga Division
8,037.9
227
2.39
964
17.7
23.6
54.4
26.9
20.3
6.9
Chikmagalur
1,017.3
205
1.10
977
20.8
16.9
70.6
51.5
19.3
2.6
Dakshina Kannada
2,694.3
225
1.26
1063
22.4
28.3
84.7
68.3
6.5
3.9
Hassan
1,569.7
68.9
45.1
17.4
1.1
112
1.47
1000
20.2
17.4
Kodagu
488.5
46
0.56
989
21.8
16.1
74.5
61.4
12.1
8.3
Mandya
1,644.4
155
1.49
962
18.5
16.2
59.1
36.9
13.8
0.7
Mysore
3,165.0
308
200
953
19.3
29.8
56.1
37.9
18.9
3.2
Mysore Division
10,579.1
170
1.49
993
20.4
23.6
67.8
49.3
14.4
2.9
Karnataka
44,977.2
235
1.93
960
19.2
30.9
67.3
44.3
16.4
4.3
• Literacy percent among population aged 7 years and over
Generally, Gulbarga Division, comprising the districts of Gulbarga, Bellary, Bidar and Raichur
along with Bijapur district in Belgaum Division, is the most backward in terms of health and
socio-economic indicators. These above five districts show higher growth rates over the ten
year period for the years 1981-91. The highest growth was, however, registered in Bangalore
District, reflecting rural-urban migration and rapid urban growth. The population growth rate
for the decade 1981-911 declined in all districts excepting Bidar, Bijapur, Gulbarga and
Raichur. The annual compound growth rate of the population of these four districts increased
from 1.99 percent in the decade 1971-81 to 2.25 percent in the decade 1981-91, suggesting
that the decline in mortality has been more than the decline in fertility On the other hand,the
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
5
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNA7 A5.A
J
annual compound growth rate declined in the remaining sixteen districts from 2.50 percent
during the decade 1971-81 to 1.85 percent during the decade 1981-91.
The sex-ratio is the most favourable in Mysore Division, with Dakshina Kannada and Hassan
boasting of a female to male sex- ratio of over 1.0. This division also has the highest mean age
at marriage. Conversely, the lowest mean age exists in the four districts of Gulbarga Division
together with the adjacent Bijapur district. Crude birth rate is also significantly higher in this
part of the State and female literacy is lowest in the Gulbarga Division. Similarly, the Gulbarga
Divisions Districts have relatively lower per capita income levels
In general, one can state that there is a North South divide with the Southern parts of the
State, being somewhat better placed in demographic status, compared to their Northern
counterparts.
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
6
]
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
3.
HEALTH STATUS
3.1.
Morbidity
4
According to the Forty Second Round of the National Sample Survey conducted in 1986-87,
40.3 persons per thousand population suffered from some ailment or other during the 30 days
preceding the date of interview and 89.6 percent of them consulted a doctor. During the
preceding year, 21.8 per thousand population were admitted as inpatients.
3.1.1. Morbidity Pattern Among Users of Government Facilities
The estimates of outpatients and inpatients per thousand population per year for the
government hospitals derived from the findings of the Forty Second Round of National
Sample Survey conducted in 1986-87 were 168.2 and 12.0 respectively. These estimates are
close to those estimated from data on morbidity compiled from returns submitted by hospitals
in the government sector for the year 1992. The average number of registrations in outpatient
department is 176.8 per thousand population and for inpatients it is 12.3 per thousand
population.
Between 1982 and 1992 there has been an overall increase in outpatient consultations as well
as inpatient admissions. The outpatients have increased by 47 percent, the inpatients by 65
percent, while the increase in total population has been 21 percent. The increase in treatment
as outpatients for the respiratory, digestive, genito-urinary systems, complications due to
pregnancy and the puerperium, injuries and poisoning has been above the average of all
diseases.
The increase in inpatients for treatment of infectious diseases, neoplasms, endocrine,
nutritional & metabolic diseases and immunity disorders, mental disorders, diseases of
circulatory system, diseases of genito-urinary system, complications due to pregnancy and the
puerperium, diseases due to injuries and poisoning, has also been higher than the increase in
total hospital admissions. The increase in inpatients between the years 1982 and 1992 may be
due to increase in morbidity level or in utilisation of hospital services or both.
Clearly, a substantial proportion of admissions are due to accidental injuries. It is assumed
that a large proportion of these are related to motor vehicle and occupational injuries. Bums
from domestic accidents, e.g., with kerosene stoves, are probably also common.
Environmental and occupational safety could be improved through public education using
effective information, education and communication (IEC) strategies to reduce hospital
admissions of this type and the resultant burden on hospital care.
Table 3.1 presents morbidity data by category as per International Classification of Diseases,
1975, Revision IX adopted to Indian conditions.
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
7
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
i
Table 3.1. Morbidity Pattern by Category of Diseases Recorded in Government Hospitals
(1992)_______________________________________________ _______ __ ________________
Infectious and Parasitic Diseases 001-139
__________________ _
Neoplasms 140-239__________________________________ ____ ______
Endocrine, Nutritional & Metabolic Diseases and Immunity Disorders 240-279
Diseases of blood and blood forming organs 290-319________________ __
Mental disorders
_______________________________________ _
Diseases of the Nervous System and sensory organs 320-389__________ _
Diseases of the circulatory system 390-459____________________ ___
Diseases of the respiratory system 460-519__________________ ________
OiseasesofUie_d^estive_s^stem_520-^^____________________________
Diseases_oUhe_2eruto-i£inar£SYst^
__________________
Complications of pregnancy child birth, and the puerperium 630-679_______
Diseases of the skin and sub-cutaneous tissue 680-709 ______________ _
Diseases of the musculo skeletal system and connective tissue 710-739
Congenital anomalies 740-759_____________________________ ______
Certain conditions originating in the perinatal period 760-779_____________
Signs .symptoms and itt-defined conditions 780-799 _________________
Injury and poisoning 800-999__________________________ ___________
PER THOUSAND POPULATION
INPATIENTS
OUTPATIENTS
1982
1992
1992
1982
2.35
1.37
24.16
26.73
0.09
0.18
0.80
0.90
0.43
0.28
5.24
6,30
0.40
0,51
14.77
12.57
0.05
0.24
0.44
0.01
0.53
0.47
9,07
10.32
0.45
0.30
3.54
3.82
1.23
1.53
33.64
27.30
0.49
0.62
7.99
11.32
0.34
0.24
4.72
1 90
2.38
1.14
4.95
2.29
0.22
0.06
13.27
6.70
0.11
2.86
0.11
2.47
0.02
0.03
0 11
0.06
0.04
0.04
0 50
0.44
0.13
0.17
1.79
1 61
2.83
1.93
42.92
32.83
TOTAL
141,77
CATEGORY OF DISEASE
176.80
8.78
*
12.32
3.1.2. Death Rate of Inpatients
The deaths in hospitals for treatment of various diseases has increased from 1.77 percent of
hospital admissions in 1982 to 2.63 percent in 1992. The disease groups in which the death
rate has increased by more than 80 percent are diseases of the circulatory system, congenital
anomalies, conditions originating in the perinatal period, ill-defined conditions and injury and
poisoning.
During the same period the number of patients admitted in government hospitals has increased
from 332,546 to 548,812 representing an increase of 65.0 percent putting pressure on hospital
facilities. The pressure on hospitals to admit more patients without commensurate increase in
infrastructure and other facilities may have resulted in increased mortality among hospital
inpatients.
The data on deaths among inpatients of government hospitals by disease group is presented
for the years 1982 and 1992 in Table 3.2.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
8
r
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION. KARNATAKA
Table 3.2 Deaths among Inpatients of Government Hospitals
CATEGORY OF DISEASE
PERCENT OF THOSE ADMITTED
FOR THE SPECIFIC DISEASE
1982
1992
3.92
3.27
5.54
3.86
3.98
2.34
2.21
2.34
0.39
1.27
1.47
1.33
4,75
9.07
0.46
1.48
1.61
2.47
2.13
1.88
0.13
0.16
0.00
0.51
0.17
0.28
2.87
6.94
6.73
12.40
1.87
7.30
1.33
3.95
Infectious and Parasitic Diseases 001-139___________________________
Neoplasms 140-239
Endocrine. Nutritional & Metabolic Diseases and Immunity Disorders 240-279
Diseases of blood and blood forming organs 290-319___________________
Mental disorders_______________________________________________
Diseases of the Ner/ous System and sensory organs 320-389____________
Diseases of the circulatory system 390-459__________________________
Diseases of the respiratory system 460-519__________________________
Diseases of the digestiye system 520-579___________________________
Diseases of the genito-urinary system 580-629________________________
Complications of pregnancy child birth, and the puerperium 630-679_______
Diseases of the skin and sub-cutaneous tissue 680-709_________________
Diseases of the musculo skeletal system and connective tissue 710-739
Congenital anomalies 740-759____________________________________
Certain conditions originating in the perinatal period 760-779_____________
Signs .symptoms and ill-defined conditions 780-799____________________
Injury and poisoning 800-999
TOTAL
2.63
1.77
Mortality
3.2.
The crude death rate (CDR) in Karnataka for 1993 has been estimated at 8.0 per thousand by
the Sample Registration System. The CDR for rural Karnataka was 9.5 as compared to 5.2 for
urban Karnataka..
CHART 3.1: Crude Death Infant Mortality Rate for Karnataka and India (1970-1991)
16
14
12
10
8
6
2—
° -I—
—
1970
1975
“1H----------------------1----------1
-----1-----i— ---4—
—1----------------- 1------------------- 1—
1980 1981 1982 1983 1984 1985 1936
—A—CDR Karnataka -M-CDR India
—i—
1987
—4—
1988
1989
—I—
1990
■<
1991
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
9
1
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
During the same period, the infant mortality rate (IMR) has been 67 per thousand births. The
LMR in rural areas was 79 as compared to 41 in urban areas. Over 70 percent of infant
mortality is accounted by neornatal mortality.
CHART 3.2: Infant Mortality Rate per 1000 Live Births for Karnataka and India, 1970-1991
140
120
«■
100
A
-Bk
80
♦
♦
♦
«-
♦
♦
60
40
20
0 ----------- 1-----------(---------- 1——i---------- 1------------ 1— —1-------- 1------------- 1--------- 4-----------+1-----------1— —♦k—
1970 1975 1980 1981 1982 1983 1984 1985
1986 1987 1988 1989
1990
+
1991
—♦—IRM Karnataka —»—IRM India
It will be observed from the infant mortality data available from 1981 census and presented in
Table 3.3 that there is considerable variation across districts.
Table 3.3: Infant Mortality by District (1987)
IMR
55
DISTRICT
Tumkur
Dharwad
85
Mysore
IMR
77
"67"
Hassan_____________
80
Raichur
"90"
"sT
Gulbarga
83
Shimoga
"83"
Bijapur
Chikmagalur
"W3
Kodagu
57
Uttara Kannada
"Tm”
Kolar
69
Chitradurga
“tF
Mandya
84
Karnataka
81
DISTRICT
Dakshina Kannada
Belgaum
IMR
60
"67'
Bellary
~92"
Bidar
DISTRICT
Bangalore
.
A breakdown by location shows that the relative stabilisation of, or slight increase in, infant
mortality occurs in rural Karnataka, whereas the urban data continues to improve (Table 3.4).
Furthermore, neonatal mortality has also increased slightly since 1981, more so in the rural
reported rates, compared to the country wherein substantial gains have been achieved (Table
3.4). Post-neonatal mortality, on the other hand, has declined in Karnataka, albeit far less
than that seen in India. In addition, this decline has occurred largely for the urban areas. The
stable infant mortality rates, thus, appears to be related to lack of improvements in deaths in
the neonatal period. This influence is significant because over 70% of infant mortality occurs
in the neonatal period.
It is generally recognised that neonatal mortality has a closer relationship with maternal risk
factors, such as nutritional status and parity, and factors at time of delivery. The contributions
of low birth weight, prematurity, congenital abnormality and declines in breastfeeding practice
to infant deaths cannot be inferred in the absence of data. Nonetheless, these factors are most
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
10
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
7
probably relevant in the case of Karnataka. Earlier, it was shown that hospital-based deaths
due to perinatal conditions and congenital abnormalities have increased in the state. Based on
hospital treatments per 1000 population, data also indicates an increase in congenital
abnormalities from 0.06 in 1982 to 0.11 in 1992 (Directorate of Health, Karnataka State).
Part of this may be due to improved diagnosis. Post-neonatal mortality tends to be associated
with environmental factors, such as quality of drinking water and sanitation, contributing to
diarrhoeal diseases and respiratory infections. In this case, there has been some success in
controlling these, particularly in urban Karnataka. This is supported by the hospital morbidity
data, described above.
TABLE 3.4 : Infant Mortality and Stillbirth Rates in Karnataka and India
TOTAL
URBAN
RURAL
KARNATAKA
INDIA
62.5
58.9
50.0
69.1
69.4
70.0
73.0
110.4
97.2
80.0
-8.9
-20.0
5.6
-27.5
75.6
66.6
57.4
29.3
25.8
29.8
38.5
33.3
30.9
48.6
45.0
51.1
69.9
60.1
52.5
5.1
-24.1
1.7
-19.7
5.1
-24.9
1981
1985
1990
22.2
27.2
22.5
43.5
39.9
28.9
15.7
14.3
9.1
24.0
25.6
19.5
20.5
24.4
19.3
40.5
37.1
27.2
% Change
1981-90
1.3
-33.6
-42.0
-18.7
-5.9
-32.9
Stillbirth rate
1981
1985
1990
13.1
9.8
20.3
11.4
10.8
11.0
7.6
10.2
10.8
6.2
8.9
11.0
11.7
9.9
18.0
10.6
10.4
11.8
% Change
1981-90
55.0
4.4
Source: Registrar General India (Sample Registration Scheme)
42.1
77.4
53.8
11.3
INDICATOR
YEAR
KARNATAKA
INDIA
KARNATAKA
Infant mortality rate
1981
1985
1990
1992
77.1
78.8
80.0
82.0
119.1
106.5
86.0
45.0
40.1
39.0
41.0
1981-92
6.3
-27.8
Neonatal mortality
rate
1981
1985
1990
54.9
51.1
57.7
% Change
1981-90
INDIA
% Change
Postnatal mortality
rate
In contrast, stillbirth rates have increased for the state as well as for India (Table 3.4). Clearly,
however, the increase is far more in Karnataka, which has a much higher stillbirth rate (1991
data). The sharp rise in still birth rates could be due to improved registration of pregnancies
and reporting arising partly from increased deliveries by trained Personnel. Previously, more
stillbirths may not be reported.
Apart from improved registration and reporting, it is
interesting to note that the highest increase in stillbirths have occurred in urban India.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
11
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
3.3.
Causes of Death
During the decade 1981-91, the share of deaths due to parasitic diseases declined while that
due to diseases of the circulatory system increased. The share of deaths among female^ due to
complications of pregnancy and child birth declined.
In 1991, diseases of the circulatory system constituted the single largest cause of*deaths (23.5
%) followed by infectious and parasitic diseases (19.6%). Injury and poisoning took the third
place (14.6%). The fourth place was taken by conditions originating in the perinatal period
(8.8%). Diseases of the respiratory system and diseases of the nervous system came fifth and
sixth, accounting for 7.8% and 6.1% of deaths respectively. These six diseases accounted for
80.4 percent of deaths.
Analysis by age revealed that infant deaths formed 12.9 percent of total deaths. The major
causes of infant deaths were slow foetal growth, foetal malnutrition and immaturity (28.7%),
hypoxia, birth asphyxia and other respiratory conditions (20.2%) and all other causes
originating in the perinatal period (17.6%).
The age group 15-34 accounted for 28.4 percent of deaths of females due to all causes as
compared to 16.3 percent in case of males.
Table 3.5: Percent Distribution of Deaths in Karnataka by Major Cause Groups
MALE
1981
28.7
3.6
4,0
2.7
0.1
5.5
16.9
7.4
9.0
1.8
CAUSE
1991
19.8
4,3
3.2
1.6
0.9
5.9
24.5
8.3
6.2
1.3
FEMALE
1991
1981
27 3 ___ 19.4
3.4 ___
4.2
3.6
4.4 ___
2.6
4.5 ___
0.2
0.2 ___
6.2 ___
6.4
13.9 ___ 21.8
6.9
6.5 ___
5.6 ___
4.2
1.4
1.4 ___
1.8
6.2 ___
0.3
0.3 ___
0.1
0.1 ___
1.2 ___
0.1
9,1
8.7 ___
1.6
2.3 ___
7.8 ___ 16.3
100.0
100.0
Infectious and Parasitic Diseases___________________________
Neoplasms____________________________________________
Endocrine, Nutritional & Metabolic Diseases and Immunity Disorders
Diseases of blood and blood forming organs___________________
Mental disorders________________________________________
Diseases of the Nervous System and sensory organs____________
Diseases of the circulatory system__________________________ _
Diseases of the respiratory system__________________________
Diseases of the digestive system___________________________
Diseases of the genito-urinary system________________________
Complications of pregnancy child birth, and the puerperium_______
0.2
0.3
Diseases of the skin and sub-cutaneous tissue_________________
0.2
0.1
Diseases of the musculo skeletal system and connective tissue
1.4
0.1
Congenital anomalies____________________________________
8.7
7.1
Certain conditions originating in the perinatal period_____________
1.3
2.0
Signs .symptoms and ill-defined conditions___________________
13.6
9.4
Injury and poisoning
100.0
___________________________________________________________________ 100.0________
Source: Report on Medical Certification of Cause of Death in Karnataka, 1991; Directorate of Economics and Statistics, Govt, of
Karnataka, Bangalore.
3.4
Maternal and Child Health
The emphasis on primary health care in the state of Karnataka has contributed to
improvements in maternal and child health, as shown by safe deliveries, child immunizations
and contraceptive use. Improvements in these areas have undoubtedly led to reduced infant
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
12
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
mortality, as described earlier. The training and use of community-based auxiliary nurse
midwives (ANM) has played an important role in this regard.
!.
In terms of immunizations, the proportion ot children aged 12-23 months immunised ranges
from 55% tor measles to 82% for BCG (Table 3.6). Furthermore, the disparity in
immunisation rates between urban and rural areas is relatively small. It is understandable that
there is higher attrition for vaccinations administered later because of access to the children.
TABLE 3.6 : Immunisation Rates among Children 12-23 month in Karnataka
_____ Immunisation
Rural
BCG
81.4
DPT 3doses
69.6
Polio 3 doses
67.2
Measles
52.2
All vaccines______
47.5
Source:Registrar General India (Sample Registration Scheme)
Urban
Total
82.4
73.3
70.9
61.2
55.8
81.7
70.7
68.3
54.9
50.0.
Another indicator relevant to infant as well as maternal mortality is the percentage of safe
deliveries, measured by the percentage of deliveries by trained Personnel, including traditional
birth attendants or “dais”. Overall, about 62% of deliveries are by trained birth attendants,
more than the figure for India (Table 3.7). In fact, the improvement in this indicator has been
very substantial compared to the country as a whole, with the major change being in rural
deliveries. Unfortunately, there is no data on trends in maternal mortality to correlate with this
factor.
As a demographic indicator relevant to maternal health, fertility rates have declined since 1981
to a smaller extent than that achieved for India (Table 3.7). However, from 1981 fertility was
already lower than the country average. Fertility reduction was also lower in urban than rural
areas.
Correspondingly, couple protection rates have increased more than twice in the state (Table
3.7). This is slightly more than achieved for the country (Table 3.7). The most common
method is sterilisation (40%) followed by the intra-uterine device (IUD) (6%) (Population
Centre 1993).
Sterilisation as the major method applies to all districts, with those in
Bangalore and Mysore Divisions having slightly higher sterilisation prevalence (38-55%)
compared to the other Divisions (26-41%) (Population Centre 1993). The average age at
sterilisation for women is about 31 years after an average number of about three children
(Population Centre 1993).
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
13
1
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
TABLE 3.7: Fertility, Safe Delivery and Couple Protection Rate in Karnataka and India
TOTAL
URBAN
RURAL
KARNATAKA
INDIA
INDICATOR
YEAR
KARNATAKA
INDIA
KARNATAKA
INDIA
Total fertility rate
1981
1985
1990
3.8
3.9
3.5
4.8
4.6
3.8
3.0
2.9
2.6
3.3
3.3
2.8
3.6
3.6
3.2
4.5
4.3
3.8
1981-90
-8.6
-26.3
-15.4
-17.8
-12.5
-18.4
1981
1985
1990
24.7
45.4
54.0
26.3
31.0
36.4
69.2
72.6
87.2
65.8
72.3
78.9
33.5
52.1
61.9
36.2
38.6
44.2
1981-90
118.6
38.4
26.0
19.9
84.8
15.7
22.3
32.8
45.4
49.1
22.3
32.1
43.3
44.1
120.2
97.8
% Change
% Deliveries by
trained Personnel
% Change
Couple
protection rate
1981
1985
1990
1992
% Change____________
1981-90
Source:Registrar General India (Sample Registration Scheme)
Sterilisation, primarily by tubectomy, is done on a voluntary basis whereupon women are
disbursed a sum of Rs 140. The procedure is carried out at all levels of care from the Primary
Health Centre. Most Community Health Centres and General Hospitals also have weekly
camps for sterilisation operations on women. Although men were targets of sterilisation
efforts in the seventies, the focus currently is almost entirely on women.
TABLE 3.8: Age Specific Fertility in Karnataka by Rural - Urban Location
AGE
Age Specific
Fertility
Karnataka
15-19
20-24
25-29
30-34
35-39
4044
45-49
1981
73.2
213.3
203.0
142.8
83.5
30.9
14.7
RURAL
1985
97.9
249.0
207.1
121.8
70.0
27.9
10.0
1990
86.5
257.1
179.8
95.9
48.4
20.2
7.0
1981
75.5
174.2
164.1
114
61.4
26.0
6.4
URBAN
1985
56.1
203
159.2
97.2
6.6
18.7
5.1
1990
48.4
195.4
164.5
74.8
31.3
11.0
1.9
1981
69.0
201.4
191.1
134.3
77.8
29.6
12.6
TOTAL
1985
Tj 1990
85.4
235.1
191.4
115.4
60.0
25.8
7.1
76.3
239.3
175.1
89.5
44.1
17.6
5.9
Age-specific fertility indicates reduced fertility for all age-groups except for the 20-24 years
group among whom a slight increase is observed (Table 3.8). More specifically, this increased
fertility occurs in this age-group, whereas in the urban areas, an increase occurs later in the 2529 years group. Above 30 years, fertility falls substantially. This supports the contraceptive
use data which shows this to be the average age that many women are sterilised.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
14
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
4.
ORGANIZATION OF PUBLIC HEALTH CARE SYSTEM
4.1.
Organization at The State Level
The primary responsibility for health care and family welfare is with the State Government
under the Department of Health and Family Welfare (DHFW). The Central Government is
only the national coordinating and policy recommending body with little control over
implementation. Within the State, there are three levels of responsibility.
State level:
Health policy, budget, tariffs, capital investment, salaries, 40% of the supply of drugs and
consummables, training, manpower and IEC.
Division level:
Each of the four Divisions in the State, covering four to six districts, is an administrative
and coordination unit responsible for medical equipment maintenance.
District level;
The district level prepares the budget (excluding the budget for District Hospitals and
hospitals above 100 beds) and is responsible for building maintenance, office expenses and
60% of the supply of drugs and consumables.
The Secretary, Health & Family Welfare is responsible for formulating and implementing
policies of the Government in the field of Health Care. He is assisted in the Secretariat by an
Additional Secretary, Deputy Secretary (Medical Education), Deputy Secretary (Health) and
an Internal Financial Advisor.
The Director, Medical Education (DME), Director, Health and Family Welfare Services
(DHS), Director, Indian Systems of Medicine and Homeopathy and the Drugs Controller
report to the Secretary.
The Medical Colleges run by the State and the government hospitals attached to the teaching
institutions including private medical colleges, nursing colleges and nursing schools come
under the jurisdiction of the Director Medical Education. While the teaching staff are under
the administrative control of the DME, the staff of the hospitals attached to the teaching
institutions are under the control of DHS.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
15
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
CHART 4.1: Organization Chart of Public Health Care System
Secretary
A.ddl. Secretary
Department of Health &. FW
Director
Health &. FV/ Services
Chief Acc. Officer
Additional Director
FW & MCH
Joint Director
FW &. MCH
Chief Adm. Officer
—___ ___ _________
Additional Director
AIDS
Additional Director
Projects
Joint Director
IPP- IX
Joint Directors
Planning, H.E.T
Medical, IEC
Malaria, T.B
Leprosy
Blindness
Med. Store
The Director of Health Services is responsible for Public Health, Primary Health Care, and
Secondary level Hospitals. He is assisted by three Additional Directors — one each for MCH
& FW, AIDS and Projects. The Additional Director (Projects) is responsible for implementing
externally assisted projects such as IPP-DC He is also designated as ex-officio Additional
Secretary, to facilitate issue of Government Orders after obtaining the approval of the
Secretary, Health.
At the Directorate level, The Director Health & Family Welfare Services is assisted by a Chief
Administrative officer, a Chief Accounts Officer and nine Joint Directors.
There is one Divisional Joint Director in-charge of each of the four Revenue Divisions and
report to the DHS. In each district, there is a District Surgeon to manage the district hospital
and a District Health Officer (DHO) to manage primary health care at all hospitals excluding
the district hospital and programmes to control diseases. The activities managed by the DHO
fall under the jurisdiction of the Zilla Panchayat. Consequently, he reports to the Chief
Executive Officer (CEO) of the Zilla Panchayat, who is an IAS officer. The DHOs are under
the administrative control of the DHS in so far as evaluation of their performance, promotions
and transfeRs are concerned. The organizational set-up under the DHO is almost similar to
that under DHS.
The Zilla Panchayats receive grants from the State Government to meet expenditure on health
care. Such grants and actual expenses are reflected in the Health Budget of the State, under
the District Sector component.
The Karnataka Panchayat Raj Act, 1993, which is now in force in the State, specifies the
functions to be performed by the Zilla Panchayats, Taluka Panchayats, and the Grama
Panchayats. The matters to be dealt with by the Zilla Panchayat, in respect of Health and
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
16 •
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
Family Welfare, at the district level, are: (1) Management of hospitals and dispensaries
excluding the District hospital and hospitals under the direct management of Government
(above 50 beds); (2) Implementation of maternity and child health programmes; (3)
Implementation of family welfare programmes; (4) Implementation of immunisation and
vaccination programmes. The Taluka Panchayats deal with: (1) Promotion of Health and
Family Welfare programmes, (2) Promotion of immunisation and vaccination programmes at
the Taluka level: and, (3) Health and sanitation at fairs and festivals. At the village level, the
Grama Panchayats deal with implementation of family welfare programmes, prevention
measures against epidemics, regulation of sale of food articles, participation in immunisation
programmes, licensing of eating establishment, and regulation of offensive and dangerous
trades. Apart from operating the District Sector budget, the Zilla Panchayats also implement
such State Sector schemes as are entrusted to them by Government.
4.2
Structure of Health Care System
The health care delivery system in Karnataka has been structured on the basis of national
norms which have been formulated with the objective of integrating promotive, preventive and
curative aspects of health care. The health services delivery structure existing in the State is
described below:
•
For each District (approximately 2 million population): One District Hospital with 250
beds with specialized curative services
•
For each Sub-District (approximately 500,000 population): One Sub-District Hospital with
100 beds with curative services
•
For each Taluk/block (100,000 to 120,000 population): A Community Health Centre
(CHC) level hospital with 30 beds with specialized medical care services in gynaecology,
obstetrics, surgery and medicine.
•
For an area covering 30,000 population: A Primary Health Centre (PHC) to render
preventive, promotive and curative services.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
17
UPGRADING GF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
|
CHART 4.2: Organization of Health Care Delivery System
STATE
Director Health Services
r
............... I...... ...........
1 ..............
DIVISION
DIVISION
Joint Divison Director
Joint Divison Director
_____ ~
DIVISION
Joint Divison Director
DIVISION
Joint Divison Director
j..
DISTRICT
District Health Officer
DISTRICT
i
Medical Superintendent |
SUB-DISTRICT HOSP. \
=<100 beds
SUB-DISTRICT HOSP.
=> 100 beds
|.... .
..
DISTRICT
District Surgen
DISTRICT HOSPITAL
E
CH-CENTRE
r~
~|
PHC
PHC
n
§ SUB-CENTRE
I
i
SUB-CENTRE
The state of Karnataka provides health care services in all levels of the delivery system. In the
last decade, the emphasis in health care has been at the primary level, for which various
programmes (IPP) have been implemented, including the upgrading of facilities. Based on the
number of beds, secondary level facilities are mainly available ip the district capitals while
tertiary level services are mostly in the state capital of Bangalore.
Primary level care is mainly served by SCs and PHCs, whereas CHCs, GHs, Sub-District
Hospitals (also known as Taluk Hospitals) and District Hospitals are mainly providing
secondary level services. Some of the District Hospitals are also. Teaching Hospitals which
provide tertiary services as well. The basic structure of the health facilities is shown in
CHART 4.3.
CHART 4.3: Type of Health Care Facility
*
D I S TR I CT H 0 S PITA L j
1
J
J”
TALUKA HOSPITAL
TALUKA HOSPITAL
j
...
TALUKA HOSPITAL
_ LZ
I
ZLZ
I
CHC
SUB-DISTRICT
HOSPITAL
CHC
SUB-DISTRICT
HOSPITAL
PHC
I . .
SUB-CENTRE
PHC
TALUKA HOSPITAL
~1
PHC
1
SUB-CENTRE :i [ SUB-CENTRE
------ 1
SUB-CENTRE
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
18
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
5.
HEALTH FACILITIES IN KARNATAKA AND THEIR USAGE
5.1.
Medical Practitioners
There are nearly 17,000 practising physicians in Karnataka according to a survey conducted by
ORG. The number of doctors in the private sector in the State is estimated at about 11,000.
The number of doctors in the Government sector is 5.828, accounting for 35 percent of the
doctors.
About 82 per cent of doctors in the Government sector are general duty doctors. The
distribution of doctors in the Government sector by specialisation is presented in Table 5.1
Table 5.1: Government Medical Practitioners by Specialisation.
SPECIALISATION
NUMBER
General Duty Medical Officer
Specialists
General Medicine
Obstetrics & Gynaecology
General Surgery
Paediatncs
Anaesthesiology
Orthopaedics
Optholomology
ENT
Skin/Dermatology
Psychiatry
Pathology
Tuberculosis
Forensic Medicine
Radiology
Super specialities
TOTAL
5.2.
PERCENT
4775
1053
82
18
5828
100
157
168
145
130
114
56
54
39
34
23
20
30
13
24
46
Hospitals
There are 31,840 beds in government hospitals in Karnataka excluding those run by Defence
Services, Railways, Employee State Insurance and Public Sector undertakings which are not
open to the general public. Out of this bed strength, 3,330 beds are in hospitals for specific
diseases such as tuberculosis, infectious diseases etc., leaving 28,510 beds for general use.
There are varying estimates of the number of private hospitals. Of these, the estimate made by
ORG is more exhaustive and also provides data on bed strength. ORG estimated that there are
307 hospitals and 439 nursing homes in the private sector with a total bed strength of 17,668
in Karnataka.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
19
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
The total number of beds in the Government sector, excluding those in specialty hospitals and
private sector put together is 46,178 for the estimated population of 47-51 million in 1994 or
1029 persons per hospital bed as compared to the norm of 1000 persons per bed set by the
Planning Commission. The beds in the Government sector account for 57.5 percent of total
beds as against the norm of 66.7 percent set by the Planning Commission. The Planning
Commission has also recommended that 15 percent of the beds should be at the primary level,
70 percent at the secondary level and 15 percent at the tertiary level. The'actual distribution of
hospital beds at different levels in Karnataka is 23.1 percent at the primary level, 54.5 percent
at the secondary level and 22.4 percent at the tertiary level.
Table 5.2 presents the estimated number of institutions and existing bed capacity in
Government and private sectors.
Table 5.2: Distribution of Institutions and Bed Strength
NUMBER
OF
SECTOR AND TYPE
total bed:
STRENGTH
% OF BEDS IN
PERCENT
GOVT. SECTOR
OF TOTAL
BEDS
INSTITUTIONS
Govt. Hospitals used for Teaching
11
6400
22.45
13.86
Govt, run CHCs, Sub-District and District
227
15518
54.43
33.60
PHCs/PHUs
1874
6592
23.12
14.28
Total Government Sector
2112
28510
100.00
61.74
Private Hospitals
307
12388
70.112
26.83
Private Nursing Homes
439
5280
29.88
11.43
Total Private Sector
746
17668
100.00
38.26
TOTAL
2858
46178
100.00
The distribution of hospitals in the Government sector by size and type is presented in Table
5.3.
Table 5.3: Distribution of Govt. Hospitals by Type and Size
NUMBER OF BEDS ■'
TOTAL
OTHER •
CHC
PHC
PHU
0-10
600
1167
______ 38
1
1806
11-20
18
70
______ 19
3
_______ 110
21-30
2
11
______ 64
2
________ 79
31-50
1
________ 4
______ 39
2
________ 46
51-100
0
1
______ 18
10
________ 29
101-200
201-300
__ 0
0
________ 0
________ 0
_______ 1_
_______ 0
14
5
_________15
__________5
301-500
0
0
0
0
0
10
10
_________ W
0
621
1253
179
57
2110
501 & Over
TOTAL
10
• Includes District, Major and Teaching Hospitals.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
20
*
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
At the state level the persons per bed, including the beds at the tertiary level and speciality
hospitals in the government sector, as per service statistics, is 1,481, which is close to the
norm of 1,500 set for the government sector. However, thereiis considerable variation across
districts . In half the districts the availability of beds is below the norm and in five of them the
number of persons per bed exceeds 2,200. The distribution of hospitals and beds in the
Government sector by district is presented in Table 5.4.
Table 5.4: Distribution of Hospitals and beds in Government Sector by District
DISTRICT
POPULATION (1991)
NUMBER OF
NUMBER OF
POPULATION
POPULATION
(THOUSANDS)
HOSPITALS
BEDS
PER
PER BED
INSTITUTION
Bangalore_____
4,839 2
Bangalore Rural
1,673.2
Belgaum
3,583.6
Bellary________
1,890.1
Bidar
69
4769
_________ 70,133
1,015
98
574
_________ 17,073
2,915
133
1610
_________ 26,944
2,226
85
1600
________ 22,236
1,181
1,255.8
53
668
_________ 23,694
1,880
Bijapur___________
2,928,0
93
1293
_________ 31,484
2,265
Chikmagalur
1,017.3
86
925
_________ 11,829
1,100
Chitradurga______
2,180.4
133
1962
_________ 16,394
1,111
Dakshina Kannada
2,694.3
135
2360
_________ 19,958
1,142
Dharwad
3,503.2
135
2507
_________ 25,950
1,397
Gulbarga
2,582.2
119
1455
_________ 21,699
1,775
Hassan
1,569 7
124
1062
_________ 12,659
1,478
Kodagu
488.5
40
1481
_________ 12,213
330
Kolar
2,216.9
114
1538
_________ 19,446
1,441
Mandya
1,644.4
98
853
_________ 16,780
1,928
Mysore
3,165,0
189
3385
_________ 16,746
935
Raichur
2,309.9
82
905
_________ 28,170
2,552
Shimoga
1,909.7
121
1178
_________ 15,783
1,621
Tumkur
2,305.8
121
941
_________ 19,056
2,450
Uttara Kannada
1,220,3
84
774
14,527
1,577
44,977.2
2112
31840
21,296
1,413
Karnataka
5.3.
Usage of Medical Services
The Forty Second Round (1986-87) of National Sample Survey (NSS) provides extensive
information on utilization of services by the community. Information relating to Karnataka and
where relevant for India has been extracted from the NSS report and is presented in this
section.
5.3.1. Outpatient Service
It was found that 1.68 million persons or 4.03 percent of total population of Karnataka
reported that they had an ailment during thirty days prior to the date of interview. Ninety
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
21
1
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
percent of those who had an ailment had consulted a doctor. The average duration ot sickness
was eleven days.
Only 2.6 percent of the patients had gone for systems of medicine other than Allopathic
system.
When the respondents who did not take treatment were asked the reasons fornot obtaining
treatment, 70 percent stated that the ailment was not considered serious. Finance was the
second most important reason advanced by 15 percent of the respondents.
Table 5.5: Reasons for not Taking Treatment
RURAL
URBAN_______
COMBINED
Not considered serious______________________
______ 67.61
_________ 81.63
_________ 71.94
Financial reasons___________________________
_______ 14,63
_________ 11.26
_________ 13.59
No facility / long waiting______________________
________5.45
__________ 0.71
___________ 3.99
Lack of faith
________ 3.40
173
__________ 2.88
8.91
4.67
7.60
100.00
100.00
100.00
REASON FOR NOT GETTING TREATED
___________________________
Other reasons
TOTAL
Private doctors and hospitals run by Non-Govemment Organizations (NGOs) accounted for
62.9 percent of the treatments both in rural and urban areas. Those who received treatment in
institutions run by State and Central Governments and public sector undertakings accounted
for 37.1 percent of the total treated.
Table 5.6: Percent Treated as Outpatients by Type of Facility
FACILITY
COMBINED
URBAN
RURAL
________ 42.03
Private Doctor__________
41.51
43.19
Private Hospital / Institution
_______ 19,81
23.32
_________ 20.89
Public Hospital__________
PHC____________ ‘
25.72
27.00
_________26.12
________ 8.47
1.71
__________ 6,38
________ 1.27
1.23
__________ 1.26
_________0.94
1.36
___________ 1.07
2.28
2.09
2.22
100.00
100.00
100.00
Public Dispensary_______
ESI__________________
Others
TOTAL
________
Forty-five percent of the outpatients in rural areas and thirty-eight percent in urban areas did
not pay for medical services. In one-third of the cases, both in urban and rural areas, payments
for medical services were made to private hospitals/doctors. Employers' Medicare schemes
paid for one out of eight cases in urban areas and one out of forty cases in rural areas. In rural
areas, 20 percent of the patients made payments to Government hospitals; the corresponding
percentage in urban area was 15. On an average, Rs 50 were paid to government hospitals and
Rs. 64 to private hospitals and doctors.
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
22
1
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
Table 5.7 (a): Percent Paying for Medical Services
RURAL
URBAN
No payment made_______________________
4472
37.57
42,51
Employers' Medicare_____________________
2.40
12.51
______ 5.53
COMBINED
Payment made to Govt. Hospital____________
19.97
15.17
18,49
Payment made to Pvt. Hospital /Doctor_______
32.91
34,17
33,30
Not identified party to whom payment was made
0.00
0.58
0.18
100.00
100.00
100.00
RURAL
___ ________ URBAN
COMBINED
Average amount paid to Govt. Hosprtal_____
41.93
68.37
50.10
Average amount paid to Pvt. Hospital / Doctor
58.64
74.66
63.59
TOTAL
Table 5.7 (b): Amount Paid for Medical Services
EXPENSE IN RUPEES
5.3.2. Inpatient Services
It has been estimated that 909,000 persons or 0.22 percent of the population were admitted
during 365 days preceding the date of interview to hospitals as inpatients for treatment. The
admission of females as in-patients is considerably lower in rural areas than in urban areas.
Table 5.8: Gender Difference in Rural Karnataka for Hospital Admission
SEX RAT1O(FEMALES TO THOUSAND MALES)
TOTAL
POPULATION
IN-PATIENTS
Rural Karnataka
________ 975
760
Urban Karnataka
930
966
Combined
960
800
The utilization of inpatient services in government and private sector institutions is presented
in Table 5.9. Hospitals in the government sector in Karnataka are utilized by 58 percent of the
rural patients and 49 percent of the urban patients while at the national level 60 percent of the
rural as well as urban patients used health facilities in the government sector. In Karnataka, the
private sector plays a greater role in providing health facilities especially in urban areas as
compared to that in the country.
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
23
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
Table 5.9: Utilization of Inpatient Services by Sector
PERCENT OF INPATIENTS
COMBINED
URBAN
RURAL
FACILITY
Karnataka
India
Karnataka
India
Karnataka
55.31
55.40
48.51
59.51
53.21
56.47
_________________
2.71
4,34
0.39
■0.75
1.99
3.40
Total Government. Sector
58.02
59.74
48.90
60,26
55.20
59.87
Private Hospital / Institution
32.94
31.99
40.49
29.55
35.27
31.35
Nursing Home__________
5.62
4,86
9.05
7,04
6.68
5.43
Charitable Institution
2.51
1.71
1.26
1.91
2.12
1.76
Others
0.91
1.70
0.29
1.24
0.72
1.58
Total Private Sector
41.98
40.26
51.09
39.74
44.79
40.12
TOTAL
100.00
100.00
100.00
100.00
100.00
100.00
Public Hospital
.^PHC
India
In rural areas nearly 60 percent use free wards while in urban areas less than 40 percent use
free wards.
Tabie 5,10: Distribution of Inpatients by Type of Ward
PERCENT OF INPATIENTS
TYPE OF WARD
Rural
Urban
Combined
Free_______ _
58.50
36.31
51.64
Paying General
29.36
34,61
30.98
Paying Special
12.14
29.08
17.38
TOTAL
100.00
100.00
100.00
The average stay of an inpatient in rural areas is 16.9 days as compared to 14.8 days in urban
areas mainly due to the fact that more patients go to government hospitals in rural areas as
compared to urban areas. Further the length of stay in Government hospitals is more than in
private hospitals.
Table 5.11: Average Length of Stay in Hospital
: ’• ■: .y. • •• t
:
AVERAGE STAY (DAYS)
Payment Category____
Rural
Urban
Government Hospital
Private Hospital
Free Ward
Paying General Ward
Paying Special ward
17.7
20.3
11.4
20.5
12.0
9.8
14.6
11.8
20.2
20.3
23.6
11.5
10.0
8.9
_______
16.9
14.8
Free Ward
Paying General Ward
Paying Special ward
Combined
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
9.8
11.6
24
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
Nearly 80 percent of the inpatients in Karnataka make payments to the institutions, whether
they are in the Government sector or private sector, as compared to 70 percent at the national
level. The average amount paid by an inpatient in the State is higher than the national average.
Table 5.12: Distribution of Inpatients by Payment Category anc Amount Paid
______ RURAL
Payment category_____
Karnataka
No Payment %
__
______ URBAN
India
Karnataka_____
India
23.2
12.3
19,6
Employers' Scheme %
3.8
6.2
10.3
13,0
Payment to Institution %
79.5
70.7
77.4
67.4
280
1048
815
320
733
597
525
1178
1029
385
1206
933
919
853
1231
1183
Amount Paid Rs.
to Govt. Hospital
to Pvt. Hospital
to both
TOTAL EXPENDITURE FOR
TREATMENT
In nearly two thirds of the cases, medicines and X-ray, ECG and EEG facilities are provided
free by Government hospitals to both urban and rural patients, when required. In case of other
services such as other diagnostic tests, physio-therapy, radio therapy and surgery nearly 90
percent of patients in rural areas who are in need of such services are provided free service by
government hospitals. In urban areas, surgical services are provided free of charge in nearly 60
percent of cases and 70 percent in diagnostic tests and physio-therapy and radio therapy.
Hospitals in the private sector provide free services to about 9 percent of the patients in rural
areas and 3 percent in urban areas.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
25
UPGRADING OF SECONDARY LEVEL HOSPITALS GULBARGA DIVISION, KARNATAKA
Table 5.13: Percentage Distribution of Hospitalized Cases by Types of Medical Services,
Sector and Region______
OTHEf? DIAG.
TESTS
X-RAY, ECG,
MEDICINE
EEG_
Rural
Sector
Urban
Rural
Urban
Rural
Urban
Rural
Urban
48.93
51.07
57.93
48.93
58.14
42.07
51.07
41.86
48.92
51.08
1.06
4.97
47.15
0.76
16.68
51.89
1.09
5.04
46.58
0.78
17.04
20.02
0.74
41.98
100.0
35.60
1.911
77.33
100.0
100.0
5.97
2.51
0.49
0.78
0.00
8.77
0.00
32.42
67.09
100.0
58.18
47.46
52.54
57.71
42.29
48.69
51.31
<41.82
Free
Partly Free
On Payment
63.25
20.86
60.20
22.20
52.30
13.16
16.73
22.57
1.68
8.54
31.40
0.76
Not Needed
2.73
0.50
67.58
8.54
58.70
41.67
35.41
All
100.0
100.0
100.0
100.0
100.0
100.0
Free
9.58
1.18
1.54
Partly Free
On Payment
Not Needed
1.27
88.06
5.92
0.86
90.41
0.31
41.36
0.0
5.95
0.79
2.45
0.00
62.60
1.81
100.0
57.15
100.0
44.36
54.10
100.0
61.05
1.09
100.0
32.21
100.0
34.95
100.0
Both
Free
Partly Free
On Payment
38.70
11.90
30.33
16.37
0.37
Not Needed
1.98
1.23
22.42
63.17
31.97
56.34
32.92
0.95
28.42
24.32
0.37
47.42
8.41
60.03
13.31
1.10
37.71
All
100
100
100
100
100
Private
SURGICAL
OPERATION
Urban
Rural
54.26
45.74
Government
PHYSIO
THERAPY
Government
19.18
0.00
13.65
67.17
100.0
Private
All________
0.00
60.97
32.28
100.0
62.85
34.64
100.0
21.12
24.07
0.38
40.44
15.31
0.43
40.13
32.57
0.96
28.57
9.85
9.63
0.00
23.24
35.18
37.90
35.11
100
100
100
74.31
100
67.13
100
70.11
100.0
Note: Not needed includes not taken
5.4.
Bed Occupancy
The average duration of stay in the Government and private sectors has been presented in
Annex 3. The bed occupancy estimated on the basis of average duration of stay is presented
in Annex 3. As the estimates of duration of stay for Government hospitals are very high,
alternative estimates of bed occupancy based on duration of stay in Government hospitals are
25 percent over private hospitals. These estimates are only indicative of the level of bed
nrmnanrv
occupancy. Tn
In the Government sector, the bed occuoancv
occupancy is very low in PHCs, while in all
other hospitals the occupancy is reasonably good. The bed occupancy in the private sector is
close to 70 percent.
Table 5.14: Estimated Bed Occupancy
__
BED OCCUPATION IN PATIENT
YEARS
TOTAL BED
STRENGTH
Alter-native 2
PHCs____________
6592
Alter-native 1
_________ 980
____ 784
Other Govt. Hospitals
25248
_______ 24382
__ 19506
All Govt. Hospitals
Private Hospitals
31840
17668
________ 25362
PERCENT OCCUPANCY
Alter-native 1
Alter-native 2
14.9
_______ 11.9
96.6
_______ 77.3
79.6
_______ 63.7
67.9
67.9
20290
11994
Alternative 1: Based on NSS Estimates of duration of stay in Govt. Hospitals
Alternative 2: Duration of stay in Govt. Hospitals as 25 percent over NSS estimates for Private Hospitals
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
26
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION. KARNATAKA
6.
PUBLIC HEALTH EXPENDITURE AND COST SHARING
6,L
Expenditure on Social Services
|
The expenditure of the State Government on Social Services has been hovering around 38
percent of total revenue expenditure. It. has increased at an annual rate of 16.7 percent from Rs
3.403 billion in 1980-81 to Rs 34.325 billion in 1995-96. Adjusting for inflation, the annual
rate of increase in expenditure on social services has been 6.4 percent. The overview of
expenditure for the last five years related to Government spending for social services is
provided in ANNEX 2.
Assuming that the State would continue to maintain this growth in outlay on health and family
welfare, the per capita expenditure on health and family welfare in the year 2000-2001 will be
Rs. 163 at current prices. The projected outlay for expected population of 52.174 million
would be Rs. 8,304 million.
The share of health and family welfare in the total expenditure of the state is around 4.5
percent. In 1994-95, the Non-Plan expenditure accounts for 60 percent of the total
expenditure on health and family welfare. The Non-Plan expenditure, which is met from
resources raised internally by the State, is expected to increase from Rs. 3,160 million in 199495 to Rs. 5,565 (or 67 percent of projected expenditure in the year 2000-01).
Outlay on Health & Family Welfare
6000
5000 --
4000
w*
i
3000
2000
1000
0
oo
S
oo
3
2
xo
OO
rOO
oo
OO
o
OO
o
QX
*
04
CA
m
ox
SI
Ox
Year Ending March 3 1
The breakdown of revenue and capital expenditure (Plan and Non-Plan) is presented in Table
6.1. The revenue expenditure has been increasing at the rate of 18 percent per annum.
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
27
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARf IATAKA
Table 6.1. Structure of Revenue and Capital Expenditure
Bil/ion Rs
1992-93
1990-91
1991-92
ACCT.
ACCT.
ACCT.
REVENUE EXPENDITURE
1993-94
ACCT.
1995-96
BUDGET
1994-95
REV. EST
General Services
11.746
14.220
16.997
19.049
23.941
27.7.28
Social Services of which
15.389
18.928
20.823
23.785
28.577
34.325
Education
Health & Family Welfare
Water Supply & Sanitation
Others_______________
Economic Services
8.020
2.430
0.061
4,329
11.593
9.614
2.954
0.810
5.551
15.214
10.978
3.602
0.958
5.285
16.851
12.781
3.912
1.186
5.906
18.009
15.349
4.872
1.641
6,715
22.523
17.755
5.688
2.267
8.615
27.346
Grants-in-Aid
0.983
1.179
1.247
1.493
1.476
1.537
62.336
76.517
90.936
Total Revenue Expenditure
39.711
49.541
55.917
CAPITAL EXPENDITURE
-
/
■
0.114
0.136
0.091
0.230
0.255
0.300
Social Services of which
0.177
0.325
0.387
0.521
0.879
1.117
Education
Health & Family Welfare
Water Supply & Sanitation
Others_______________
Economic Services
0.017
0.066
0.000
0.094
6.258
0.036
0.053
0.000
0.236
7.398
0.058
0.071
0.000
0.258
7.288
0.091
0.102
0.000
,0328
11.128
0.149
0.122
0.000
0.608
9.544
0.078
0.316
0.000
0.723
10.412
Grants-in-Aid
0.000
0.000
0.000
0.000
0.000
0.000
TOTAL CAPITAL EXPENDITURE
6.549
7.859
7.866
11.879
10.678
11.830
General Services
The average annual expenditure on health related items of expenditure was Rs 5.535 billion
during the period 1990-95, and accounted for 25.7 percent of expenditure on Social Services.
The breakdown for expenditure (planned and non planned) is shown in Chart 6.1.
on
Others
21%
Housing
2%.
Nutrition
2%
Water Supply
and Sanitation
5%
Health & Family
W elfare
17%
Education
53%
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
28
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
The outlay on Health and Family Welfare increased from Rs 0.647 billion in 1980-81 to Rs.
5.363 billion in 1994-95, representing an annual compound growth of 16.3 percent. The per
capita outlay increased at an annual rate of 14.3 percent from Rs. 17.6 to Rs. 115.0. Adjusting
for the observed annual rate of inflation of 8.3 percent during 1981-82 to 1992-93 in
Karnataka, the annual increase in real terms in per capita expenditure is 6.0 percent.
The revenue and capital expenditure (Plan and Non-Plan) for Health and Family Welfare in the
last five years have been increased from Rs 2.496 billion in the year 1990-91 to Rs 4.994
billion in the year 1994-95. For the year 1995-96 the budget allocation amounts to Rs 6.004
billion. The increase between the years 1990 and 1996 represents 240%
Primary Health Care has a major share (38 percent) of the expenditure in the Health
Department. Secondary and tertiary hospitals come next with (33 percent) share in
expenditure. Family Welfare accounts for 17 percent Education & Training for 10 percent and
Administration for 2 percent
Chart 6.2: Breakdown of Expenditure on Health
F a m ily
W eIfa re
A drain ist rat ion
P ro g ra m m e
2%
17%
Training
10%
H o s p ita Is
33%
P rim ary H e alth
c are
3 8%
Primary health care takes the lion’s share of expenditure on health care services with a 64.8
percent share. Secondary and tertiary sectors respectively account for 19.4 and 15.8 percent
share. Furthermore the growth in the last three years has been mainly on primary level care
and the increase in secondary and tertiary level care has been minimal.
/
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
29
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
Chart 6.3: Spending on Different Sectors in Health Care
□ 1995-96
Secondary
1993-94
0
500
1000
2000
1500
2500
3000
3500
Expenditure on In Million Rs.
The breakdown of expenditure on health by sector is presented in Table 6.2. The expenditure
on family welfare has been increasing by 23 percent per annum while that on medical
education and primary health grew at 18 percent per annum. Expenditure on secondary and
tertiary care had the lowest growth rate of 16 percent per annum.
Table 6.2: Structure of Health Revenue Expenditure
Million Rs.
Administration
Medical Education/ Training
1994-95
REV. EST
99.99
1995-96
BUDGET
118.048
1992-93
ACCT.
80.412
1993-94
ACCT.
84.632
289.02
378.062
• 340.592
493.028
526.495
1403.83
1608.802
1767.931
1990-91
ACCT.
62.541
1991-92
ACCT
84.957
222.19
Secondary & Tertiary Level Health Care
831.512
1027.731
1173.376
Primary Health Care
931.212
1013.335
1382.969
1452.94
1834.879
2158.126
Family Welfare Programme
382.706
538.662
590.607
630.424
835.003
1117.891
Total Health Expenditure
2430.161
2953.705
3605.426
3912.418
4871.702
5688.491
6.2.
Increase in Recurring Expenditure
The increase in recurring expenditure on account of the development plan outlined in the
preceding chapters is estimated at Rs. 855 million per annum. This forms 35 percent of the
increase in Non-Plan expenditure which is of the order of Rs. 2405 million between 1994-95
and 2000-01 or about 10 percent of projected expenditure in the year 2000-01.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
30
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
6.2.1
Current Status
The Government of Karnataka has a system of levying charges for diagnostic services,
treatment and usage of wards in the hospitals managed by it. The last revision of these user
charges was made in 1988 vide order No: HFW 126 SMM 86 dated March 10, 1988.
There are other types of charges levied e.g. certificates for physical fitness, wounds etc. Fifty
percent of the charges collected are retained by the government and the balance given to the
doctor issuing the certificate. Charges for the issuance of such certificates were fixed last in
1946 and have not been revised to date
The user charges are to be collected and remitted to the treasury. Neither the hospital
collecting the charge nor the Department of Health has access to the user charges collected.
As a consequence, there is no incentive to collect user charges. The average collections of user
charges per year during 1990-93, amounted to Rs. 107 million. Approximately 40 percent or
Rs. 41 million is on account of issuance of certificates and the balance amount of Rs. 66
million on account of ward charges and charges for surgery and investigations. In 1992-93 the
collection accounted for 3 percent of the expenditure of the health department.
6.2.2 Current Pattern of User Charges
No charge is levied on outpatients. The registration charges which used to be levied earlier
have been discontinued.
Inpatients with annual family income of below Rs. 8,001 are <exempted' from
~
‘
paying
charges
for any service as they are considered to be economically weaker sections. The patients with
family income of over Rs. 8,000 and admitted in general wards are charged a nominal amount
of Rs. 2 per day. There are charges for special wards, graded according to the number of beds
in such special wards, the maximum charge being Rs. 30 per day for a single bed in special
ward with basic diet included.
A schedule of rates has been prepared for different services. Those admitted in special wards
irrespective of income and those with family income of over Rs. 20,000 admitted in general
wards have to pay the full charge as listed. Those admitted in general wards and with family
income of Rs. 8,001 to 20,000 per annum have to pay 50 percent of the charges while those
with income below are exempted from all charges.
The charges for issuance of certificates are low, when one considers the present day cost of
living. For example, the charge for issuing certificate for physical fitness is Rs. 5. There is
justification for substantial revision of these charges. Increasing the charges especially for
wound certificates does not affect the economically weaker sections since the certificates are
collected by the police without paying any charge when a complaint is lodged by them with the
©< O'V ~ HQ
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMEN
07938
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KAR NATA KA
7.
HEALTH POLICY AND PROGRAMMES
7.1
Health Policy
The health situation in India is typical of a developing country whereby communicable diseases
and malnutrition feature prominently, with poor maternal and child health outcomes.
Population growth, poverty and poor education continue to be major concerns and challenges
to the achievement of‘Health for AH’. Towards this end, the Government of India (GOI) has
formulated a National Health Policy in 1983 under the jurisdiction of the central Ministry of
Health and Family Welfare. This Policy recognizes the need to integrate policies for health
and human development with socio-economic development, particularly in the health-related
sectors such as pharmaceuticals, agriculture and food production, rural development,
education and social welfare, housing, water supply and sanitation, food quality control, and
environmental conservation (National Health Policy 1983). The overall aims are to provide
universal, comprehensive and affordable primary health care services in line with the needs and
priorities of the community, ensuring community participation in the planning and
implementation of health programmes, and adequate utilization of private voluntary health
care services.
Thus, the National Health Policy encompasses a 20-point Programme that gives priority to
family planning on a voluntary basis; universal provision of primary health care; control of
leprosy, tuberculosis and blindness; social welfare programmes for women and children;
nutrition programmes for pregnant and lactating women and children, especially in tribal, less
accessible and less developed areas. At the same time, there is also emphasis on provision of
safe drinking water to problem areas, low-cost housing, production of essential food crops,
integrated rural development, universal education and expansion of the public distribution
system. The components are:
•
•
•
•
•
•
•
•
•
•
Population stabilization
Medical and health education
Provision of primary health care with special emphasis on preventive, promotive and
rehabilitative aspects
Reorientation of existing health personnel
Phasing out private practice by government medical staff (with provision of appropriate
compensatory non-practising allowance)
Integration of traditional sources of health care
Health education and communication
Management information system
Development of the bio-medical industry
Health insurance to mobilize additional resources for health promotion and ensure that the
community shares the cost of services proportionate to their paying capacity.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
32
|
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
TABLE 7.1: Targets for Health and Family Welfare in National Health Policy 1983
GOALS FOR HEALTH AND FAMILY WELFARE PROGRAMMES
INDICATOR
Infant mortality rate
Perinatal mortality
Crude death rate
Pre-school child (1-5 yrs) mortality
Maternal mortality rate
Life expectancy at birth(yrs)Male
Life expectancy at birth(yrs)Female
Babies with birth weight below 2500 gms. (%)
Crude birth rate
Effective couple protection (%)
Net Reproduction Rate (NRR)
Growth Rate (annual)
Family size
Pregnant mothers receiving ante-natal care (%)
Deliveries by trained birth attendants (%)
Immunizations status (% coverage)
TT (for pregnant women)
TT (for school children)
10 years old
16 years
DPT (children below 3 years)
Polio (infants)
BCG (infants)
DT (new school entrants 5 - 6 years)
Leprosy - (% of disease arrested cases out of those detected)
TB - (% of disease arrested cases out of those detected)
Blindness - Incidence of (%)
GOALS
1990
1985
2000
122
12
20-24
3-4
55.1
54.3
25
31
37
1.34
1.9
3.8
50-60
50
10.4
15-20
2-3
57.6
57.1
18
27
42
1.17
1.66
60-75
80
30-35
9
10
Below 2
64
64
10
21
60
1
1.2
2.3
100
100
60
100
100
40
60
70
50
70
70
40
60
1
100
100
85
70
80
85
60
75
0.7
100
100
85
85
85
85
80
90
0.3
Within this Health Policy, national goals have been set for specific indicators (TABLE 3.1). In
the description of health status in the next section, some of the indicators for Karnataka state
are compared to these national goals.
Furthermore, due to the priority given to population control, the states and Union Territories
of India have been divided into three regions based on the expected period when the targeted
net reproductive rate (NRR=1) should be achieved. This categorization was based on the
couple-protection rate in April 1983. Under this scheme, Karnataka falls under Group B
which should attain NRR of 1 in 1996-97. Group A areas, which include the neighboring
states Kerala, Andhra Pradesh and Maharashtra, are expected to attain this goal in 1991-92.
7.2
Health Programmes
The current health and population programmes in Karnataka are funded by the central and
state governments as well as by international donors. These state-wide programmes are
implemented within the primary health care system.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
33
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
I
7.2.1
Integrated Child Development Services
In 1975, the Integrated Child Development Services (ICDS) was implemented in 33 pilot
projects and later expanded nationwide. This was the initiative of the Government of India
with support from state governments. The objectives are to:
•
•
•
•
•
improve nutritional and health status of children aged 0-6 years
nurture the proper psychological, physical and social development of children
reduce mortality, morbidity, malnutrition and school attrition
achieve effective coordination of policy and implementation among various departments to
promote child development
enhance the capacity of the mother to look after the normal health and nutritional needs of
the child through proper nutrition and health education
The ICDS is implemented throughout Karnataka state at the primary care level.
7.2.2
Child Survival and Safe Motherhood Project
In the mid-1980s, the Government of India launched the Child Survival Safe Motherhood
(CSSM) Programme throughout the country. This was focused on maternal and child health
care services, including family planning and immunization. The components include:
•
•
•
•
•
•
Immunization for children and child bearing women
Control of diarrhoeal diseases, including social marketing of oral dehydration salts through
private and commercial channels
Control of acute respiratory infections
Prevention of blindness and vitamin A supplementation
Enhanced neonatal care
Promotion of breastfeeding
This state-wide project includes the provision of sterile delivery kits to community-based
auxiliary nurse midwives (ANMs) who distribute them free to pregnant mothers to be used
during domiciliary births attended by traditional birth attendants. It also includes the provision
of portable sterilizing equipment to the ANMs.
7.2.3
India Population Projects
The India Population Projects (EPP) are supported by the World Bank up to the most recent
IPP IX. Karnataka has been included in four of these - IPP I, IPP III, IPP VIII and IPP IX.
Up to nine India Population Projects (IPP) focusing on health and family welfare have been
implemented with support from the Government of India and various international donors.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
34
|
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
|
Karnataka has been the recipient of four of these projects, including the most recent IPP-IX.
IPP I and III covered 70% of the state population while IPP-VIII is focused on the urban poor
in Bangalore. IPP IX will include 13 districts. In sum, these IPPs will have covered the entire
state.
EPP-I (1973-80) was supported by the Ministry of Health and Family Welfare (MoHFW),
- Government of India with assistance from the International Development Authority and the
Swedish International Development Authority. The project was implemented in six districts in
the Bangalore Division, including Urban Bangalore, covering 12 million people or about 33%
of the state population (1981 data). The project aims were:
•
•
•
•
expansion of health infrastructure
linking family planning provision with nutrition supplementation
setting up of a population centre for continued evaluation and to design and operate
Management, Information and Evaluation System (MIES)
provision of technical assistance
EPP-III (1984-92) was implemented by the MoHFW with support from the International
Development Authority. It was implemented in six districts in the Belgaum and Gulbarga
Divisions covering about 16 million (1991 data) or about 36% of the state population. IPP-III
districts had the lowest literacy levels among men and women. Based on 1980 data, IPP-III
districts also had higher infant mortality (males and females), total fertility rate and crude birth
rate compared to IPP-I and other districts. Conversely, 1992 figures show that the couple
protection rate was also lowest compared to IPP-I and other districts.). In addition, childhood
immunizations, with the exception of BCG, had the lowest coverage in the IPP-III areas as
pointed out in the IPP-IX Project Proposal, Final Version (DHFW 1994). Justifiably, the
objectives of IPP IX were to reduce fertility in accordance with the country’s population
policy, and to reduce infant, child and maternal mortality by:
•
•
•
•
•
generating demand for family welfare services through Information, Education and
Communication (IEC) strategies
augmenting staff and facilities
improving professional and technical skills
improving management capabilities
involving community, voluntary organizations, other government and local authorities in
the family welfare programme.
Although aimed at improving maternal and child health, nutrition supplementation for
pregnant women in the last trimester, nursing mothers and young children (6-24 months) was
not included in IPP-III as in IPP-I.
IPP-VIII (1994), as mentioned earlier, is focused on the urban poor in Bangalore city and
planned for extension to other cities in the future. Its scope covers primary health care,
maternal and child health and family planning, health education and sanitation. The urban slum
areas of Bangalore will benefit from this project.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
35
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
[
EPP-IX (1994-2001) is the most recent population project to be implemented with
support from the World Bank. The largest to date in terms of area coverage, it
will be implemented in, initially 10 districts and now
in 13 districts in all
Divisions. The objectives are to reduce birth rates, infant mortality and maternal mortality
and increase contraceptive usage according to specific targets (EPP-IX Project Proposal 1994)
through:
•
•
•
•
•
•
•
involvement of the community in promoting and delivering family welfare services
strengthening service delivery by providing drugs, health kits and supplies to traditional
birth attendants (TBAs),
sub-centres and primary health centres (PHCs)
increase mobility at sub-centre level by providing loans for vehicles
providing buildings for sub-centres with accommodation for ANMs
providing residential quarters for medical officers
improving quality of services by providing training to personnel, official and non-official,
at various levels including TBAs, community leaders and voluntary agencies
strengthening monitoring and evaluation by developing and operating MIES at district to
state level.
Under EPP-IX, four training centres, one iin each Division, will be set up for training
paramedical staff, namely ANMs and Lady Health Visitors (LHV), as well as training in IEC
and MIES for all districts.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
36
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
8.
HEALTH SECTOR ISSUES
8.1.
Integration of PHCs and Secondary Hospitals
The IPP projects have concentrated on strengthening the infrastructure for delivery of primary
health care services, improving the quality of services and generating demand for family
welfare services. The institutions strengthened are sub-Centres and Primary Health Centres.
Under IPP-IX, rehabilitation of Community Health Centres (CHC) as well as upgrading of
selected CHCs into first level Referral Units (FRUs) is being taken up.
The PHCs and CHCs in a district are independent and each unit reports directly to the District
Health Officer (DHO). The sub-District or Taluka hospitals also report directly to the DHO.
On the other hand the District Hospital falls under the jurisdiction of the District Surgeon.
There is no linkage between District Hospital with sub-District Hospitals, sub-District
Hospitals with CHCs, and, in turn CHCs with PHCs falling within its catchment. As a result,
technical supervision and up-gradation of skills of medical and paramedical staff are
inadequate.
The common perception is that the higher the share of expenditure on hospitals, the lower the
equity in the overall health system. This is based on the assumption that if more resources are
devoted to primary care programmes and facilities it will be possible to provide relatively low
cost preventive and curative services to a larger segment of the population who are more
vulnerable. Both hospitals and PHC programmes cover multiple and overlapping functions.
PHC is associated with community-level delivery programmes, whereas hospital services are
delivered through large facilities socially detached from the community. Hospitals and PHC
should be more integrated, and the services provided by the health sector should be balanced
and inter linked, from lower level preventive and curative outreach programs to upper level
facilities. Similarly, there is need to have integration between the health and the family welfare
structures. The question remains, however, of the appropriate balance of services within the
integrated system. Efforts to integrate lower-level hospitals could increase the effectiveness of
outreach and community-based programs. Hospitals can also provide technical support for
lower level services and provide a focus for training of skilled manpower
8.2.
Resource Allocation
Not only is there a need to increase the allocation of resources to the public health system to
match the needs, but also more balanced distribution between primary, secondary and tertiary
sectors. The emphasis on primary health care has resulted in under funding of hospitals at the
secondary level. This under funding has led to deterioration in the quality of buildings and
equipment, supply of drugs and staffing especially medical and skilled paramedical personnel.
Many of the buildings need to be rehabilitated by providing continuous water supply,
uninterrupted power, clean and adequate number of toilets and arrangement for managing
solid wastes. Most of the equipment have become obsolete and needs to be replaced. The
quality of medical care needs improvement. Therefore, there is need for enhancing the
allocation of funds to the public health system, and to introduce efficiency in the utilization of
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
37
resources. A reallocation of resources will have to be based on the cost effectiveness of
different components of the health system.
’/•i
Planning and Management
8.3.
There are major weaknesses in the management of the health system in the State. At the
Directorate level, there is lack of clarity in the roles among various functionaries. There is also
a lack of adequate administrative and financial accountability. At the lower levels, the hiatus is
often sharper. While the medical officer is required to manage the hospital, all decisions on
medical and financial aspects are taken at the Directorate. In specific areas the delegation of
powers such as the maintenance of infrastructure viz., building and equipment, both at the
district and State levels is poor leading to deterioration of assets. The Government is also
considering the delegation of responsibilities to the Division and district levels. The process is
in Annex 10.
There is also a need to have an institutionalized system to study on a continuing basis:
•
•
•
changes in epidemiological profile and disease burden;
cost effective means of utilizing resources; and
continuous upgrading of manpower skills.
8.4.
Quality of Services
The hospital system in the State suffers from major handicaps. Budgets meant for maintaining
equipment and building need to be stepped up. Diagnostic facilities, equipment, ambulance
and trained personnel require strengthening. Existing norms for staffing at various levels have
to be reviewed, given the heavy pressure on the hospital system which currently results in poor
quality of services. Similarly, norms for equipment and the range of clinical services at each
level need to be worked out on a rational basis. The infrastructure needs thorough overhauling
as well as expansion to meet the needs of the over strained hospital system. Management skills
at the hospital level need to be continually upgraded. The overall environment in which the
hospitals function need improvement.
8.5.
Access and Equity
Access to public health facilities in the state is uneven. Even where physical facilities exist, the
quality and range of services is poor. Typically, in areas of the state where health status is
poor, the gaps in infrastructure are large.
There is need to have significant increase in the bed capacity in poorly served regions. Only in
18 percent of the taluks, the bed availability is equal to or more than the norm of 1679 persons
per bed, determined on the basis of epidemiology. In 35 percent of the taluks, the persons per
bed, ranges between 1,700 to 5,000. In 29 percent of the taluks, the bed availability ranges
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
38
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
|
between 5,000 to 10,000 persons per bed. Persons per bed exceeds 10,000 in 18 percent of
the taluks.
The Northern districts of Gulbarga, Bidar, Raichur, Bellary, Dharwad and Bijapur have a
relatively poorer developed health infrastructure.
There is also a major urban-rural divide with most of the well equipped hospitals located in a
few urban agglomerations of the State. The rural poor have limited access for obtaining critical
health referral services. In the urban areas also, there are imbalances. In major metropolitan
cities such as Bangalore, there are glaring inadequacies in the first referral network. The
availability of infrastructure is inadequate, as it has to not only cope with fast rising urban
population, but also with the pressure from rural areas.
There is no conscious effort to focus on reducing morbidity and mortality rates among the
disadvantaged segments of the society, such as Scheduled Castes and Scheduled Tribes.
Utilization of services by women is poor. This issue is intricately related to the low level of
women’s status, lack of public health education, as also the physical inadequacy of the hospital
services required by women.
8.6.
Work Force
In some parts of the State there is a severe shortage of staff, both in respect of doctors,
nursing staff as well as para medical personnel. Due to various reasons the recruitment
procedures have been slow. The situation is made worse by many cases of unauthorized
absence and indiscipline in the work-force, adversely affecting the quality of services.
Manpower development, specially clinical skills training and training in the maintenance of
equipment have remained neglected areas.
8.7.
Referral System
At present, the referral system does not function effectively. This is due to the following
reasons: (i) Overloading of hospitals with self-referrals; (ii) lack of confidence in lower-level
facilities because of perceived low quality of care; (iii) lack of organizational and management
links between hospitals at various levels. An effective referral system has to be designed by
focusing on three important areas: the structure of the referral system, management co
ordination and quality improvement.
It is necessary to define the mix of patients to be served and the services to be made available
at each tier of the hospital system. Referral criteria have to be established for diagnosis and
treatment for different disease categories. Manuals need to be prepared, information
disseminated, and training needs met for medical, paramedical and laboratory staff.
The effectiveness of the referral system depends on the (i) quality of services at all levels; (ii)
awareness among the public about the type of services available at each level of the health
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
39
j
1
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
system and (iii) enforcement of procedures to ensure that patients do not bypass one level,
without the consent of the health personnel at the lower level.
While designing the referral system it is necessary to involve the community. Wide publicity
has to be undertaken to disseminate information about the diagnostic, treatment and surgical
services available at the Primary level (CHC), Secondary level (Sub-District Level) and
District level Hospitals.
Management of Communicable and Other Diseases
8.8.
The recent outbreak of plague and recurrence of malaria in Karnataka serves to emphasize the
need to more effectively manage the communicable diseases. Hospital data show that
Karnataka has high incidence of the following diseases:
•
•
•
•
Tuberculosis,
Malaria,
Filaria, and
Blindness
While there are national programmes for the control of diseases, there is a need to strengthen
the r,cvct^m
surveillance system fnr
for thpir
their parlv
early dptftctinn
detection and manacement.
management. There is also a need to
effectively integrate the hospital system with the management and control of diseases at the
primary level.
Burns and Injuries
8.9.
The casualty departments of hospitals are understaffed and under equipped to handle the
increasing number of cases of bums and injuries. There is an urgent need to improve the
casualty wards by providing basic facilities in each hospital. There is also need to address the
gaps in providing emergency health care services for victims of accidents, specially along
major highways and in the proximity of factories.
8.10.
Chronic Illnesses
The increase in life expectancy that has occurred over the last four decades and that is
continuing to increase will pose greater problems of medical care for the population in the
management of chronic illnesses, specially among the older age groups.
8.11.
Role of Private sector
In terms of number of patients being served by the private sector, the role of private sector
appears very significant. Forty two percent of out patients and thirty five percent of inpatients
are treated by the private sector. There is no yardstick developed by the government to assess
their quality and ensure that unlicensed and unqualified practitioners do not provide services.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
40
UPGRAD|NG QF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
The private sector is also under-utilized in managing communicable diseases, respiratory
infections and high risk births. There is also need to utilize the services of voluntary
organizations, specially in remote and inaccessible areas. In the hospitals, contracting out
services to private agencies has not been tried out, though it could lead to significant
improvements in efficiency.
8.12
User Charges and Sustainability
The appropriateness of adopting user charge principles and imposing user fees depends on the
type of service provided. Hospital services are mostly patient related curative services. There
is a scope to levy fees or charges on curative services provided. A mechanism exists to adjust
fees depending on the patients ability to pay. Studies have shown that prescription fees
accompanied by improvement in quality can lead to increased utilization. However, the
additional revenues generated by levy of user fees may not be adequate to cover fully the
expenditure in improving quality through better facilities in terms of equipment and drugs. The
levy of user fee may be a step in restoring equity; the poor may benefit proportionately more
than the non-poor. Cost recovery with a dispensation that provides for ploughing back of
resources will be appropriate for promoting efficiency and equity.
Prescription fees will augment resources for the health sector and should, therefore, lead to
improvements in supply both in qualitative and quantitative terms. Sustainability would also be
promoted to a large extent because the revenue realised would finance a portion of the
operational costs, thereby relieving the budgetary constraint. Cost recovery would result in
improvements in the quality of care if the resources generated internally are ploughed back for
improving the availability of drugs and maintenance of facilities.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
41
|
]
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
9.
HEALTH SECTOR DEVELOPMENT STRATEGY
The State Government has begun a serious exercise to assess the strengths and weaknesses of
its Health care system. The major issues on which the State Government is engaging its
attention, and the direction of its future Reform package has been spelt out in the Health
Sector Development Policy matrix seen below.
1.
2.
ISSUE
________ EFFECT________
Adequacy of Public health expenditure is
the
overall about 5% of the state budget
size of the and 1.48 % of GDP. These
health budget health
expenditures
are
to
meet inadequate
to
provide
public health essential primary health care
goals
together with a basic package
of clinical/curative services
Imbalances in With increasing expenditure
public
on tertiary level health care,
expenditure
there has been a relative
between
decline in the investment in
different
primary and secondary level
levels of the facilities. This imbalance
health sector
needs correction.
3.
Management
4.
Regional
imbalance
PROPOSED CHANGE OR ACTION
Recognising the link between basic public health
provision and poverty alleviation, the Government will
not only maintain the share of health sector allocations
within the overall budget at least at the current level,
but will step up the allocations progressively.
The State recognises the need for focussing attention on
the primary and secondary levels of health care and also
to step up allocations for the same levels. While a
beginning has already been made, it is expected that by
the year 2000 the imbalance will have been corrected. A
riable referral system will also relieve pressures on
tertiary hospitals themselves, which will function in a
more organised and efficient manner._______________
Management of public health District, sub-district and Taluka hospitals will be
facilities in Karnataka is strengthened by improving their implementation
weak which produces low capacity. Five key areas will be addressed:
service
efficiency
and strengthening structures, systems and procedures;
effectiveness. Moreover, lack culture of service delivery; resources; decentralisation &
of appropriate management autonomy, and training. At the Directorate level the
arrangements and authority focus would be on improving management
to act means that there are effectiveness; at Taluka, sub-district and district
few incentives for hospitals hospitals; the emphasis would be on strengthening
and their staff to improve service delivery management. These changes will be
hospital
operations
and facilitated by introducing mechanisms to give back a
quality of services.
major portion of the income generated through user
charges for use by the concerned institution.__________
The six districts of Gulbarga, Through both project as well as non-project
Bidar, Bijapur, Raichur, interventions, a policy of positive discrimination in
Dharwad and Bellary show favour of the poorer developed districts will be followed
poor health indicators on to reduce the existing imbalance. This differential
account
of
uneven policy is already under implementation. The State
development in the health Government has earmarked funds for providing
infrastructure and delivery of additional resources to these districts for filling critical
services
gaps in the Primary Health Care infrastructure - in
terms of sub-centres, drugs and MCH inputs.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
42
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
5.
Quality
of
and access to
hospital
services
Quality of medical services is
inadequate;
in addition,
access to health care services
is limited especially for
populations in the least
developed areas of the State,
particularly
women,
scheduled
castes
ancT
scheduled tribes.
6.
Strategic
Planning
7.
Workforce
Inadequate
strategic
planning capacity in the
health sector has resulted in
sub-optimal use of resources.
Decisions on public health
spending priorities presently
do not take into full
consideration the size and
scope of services provided by
private-commercial
and
voluntary sectors; the health
manpower supply situation;
and the predicted future
epidemiological profile in
Karnataka._______________
Improvement of services at
hospitals is significantly
restricted
by
workforce
problems, both in terms of
quality and quantity. The
number of staff sanctioned at
hospitals does not fit current
needs; there are many
vacancies due to poor and
recruitment
cumbersome
and
procedures,
personnel
unimaginative
policies. The distribution of
medical specialists is not
commensurate with the need
e.g.: a general surgeon in
place of an O&G Surgeon
Quality and access will be improved, especially for the
poor and underprivileged, by: i) upgrading and
expanding physical capacity, ii) upgrading clinical
effectiveness and quality of services at Taluka, sub
district and district hospitals; iii) improving the referral
system e.g. for essential obstetric care for women with
high risk pregnancies; and iv) adopting staffing and
technical norms at the Taluka, sub-district and district
hospitals in line with the recommendations of the high
level committee which has been accepted by
Government. In respect of Scheduled Caste and
Scheduled Tribes access will be improved through a
system of Health Cards and bi-annual health check ups. In respect of Tribal groups this will supplement the
efforts being made through EPP-IX. NGOs will be
encouraged to maintain and operate facilities in remote
tribal areas. Poor patients who cannot afford high cost
treatment will be provided support through the recently
set up CM’s Medical Relief Fund, while at the same
time encouraging the high-tech tertiary government
institutions to enhance charges in respect of those who
can afford to pay. _____________________________
The capacity for strategic planning will be enhanced
through establishment of a Planning Cell in the Dept, of
Health and Family Welfare. This will, either
independently or through specific research projects:
study the role of the private sector; review the suitability
of present regulations evolving epidemiological profile
in Karnataka; monitor the burden of disease and
recommend cost-effective means for achieving the best
use of limited resources; and undertake periodic review
of the health manpower supply situation and training
needs in the state.
No economy orders will be imposed with regard to
recruiting staff. In a short period the problem of
mismatching in medical staff will be solved; OOD
posting banned; doctors recruited on contract where
direct recruitment process is slow and doctors will be
asked to serve a mandatory period of six years in rural
areas before being considered for posting at more
preferred places. The State Government has already
taken a decision to ban private practice by Government
Doctors, and to provide compensatory non-practising
allowance.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
43
TABLE 11.1: PROJECT GOALS
INPUT INDICATOR
OUTPUT INDICATOR
OBJECTIVE
Significant
improvement in the
Health Status of SocioEconomic backward
regions in the State
Selling up a
comprehensive referral
system in the Division
through strengthening
and revamping of the
Secondary Hospital
network in the
Division.
____________ ACTIVITIES__________
• Physical upgrading and renovation of
secondary level hospitals
•
•
•
•
•
Increase number of specialists in
medium size hospitals
Sanctioning and employment of staff in
accordance with the guidelines
Increase of drug budget
•
•
•
Upgrading and renovation of 26 hospitals
in the first phase and district hospitals in
second phase
Renovation of 7 hospitals
Upgrading of 19 hospitals with additional
650 new hospital beds
Building of staff quarters_____________
Providing more specialized services in 50
bed and 100 bed hospitals (Anaesthesist,
Paediatrician, Ophthalmologist)
Filling vacant posts for medical and non
medical designations
•
•
•
•
In each district one workshop will be set
up
Maintenance staff available at secondary
level
User training for equipment
Establishment of workshop facilities
Increase of allocation for maintenance
Assumption of maintenance
responsibilities by DHFW
•
•
•
•
•
Alternative approaches for operation
(autonomous institutions, NGO’s)
Improvement and rationalisation of cost
sharing
Introduction of reporting and
monitoring procedures
Training of collecting personnel
Reorganization of user charges_______
•
•
Improve motivation for fee collection
Increase of funds available for hospitals
and primary health care facilities
Easier accesability to curative care
Higher utilization of GH and sub
district hospitals
Less pressure on district hospitals
Staff quarters to attract doctors/staff to
rural hospital
__________________
•
•
•
•
•
Sustainability of
infrastructure and
equipment
Increase sustainability
of health care
•
•
•
•
•
•
•
•
•
Increased Acceptance of medium sized
hospitals by the population
Increase in number of out and
inpatients
Reducing of certain fatalities for
specific conditions
Reduction of infant mortality
Improvement of neonatal care,
reduction of neonatal mortality
Improvement of maternal care_______
Longer life span of medical equipment
increase the availability of equipment
due to fewer breakdowns
Lower capital investment for building
and equipment
systematic servicing of equipment
Increase efficiency of hospital
operation
Increased awareness of healtli care
cost
Greater autonomy and responsibility at
hapital level
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
|
The upgrading of services and facilities at secondary level hospitals will provide the basis for
the implementation of a more effective cost recovery system.
Within the framework of the project, measures will be implemented by the Government of
Karnataka to safeguard the operation and maintenance of the hospitals. With the
implementation of the approved Government guidelines for secondary health care facilities, the
physical upgrading concomits with the provision of better facilities as well.
Finally, the Government of Karnataka is fully committed to improving the cost sharing system.
At present, this involves income-generation from user fees and a new income distribution
structure such that the bulk of the user fees will benefit the respective health facilities. The
goals of the project are summarized in TABLE 11.1.
11.2
Selection Criteria
As mentioned earlier, the project will cover four districts in Gulbarga Division. These districts
were selected based on specific health and socio-demographic measures, i.e., comprising the
less developed areas in the state.
Activities for this project will be confined to 50 and/or 100-bed secondary level hospitals
primarily located in the taluka headquarters, i.e., the sub-district hospitals. The upgrading of
PHCs to CHCs is not included in this project because the 30-bed CHCs, as per current
standard norms, do not constitute health care facilities which provide the minimum hospital
based services for the community. As such, these facilities tend not to be utilized by patients
seeking care. Instead, the next higher level of hospital care is utilised, i.e. the 50 or 100-bed
facilities. The location of some of the 30-bed CHCs are also more remote, hence, staffing is
problematic due to the lack of facilities such as housing and schools.
In each district, facilities to be upgraded were identified based on specific criteria at taluka
level or facility level, which are as follows:
Taluka-based criteria.
•
•
•
•
socio-economic background
health indicators
population catchment size (within 15 km of facility)
population per secondary hospital bed ratio
Facility-based criteria:
•
•
•
•
patient load
physical accessibility for patients
accessibility for health personnel
conditions of buildings and facilities
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
49
MAP
OF DISTRICTS
IMPLEMENTATION
FOR
PROJECT
B idar 9
•Sulbarga
Bijapur
e
Raichur •
Selgaum
Dhar wcid
o
BeUoryCl^^Am ?
Kar war
• Chilradurg
Shimoga.
C h ickmagal ur
\_7^
e I u m k«j f
Koi ar
J
o
HaSSan
Bangalore
M andya
Niysor e
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
•
proximity to other secondary level health facilities
The above factors served as a general guide in the selection process. At the same time, other
factors specific to each facility may be incorporated as justification for selection. Based on the
above criteria, a principle list of facilities was established which is approved in principle by the
Government of Karnataka.
11.3
Project Components
The project scope comprises renovation, physical upgrading and expansion, i.e., the upgrading
of secondary health care facilities and workshops at district level for improvement of
maintenance. The project also includes measures to strengthen and improve the operation of
these facilities by sanctioning and engagement of additional manpower as well as provision of
additional operational budget for drugs and maintenace. The project components to be
included are described below.
11.3.1 Renovation and Upgrading of Facilities
Gulbarga Division has the highest ratio of population per bed in the State of Karnataka. There
are 14 CHC’s, 28 GH’s (General Hospitals or Sub-District Hospitals) and 5 DH’s.The total
number of beds (excluding beds of PHC’s is 2,959)
Within the project, secondary health care facilities will be renovated or upgraded. The
following definition applies for this project:
Renovation means that the existing buildings will be further improved, unsatisfactory
functions corrected and missing functional units added. Engineering service components
will be repaired and if necessary replaced. Non functional equipment will be replaced or
equipment required but not available provided
•
Upgrading means the existing facility will be upgraded to the next higher level facility and
all necessary buildings, engineering services and equipment will be provided. Existing
buildings and engineering services will be incorporated as part of the overall exercise and if
necessary renovated.
The total number of facilities in the project is 47 hospitals for phase one and two whereby in
the first phase 26 hospitals will be renovated or upgraded. Out of the 26 hospitals of the first
phase, 15 hospitals will be upgraded from 30 to 50 beds and 4 hospitals will be upgraded
from 30 beds to 100 beds A further 7 hospitals in phase one will be renovated. In most of the
facilities additional staff quarters will be included. The upgrading will result in the addition of
627 new hospital beds. TABLE 11.2 provides an overview of increase of hospital beds per
district
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OP KARNATAKA
50
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
TABLE 11.2: Distribution of Existing and new Hospital Beds by District (Secondary Level)
FUTURE
POPULATION
FUTURE
NEW BEDS
POPULATION
EXISTING
DISTRICT
PER BED
TOTAL BEDS
BEDS
PER BED
2,270
563
140
2,970
423
Bidar
1,710
1,105
96
1,009
1,873
Bellary
2,016
1,280
154
2,291
1,126
Gulbarga
3,611
638
213
5,420
425
Raichur
TOTAL
603
The ratio of population per bed in Raichur District after upgrading and renovation will be
reduced from 5,745 to 3,611. This ratio will be further reduced when the 500 bed hospital
financed by OPEC is implemented. Taking the 500 beds into account, the population per bed
will be further reduced to 2,025 which is in line with all the other districts.
With the physical upgrading, the hospitals will provide improved medical services in
accordance with the new guidelines by the Government of Karnataka by availing more
specialist doctors and other categories of medical staff. The guidelines for staffing, space
allocation and equipment for 30, 50 and 100-bed hospitals were finally defined by a “High
Level Review Committee” in March 1995. The basic norms are enclosed in ANNEX 3.
Under this component of the project, the financing of design and engineering, civil works,
engineering works, medical equipment, initial supply and vehicles will be provided. The
renovation or upgrading includes infrastructure, building, landscaping as well as water storage,
waste water treatment (septic tanks), emergency generator and waste treatment equipment
(incinerator).
Within the project budget, 11% of the total project cost is provided for sustaining of medical
services in district hospitals until the second phase of the project is implemented. This amount
wiil be used only for emergency purposes-.
The total amount planned for the renovation or upgrading of secondary health care facilities is
IR 233.35 million or equivalent to DM 11.11 million. This amount represents 74% of the
project cost.
TABLE 11.3 provides the overview of the project cost for each facility which will be
renovated or upgraded in the first phase of the project (four years). The description of the
scope of renovation and upgrading for these hospitals is provided in the APPENDIX (Facility
evaluation,development and costing).
The project scope for the second phase and the respective project cost for upgrading and
renovation will be defined before the mid-term review of the first phase.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
51
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
J
TABLE I l.3:Summary of Facilities to be Up graded
FAciLirr
______________PROJECT SCOPE
PROJECT COST (!R)
_________ BIDAR DISTRICT
Upgrading 30 beds to 50 beds
.degrading 30 beds to 50 beds
Upgrading 30 beds to 100 beds
GH Aurad
GH Easavakaiyan
GH 3halki
DH Bidar
GH Humnab'ad
9,057.000
9,124,000
16.378,000
Phase 2
Upgrading 30 beds to 50 beds
Renovation (equipment only)
CHC Mannekahaili
8,431,000
3,553.000
46.543.000
TOTAL
BELLARY DISTRICT
OH Bellary
Womens Children Hospital
GH Hadagalli
GH Hagaribommanahb.AjL
Phase 2
Phase 2
Upgrading 30 beds to 50 beds
4,499,000
Phase 2
Phase 2
GH Harappanahalli
GH Hospet
GH Kudliqi
B.9T2.Y3tion .(100 beds)
Upgrading 24 beds to 50 beds
Renovation
Upgrading 30 beds to 50 beds
Upgrading 20 beds to 50 beds
CHC Chikkajogihalli / TK Kudligi
GH Sandur.
GH Sirguopa
6,166,000
8.319,000
Z.31.AOOO
8,984.000
6.700.000
TOTAL
41,982,000
GULBARGA DISTRICT
Upgrading 30 beds to 50 beds
Upgrading 30 beds to 50 bees
Renovation
GH Afzalpur
GH Aland
CHC Madanahippargi / Aland
CHC Nimbarga / Aland
GH Chincholi
CHC Gaddakeshwar / Chincholi
GH Chitapur
CHC Hebbal / Chrtapur
CHC Kalgi / Chitapur
CHC Shahbad / Chitapur
DH Gulbarga
GH Jevargi
GH Gedurn
CHC Mudhol / Sedum
GH Shahapur
GH Shorapur
GH Yadgir
CHC Gurumatkal / Yadgir
10.703,000
11,512.000
9.551,000
Phase 2
Upgrading 30 beds. to 50 beds
11.546,000
Phase 2
Phase 2
Phase 2
Renovation
Renovation
3,217.000
10.243,000
Phase 2
Upgrading 30 beds to 50 beds
7,047,000
Phase 2
Phase 2
Renovation (50 beds)
6,788,000
Phase 2
10,124,000
Upgrading 50 beds to 100 beds
Phase 2
TOTAL
80,731,000
_______ RAICHUR DISTRICT
Upgrading 30 beds to 50 beds
Upgrading 30 beds to 100 beds
GH Devadurga
GH Ganawati
CHC Kanakagiri / Ganawati
CHC Koratgi / Ganawati
GH Koppai
11.476,000
12,296.000
Phase 2
Phase 2
Upgrading 17 beds to 50 beds
Upgrading 30 beds to 50 beds
Upgrading 50 beds to 100 beds
GH Kushtagi
GH Lingsugur
CHC Mudgal / Lingsugur
GH Manvi
DH Raichur
GH Sindhnur
GH Yelbarga
CHC Kuknoor / Yelbarga
9.875,000
8.228.000
T1..132,000
Phase 2
Phase 2
Phase 2
Upgrading 30 beds to 50 beds
11,083.000
Phase 2
Phase 2
TOTAL
64,090,000
TOTAL COST
233,346,000
<^ov - no
0/333
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT
X*'—is?"y
I”
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
11.3.2 Improvement on Maintenance
The main reason for the present poor maintenance is Uck of funding, insufficient maintenance
facilities and manpower, and also complicated procedures for the execution of maintenance
services. To improve the maintenance of the secondary level facilities, the setting-up of a
workshop at division and district level is proposed.
The establishment of the proposed four workshops will provide basic maintenance for the
medical equipment, engineering services and will be responsible for the management of all
maintenance activities. Each workshop will be responsible for all sub-district and district
hospitals. The workshop at division level will in addition be responsible for training o
biomedical technicians and user-training. The element comprises the establishment of building,
supply of workshop equipment and initial spare parts and consumables as well as the purchase
of a vehicle for each wokshop. The respective maintenance concept for the project is enclosed
in ANNEX 7.
Maintenance will utilize 2% of the total project cost which is IR 800 million equivalent to DM
0.38 million.
11.3.3 Clinical, Technical and Management Training
All training for Gulbarga Division will be covered within The World Bank project. The
training includes upgrading of clinical, technical and management skills of hospital staff.
11.3.4 Improvement on Sustanability of Medical Services
Besides strengthening the maintenance aspect, the improvement of cost sharing will be an
important factor to ensure better sustainability. The improvement of cost sharing wil be
treated by two means. First, the present mechanism relating to procedures for fee collection in
government health care facilities will be enforced and the respective adjustments of fees
reorganization of fee collection and establishment of a monitoring and evaluation system will
be implemented during the project period. Secondly, the distribution of income generate ,
which is presently mainly collected only in the district hospitals, will be restructured. The
income from patient fees is now transferred directly to the state Treasury and cannot be used
by the DHFW. In future, the collected fees will be reallocated such that at least 75/o ot the
income will be made available to the income-generating facility. The outline of the cost
sharing system which shall be implemented is enclosed in ANNEX 5.
’ j component will be IR 4.00 million, equivalent
The contribution for the implementation of~ this
to DM 0 .19 million which represents less than 1% of the project funding.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
53
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
11.3.5 Contribution of the Government of Karnataka
The Government of Karnataka assures that increases to the health care budget will continue in
the same proportion as in preceding years. This is in accordance with the present economic
development of the country.
With the physical upgrading of the hospital facilities, the Government of Karnataka will also
improve the services provided in the hospitals by sanctioning additional staffing and additional
operating expense budget (especially for maintenance and drugs) for the upgraded facilities as
well as for the facilities which wall be renovated or upgraded in the second phase. The basis for
the services provided in the respective facilities is outlined in the report of the High Level
Review Committee enclosed in ANNEX 4.
The estimate of the contribution by the Government of Karnataka is indicated in ANNEX 6
which is mainly for additional staffing, implementation of workshops, increase of budget
norms for drugs and maintenance and for project management participation. The total amount
contributed by the Government is IR 69.70 million, equivalent to DM 3.32 million. The
contribution of the Government represents approximately 18% of the funding provided by
KfW.
11.3.6 Project Management
At the APEX of the project management team will be the Governing Board headed by the
Chief Secretary to the Government followed by the Steering Committee headed by the
Secretary to the Department of Health. The project management will be formed at Gulbarga
Division level. The project management team will function at division and district levels.
An important difference in the present project is that all the required design and engineering,
and supervision of construction will be tendered and provided by the private sector. All civil
works and engineering works will be tendered at district level and all supply of equipment and
vehicles will be tendered locally. Tendering will be executed in accordance with the guidelines
ofKfW.
An independent project management monitoring team will be appointed by the government to
assist the project management team at division level in the execution of the project.The basic
management concept is enclosed in ANNEX 8.
For the final approval of the second phase, a mid-term review will evaluate the project
progress of the first phase after three years of implementation. The mid-term review will also
define the scope of work and the final budget of the second phase of the project.
The cost estimation of the project management amounts to IR 39.32 million which is
equivalent to DM 1.87 million. The amount represents 10% of the project funding.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA.
54
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
11.4
The Selected Facilities
The basis for the selection of facilities for upgrading are described herewith by district and
taluka. It should be noted that selection was confined to data and other information that were
provided-by the state or district health authorities. The information was verified by the survey
team at each of the sites. In accordance with the survey team’s findings, the scope of
services for upgrading was changed in some cases. Thus, the final report may differ from the
Stage Report submitted at beginning of May 1995 as the survey will be completed at the end
of May 1995.
Although the upgrading is described in terms of bed capacity, it must be noted that bed
capacity corresponds with other facilities, such as number of professional staff including
medical specialists and range of services offered.
In the following section, the socio demographic indicators and data related to existing beds
may differ from data in the previous section. The information provided in the section below
are the most recent figures from district statistics which were collected within this year.
The discription of each facility which will be renovated or upgraded is given in ANNEX 9.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
55
!
KARNATAKA
DISTRICT BIDAR
ii
Kms
5
0
.Ip Kms
10
OIGLUR
7
FROM PARIL
FROM UOGIR
50
1AURAD
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UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
11.4 1 Bidar District
Bidar District located in the far north ot the State of Karnataka is an important centre for
pilgrims who are devotees of Guru Nanak. The total population of 1,255,799 is the smallest in
comparison with the districts in the Gulbarga Division and is divided into 5 talukas. The urban
population is only about 10% and as in all other districts in this Division, the majority of the
population is comprised of agricultural workers.
TABLE 11.4: Socio Demographic Indicators BidarDistrict
~
BIRTH
DEATH
________________
RATE
RATE
LITERACY
District Bidar
n.a.
n.a.
n.a.
TK Bidar
27.4
8.8
50.96
TK Aurad
27.6
8.5
39.50
TK Bhalki
29.5
8.8
46.47
TK Humnabad
28.2
8.7
42.87
TK Kalyani
28.3
8.9
42.95
IMR
n.a.
71.0
72.0
72.1
72.0
72.3
MMR
n.a.
1.8
1.8
2.4
2.1
2.0
POPULATION
1,255,799
223,436
210,040
196,042
201,378
____ 203,592
Although the literacy level in the district is above the Division average, the birthrate is one of
the highest in comparison with all districts in the state.
Within the first phase of the project scope, four hospitals will be upgraded and an additional
140 beds provided. The CHC in Mannekahalli will be renovated in the second phase. Besides
Raichur, Bidar District has the lowest ratio erf population per secondary level hospital bed in
Karnataka. The ratio of population per bed will be reduced from the present 2,970 to 2,230.
The distribution of secondary level hospital beds is shown in TABLE 11.5 below.
TABLE 11.5: Health Services Facilities Bidar Dlistrict______
ACTUAL
PHC’s
_____ CHC's/GH’s
NO.
BEDS
NO.
BEDS
District Bidar
36
268
7
423
TK Bidar
6
58
2
283
TK Aurad
7
62
1
20
TK Bhalki
8
40
1
30
TK Humnabad
7
52
2
60
TK Kalyani
8
56
1
30
NEW
BEDS
NO.
140
30
70
20
20
FUTURE
/z<l n '
CHC's/GH's
NO.
BEDS
7
563
2
283
1
50
1
100
2
80
1
50
The district map is shown in the opposite page which indicates the location of the health care
facilities.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
56
a.
<(
cr
O
KARNATAKA
DISTRICT
RAICHUR
Kms5
Kms
FROM
GULBARGA
6
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BOUNDRY STATE
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HEAD QUARTERS DISTRICT, TAUJK. ...|
STATE HIGHWAY
RAILWAY LINE WITH STATION,
tbT^elbarga
KANAKkGlRI
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R = RENOVATION
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UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION. KARNATAKA
11.4.2 Raichur District
Raichur district is bordering the districts of Gulbarga (in the north) and Bellary (in the south).
The district population of 2.3 million has the highest ratio of population per bed in the state of
Karnataka. The district with 78% comprising of rural population is one of the poorest and is
typical for the region with the majority of the population working as agricultural workers. The
literacy levels for all talukas in this district are lower than the state average.
TABLE 11.6: Socio Demographic Indicators Raichur District
BIRTH
DEATH
RATE___
RATE
LITERACY
District Raichur
26.2
8.5
35.96
TK Devandurga
24.0
8.8
21.61
TK Gangawati
21.0
8.4
36.25
TK Koppal
21.5
8.6
42.39
TK Kushtagi
26.3
8.8
35.34
TK Lingsugur
20.9
8.5
35.19
TK Manavi
24.7
29.14
8.9
TK Raichur
21.2
8.3
43.62
TK Sindhur
20.5
8.8
34.48
TK Yelbarga
24.4
8.1
39.10
IMR
73
79
71
70
72
72
81
69
72
71
MMR
3.61
4.26
3.71
3.13
3.79
3.27
4.19
3.89
3.58
3.75
POPULATION
2,309,887
176,889
255,551
207,111
189,891
211,096
241,193
201,295
240,383
196,080
Within the first phase of the project scope, six hospitals will be upgraded and an additional 213
beds provided. Raichur District has the lowest ratio of population per secondary level bed in
Karnataka. The ratio of population per bed will be reduced from the present 5,420 to 3,620.
The distribution of secondary level hospitals is shown in TABLE 11.7 below.
There are plans to build a 500-bed district hospital financed by the OPEC Fund. However,
the construction work has not yet begun. With the establishment of the OPEC financed
hospital, the ratio of population per bed will be further reduced to 2,030.
TABLE 11.7: Health Services Facilities Raichur District
ACTUAL
PHC's
CHC’s/GH’s
NO.
BEDS
NO.
BEDS
District Raichur
69
414
13
425
TK Devandurga
5
30
1
30
TK Gangawati
10
60
3
42
TK Koppal
9
54
1
17
TK Kushtagi
6
36
1
30
TK Lingsugur
10
60
2
56
TK Manavi
9
54
1
30
TK Raichur
6
36
1
130
TK Smdhnur
8
48
1
30
TK Yelbarga
6
36
2
60
NEW
BEDS
NO. .
213
20
70
33
20
50
20
FUTURE
CHC^s/GH’s
NO, ‘
13
1
3
1
1
2
1
1
1
2
BEDS
638
50
112
50
50
106
30
130
50
60
The district map is shown in the opposite page which indicates the location of the health care
facilities.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
57
-pCE O
KARNATAKA
p/
DISTRICT BELLAS
50
Kms 5
1RUGUPPA:
i
IB
FROM
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9-
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NATIONAL HIGHWAY
............................
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50
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R = RENOVATION
EXISTING
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UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
11,4.3 Bellary District
Bellary District located in the south of the Gulbarga division has a population of 1,890,000. In
comparison to the other districts in the division, Bellary' is the most advanced district. Most of
the socio demographic indicators are above the average at division level. The urban population
comprises approximately 35 % and is the highest in the division.
TABLE 11.8: Socio Demographic Indicators Bellary District
birth
DEATH
RATE
RATE
LITERACY
n.a.
n.a
n.a.
District Bellary
TK Bellary
TK Hadagalli
36.4
27.8
8.6
TK
Hagaribommana.
25.0
40.0
8.0
27.5
41.9
TK Harpanahalli
6.2
26.0
45.0
TK Hospet
9.0
TK Kudligi
TK Sandur
30.0
8.9
39.3
TK Siruguppa
IMR
n.a.
MMR
n.a.
60.0
85.2
79.0
4
79.0
2
POPULATION
140,280
146,778
312,788
4
198,635
In Bellary there is a teaching hospital with 210 beds and the district hospital is also a medical
college with 512 beds at present. Six facilities have been selected for renovation or upgrading
and the conversion of four GH to 50 bed sub-district hospitals. Two hospitals will be
renovated whereby the sub-district hospital with 94 existing beds will be the largest hospital to
be renovated in the first phase. The total number of new beds is 96 as described in TABLE
11.9 below. The ratio of population per bed will improve from 1,870 to 1,710 after the first
phase.
TABLE 11.9: Health Services Facilities Bellary District_______
ACTUAL
CHCs/GH’s
PHCs
NO.
BEDS
NO,
BEDS
260
10
1,009
District Bellary
72
TK Bellary
18
42
2
722
8
30
20
1
TK Hadagalli
30
6
28
1
TK Hagaribommanahalli
34
1
48
13
TK Harappanahalli
94
32
1
TK Hospet
9
69
8
2
36
TK Kudligi
30
4
20
1
TK Sandur
54
1
20
6
TK Siruguppa
NEW
BEDS
NO,
96
20
R
IR + 26
20
30
FUTURE
CHC’s/GH’s
NO.
BEDS
10
1,105
722
2
1
50
30
1
34
1
94
1
2
95
50
1
50
1
The district map is shown in the opposite page which indicates the location of the health care
facilities.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
58
KARNATAKA
DISTRICT GULBARGAU
R
FROM
Kms5
WAGOAR I
50
S'
r
0
5
10 15 20Kms
o
a/TO BIDAR
TO HOM NA 8 AD
1
'■Q
"Na
Maland
tbv\
*
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TO 01 OAR
—
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50^0
—£1
• CHINC HOLirV.
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GUL SAPGA
50
TO HYDERABAD
>af2alpur
0 GHANGAPUR
SHAHABAD
i
I
Hl TAPI.
Q
WADI
£
FROM SINOGI
100
G UR MAT
YADGIR
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)
Tic
R
<Kembnavt
<-•
SHORAPURWs
I
Ttb
V
C
TO RAICHUR
FROM
DEVA DURGA
R = RENOVATION
.L^ 3
BOUNORY STATS
’•*
DISTRICT
—
—
HEADQUARTERS DISTRICT, TALUK.
STATE HIGHWAY.
RAILWAY LINE WITH
—
STATION.
B.G
PLANNED
i
I
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
11.4.4 Gulbarga District
The Gulbarga district, headquarters of the division is the largest and most populated district
(2,582,000). Gulbarga is similar to Bellary District and is one of the more urbanised districts in
the state but workers in the agricultural sector are the majority in the distict.
TABLE 11.10: Socio Demographic Indicators Gulbarga District
BIRTH
DEATH
RATE
RATE
IMR
LITERACY
District Gulbarga
32.3
9.2
73.0
34.2
TK Aland
33.1
9.1
73.0
29.9
TK Afzalpur
30.0
10.0
74.0
25.5
TK Chincholi
33.0
10.5
36.4
73.5
TK Chitapur
32.5
10.0
74.0
24.7
TK Gulbarga
30.0
9.0
71.0
30.3
TK Jevargi
32.0
9.0
72.0
25.7
TK Sedam
33.0
24.5
10.0
73.0
TK Shahapur
33.3
10.0
73.0
33.0
TK Shorapur
32.5
9.2
44.4
74.0
TK Yadgir
33.0
9.1
30.6
73.5
MMR
3.3
3.0
3.6
2.9
2.7
2.7
3.0
3.1
.3.1
3.0
3.0
POPULATION
2,582,169
234,270
150,856
189,161
234,015
219,845
188,707
139,885
208,417
247.079
216,742
The main district hospital in Gulbarga with 750 beds also serves as a teaching hospital. In
Gulbarga, five facilities have been selected for upgrading and another four hospitals for
renovation. The total number of new beds proposed is 154 as shown in TABLE 11.11 below.
The ratio of population per hospital bed will be reduced from 2,290 to 2,020.
TABLE 11.11: Health Services Facilities Gulbarga District
ACTUAL
PHC's_____
CHC’s/GH's
NO.
BEDS
BEDS
NO.
District Gulbarga
83
529
17
1,126
TK Aland
11
66
3
36
TK Afzalpur
6
36
1
6
TK Chincholi
9
54
60
2
TK Chitapur
7
72
4
57
TK Gulbarga
8
48
1
751
TK Jevargi
8
48
1
30
TK Sedam
4
25
2
56
TK Shahapur
9
54
1
50
TK Shorapur
9
54
1
30
TK Yadgir
12
72
1
50
NEW
BEDS
NQ154
20+1R
44
20
2R
20
1R
50
FUTURE
CHC’s/GH's
NO.
BEDS
17
1280
3
56
1
50
2
80
4
57
751
1
1
50
2
56
1
50
1
30
1
100
The district map is shown in the opposite page which indicates the location of the health care
facilities.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
59
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
12.
PROJECT BUDGET
The following project budget comprises the renovation or upgrading cost of each hospital
based on the hospital survey for each of the proposed facilities and cost estimation for the
other project components. All price assumptions are based on 1995 prices. Although the
exchange rate is presently (June 1995) 1DM= 22IR which is due to the low USS rate in
comparison with the DM the exchange rate for the project calculation has been assumed at
One German Mark to Twenty One Indian Rupees (1DM = 2HR).
12.1
Budget for upgrading offacilities
The need for upgrading and expansion of each facility is based on item prices for civil works
and engineering services, fees for design and engineering, medical equipment, initial supply
and vehicles. For the upgrading and renovation cost the following assumptions for each facility
has been made:
•
The cost of civil works which aso includes cost for infrastructure, landscaping and
engineering services are shown in APPENDIX A (Project Brief). In addition, 15% of the
cost of civil works are provided for minor renovation and repair works which has not been
calculated in the Project Brief.
•
The cost for new medical equipment or major replacement is shown in APPENDIX A
(Project Brief). The standard for medical and non medical equipment is in accordance with
the norms for secondary level facilities.
•
Fees for design, engineering and supervision excluding project management is based on
10% of the cost of civil works. The design, engineering and supervision will be executed
by external companies. The 10% rate takes into account for the hospital project, which
involves upgrading and renovation, a higher pecentage on fees.
•
Initial supply is based on IR 100,000 for hospital upgrading from 30 to 50 beds and IR
200.000 for upgrading from 30 beds to 100 beds. Hospitals which are only renovated will
not be provided with initial supplies.
•
Each hospital upgraded or renovated with 50 beds or 100 beds will be supplied with an
ambulance which is calculated at IR 400,000.
TABLE 12.1 provides the overview of project cost for each facility in accordance with the
above mentioned assumption.
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
60
j
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
TABLE 12.1: Summary of Cost for Renovation and Upgrading
CIVIL
WORKS
FACILITY
VEHICLE
TOTAL
100,000
100,000
200.000
100,000
_____ 0
500.000
400,000
400,000
400.000
400.000
_______ 0
1,600,000
9,057,000
9,124,000
16,378,000
8,431,000
3,553,000
46,543,000
1.373,000
2.939,000
2,316,000
2,681.000
100,000
0
100,000
0
400,000
400,000
400,000
0
4,499,000
6,166,000
8,319,000
7,314,000
100,000
100,000
400,000
400,000
400,000
2,000,000
8,984.000
6,700,000
41,982,000
100,000
100,000
0
100,000
0
0
100,000
0
200,000
600,000
400,000
400,000
0
400,000
0
0
400,000
400,000
400,000
2,400,000 |
10,703,000
11,512,000
9,551,000
11,546,000
3,217.000
10.243,000
7,047,000
6,788,000
10,124,000
80,731,000
6,635,000
5,600,000
5,177,000
4,865,000
6,900,000
6,380,000
35,557,000
2.444,000
483,000
724,000
1,468.000
379,000
568,000
2.109,000 |~13,221,000
3,162,000
GULBARGA DISTRICT
2,214.000
639,000
958,000
2.293.000
698,000
1,046,000
1.501,000
644,000
966,000
1,877,000
734,000
1,100,000
1,621,000
128,000
191,000
1,459,000
703,000
1,054,000
1.806,000
379.000
569,000
2.904,000
279,000
418.000
4,554,000
398,000
596,000
4,602,000 | 20,229,000
6,898,000_____
RAICHUR DISTRICT
2,682,000
664,000
995,000
4,696,000
560,000
840,000
2,904,000
518.000
776,000
1,647,000
487,000
729,000
1,907,000
690,000
1,035,000
638,000 __ 2.608,000
957,000
16,444,000
3,557,000
5,332.000
100,000
200,000
100,000
100,000
200.000
100,000
800,000
400,000
400,000
400,000
400,000
400,000
400,000
2,400,000
11,476,000
12.296.000
9,875,000
8,228,000
11,132,000
11,083,000
64,090,000
129,595,000
19,434,000
60,653,000
2,300,000
8,400,000
233,346,000
5,176,000
5,826,000
9,326,000
4,645,000
1,973,000
26,946.000
GH Hadagalli
GH Hospet
GH Kudligi
CHC Chikkajogthalli /
Kudligi
GH Sandur.
GH Sirguppa
TOTAL
2,101,000
2.262,000
4,403,000
3,706,000
4,833,000
3,785,000
21,090,000
GH Afzalpur
GH Aland
CHC Madanahippar.Aland
GH Chincholi
CHC Kalgi / Chitapur
CHC Shahbad / Chitapur
GH Jevargi
GH Shahapur
GH Yadgir___________
TOTAL
6,392,000
6.975.000
6,440,000
7,335,000
1.277,000
7,027,000
3,793.000
2,787,000
3,976,000
46,002,000
GH Devadurga
GH Ganawati
GH Koppal
GH Kushtagi
GH Lingsugur
GH Sindhur__
TOTAL COST
INITIAL
SUPPLY
EQUIP
2,087.000
1.341,000
4.120,000
2,124.000
1.087,000
10,759,000
GH Aurad
GH Basavakalyan
GH Bhalki
GH Humnabad
CHC M^nnekahalli______
TOTAL
TOTAL
GEN .
REPAIR ____ FEES
BIDAR DISTRICT
776,000 ”
518,000
583,000
874,000
933.000
1,399.000
465,000
697.000
197,000
296.000
2,696,000
4,042.000_______
BELLARY DISTRICT
210.000
315,000
226.000
339,000
440.OCO
660,000
371.000
• 556,000
12.964,000
The total cost of upgrading and renovation amounts to IR 233,35 million which is equivalent
to DM 11,11 million. In the following TABLE 12.2 the breakdown of the upgrading cost is
provided.
TABLE !2.2: Breakdown of Upgrading and Renovation of Facilites
______________ ITEM ____________
Civil Works & Engineering Services
Design&Engineering fees
Medical Equipment
Initial Supplies
Vehicles
________
TOTAL_______________
Exchange Rate 1DM=21IR
COST IN IR
149.029,000
12.964.000
60.653,000
2,300,000
8,400.000
COST IN DM
7.097,000
617.000
2,889,000
109,000
400,000
233,346,000
11,112,000
PERCENT
OF TOTAL
64%
6%
26%
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
1%
3%
100%
61
1
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
12.2
Provision for Sustaining of Sendees at the District Hospitals
For urgent repair of building and upgrading of engineering services and for urgent replacement
of medical equipment, an amount of IR 35.0 million or DM 1.67 million will be reserved. This
amount represents 11 % of the project budget. The amount allocated for this purpose is mainly
for the district hospitals in Bidar and Bellary
12.3
Maintenance facilities
The maintenance budget is required for the strengthening of the Division Workshop with
respect to facilities, equipment, tools and vehicles. In each district, one workshop will be
established. Also incorporated for the project period of four years, are the costs of training
technicians and user training as well as reorganization of the maintenance procedures. The
budget for maintenance is listed below in TABLE 12.3.
TABLE 12.3: Breakdown of Maintenance Budget in IR
Building cost
Equipment cost
Vehicles
Spare parts
Training
2,600,000
2,700,000
1,000,000
1,200,000
500,000
TOTAL
8,000,000
The total amount required for maintenance will be IR 8.00 million which is equivalent to DM
0.38 million.
12.4
Improvement of Cost Sharing
The project component on improvement of cost sharing will apply for the state of Karnataka.
Cost for strengthening and developing cost sharing is estimated as follows:
Local consultant fees for development of cost
sharing
Training workshops including allowance and travel expenses for trainees
TOTAL
in IR
2,500,000
1,500,000
4,000,000
The amount for improvement of cost sharing is equivalent to DM 0.19 million and represents
1% of the overall project cost.
12.5.
Project Management
The project management team will be in-charge of the implementation of the project. This
team will consist of external consultant and staff from the DHFW The budget for the project
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
62
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
management and its elements are listed in TABLE 12.4. This includes the salaries for staff
seconded by the DHFW.
TABLE 12.4: Breakdown of Budget for Project Management
MANPOWER
OFFICE EQUIPMENT
OFFICE OPERATION AND TRAVEL EXPENSES
VEHICLES
PROJECT MONITORING
MID-TERM REVIEW_____________________________ __
8,000,000
1,000,000
960,000
2,000,000
22,360,000
5,000,000
39,320,000
TOTAL
The project management budget represents 12% of the total project cost.
Summary of cost ofproject components
12.6
In the following TABLE 12.5 the summary of all project components is provided. The total
project cost amounts to IB 319.67 million which is equivalent to DM 15.22 million.
TABLE 12.5: Breakdown of Project Cost
PROJECT ELEMENTS
Construction
Fees for design and engineering
Equipment
Initial supplies
Vehicles
Provision for district hospitals
Maintenance
Cost sharing development
Project management_________
TOTAL PROJECT COST
* Exchange rate IR:: DM = 21:1
12.7
COST (Rs)
149,029,000
12,964,000
60,653,000
2,300,000
8,400,000
35,000,000
8,000,000
4,000,000
39,320,000
COST (DM)*
7.097.000
617,000
2,889,000
109,000
400,000
1.667,000
381,000
190,000
1,872,000
% OF TOTAL
PROJECT COST
47%
4%
19%
1%
3%
11%
2%
1%
12%
319,666,000
15,222,000
100%
&
Contribution by the Government of Karnataka
The recurring cost during the project period, such as salaries, drugs, diet and office expenses
will be bom by the Government of Karnataka. The government will sanction the posts for the
required additional staff for the upgraded facilities and contribute towards the respective
budget. The cost estimation for the recurring cost is based on the following assumptions:
Salary hospital staff
Salary maintenance staff
Drugs and chemicals
Diet and other expense
Maintenance
Project management
TOTAL
36,000,000
5,000,000
6,000,000
4,200,000
10,500.000
8,000,000
69.700,000
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
63
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
The total number of newly provided beds within the project is approximately 700 whereby
some hospital facilities would have been completed before the end of the project. The
contribution within the project period of completed beds and the relevant recurring costs
amounts to IR 69.70 which is equivalent to DM 3.32 million. This amount is approximately
18% of the total project cost not considering contingency and inflation.
12.8
Total Project Budget
Within the total project budget, a 10% contingency rate of project cost or 7% of total project
funding is included. Approximately 8% inflation rate per year has been considered ((8% per
year of project cost) which represents 23% of the total project funding. The present inflation
rate is approximately 10% per year but this inflation will be partly offset by the currency
exchange rate between DM and 1R. The breakdown of the total budget is shown in TABLE
12.6.
TABLE 12.6: Breakdown of Total Budget
PROJECT ELEMENTS
Project cost (Table 12.5)
Contingency
Inflation
COST (Rs)
319,666,000
32,334,000
105,000,000
COST (DM)*
15,222,000
1.540,000
5,000,000
Sub-total (Total Funding)_____
Contribution of the government
457,000,000
69,700,000
21,762,000
3,319,000
GRAND TOTAL project cost phase 1
* Exchange rate IR:: DM = 21:1
526,700,000
25,081,000
12.9
% OF TOTAL
PROJECT COST
70%
7%
23%
100%
Project cashflow
Based on the preliminary time schedule, the project budget will be subdivided over the 4 years,
as shown in TABLE 12.7.
TABLE 12.7: Distribution of Project Budget by Year
Year 1
Year 2
Year 3
Year 4
AMOUNT (IR)
KFW
!; GOV. KARN
35,000,000
3.000,000
100,000,000
5,000,000
142,000,000
24,000,000
180,000,000 j
37,700,000
AMOUNT (DM)
i GO^ KARN
KFW
143,000
1,667,000
238,000
4,762,000
1,143,000
6,762,000
8,571,000 ‘
1.795,000
% OF TOTAL
KFW f GOK
4%
8%
22% I
7%
31% '
35%
39% j
54%
TOTAL
457,000,000 I
21,762,000 j
I
100% I
YEAR
69,700,000
3,319,000
DEPARTMENT OF HEALTH AND FAMILY WELFARE. GOVERNMENT OF KARNATAKA
100%
64
[
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
12.10 Cost Estimation for the Second Phase
The second phase will mainly comprise the renovation of the district hospitals and some of the
remaining general hospitals or community health centres which will be renovated or upgraded.
The final approval of the second phase will be pending on the findings of the mid-term review
which will be undertaken in the third year of the project implementation of the first phase.
As preliminary costing, the following assumptions have been made as shown in TABLE 12.8
TABLE 12.8: Cost estimation of the Second Phase
___________________ ACTIVITY
District hospital Bidar
”
District hospital Bellary
District hospital Gulbarga
District hospital Raichur______________
Sub-total district hospitals
Renovation and upgrading of other facilities
Other project components
Inflation (30% of Grand Total)
COST IN IR
25,000,000
30,000,000
20,000,000
_______ 20,000,000
_______ 95,000,000
_______ 60,000,000
35,000,000
_______ 80,000,000
COST IN DM*
1,190,000
1,429,000
952,000
___________ 952,000
_________ 4,523,000
_________ 2,857,000
_________ 1,667.000
_________ 3,810,000
Sub-total (Total Funding) Phase 2
Contribution by the Government
270,000,000
50,000,000
12,857,000
2,381,000
GRAND TOTAL Phase 2
* Exchange rate IR:DM 21:1
320,000,000
15,238,000
The total project funding for first and second phase will be approximately IK 727.00 million
which is equivalent to DM 34.62 million. The contribution of the Government of Karnataka
can be assumed to be IR 119.70 million or DM 5.70 million. Table 12.9 summarize the total
cost of the overall project.
TABLE 12.9: Total Project Cost for Phase 1 and Phase 2
PHASE 1
PHASE 2
KFW FUNDING
IP
T
DM
457.000,000
21,762,000
270,000,000 j
12,857,000
TOTAL
727.000.000 !
34,619,000
CONTRIBUTION GQK
IR
T
DM
"”69700,000
3,319,000
50,000,000 j
2,381.000
________ TOTAL
320,000,000 j
DM
25,081,000
15,238,000
119,700,000 >
846,700,000 i
40,319,000
5,700,000
—
JR . I
526,700.000
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
65
TABLE 13.1 PROJECT SCHEDULE
-----------
---------------- MONTH
2
4
6
rrr
10
12
2
4
T
8
4 YEAR
3. YEAR
2. YEAR
1. YEAR
10
12
2
4
6
8
10
2
12
4
6
8
10
12
Project initiation and nomination of Project Director
Preparation and equipping of office
---------------------
Preparation of tender for project vehicles___________
Preparation of tender for project architect & engineers
Preparation of tender for project monitoring
Award of contract for office equipment and vehicles
Award of contract for project architect and engineers
Award of contract for project monitoring consultant
p re p a ration of project design brief_________
Preparation of tender for construction & eng, works
I
■<
-11
Approval of design and tender documents_______ __
I
'•7.
Dcsign , engineering and supervision
_________
Tendering of construction & eng, works by district
1
Award of contractor for construction by district
Biff
Construction
_
_
Preparation of the final bill of quantity of equipment
Preparation of tender for equipment and vehicles
-
Approval of equipment list and tender documents
Tendering of equipment and vehicles
Award of contract for equipment and vehicles
Government order for staffing
____
_________
ImpIementation of cost sharing measurements
Supply of equipment and vehicles_________ _____
Project mid-term review
__
Definition of project scope for 2. phase
__
Implementing of staffing for the upgraded hospitals
Handing over of the hospitals
Traming of equipment user
Pinal project documentation for Phase 1
___
— —
>;
__ -
UPGRADING OF SECONDARY LEVEL HOSPITALS IN GULBARGA DIVISION, KARNATAKA
13.
IMPLEMENTATION SCHEDULE
The intention of the Government of Karnataka is to start with the project at the beginning of
1996. The overall implementation of the project in two phases will take approximately seven
years.
For the first phase it is assumed that the 26 hospitals could be renovated and upgraded in four
years. The first stage of the project will require preparation of all design and engineering
works as well as the preparation of the tender documents. In the second and third year the
construction and engineering works for all hospitals will take place. During the same period
the supply of medical equipment will start.
The first hospitals should be ready in the third year of the project and the final handing over of
all facilities should be finished in the last month of the fourth year.
In the third year of the project the mid-term review will initiate the second phase of the project
which should at the very latest begin after the first phase is completed. The overall project
schedule is indicated in TABLE 13.1.
r
DEPARTMENT OF HEALTH AND FAMILY WELFARE, GOVERNMENT OF KARNATAKA
66
ANNEX 1
MINUTES OF MEETING
UPGRADING SECONDARY LEVEL HEALTH CARE
FA CUTTIES IN KARNA TAKA
Minutes of Meeting
Upgrading Secondary.Level Health Care Facilities in Karnataka
A mission of KfW (the mission)
isi ted fPangalore, Karnataka from 11.-13.
J une, 1995 to discuss the mid-term y'eport for the present assessment
phase.
The mission would like to express .its sincere gratitude to
the Chief
Minister,
the
Health
Minister, 'the Chief
Secretary,
other • Senior
Officers, the
t........
Healh Secretary and .his staff for the excellent preparation
of the fruitful discussions and Mr their hospitality.
The Government of Karnataka made a concise presentation of
which are summarised as follows:
•
•
•
•
•
•
•
its findings,
The Project will cover the 4 districts of I
’
■
the
Division
of Gulbarga.
In the first phase (approx. DM 23 million),
U
“
J
. . the Project
will consider
the level of the General Hospitals and Taluka Hospitals.
In the second phase, district hospitals wilI
will be considered,
The final
scope for upgradation and, if necessary expansion of ithe district
hospitals will depend on the findings of a mid termi review for
evaluating the effect and impact of the implementation of the first
phase on the utilisation of the facilities already available in the
district hospitals. Expansion will be considered where there is a
need.
The Project will not consider construction of new hospi ta 1 s bu t will
concentrate
on
consolidation.
repair
and
upgrading
of
existing
hospitals.
A viable cost-sharing mechanism will have to be developed within the
health system. The State Government
has agreed to consider specific
--steps for, not only generatino
generating internal revenues on a significant
scale, 1but also
'
"
_permitting
___
2^ _ of the funds thus collected
for
use
-- for the
improvement of the concerned institut ions.
An innovative scheme already under consideration to entrust
the
operation of
some primary health
facilities
in di fficult/remote
regions to NGOs act-ive in the area needs to be promoted vigorously.
The Government of Karnataka assumes the responsibility for increasing
the maintenance budget as required.
The Government of
Karnataka will
be supported
in
the detailed
planning,
elaboration of bidding
for construction and
documents
for.
procurement, supervision of works and procurement, by a team of
external and local consultants. Tl._
The Consultant team will be selected
by KfW and Government of Karnataka, Both sides will agree on the Terms
of Reference (TOR) . The detailed TOR shall be drawn up during the
appraisal.
Commitment of the State to create necessary posts and to finanee the
respective salaries, and to deploy staff with required skills, e . g . , a
doctor with skills in OB/GYN and Anaesthesil a for a general hospital.
A co-ordination mechanism shall be established at the DHFW level to
ensure smooth co-operation between the World Bank and KfW sponsored
proj ects.
The Mission was informed that the World Bank i s tentatively planning to
appraise
a
Project
c omp r i s i ng
tj. nanc i a 1
and ’ technical
co-operation
measu res i n September of this -~ybar. The scope of the financial cooperation shall cover the whole state except the -Gulbarga Division and
does not over1ap w i t h the present Project, The technical assistance
(training components ,
strengthening of
the district health system),
however. shall include the Di is ion of Gulbarga.
Provided that the final report c-f the a nr. on .cm-** nr- ph.-i
ir, prcn^ntrj.-l |:.y
duly of this year, a KfW appraisal in i r-r- i ■ »i i coul'.l be ’■■.•ntai: i •/•••? Ly {.'Lanued
b- r
Sep t embe r; /C’c t obe r
1995 .
Du r i ng
111•£• appraisal mission
i .a.
rha
I o 1 1 ov.'i ng issues will he d i scusse'i :
/
The overall Project goals as well
we 1 I as specific ol?i^ct i. ves riQ'-^d i:<? be
formulated.
The
indicators
for
m‘'.»?tu r i n* i
i hr.
.vhi* ••iib'iii
f o!
-q
| hr*
objectives will be defined. ""
I h e •• v•? 1.11iiik- n i- o | p n t nw [ [ [
s
»
11?31
a
n
t
i
a
te
the availability of adecuate primary health care services f*r
justi
tying
a specific Project on secondary level health care services.
Organisa
In order tto guarantee continuity in
in the .nanagern^nt of th* Project, the
Government. of Karnataka will cons idee by
September t he possibility of
exempting the key staff who are engaged in th* Pi eject
preparation work
from transfers.
The overall scope and components
components of the Project shall
require prior
approval of the Government
-- of India. The DHFW of Karnataka shall
be fully
J;TS?Onsi^le for the implementation of
of the Project
: through an appointed
Project Director who shall function as
the
Chief
*1
as
be delegated full financial and administrative Executive. He/she will
powers necessary for
smooth implementation of the Project. A <'
‘
detailed
description of the
management structure and the responsibilities at different
--------levels will be
finalised.
Parts of the equipment to be tendered and p
l._
Purchased
locally in India and
imported from abroad will have to be specified*.'
In this context special
attention will be paid to ensure in future
smooth maintenance and
procurement of spare parts.
Cos ts
The following items form part of th° Prop ect
and their costs may be
respectively defined as Project costs:
1 - infrastructure measures
2 . purchase of
ui equipment,
equipment, drugs,
drugs, consumables
3 . consultancy services
4 . ^,he Pr,o^e<?t c?-°rdination cell
5. the additional recurrent
costs of the health institutions included in
the Project
The general administration ccosts' of the DHFW. of
administration of the healthi institutions in the Karnataka, the DHOs and
Project area do not form
part of the Project costs.
Financing
The consultancy services for the tender procedure,
supervision of works.
and procurement shall be financed
-- -1 fully out of the grant.
The contribution of the Government of
to the overall Project
cost shall be at least 10-15 percent. Karnataka
It
shall
finance the recurrent
cost for the Project co-ordinat ion
unit as well as the additional
recurrent costs of the various heal tti
institutions.
However,
However, basic
equipment of the
t'_ ZProject Co-ordination Cell
( fax. computer, vehicle) may
be financed out
of
-the financial co-operation;
To enable the Project co-ordination cell
to
the Project
smoothly, a direct channelling of t|le funds to implement
the Project should !>e
ensuied without delay.-, (for exatup I
i: he disbursements to a Project
account may occur directly upon request
t=
by the Project Director).. To
enable smooth Project implementation
J
and
to
avoid any liquidity problems,
the Government of Karnataka will
propose by September a procedure for
disbursement of the financial
co-operat i on fundr.. This procedure (which
should be discussed with the responsible
that the funds will be at th° disr-osal authority in Delhi.) shall ensure
o f r he <1 iij ah] i s r i c t 1 eve Is
wh*n*vor r*qu j r «••••! .
TC is understood that the funds allocated out of the financial •;•?•he
vrunonli
operation of
this
Project
shall
t.-e
additional
•to
allocations for the health sector. For the appraisal iin September /Octiebeu
1995, the projected trends of Government expenditures on h«?a 1 C h I: o r Che
next 5 years will be indicateded.
The findings and receinmendat ions made above are subje-.:t to approval by
the Government of Karnataka and by the Management of KfW and the 'German
Government.
Bangalore, June 13.,
1 995
Government of Karnataka
Mr. Gautam Basu
Secretary to Governnient of Karn-ataka,
Health and Family Welfare Bangalore
Ms. I. Huber
For KfW mission
1
ANNEX 2
HEALTH CARE EXPENDITURE
TABLE 1: Population and Net State Domestic Product i
37.141
~[
Population (million)
1981
1991'
44.98,
1
90/911
91/92!
~Rl
i
92/93
PR|
=3
____ I
93/94!
95/96
__ A?
I
i
Rs. Crores
-------------- 1
Net State Domestic
Product at Current
Prices
_______I
T
|
26487-
20595
___ I
297231
I
32927
36345’
NA
10682
111251
11514
NA
___ 1
Net State Domestic
Product at 1980/81______
Prices
___ I
10241|
9160
90/91 & 91/92: Revised Estimates
92/93: Partially Revised Estimates
94/95: .Anticipated
j
Source: Economic Survey, 1994-95 Planning Department, Govt of Karnataka.
:________
94/95?
I
93/94: Quick Estimates
NA: Not Available
j
i
TABLE 2: Recent Trends in Public Expenditure and Receipts
~
_____ t
~__ I
Rs. Crores
94/95
95/96
Rev. Est. udget Est.
90/91
Acct.
91/92
Acct.
92/93
Acct.
93/94
Acct.
Revenue Receipts
3,892.18
4,775,47
5,421.66
6,324.65
7,464.86
8,879.97
State Tax Revenue
Non-tax Revenue
States Share of Union taxes
Grants-in-aid from Central Govt.
2,332.12
517.20
660.35
382.51
2,900.20
621.28
782.08
471.91
3,097.81
_802A4_
931.97
589.33
3,812.34
733.58
1,6'17.41
761.33
4,408.52
1,014.83
1,135.93
905.59
5,115.96
1.122.53
1,439.51
1,201.98
Revenue Expenditure
3,971,09
4,954,12
5,591.69
6,208.25
7,651,71
9,093.63
Non-Plan expenditure
Plan expenditure
3,077.64
893~45
3,926.03
'1,028.09
4,406.41
1,185.28
4,571.50
1,512.83
5,512.42
1,991.65
6,542.59
2,551.04
Revenue (Deficit) / Surplus_____
(Revenue receipts minus Revenue
expenditure)
(78.91)
(178,65)
(170.03)
116.40
(186.84)
(213,66)
Capital Expenditure
654.81
785.86 i
786.63
1,187.80
1,067.81
1,622.49
Non-Plan
Plan
90.99
563.82
131.551
654.31!
194.40
592.24
209.62
978.18
250.03
817.79
740.40
882.09
Fiscal Deficit________
(Revenue deficit minus Capital
expenditure)
733.72
964.51
956.66
1,071.40
1,254,65
1,836.15
Outstanding Debt of State Govt.*
Central Government_____
Internal Debt_________
Provident Fund etc.___________
Reserve Funds/Deposits
* Excluding Reserves & Depreciation
5,417.27 6,079.38
3,009.73 ' 3,380.69'
977.92 ~
995.50'
989.00 '
835.73 '
593.90'
714.20 '
I
!
I
7,081.29, 8,338.84
3,869.931 4,374.29
1,323,73 '1,531.73
1,152.94 1,340.40
734.67 1,092.43
9,800.59 11,291.81
5,419.09 6,261.88
1,733.67' 1,973.10
1,555.40
1,802.40
1,092.43' 1,092.43
____ I
TABLE 3: Structure of Revenue Expenditures |
90/91 j_________
91/921
Acct. I
Acct. I
I_________ I
I Non-Plan I
A
General Services
Social Services
,________
of which_______ 22__________
Education_______________
Health & Family Welfare
Water Supply and Sanitation
Others
Economic Services
Grants-in-Aid
Total Non-Plan Revenue Expenditure
92/931
Acct i
________ I_________
'Rs. Crores
_____ I
93/94j
94/951
95/96
Acct. I Rev. Est.f udget Est.
____
L
________I
1,900.42
2,388.83
2,766.76
-----!------- 1
T------1,172.051 1,453.81---- 1,545.831, 1,680.09
1,891.56
2,109.94
1,169.70
1,416.90|
_____ I
1,692.85!
716.211
166.17|
10.34|
279.33 ’
855.19
205.60
16.80
376.22
____ I
951.14
252.31
15.74
326.64
647.45
937.44
1,043.06
990.99
1,232.04
1,512.19
______ L
1,068.51
269.23
11.59
330.77
L221^0
312.90
9.91
339.95
1,368.67
342.25
22.02
377.00
98.27
117.89
124.67
149.30
147.63
153.69
3,087.47
3,926.04
4,406.41
4,720.80
5,660.05
6,542.59
Plan
General Services
4.89
5.10
6.84
4.50
5.28
6.03
Social Services______________
of which___________________
Education______________
Health & Family Welfare
Water Supply and Sanitation
Others
366.87
439.03
536.43
698.42
966.12
1,322.60
85.88
76.85
50.52
153.62
106.20
89.77
64.20
178.86
146.62
107.90
80.03
201.88
209.61
122.02"
106.98
259.81
306.08
174.27
154.24
331.53
406.78
226.60
204.68
484.53
Economic Services
511.86
583.95
642.01
809.91
1,020.25
1,222.42
0.00
0.00
0.00
0.00
0.00
0.00
883.62
1,028.08
1,185.28
1,512.83
1,991.65
2,551.04
91/92
Acct
92/93
Acct.
93/94
Acct.
Grants-in-Aid
Total Plan Revenue Expenditure
________________________________ [
TABLE 4: Structure of Capital Outlay
90/91
Acct.
Rs. Crores
94/95
95/96
Rev. Est. udget Est.
I
General Services
11.39
13.59
19.08
22.97
25.48
30.02
Social Services______________
of which___________________
Education_______________
Health & Family Welfare
Water Supply and Sanitation
Others
17.67
32.53
38.72
52.06
87.91
111.70
1.72
6.57
0.00
9.38
3.63
5.28
0.00
23.62
5.75
7.12"
0.00'
25.84
_9.06
10.25
0.00
32.75
14.90
12.24
0.00
60.77
7.81
31.56
0.00
72.34
Economic Services
625.82
739.82
728.83
1,112.83
954.43
1,041.25
0.00
0.00
0.00
0.00
0.00
0.00
654.88
785.94
786.63
1,187.86
1,067.81
1,182.96
Grants-in-Aid
Total Capital Expenditure
TABLE 5: Structure of Health Revenue Expenditures- Plan Expenditure I
1990-91
MEDICAL
1991-92
11.221
1992-93
1993-94
]1994-95
I Rs. Crores
i 1995-96
13.47
16.52
20.441
32.501
36.34
—
Allopathy
10.34
12.93
16.20
20.10
31.75!
35.37
.Administration: DME___________________
Administration: ESIS___________________
Medical Colleges: DME
_________
Teaching Institutions: Drug Controller_____
Training Institutions/ Programmes: DHS
Hospitals .Attached to Med. Colleges: DME
Other Hospitals: DHS___________________
Other Hospitals: ESIS___________________
0.03
0.17
1.44
0.14
0.01
0.04
2.92
0.12
0.00
4.41
5.66
3.05
0.01
0.10
3.54
0.12
0.00
7.53
5.77
3.04
0.88
0 54
0.33
0.34
0.00|
0.221
10.211
0.23|
0,001
8.181
8.681
4.24|
_____ I,
0.751
221
1.99
0.021
0.02’
2.90'
0.39 '
0^00 '
3.08 '
4.97 '
1.54’
22£
2.37
4.J2
Indian Medical Systems & Homeopathy
0.39
10.94
_0.26
0.00
6.64
12.89
4.24
0.97
___ L
.Administration
Teaching/ Training Institutions
Hospitals___________________
Dispensaries: ESIS__________
Primary Health Care
0.12
0.46
0.02
0.00
0.28
0.00
0.45
0.08
0.00
0.01'
0.07
0.22 '
0.04;
PUBLIC HEALTH
65.59
■Administration: DHS_______________________
Training, Allopathy: DHS___________________
Training, IMS________________________ •
National & State Programmes: Allopathy, DME
National & State Programmes: Allopathy, DHS
Public Health :IMS
Family Welfare Programme__________________
TOTAL
0.031
0.241
0.16!
0.00 i
0.00
0.14
0.04
0.00
0.15
76.19
91.30
0.04
0.06
0.00
0.94
28.60
0.81
35.17
0.11
0.01
0.00
0.62
24.08
1.09
50.38
76.85
89.77
0.09
0.31
0.001
oj2
o.oo
0.321
0.38
101.54
141.611
190.06
0.07
0.00
0.00
0.98
32.09
3.26
54.98
0.03
0.00
0.10
0.75
38.70
2.58
59.42
0.161
~ 0.021
0.17|
I.39|
57.681
3.281
79.071
0.20
0.04
0.00
1.81
77.48
4.09
106.65
107.90
122.02
o.oot
____ I
174.271
226.60
1994-95]
Rs. Crores
1995-96
TABLE 6: Structure of Health Revenue Expenditures- Non-Plan Expenditure
LZ
__
I 1990-91
1991-921
1993-94
-----r
1992-931
MEDICAL
96.23
121.55
140.74
156.241
180.411
196.88
Allopathy
92.01
116.71
134.73
148.97
172.17|
187.26
■Administration: DME___________________
Administration: ESIS_________________
Medical Colleges: DME________________
Teaching Institutions: Drug Controller_____
Training Institutions/ Programmes: DHS
Hospitals .Attached to Med. Colleges: DME
Other Hospitals: DHS
__________
Other Hospitals: ESIS________________ ___
0.55
' 1.62
16.62
0.42
0.36
38.69
22.47
11.27
0.66
3.18 '
21.23 '
0.85
1.91
29.45
0.50
0.48
53.00'
1.12
_2_46[
30.761
0.911
0.68 '
72.91 '
16.54
0.96
2.08'
24.00 '
0.63 '
0.56 '
66.25 '
36.55 '
17.951
1.20
2 64
32.58
0.97
0.71~
79.62
43.51
26.03
Indian Medical Systems & Homeopathy
4.22
6.011
7.27
8.241
9.62
0.471
2.99
3.24 '
0.08 '
0.48 ~
112.981
0.451
3.791
3.391
0.051
0.571
0.001
132.491
0.50
4,76
3.67
0.07
0.63
0.00
145.37 .
5.57!
1.96 {
0.34 j
0.901
I14.16i
5.12!
~ 4 43
_ 6T7
1.60
0.49
0.021
96,92!
__ £571
A08[
4,81!
_L751
0.24i
0.67|
97,361
"4,511
3.631
352.65?
269 231
312.90*
342.25
XArnirnslrztxon
Teaching/ Training Institutions
Hospitals___________________
Dispensaries: ESIS__________
Primary Health Care_________
0.46
0.49 '
50.51 '
28.46 '
11.73 '
ZZI
4.841
_____ I
2122.
39.101
24.241
____ I
_JI
PUBLIC HEALTH
0.19
1.57
2.14
0.01
0.31
0.00
69.93
Administration: DHS
Training, Allopathy: DHS___________________
Training, IMS__________________
National & State Programmes: .Allopathy, DME
National A. State Programmes: .Allopathy, DHS
Public Health :IMS_______________________
Family Welfare Programme
3.531
0.96 j
0.18!
O.()4j
59.401
2.71 j
3. IO|
1'0 TAI.
i66j?f
0.30
' 1.731
2.40 ~
0.011
" 0-391
0.00|
’ 84.051
—
r
4.19I
1.05
0.19|
0.021
^72. Tot
2.931
3.481
0.34|
2,561
2.651'
0.031
0.42|
0.001
11 i.~9iT
4,76|
1.26|
------ T
205.601
o.oo'
.,1-19
127.28
2.89
5.14
TABLE 7: Composition of Revenue Expenditure on Primary, Secondary & Tertiary Care
Rs. Crores
1994-95
1993-94
Primary Secondary Tertiary
Primary Secondary Tertiary
Salaries & Allowances
Travel_______________
Office
Rents________________
Elec. & Water_________
Motor Vehicles________
Drugs _____________
Materials_____________
Machinery'____________
Maintenance__________
Diet_________________
-v
Scholarships & Stipends
Others_______________
Buildings____________
Lump Sum *__________
Externally Aided Projects
Total Expenditure
3.29
28.09
0.11
4.62
0.00
0.25
0.00
5.87
0.37
2.67
0.05
1.78
0.16
0.09
0.00
31.59
0.00
21.24
0.11
9.59
0.00
0.68
0.00
2.46
0.11
2.83
0.03
2.03
0.04
0.26
0.00
23.57
0,00
11.93
0.19
0.77
0.00
0.00
0.82
7.09
9.60
2.76
0.20
0.20
0.00
0.04
7.09
234.08
15.22
33.40
0.14
2.54
0.00
0.71
0.00
9.38
0.34
0.92
0.05
3.08
0.03
0.00
0.00
34.24
0.00
251.42
75.66
62.94
274.77
84.83
10.31
0.05
1.68
0.00
0.00
0.40
14.92
15.26
4.16
0.00
0.04
0.03
0.16
7.76
196.64
25.29
0.07
2.92
0.00
2.05
Primary
1995-96
Secondary
37.04
0.14
2.67
0.00
0.85
0,05
Teiliary
27.43
7.93
0.17
0.57
0.07
2.98
0.03
0.80
0.00
28.21
0.34
13.85
1.00
0.32
0.00
0.00
0.67
7.37
~ 15.56
4.49
0.30
0.21
0.00
0.54
7.31
273.83
28.99
0.28
0.97
0.29
3,40
0.03
0.00
0.02
38.69
2.00
^TOO
0.00
2.43
' 0.01
850
_0.17
057
~ 0.07
3,28
0.03
0.40
000
~27,55
"0.58
71.09
325.45
94.72
73.77
0.01
'
10.28
ANNEX 3
DEMAND OF SECONDARY HEALTH CARE BEDS
ANNEX 3
DEMAND FOR HOSPITAL BEDS IN GOVERNMENT SECTOR
o
The Directorate of Health and Family Welfare Services has under its control 255 hospitals,
CHCs, taluk and district level general hospitals with a total bed strength of 25,376 as per
records of the Directorate of Health and Family Welfare Services. The 24 taluk or sub- district
level hospitals and the 179 CHCs have -a total bed strength of 8,655. The District level and
teaching hospitals numbering 42 institutions account for 16,721 or 65.9 percent of beds in
CHCs, taluk and district level general hospitals.
The Planning Commission, in the seventh Five Year Plan document, has suggested a norm of
one bed per 1,000 population which includes both government as well as private sectors. It
has also stipulated that two thirds of the total beds, that is, one bed for 1,500 persons should
be provided by the government sector. As compared to this norm of 1,500 persons per bed,
there are 1481 persons per bed in the government sector. However, if one looks at the
distribution of beds by taluk, it will be observed that in 134 out of 175 taluks the persons per
bed exceeds 1,500 and in 90 taluks there are more than 2,500 persons per bed..
The epidemiological approach has been adopted in arriving at the requirement of beds in the
government sector. The results of the 42nd Round of National Sample Survey indicate a
hospital admission rate of 21.5 per thousand population and an average stay of 15 days. At an
average occupancy rate of 80 percent, the total beds in the government and private sectors
works out to 1,120 persons per bed. As two thirds of the beds are to be provided by the
government sector, the persons per bed should be 1,679 which is close to the norm set by the
Planning Commission.
The requirement of beds has been worked out by taluk. In determining the available beds, the
beds in PHUs and PHCs and hospitals for infectious diseases, Tuberculosis and other specialty
hospitals have been omitted. The PHU and PHC beds have been omitted as they are not
staffed to provide 24 hour nursing care and consequently their bed utilization is only 15
percent. The requirement of beds by taluk and the summary by district is presented in Table 1.
The shortage of beds is estimated at 11,831 beds on the basis of average stay in the
government hospitals of 15 days based on Assumption 1. However, it is expected that with the
various Project interventions the average stay will be brought down to 10 days which is similar
to the case of hospitals in the private sector. In this scenario (Assumption 2), the shortage in
beds is reduced to 6,084.
It has been decided to leave 52 CHCs located in places other than Taluka headquarters out of
the Secondary level Hospital network for the purpose of this Project. These will be treated as
first level referral units for providing expanded MCH and FW services.
DEMAND FOR HOSPITAL BEDS IN KARNATAKA
1
ANNEX 3
Table 1: Projected Bed requirement in Government Sector
Population in
Thousands
4839.2
Beds Required
Bangalore Rural
District
3207
Beds Available
Assum. 1
2875
Beds Available
Assum. 2
1922
1673.3
328
997
665
669
Belgaum
3583.6
1101
2134
1423
1429
852
Bellary
4890
1086
1127
751
525
252
Bidar
1255.7
475
748
499
381
197
Bijapur
2927.8
902
1747
1163
1026
579
Chikmagalur
1017.2
658
606
404
166
36
Chitradurga
2076.9
1623
1236
825
492
247
Dakshin Kannad
2797.8
1812
1665
1111
502
226
Dharwad
3503.3
1639
2087
1391
953
452
Gulbarga
7582.2
1117
1537
1025
859
451
Hassan
1569.7
827
933
623
349
157
Kodagu
488.4
1168
291
194
0
0
Kolar
2216.9
946
1320
880
450
163
Mandya
1644.4
446
979
653
575
325
Mysore
3165
2119
1885
1257
886
428
Raichur
2309.9
567
1376
917
865
478
Shimoga
1909.8
935
1138
758
456
242
Tumkur
2305.8
593
1374
916
852
479
Uttar Kannad
1220.1
-44977
535
728
485
283
101
22084
26783
17862
11834
6084
Bangalore
Karnataka
Shortfall
Assum. 1
Shortfall Assum.
2
116
72
350.
♦
The available beds in CHCs, taluk, district and teaching hospitals have been estimated from actual survey of
66 percent of such hospitals. The actual beds in CHCs are 79.5 percent of beds as per records of the
Directorate and 107.5 percent in other hospitals.
# Sum of shortfall in beds of taluks having beds less than norm.
The location and utilization of existing bed capacity of the remaining 170 Taluka hospitals
were studied. On the basis of need a list of 136 hospitals have been identified for expansion of
bed strength and 34 selected for rehabilitation. In all 4,987 beds are being added to the 136
Taluka Hospitals. A detailed survey of each institution is presently underway. The survey may
result in identifying an additional few hospitals for expansion.
Of the 46 hospitals located in District Headquarters, 31 are general hospitals and 15 are for
specific diseases. It has been decided to expand the district hospitals to a minimum bed
strength of 400 beds so that 100 beds could be set apart exclusively for women and children.
In all 1684 beds are proposed to be added in fourteen district hospitals.
Most of the fifteen hospitals for specific diseases are in a run down condition and need also
extensive rehabilitation.
DEi\LAND FOR HOSPITAL BEDS IN KARNA TAKA
2
o
ANNEX 4
NORMS FOR HEALTH CARE SER VICES
Report of the High Level Review Committee
A
High
Level
Review
Committee
was
constituted
to
examine
the
recommendations of the different working groups and finalise the norms for services,
equipment, physical space and staffing to be adopted for all hospitals at the secondary
level. The committee met on March 30, 1995. The members present were:
1. Mr. Gautam Basu, Secretary, DoHFW
2. Mr. Sanjay Kaul, Additional Secretary, DoHFW
3. Dr. Shivakumar Reddy, Deputy Secretary, Medical Education, DoHFW
4. Dr. M. T. Hema Reddy, Director, Health & Family Welfare Services
5. Dr. S. Kantha, Director, Medical Education
6. Dr. P.N. Halagi, Add! Director (Projects)
7. Dr. Jayakeerthi, Superintendent, Victoria Hospital
8. Dr. G. V. Vijayalakshmi, Jt. Director (Medical)
9. Dr. D. Timmaiah, Jt. Director, (Projects)
10. Mr. D.V.N. Sarma, Chairman, STEM, Bangalore
The committee scrutinised the recommendations of the various working
groups. The main conclusions are summarised below.
1.
A note of caution was added to the conditions and procedures recommended
by Medical, Surgical and Diagnostic Groups. No case should be refused
attention. At each level, all cases should be managed depending upon the
urgency, severity and immediacy of illness, stabilised and then referred, if
necessary, to the appropriate level.
2.
Modifications were made to some of the conditions and procedures
recommended by individual groups. These changes have been incorporated in
the recommendations of the respective groups.
3.
Staffing:
•
One post of R.M.O. has been created at the District Hospital to relieve
the District Surgeon of routine hospital duties and enable him to
oversee the functioning of other secondary level hospitals in the district,
f or this purpose the District Surgeon should be provided a vehicle.
52
. The Indian Nursing Council norm of one staff nurse for every five beds
has been accepted^/^
The office staff has been reduced since computerisation of patient
•> >;
records, inventory of equipment, drugs and supplies and accounts is;
Xgontemplated.
Where feasible, kitchen services should be contracted out.
Laundry services should be contracted out:
Cleaning services should be contracted out.
The number of Group D posts is reduced from one for twp beds to one
for three beds for hospitals with 50 beds or less and one for four beds
for hospitals with 100 or more beds.
'The norms for maintenance staff will be finahsed after receipt of report
of the recently constituted working group on maintenance.
The staffing norms by category of staff and type of hospital as accepted by the
Committee is presented at Annexure 1.
4.
Equipment:
The recommendations of the working groups were scrutinised and the
approved norms for equipment are presented at Annexure 2.
5.
Physical Space:
The norms for physical space in terms of number of rooms and area has been
finalised by the Working Groups accordingly to Bureau of Indian Standards
(BIS) which is presented at Annexure 3. The BIS norms appear to be on the
high side. The area of each room has to be fine tuned on the basis of furniture
and equipment to be housed. The functional needs should be paramount in
deciding the physical space for each facility. For example, it was felt, it was not
necessary to provide attached toilets to each medical specialists.
53
J
6.
Referral System:
A working group has been set-up to develop the referral system and design the
requisite forms.
7.
JL-service Training:
The working groups have recommended updating of clinical skills of medical
and paramedical staff. Training in hospital administration has also been
indicated. A working group has been constituted to assess the training needs,
design course content and work out the training programme for various
categories of staff.
54
Annexure 1
Staffing Norms for District and Sub-district Hospitals
' I
Category
Grade
Bed Strength
50
100
30
1. Surgeon ______________
2. Dy. Civil Surgeon (R.M.O.)
3. Assistant Surgeon________
4. Dental ^Assistant Surgeon
5. Nursing supdt. Grade-1
6. Nursing Supdt. Grade-H
7. Nursing Tutor___________
8. Staff Nurse______________
.■9. Physiotherapist
10. Pharmacist Grade I_______
11. Pharmacist Grade II
12. Sr. Lab Technician________
13. Jr. Lab Technician
14. Jr. Lab Attendants
15. Refractionist____________
16. Radiographer____________
17. X-Ray Technician________
18. Dark Room Assistant_____
19. Lay Secretary »
20. Office Superintendent
21. Senior Assistant <
22. Junior Assistant ..______
23. Typist-cum-clerk_________
24. Medical Record Technician
25. Electrician______________
26. Carpenter
___________
27. Plumber________________
28. Cook__________________
29. Helper to Cook___________
30. Group D________________
38. Driver__________________
39. Psychiatrist_____________
40. Clinical Pyschologist______
41. Pyschiatric Social worker
42. ECG Technician__________
43. Social Worker (Skin VD)
3170-5300
2600-4575
2375-4450
2375-4450
2150-4200
1900-3700
1900-3700
1520-2900
1520-2900
1400-2675
1280-2450'
1400-2675
1280-2375
870-1520
1280-2375
1400-2675
1280-2375
840-1340
1900-3700
1720-3300
1280-2375
1040-1900
1040-1900
1400-2675
1400-2675
870-1520
870-1520
870-1520
840-1340
840-1340
1040-1900
3300-5300
2375-4450
1400-2675
1280-2375
1400-2675
£
1
J.
2
£
£
i
1
1
>250
____ 1_
____ 1_
___ 21
____ 1_
____ 1_
____ 5_
__ £
6
10
___ 60
£
20
1
1
2
2
2
1
£
£
£
___£
___£
1
1
1
1
1
1
1_
1
1
£_
1*
1
2^
i
i
£
2
1
2
____ 2
____ 6_
____ 4
____ 2_
____ 1_
____ 2
____ 3
£ ____ 1_
£ ___ £
£ ____ 2
2
2
1
2
___ £
____ 2
____ 2
___ £
___ £
___ £
1
2
10
1
i
2
15
2
i
2
25
2
____ 2
____ 4
___ 50
____ 4
___ £
___ £
___ £
___ £
2
55
Doctors by Specialization
Category
1. Physician_______ .
2: General Surgeon
3. Gynaecologist_____
zv
4. Dental Surgeon_____
5. General Duty Doctor
' 6. Anaesthetist_______
7. Paediatrician_______
8. Optholomologist
9. Orhopedic Surgeon
10. ENT Surgeon______
11. Skin Specialist_____
12. Psychiatrist_______
13. Radologist________
14. Pathologist________
15. Forensic Expert
16. Doctors to assist
Total
30
___ l_
___ !_
1
2_ i
Bed Strength
100
50
__ !_
___ [
__ [
1
__ £
>250
____ !_
____ [
1
1
2_ i
i
1
1
1
1
2
1
1
1
1
1
1
__ !_
i
1
x
1
1
3
5
7
10
23
56
Annexure 2. Furniture and Equipment Norms
Equipment
Unit Price
Rs. 000s
II. Electro Medical Equipment_______
1, E.C.G.___________________________
2, Cardiac Monitors_________________
3, Defibrilators____________________ _
4, Audiometers______________________
5, Baby Incubators___________________
6, Phototherapy Unit_________________
7, Endoscope Fibre Optic
________
8, Operating Microscopes____________
9, Cyro Surgery (Delux)_____________
10 Foetal Monitor____________________
50
30
Bed Strength_________________________
I, Imaging Equipment_______________
1. 500 mA X-Ray____________________
2, 300 mA X-Ray____________________
'' 3, 200 mA X-Ray____________________
4, 60 mA X-Ray (mobile)____________
5, Dental X-Ray_____________________
7. Ultra Sound Scanner (Linear Sector)
Community
Hospitals
950
800
430
150
60
700
17
25
65
50
20
_ 6_
200
65
8
6
20
75
125
60
5
21
3
6
20
11, Short wave Diathermy_____________
12, Ventilators_______________________
13, Boyles Apparatus with flou tech
14, Boyles Apparatus without flou tech
15, Opthalmoscope___________________
16, Slit Lamp________________________
17, Retino Scope_____________________
18, Perimeter________________________
19, Emergency Resuscitation Kit______
20, Baby Emergency Resuscitation Kit
21, Delee Mucous Asprator___________
22, Sigmoido Scope__________________
2
23, Head Light_______________________
1
24, Pulse Air Tonometer______________
__ 5
25, AMC Equipment (2 Monitors. 1
250
Ventilator. 1 Defibrillator,A/C)_____
__6
26, Radiant Heater (4 Kw)____________
5
27, Cryo surgery (Basic)______________
100
28, Pulse Oxymeter__________________
450
29, Blood Gas Analyser______________
III. Pneumatic, Hydraulic & Steriliztion Equipment
28
1, Dental Unit________________
14
2, Dental Chair_______________
21
3, Air rotor___________________
8
4, Operation Table (ordinary)
5, Operation Table (Hydraulic)
35
no
6 Autoclave HP (Horizontal)
30
7 Autoclave HP (Vertical)
6
3 Autoclave with Burners 2 bin
Sub
district
Hospitals
100
District
Hospitals
2
2
2
2
_2
X>250
(1)
1
1
1
1
__L
i
i
i
i
1
3
3
2
2
1
1
1
_ £
1
1
1
1+1
2
1
i
2
__ i_
1
1
2
2
100
1
2
1
1
1
1
20
1
1
30
i
60
1
2
2
2
i
1
1
I
I
2
2
I
2
2
2
2
i
I
i
2_
2_
2_
2
4_
2_
2
57
Equipment
Unit Price
Rs. 000s
Bed Strength_____________
9, Shadowless lamp (mobile)_________ 8
10, O T Lights (Shadowless)
45
11, Focussing lights (Mobile) Flurotic
1
12, Suction Apparatus (High Vacuum
8
Community
Hospitals
30
1
I
1
I
50
1
1
1
1
Sub
district
Hospitals
100
2
2
1
1
District
Hospitals
X>250
____ 6
____ 6
1
4
(MTPL)_________________________
13, Suction Apparatus (Electrical)______
14, Foot SuctiorTApparatus___________
15, Vacuum Extractors_______________
16, Instrument Sterilizer_____________
17, Diathermy Machine______________
18, Gynaec electric cautery___________
19, Automist/Dehumidifier___________
20, Dental Lab (Bath, Motor, Lathe)
IV. Laboratory Equipment__________
1. Microscopes (Binocular)__________
2. Chemical Balances_______________
3. Simple Balances_______________
4. Photo electric Calorimeter_________
5. Flame Cell Photometer____________
6. Spectro Photometer______________
7. Auto analyser________________
8. Micro Pipettes___________________
9. Water Bath_______________ _
10. Hot Air Oven____________________
11. Lab. Incubators__________________
12. Distilled Water stills______________
13. Centrifuges
______________
14. Hot Plates___________________
15. Rotor/Shaker____________________
16. Counting Chamber_______________
17. PH meter_______________________
18. Glucometer_______________
19. Hemoglobin Meter_______________
20. Microtom_________________
21. Oven (Wax embedding)___________
22. Tissue Processor_______________
23. Quick Test Kit for ASLO, Titre, ESR
24. Timer stop watch________________
25. Alarm clock_____
V. Refrigerator & AJC______________
1. Refrigerators 300 ltrs._____________
2. A/C machines with Stabilizer______
3. Water Coolers___________________
4. Two body mortuary (Cold Storage)
VI. Hospital Plants_____________
1. Generator 5 KVA________________
2. Generator 1 5 KVA___________
3 Generator 50 KVA_______________
4, Generator 62,5 KVA______________
5 Hot water Systems (Solar unit)
5
1
2
2T
12
1
5
20
9
6
1
8
18
22
40
5
3
8
8
3
4
2
2
1
15
6
1
12
8
70
i
3
2
~2~
1
5
3
2
H
1
1
10
1
2
2
1
1
2
1
1
J.
4
2
2
20
2
4
3
1
4
1
1
1
1
1
1
1
1
2
1
1
3
1
1
1
1
1
4
1
1
1
10
1
1
T
1
J.
1
1
1
1
2
1
1
1
1
1
1
1
2
0.7
0.4
1
2_
1
20
28
15
100
I
100
150
200
250
20
I
4
f
I
2
T
1
1
8^
2
i
T
I
I
2
I
I
I
58
Equipment
Unit Price
Rs. 000s
Bed Strength_________ _____
VI. Hospital Plants Continued
6. Pirolator_____________________
7. Incinerator 5K\V_____________
VII. Administration ____________
1, Typewriters_________________
2, Photocopier ___________ •
3, Cyclostyling Machine_________
4, Intercoms (15 lines)___________
5, Intercoms (40 lines)___________
6, Fax Machine_________________
7, Telephone (External lines)_____
8, Library (Facility)_____________
Community
Hospitals
30
50
70
Sulk
district
Hospitals
District
Hospitals
50
100
X>250
1
I
1
1
1
2
4
2
65
20
80
200
i
1
2
2
30
11
5
1
2
4
1
VIII. Transport_______________ _
1. Ambulance__________________
IX. Surgical Instrument Packs
1. D.D. & C____________________
2. M.T.P.______________________
3. Cervical Biopsy______________
4. Evacuation ________________
5. Delivery_____________________
6. P.N.Strilization______________
7. Episotomy___________________
8. Venisection__________________
9. Copper T______
10. Caesarean Section____________
11. Incision & Drainage__________
12. Vaginal Hysterectomy_________
13. Abdominal Hysterectomy______
14. Vagotomy___________________
15. Appendectomy________________
16. Hydrocele___________________
17. G.J._________________________
18. Hemorrhoidectomy___________
19. Suture Removal______________
20. Suturing Tray________________
21. L.P. Tray____________________
22. Cholecystectomy_____________
23. Thyroid_____________________
24. Catherization Tray____________
25. l.M.Nailing__________________
26. S.P. Nailing_________________
27. Dynamic Comression Plating
28. A.M.Prosthesis_______________
29. Dynamic Hip Screw Fixation
30 Fixation of Radius &. Ulna_____
3 I Cataract operation____________
32. Needling & Cataract Evacuation
33. Iridectomy___________________
34. Iridenclisis
350
1
1
1
2
1.2
1.1
0.7
0.55
1
2
2
2
2
2
2
2_
2
2
£
2
2
_4
4-
0.7
0.8
0.4
___2
___ !_
2,
2
2
J_
J_
2
2
2
2
x
2
2
__2
___5
2.5
2,5
1.2
2,5
2,7
0.4
0.9
0.45
0.8
£
£
■4
_4
4
4
2
_4
4_
4_
_4
2_
2_
2.
2,
4
2
2
2
2
2
2
2
2
2
1
1
_4
4
2
3
2
4
1
2
4_
£
2
2
2
3.0
0.1
1.0
1.5
3,5
1.5
10.5
0.25
58
6,0
___ l_
2
2
2
2
2
2
2
£_
1
£
£
2
£
2
7
4_
4
4
2
2
59
Equipment
Unit Price
Rs. 000s
Bed Strength
_________________
35 Extra Capsular Operation_______
36, Chalazon__________________
, 37. Tarsorraphv_______________
38. Enucleation
39. Probinu, of Lacryinal Passages
40. DC.R_____________________ '
41. Lachrymal Sac Extension ______
42. Trabeculectomy_______
43 Pterygium Excision
44. Entropion Correction________
45. Foreign Body Cornea____
46. Foreign Body in A.C.___________
47. Conjectival Cyst Excision______
48. Ear Examination____________
49. Mastodectomy__________________
50. Macro ear Set Myringo, Tympano,
Stepedo Plasty____________________
51. Nasal Set SMR Septoplasty
Polypectomy_______________
52. D.N.S___________
53. Rhinoplasty___________________
54. Adeno Tonsillectomy___________
55. Tracheostomy_________________
56. Endo Laryngea Micro Surgery
57. ENT General____________
58. General Anesthesia Kit_________
59. General Orthopaedic Kit________
60. Dental Kit
X. Minor Equipment_________
1, X-Ray Viewing Box________
2, Developing tanks (X-Ray)_______
3, Safe Light X-Ray Dark Room
4, Cassettes X-Ray________________
5, Intensifying Screen (various)_____
6, Lead aprons____________
7, Lead Protection Screen_____
8, Chest Stands X-Ray ___________
9, Stethoscope____________
10. B P, Apparatus__________________
1 1. BP Apparatus 43 size cups, infant,
new born child
12, Transcutaneous Billirubinometr
1 3 Digital Thermometr_____________
14, Weighing machine Adult________
15, Weighing Machine infant________
16, Infra-red Lamps___________
17, Oxygen Cylinders___________
14. Nitrogen cylinders
18 Regulatoi & Flowmeter for medical
Gas
Community
Hospitals
30
Sub
district
Hospitals
District
Hospitals
50
100
X>250
_____ 4
_____ 4
_____ 4
_____ 4
1
2
2
2
2
2
2
2
2
2
2.25
0.67
0.86
1.0
0,2
0,35
0.35
3,3
0.86
1.25
0.55
1.35
0.9 '
2
2
2
_______2_~
_______2_~_
______ 2_~_
2
1.7
10.
23.0
___ £
___ £
___ £
___ £
___ £
___ £
___ £
___ £
___ £
___£
__ £
4
9.8
2
4
7.0
6.8
7.5
0.4
16.5
1.6
4.0
20.0
5.0
2
2
2
2
£
£
£
2
£
£
1.5
0.75
0.25
0.40
2.0
2.6
7/5
0.9
0.5
2
2
2
2
2
2
2
. 1
i
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
2
5
2
i
2
2
2
1
4
2
2
2
2.8
2,3
9
T
10
4
_2
4
4
_£
J_
2
2
2
2
£
_£
10
2
30
3
2
4
4
4
2
30
3
8
1
0.6
0.6
0.4
4
3
1
1
2
2
1
30
4
6
6
3
60
6
12
20
10
60
Equipment
Bed Strength
Unit Price
Ks. 000s
Community
Hospitals
30
_______________________
50
19, Standing, BP Apparatus_____________
20 Ambu Ba^s______________________
21, Hot Plate Domestic________________
21, Emergency Lamp__________________
23, Fire Extinguishers_________________
24, Laryngoscope_____________________
25, Baby Laryngoscope with 3 size blades
0.6
1.2
1.0
1.5
0.6
2
2
_1_
2
T
0.4
1.2
1
£
18. Mayo's Trolley____________________
19. Instrument Cabinet________________
20. Instrument Trolley________________
21. Linen Trolley_____________________
22. Kick Bucket______________________
23. Attendant Stool___________________
24. Traction System__________________
25. Postmortem Table_________________
26. Wash Basin______________________
27. Instrument Tray__________________
28. Chairs___________________________
29. Wooden Tables___________________
30. Steel Cupboard___________________
3 1, Swab Rack (OT)__________________
32, Fracture Table____________________
33. Blood Donor Table Wooden________
1.4
1.25
0.6
0.5
0.25
0.2
0.85
1.5
5.5
2,9
0.3
0.6
5.2
1.25
1.8
1.25
1.65
0.9
4.25
1.6
1.1
0.55
0.25
0.5
4.0
0.4
0.5
0,45
1.6
2.0
0.8
6,6
4,0
34, Mattress_________________________
1,2
35. Pillows__________________________
36. Wooden Benches_________________
37. Patella Hammer__________________
0.1
2,5
0.1
38, Tongue Depressor________________
0.03
39, Oxygen Mask
0.13
26, Otoscope_________________________
27, Universal Bone drill_______________
XI. Furniture & Other Equipment
1, Examination Table________________
2, Delivery Table____________________
3, Foot steps________________________
4, Bedside Screen___________________
5, Revolving Stool___________________
6, ’ .Arm Board Adult & Child_________
7, Saline stand______________________
8, Wheel Chair______________________
9, Emergency Recovery Trolley_______
10. Stretcher on Trolley_______________
11. Oxygen Trolley___________________
12. Height Measuring stand____________
13. Fowler Bed_______________________
14. Iron Cot_________________________
15. Baby Cot_________________________
16. Bedside Locker___________________
17. Dressing trolley___________________
Sub
district
Hospitals
District
Hospitals
100
X>250
___ 4
4-2
___ 6
___ l_0
___ 8
___ 6
___ 4
___ 4
2
r
4
4_
_1_
6_'
2.
2
2
i
2_’
T~
_4
4_4_
4
1
2
T
6
2
6
6
6
6
10
2
1
2
^4
1
5
30
50
2
50
2
2
2
1
1
10
50
6
4
15
10
4
1
10
6
30
20
10
2
30
30
1
1
1
1
40
40
8
1
5
2
60
60
12
2
To
4
10
~To~'
io
io
io
20
3
2
3
6
2
4
100
10
100
4
4
4
2
_ 1_
20
100
_ 2_
__ 1_
20
15
50
30
15
_ 2_
__ 1_
__ 1_
120
120'
20
__ 3
15
6
__ 20
__ 4_
20
__ 20
__ 20
__ 20
__ 40
__ 10
_ £
___ 6_
__ 10
_ £
_ £
___ X
__ 20
___ X
__ £
__ £
___ 10
__ £
__ £
___40
___ X
____ 4
____ 2
__ 50
___ 30
100
___ 50
___ 50
____ 4
2
2
1J*X
i.rx
___ 40
___ 10
___ 30
10
6?
Equipment
Bed Strength
_____________
40, Torch Light_______________
41, Medicine Cabinet__________
42, Side Rails________________
43, Bucket Galvanized________
44, Bed Pans &. Urinals________
45, Bowls____________________
4(1 Kidney Tray______________
4T Racks
48 Patient's Attendant Cots
49. Wooden Benches__________
50. Bedside Attendants Chair
51. Baby Mask Various Sizes
52. Pleural Aspiratio Set B-Way
53. Exchange Transfusion Set
54. Nebulizer
Unit Price
Rs. 000s
Community
Hospitals
30
0.05 j
2.0 |
0,3
0,12
0.15
0,10
0.08
0,25
1.0
4
2
2
2?
6
6
_6
4
10
5
District
Sub
Hospitals
district
Hospitals
X>250
100
50
____ 20_
6 _______ 10
2 _______ 4_
10
_____ 8_
2- _______ 4
100
20
10
____
50
20
10
____ 50
20
10
____ 50
20
10
____ 40
10 ______ 20
____ 20
_______ 10
____ 60
15
30
____ 50
20
10
2 ________4_
_____ 6
____ 10
3 _______6_
_____ 6
________ 3_
4
2
1
62
Annexure 3
Working Groups’ Recommendations for Space
District
Sub-district
Community
[00
Beds
250 Beds
30/50 Beds
.Area
Rooms
Area
Rooms Area Rooms
: ~No~ Sq.m.
No? Sq.m.
No. Sq.m.
OPP_________ __ _______________________________
1. Entrance Hall (Vrith Counters for enquiry, cash and
j records)______ ___________________ _________
I 2, OPP Medical Record Room____________________
|3, Lavatories_______ •__________ __ ________
I 4.1 (a) Consultation Rooms: Medical
I 4.1 (b) ECG Room
I 4,2 (a) Consultation Rooms: Surgical
I 4,2 (b) Treatment and Dressing /Minor Surgery
1
28.0
1
56.0
2
14,0
17,5
17.5
2
28.0
28.0
17.5
17,5
10.5
17.5
i_
i
98.0
i
i
17.5
10.5
17.5
_i
i
35.0
70.0
17.5
14,0
17.5
14,0
17.5
i__
20.0
1
17.5
£ 17.5
2
T
4.
1
_
4.3 (a) Consultation Rooms: Gynaecology &
[Obstetrics
_
I 4.3 (b) Endoscopy Room with Toilets
_
[ 4,4 (a) Consultation Rooms: Dental_____________
1
I
17.5
1
| 4.4 (b) Dental Hygienist________________________
I 4,4 (c) Dental Workshop
___________________
I 4.5 (a) ConsultationRooms: Paediatrics____________
I 4,5 (b) Treatment & Dispensing
| 4.5 (c) Immunization
__ ____________________
I 4.6 (a) Consultation & Examination Eye Clinic
I 4,7 (a) Consultation & Examination: ENT
]_
1
17.5
1
1
14.0
17.5
17.5
1
17.5
14.0
17.5
17,5
14.0
17,5
28.0
17.5
14.0
17.5
17,5
17.5
17.5
8.5
28.0
14,0
55.8
35.O'
2
2
2
j.
_i_
| 4.7 (b) Audiometric Room
I 4,8 (a) Consultation Rooms: Orthopaedic Clinic
I 4.9 (a) Consultation Rooms: Skin & STD__________
I 4.9 (b) Treatment Room__________________
I 4.9 (a) Consultation Rooms: Psychiatry____________
I 4.9 (b) Social Worker
j
2
2
2
__
__
2
14,0
3
I
9.0
1
21.0
9.0
8. (a) Pathology: reception. Sample collection,
[waiting area
_____________
| 8. (b) Specimen disposal and sluice room__________
| 8. (c) Laboratory &?Autoclave room
1
21.0
1
28.0
i
4
1
1
1
£
£
2
90
12,0
17.5
14.0
£
13.0
1
2
15.0
17.5
28.0
1
15.0
20.0
17.5
42.0
2
14,0
I 5. Waiting Rooms
I 6, Central Injection Room
I 7. Physiotherapy: Hall & Treatment
I 9. (a) Pharmacy
_________
[ 9. (b) Pharmacy Store
____________ _____
[Rdiology / Radio Theraphy
[ 10. (a) Radiology Reception Counter
__
110. (b) Radiography
__________________
[10. (b) Film Developing & Processing____________
110. (c-) Contrast Study
__
i
£
17.5
4.5
1
10.5
17.5
4.5
4.5
1
4.5
7.0
1
__ _________
____
I
7.0
£
I
I
110. (d) Store
[10. (e) Radiologist Room
i
__________________
10 (f) Technician’s Room
110. (g) Trolley bay
___
2'
_i_"
2
2
2
2
»'
17,5
4.5
4.5
45
10.5
10.5
4.5
63
10. (h) Switch room •
10 (i) Janitors room
11. (a) Radio Therapy: Cobalt Theraphy
11, (b) Radiotherapist's room_____________________
11. (c) Physicist room with lab
11. (d) Mould room
11. (e) Simulator Room
11.(0 Treatment Planning System________________
11. (g). CT Scan
11. (h) Ultra Sound room________________________
Labour/OT___________________________________
16, Preparation Room with Toilet_________________
17, (a) Labour Room: Clean_____________________
17, fo) Labour Room: Septic_____________________
17. (c) Labour Room: Eclempsia
17 (d) Baby Reception & Resusciation Area________
18. OT Major
19. OT Minor
20. (a) Changing Room with Toilet: Doctors (Tvf &F)
20. (b) Changing Room with Toilet: Other Staff (M
&F)__________________________________________
21. Sterilization
22. Gas Cylinder Storage
23, Scrub Area_________________________________
24, Recovery Room_____________________________
25, (a) ICU(5 Beds)___________________________
25. (b) Nursing station
25. (c) Sluice Room_____________________________
Wards________________________________________
26. Duty Doctors Room_________________________
27. Nurses Station
28. Wards (each with 12 beds and Toilet Block)
29. Special Ward
30. Treatment Room
31. Ward Store_________________________________
Administration________________________________
32. Medical Suerintendent
33. Nusring Superindent______________________
34. Admin Officer
35. Staff
Hospital Services___________________
36. Central Sterilization_________________________
36. (a) Washing & Cleaning
__________
36. (b) Autoclave
36. (c) Sterile Store
37. Dietary Service
37. (a) Cooking area
_________________
37. (b) Store
100 Beds
250 Beds
30/50 Beds
Rooms .Area Rooms Area Rooms Area
No. | Sq.m,
No.| Sq.m.
No. Sq.m.
____ [
4.5
____ [
2.3
____ [ 46.5
____ [ 15,0
10.5 _____ 1.
22,5
1
____ 1.
15.0
____ [ 35.O'
1
1
21.0
j.
j.
1
2
2
2
7.0
35.0
28,0
10.5
10.5
1
1
1
10.5
10.5
7.0
14.0
T
2
J_
2
2
J.
!_
1
____ 1
____ [
10.5
1
9,0
21,0
10.5
10.5
28,0
15.0
14.0
42.0
21,0
14.0
10.5
35,0
28.0
10.5
10.5
10.5
35.0
28.0
10.5
10.5
10.5
10.5
7.0
21.0
_1_
1
j_
2
2
2
2
2
2
2.
2
2
10.5
10.5
10.5
28,0
52.5
10.5
2
2
7
2
4
2
i
17.5
120.0
14.0
10.5
10.5~
17.5
10.5
10.5
3.1.5
21.0
j4
£
4
_8
8
£
1
T
J:
1
I
14.0
10 5
17,5
10.5
10.5
42
1
28.0
17.5
17.5
1
35,0
10.5
_L4_£
i
17.5
17.5
120.0
14,0
10.5
10.5
1
7.0
2
_8
20
10
20
20
17.4
17.5'
120,0
14.0
10.5
10.5
17,5
I
1
2
2
10.5
73.5
i
21,0
21,0
28.O'
I
56
10.5
64
30/50 Beds
Area
Rooms
No? Sq.m.
38. Laundry
38 (.a) Dirty clothes receiving
33. (b) Clean Clothes Storage Area
39. General Store_____
Mortuary
40. (a) Walk in Cooler___________
40. (b) Postmortem Area_____
£
100 Beds
250 Beds
Area Rooms Area
No” Sq.m.
No~ Sq.m.
I
1.
10.5
10.5
21.0
i
14.0
14.0
35.0
1
14.0
1
17.5
40. (c) Doctors Office
Total Area Sq m,
Casualty (Optional at 30/50 bed hospitals)
Examination and Treatment Cubicles______
X- Ray Room with Dark Room
Operation Theatre_______________
Instrument Sterilixzation__________
Scrub up
Dirty Wash
Resusciation Room
______________
Nursing Station with Store_______
Nurses Retiring Room
Duty Doctors Room
Total Casualty Area Sq.m.
1338
j.
2
]_
i
10.5
21.0
21.0
7,0
7.0
7,0
21.0
7.0
10.5
10.5
112
I
i
2
14.0
i
21,0
17.5
2379
V
2
j.
i
10.5
28,0
21.0
7.0
7,0
7.0
35,0
10.5
10.5
10.5
147|
21.0
21.0
60. o'
5393
4-
2
2_
j.
i
10.5
35,0
35.0
10.5
10.5
10.5
63,0
10.5
14.0
14.0
231
65
ANNEX 5
SCOPE FOR COST SHARING IMPROVEMENT
ANNEX 5
STRENGTHENING OF SUSTAINABILITY OF HEALTH CARE SERVICES
1.
CURRENT STATUS OF USER CHARGES
The Government of Karnataka has a jsystem of' ‘levying charges for diagnostic services,
treatment and usage of wards in the hospitals managed by it. The last revision of these: user
charges was made in 1988 by order No: HEW 126 SiMM 86 dated March 10, 1988.
There are other types of charges levied e.g. certificates for physical fitness, wounds etc. Fifty
percent of the charges collected are retained by the government and the balance given to the
doctor issuing the certificate. Charges for the issuance of such certificates were fixed last in
1946 and have not been revised to date
The user charges are to be collected and remitted 1to the
’ treasury. Neither
\
the hospital
collecting the charge nor the Department of Health has access to the user charges collected.
As a consequence, there is no incentive to collect user charges. The average collections of user
charges per year during 1990-93, amounted to Rs. 107 million. Approximately 40 percent or
Rs. 41 million is on account of issuance of certificates and the balance amount of Rs. 66
million on account of ward charges and charges for surgery and investigations. In 1992-93 the
collection accounted for 3 percent of the expenditure of the health department.
No charge is levied on outpatients. The registration charges which used to be levied earlier
have been discontinued.
inpatients with annual family income of below Rs. 8,001 are exempted from paying charges
for any service as they are considered to be economically weaker sections. The patients with
family income of over Rs. 8,000 and admitted in general wards are charged a nominal amount
of Rs. 2 per day. There are charges for special wards, graded according to the number of beds
in such special wards, the maximum charge being Rs. 30 per day for a single bed in special
ward with basic diet included.
A schedule of rates exist, specifying fees for different services. Those admitted in special
wards irrespective of income and those with family income of over Rs. 20,000 admitted in
general wards have to pay the full charge as listed. Those admitted in general wards and with
family income of Rs. 8,001 to 20,000 per annum have to pay 50 percent of the charges while
those with income below are exempted from all charges.
The charges for issuance of certificates are low, when one considers the present day cost of
living. For example, the charge for issuing certificate for physical fitness is Rs. 5. There is
justification for substantial revision of these charges. Increasing the charges especially for
wound certificates does not affect the economically weaker sections since the certificates are
collected by the police without paying any charge when a complaint is lodged by them with the
police.
STRENGTHENING OF SUSTA1NABIUTY
ANNEX 5
2
OBJECTIVE OF STRENGTHENING OF SUST.AIN ABILITY
The appropriateness of adopting user charge principles and imposing user fees depends on the
type of service provided. Hospital services are mostly patient related curative services. There
is a scope to levy fees or charges on curative services provided a mechanism exists to adjust
fees depending on the patients ability to pay. Studies have shown that imposition of user fees
accompanied by improvement in quality can lead to increased utilisation because of the
switching effect i.e.—shift from private providers to Government facilities. However, the
additional revenues generated by levy of user fees may not be adequate to cover fully the
expenditure in improving quality through better facilities in terms of equipment and drugs.
The argument for levy of user fee is based on efficiency. If no user fee is imposed there will be
an "excess demand" for services especially hospital beds. Government hospitals are crowded
and often the resourceful but the undeserving people get free access, whereas the poor have to
incur " transaction costs" to get treatment or a hospital bed. Graded cost recovery from the
non-poor is expected to restrict demand for beds thereby releasing beds for the poor. Thus,
user fee may be a step in restoring equity; the poor may benefit proportionately more than the
non-poor.
Prescription or user fees may only slightly affect the demand negatively for health services
because demand for inpatient and outpatient care is highly inelastic. However, consumers will
be more responsive to the quality of care, time costs and the relative prices of alternative types
of care givers. Prescription or user fee will augment resources for the health sector and
should, therefore, lead to improvements in supply both in qualitative and quantitative terms.
Sustainability would also be promoted to a large extent because the revenue realised would
finance a portion of the operational costs thereby relieving the budgetary constraint. Cost
recovery would result in improvements in the quality of care if the resources generated
internally by a hospital are ploughed back for improving the availability of drugs and
equipment in that hospital.
To ensure a long term development of the health care delivery system it will be more and more
important to strengthen the cost sharing in the public health sector. The main objectives are:
•
Generate additional revenues for improving the quality of care at secondary level facilities
and at primary level facilities.
•
Encourage patients to use preventive and primary level facilities which will continue to
provide services free.
•
To force people to become more responsible for their own health care by sharing the cost
of curative services.
STRENGTHENING OF SUSTAINABILITY
2
ANNEX 5
3.
STRATEGIES TO IMPROVE COST SHARING
3.1
Raising Revenue through User Charges
The ethical and social question really is: should the government provide medical services free
of charge to everyone or only to the poor? It may appear rational to expect the government to
provide only for the poor but this also has a disadvantage. Typically, targeting has its own
share of practical and administrative difficulties. Apart from incurring high administrative
costs, several schemes designed for the poor have left out significant proportions of the poor
and perhaps some undeserving ones have got included. Exclusion of the wealthy and middle
income groups can also lead to erosion of political support for the package and therefore, lead
to decreased funding. It is therefore to be recognised that imposition of user charges has to be
approached with a great deal of care and caution.
The National Sample Survey data shows that 56 percent of the patients from rural areas and
46 percent from urban areas admitted to general free wards in government hospitals, are from
middle and upper classes. Either the better off patients are understating their income to get
free services and/or there are not adequate special and paying general wards in government
hospitals. Currently, the government policies do not encourage spending government
resources in creating special wards.
A two-day workshop of District Surgeons and Specialists working in Secondary Level
Hospitals was organised in May 1994. The workshop recommended, among other things, that
in order to raise additional resources through user charges, at least one third of the beds in
government run hospitals should be converted over time into fee paying general and special
wards. Admission to general free wards might be restricted to those who are poor to prevent
the non-poor from enjoying free services. As a step towards this, one third of the proposed
increase of 3500 beds in district, sub-district, and Taluka hospitals will be planned as special
wards. The special wards then win account for 20 percent of total beds in these hospitals. A
moderate charge of Rs. 50 per day may be levied to recover a major part of the current
average cost excluding staff salary, of servicing a bed per day, which is estimated at Rs 70.
Some of the beds in special wards could be reserved for the public sector, private sector and
co-operative institutions located in the district against a fixed annual payment so that
availability of special ward to their employees is assured. An attempt will be made to obtain
administrative and political clearance for this from the Government of Karnataka.
A nominal registration fee say of Rs. 2 for each outpatient and Rs 5 for inpatients could be
introduced. The schedule of charges should be reviewed and should be related to cost of such
charges. Waiving of charges should be on criteria other than income as declared by the patient,
to prevent undue advantage taken by the non-poor.
There is also a potential for raising resources through a scheme of pre-paid health care plans
through organisations or co-operatives which supply inputs for agriculture and dairy and also
undertake collection, processing and marketing of produce. Workers in the organised sector
could also be covered. The hospitals could also offer health insurance policies.
STRENGTHENING GF SUSTAINABILITY
3
ANNEX 5
The fees for issuance of certificates need to be enhanced substantially. The charge for issuing
physical fitness certificate should be raised from Rs. 5 to Rs. 100 and similar increases could
be effected for other certificates.
The receipts from certificates can go up from Rs. 40 million to 800 million if the suggested
charges are implemented. Creation of 3600 beds in special wards of sub-district hospitals and
charging Rs. 50 per day would yield over Rs. 50 million at 80 percent bed occupancy.
Introduction of registration charges as indicated is expected to yield nearly Rs. 20 million at
the current level of outpatients and inpatients treated in government hospitals.
It is proposed to engage a consultant to assess the present arrangement, review the existing
pattern of user charges throughout the State and suggest to Government a revised schedule
consistent with the present needs.
3.2
Strengthening of Reporting and Monitoring System
With the revision of the fee structure an extensive programme will be developed with the aim
to implement the necessary collection, accounting, reporting and monitoring system. As basis
for decision making in DHFW a comprehensive survey in the Gulbarga Division will be
conducted with emphasis on the following:
•
•
•
•
Survey to assess the ability of patients to pay for services provided in public hospitals and
the scale of fees.
Perception of patients on the introduction of fees for medical services in return for quality
patient care.
Assessment of teaching and autonomous institutions in the area of cost sharing with
special emphasis on the adaptability of the existing system to government hospitals.
Assessment of patient fees and quality of services provided by private hospitals.
Based on the survey, the relevant documentation for strengthening of cost sharing will be
developed. For each hospital, a manual for cost sharing will be developed which will provide
the terms and references whereby all necessary information on fee collection will be provided
and this will include the following:
•
•
•
•
A guideline on charges for certificate, registration, consultation, diagnostic
procedures,ward charges, operation, medication etc.
Waivers and exemptions on charges for different categories of the population.
Strict accounting procedures and documentation for eveiy level of the health care delivery
system.
Reporting structures
Based on the information contained in the manual which will be made available to all districts,
a training workshop will be held to inform and train the respective staff in the hospital on the
procedures set out in the manual and how to implement the system in an equitable manner.
STRENGTHENING OF SUSTAINABILITY
4
ANNEX 5
Parallel to the above manual, a monitoring system will be developed with the following aim:
•
•
•
•
•
•
Identification of indicators per hospital by category and district
Revenues generated per facility
Assessement of how income generated is being spent in the district (Development fund)
Impact on quality of care
Impact on patients
Impact on services
The monitoring and evaluation programme shall ensure a balanced approach to cost sharing
measurements.
3.3
Autonomous Institutions
The State has four Super Speciality institutions which provide high quality care, located in
Bangalore. These institutions are:
1.
2.
3.
4.
Kidwai Memorial Institute of Oncology
Jayadeva Institute of Cardiology
The Indira Gandi Institute of Child Health
The Sanjay Gandhi Accident and Rehabilitation Institute
These institutions have been “autonomous” and are not bound by Govt, regulations. They are
managed by a Governing Body, which includes experts, the Secretaries of Finance and Health
besides the Health Minister and the Minister of Medical Education. The Chief Minister heads
the Governing Council.
It is significant to note that apart from a nominal grant-in-aid towards salaries and some
miscellaneous expenses received from the State Govt, these institutions have been structured
to raise resources through user charges. The Kidwai and Jayadeva Institutions have been quite
successful in levying user charges both for diagnostic as well as inpatient services.
This kind of restructuring will enable the State Govt, to devote greater attention and resources
to primary and secondary level health care. The entire revenue realised by the autonomous
institutions through “user charges” is retained by them and used for the upkeep and
maintenance of the facilities.
STRENGTHENING OF SUSTAINABILITY
5
ANNEX 5
4.
DEVELOPMENT FUND
Introduction of measures to augment resources will not automatically raise the level of
infrastructural work unless the concerned institution is in a position to reinvest a substantial
portion on the hospital. Ideally, each secondary and tertiary level hospital should establish a
"Development Fund” and open a Bank account where the collections from user charges would
be remitted.
All hospitals should also be entitled to receive donations from philanthropic organisations and
individuals, undertakings in the private and public sector etc. and credit to its ’’Development
Fund”. The money can then be used for undertaking civil works, purchase of equipment,
drugs, hospital supplies, etc.
However, it may not be practicable for each hospital to open a bank account. It is therefore
proposed to create a State Level Hospital Fund. All amounts realised as receipts from patients
and other fees collected would be accounted for in this fund. Based on the remittances. Health
& Family Welfare Department would release, on a quarterly basis, the estimated collections
during the quarter as an additional amount to its own departmental budget.
Health and Family Department will set up at the District level, a District Hospital
Development Committee with the Deputy Commissioner as its Chairman. The Development
Committee will be permitted to open a bank account. This committee would be entitled to
receive donations from philanthropists individuals, public sector etc., and credit such donations
to its bank account. Every quarter based on the amounts released from the State Level Fund,
the Health and Family Welfare Department will release money to the District Hospital
Development Committees in the form of grant-in-aid, based on user charges collected.
The District Committee will comprise the following members.
1.
2.
3.
4.
5.
6.
7.
Deputy Commissioner of the District
Chief Executive officer, Zilla Panchayat
District Surgeon
District Health & F.W. Officer
Executive Engineer, P.W.D
Concerned Executive Engineer, Z.P
Concerned Superintendent of the Hospital
Chairman.
Member.
Member.
Member.
Member.
Member.
Member.
The amount received by the Development Committee both through donations and through
grant-in-aid will be used for undertaking civil works, purchase of materials, drugs, hospital
supplies etc., in respect of hospitals based on collections made and the needs of each
institution.
STRENGTHENING OF SUSTAINABILITY
6
ANNEX 5
5.
PROJECT SCOPE
The project component in terms of improvement of cost sharing will apply for the whole state
of Karnataka. Cost for strengthening and developing cost sharing is estimated as follows:
in IR
Local consultant fees for development of cost sharing
Training workshops including allowance and travel expenses for trainees
2,500,000
1,500,000
TOTAL
4.000,000
STRENGTHENING OF SUSTAINABILITY
7
A NNEX 6
CONTRIBUTION BY THE GOVERNMENT OF KARNATAKA
ANNEX 6
CONTRIBUTION BY THE GOVERNMENT OF KARNATAKA
The physical upgrading of the hospital facilities by the Government of Karnataka will improve
and expand the operational facilities such as staffing, increasing the budget allocation and to
implement the structure to maintain the facilities. Al renovated facilities will be sanctioned in
accordance with the High Level Review Committee recommendation related to staffing and
services provided.
In the first phase of the project, 30 facilities will be upgraded and an additional 800 beds will
be added, whereby some hospital facilities will be completed before the end of the project. In
the third year 200 beds will be available and in the fourth year a further 200 beds. For the 600
beds, an additional recurring cost will be provided. The following summarizes the contribution
of the Government:
• Salary of Hospital Staff
The salary cost for each additional hospital bed per year is IR 60.000. The government will
provide for two years of the project period the respective salary.
[ IR 60.000X600 beds
IR 36,000,000"]
< Salary of Maintenance Staff
The maintenance staff for the four workshops will be approximately 50 persons based on a
average salary of IR 50.000 per year. The workshops will operate for two years.
| 50 X 50.000 x 2 years
ir 5,000,odo~]
* Drugs and Chemicals
The Working Committee for Drugs and Supplies has examined the present provision for
Drugs and Chemicals and found it to be inadequate. Instead of allocating the budget on the
basis of the population of the catchment area as is done at present it has been recommended
that provision be made in the budget on the basis of beds at the following rates:
HOSPITAL TYPE AND BED STRENGTH OF HOSPITAL
CHC 30 Beds
Gen. Hosp. 50 Beds
Gen. Hosp. 100 Beds
Gen. Hosp. ^250
AMOUNT PER BED AND YEAR (IR)
Proposed
7,500
9,000
10,500
_________________________ 12,000
CONTRIBUTION OF THE GOVERNMENT OF KARNATAKA
1
ANNEX 6
The project comprises mainly 50 bed or 100 bed hospitals therefore the amount for each new
bed is assumed at IR 8,000.
I IR 10,000 X 600 beds
•
IR 6,000,000 ]
Diet and other Expenses
For diet and other expenses the amount required for each new hospital bed will be
approximately IR 7,000.
| IR 7,000 X 600 beds
TR 4,200,000~]
• Maintenance
The provision for maintenance of secondary health care facilities has been very limited and was
far below the requirement. The Government of Karnataka will therefore implement allocation
for maintenance per year based on hospital category as shown in the table below.
TYPE OF HOSPITAL
30 bed Hospital
50 bed Hospital
100 bed Hospital
District Hospital
PROVISION PER HOSPITAL PER YEAR IN IR.
135,000
225,000
450,000
_______________________________ 2,025,000
The project comprises mainly 50 bed or 100 bed hospitals. Therefore, the amount for each
renovated or upgraded hospital is assumed at IR 350,000.
I IR 350,000 X30 facilities
<
IR 10,500,000 |
Project Management
The contribution for project management (e.g. manpower, salary, travel expenses) is estimated
at IR 2,000,000 per year which amounts to IR 8,000,000 for the project period.
COKFRIBUTION OF THE GOVERNMENT OF KARNA TAKA
2
ANNEX 6
• Summary of Contribution by Government
The total amount contributed by the Government amounts to IR 70.0 million. The various
items are listed below.
Salary of hospital staff
Salary of maintenance staff
Drugs and chemicals
Diet and other expense
Maintenance
Project management
in IR
36,000,000
5,000,000
6.000,000
4,200,000
10,500,000
8,000,000
TOTAL
69,700,000
The above mentioned contribution does not include additional recurrent cost for staffing in
facilities which will be renovated. Most of the renovated facilities will also be provided with
additional staffing and higher allocation for drugs.
CONTRIBUTION OF THE GOVERNMENT OF KARNA TAKA
3
ANNEX?
SCOPE FOR IMPROVEMENT ON MAINTENANCE
ANNEX 7
1.
LNTRODUCTION
In recent years, the Government of Karnataka has invested in the development of health care
facilities at the primary and secondary health care level. The renovation period for major repairs
ot building and equipment is very short because there is no proper maintenance. The lack of
maintenance is because of an insufficient maintenance budget, lack of facilities and manpower.
Execution of maintenance work is also hampered by bureaucratic procedures organisation wide.
Presently only district hospitals have a budget for maintenance and all other maintenance requests
have to follow a complicated and bureaucratic way to get the approval and execution for any
maintenance work. The improvement on the maintenance work will not only be pending on the
funds, facilities and manpower but will also require an improvement on the procedures in
making the funds available
OBJECTIVE
With the implementation ot the upgrading of secondary health care facilities by the KfW project
and the World Bank project, the whole state of Karnataka will be covered and both projects
intend to improve the maintenance capabilities for the public sector. Financed by the Worid Bank
project, the implementation of training facilities in Bangalore for biomedical engineering is
oreseen. Besides the establishment of training facilities, maintenance facilities at division level
will be established.
The KfW project will be similar to the World Bank project and
is to establish maintenance
facilities at division level. The aim is as follows:-
Z^alysTand0?!^1™551011’ maintain and service medical equipment for diagnostic, monitoring,
•
•
•
3.
To maintain and service heating, ventilation and air conditioning systems and power systems.
Provide expert technical services/advice on the purchase of equipment, spares and service
contracts
Organize training for technicians and users
Modify existing equipment if required
Maintain records for administration and management of decision making processes
To establish and monitor external maintenance contracts
REQUIREMENTS
o achieve the above mentioned objective the establishment of workshop facilities in each of the
district hospitals m Gulbarga, Bellary, Raichur and Eidar is proposed whereby the district hospital
workshop will also provide maintenance to the other hospitals within the district At a later stage
the DHFW can expand the maintenance facilities to Taluka level hospitals.
MAINTENANCE APPROACH
1
ANNEX?
3,1
Organizational Requirements
The district hospital workshop will be provided with a budget for the district hospital and also for
the other hospitals. All maintenance and repair work for medical equipment and engineering
works will be executed and decided at district level. The'limit for a single repair work will be Rs
20,000 for the District Hospital, Rs 10,000 for the Taluka Hospital (General Hospital) and Rs
5,000 for the Community Health Centre. Above this limit, approval from the DHFW will be
required.
The workshop will administrate the maintenance work for all respective facilities and prepare the
annual budget and will propose external maintenance contracts.
3.2
Manpower requirement
The mamtenance concept is designed for repair work of medical equipment and electrical and
mechanical works in the hospital. The staffing for the hospital workshop will take charge for all
hospitals in their respective district. It is foreseen that the teaching hospitals will be provided with
more staff at the standard district hospitals. In the following table the respective staff for teaching
and district hospitals is indicated:
STAFF CATEGORY
TEACHING HOSPITAL
DISTRICT HOSPITAL
Head Maintenance Unit
1 Biomedical engineer "C*
1 Biomedical engineer *B"
Department head
2 Biomedical engineers *B"
1 Biomedical engineer "A"
Technical staff
2 Biomedical technicians
2 Electronic technicians
1 Electrical technician
2 General technicians
1 Mechanical technician
1 Biomedical technician
1 Electronic technician
1 Electrical technician
1 General technician
1 Mechanical technician
Administration staff
1 Office superintendent
1 Typist/Computer operator
1 Clerk
1 Office superintendent
1 Typist/Computer operator
1 Clerk
TOTAL STAFF
14
10
Within the Gulbarga Division the hospitals in Bellary and Gulbarga are teaching facilities and the
GH in Raichur and Bidar are confined as district hospitals. The total number of staff required for
the Gulbarga Division will be 48.
3.3
Facility Requirement
MAINTENANCE APPROACH
2
ANNEX 7
The requirement of facilities are related to building (civil works and engineering services) and
equipment for the new workshops.
•
Building
The teaching hospital in Gulbarga will require a workshop building with approximately 200 sqm
including workshop area, stores and space for the administration. The district hospitals will
require 150 sqm tor the same function. The principle functional layout is enclosed in ANNEX
7.1. The final design will be prepared by architects appointed by the Project Management Team
•
Equipment
uie workshop will be fully equipped witn workshop equipment and furniture in accordance with
me function The respective equmme-t u <hown in the 1 able bv-'w
1 he final specification ot the required equipment will be prep red m the initial project phase after
tiie basic design of the worksnop has Deen developed.
_______________ EQUIPMENT CATEGORY
Digital storage oscilloscope (100 MHz)
Dual cnannel oscilloscope (100 MHz)
Dual channel oscilloscope (20 MHz)
Regulated power supply
Signal generator
Leakage test set-up
Digital multimeter
Analog multimeter
Diathermy calibration set up
Temperature controlled station
Electronic tool kit
Electrical tool kit
Foreman tool kit
Work bench
Insulation tester
Drill
Vise
Grinder
Storage equipment
Office furniture
Computer and office equipment
TEACHING HOSPITAL
DISTRICT nOSPITAL
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
__________________ yes
yes
yes
yes
yes
yes
yes
yes
no
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
yes
______________ yes
Vehicle
To serve all main hospitals within the district, the district maintenance unit will be provided with a
jeep and basic repair tools. The vehicle will be used to organize the maintenance services of the
hospital outside of the district hospital.
MAINTENANCE APPROA CH
3
zYNNEX 7
4.
SCOPE OF THE WORKSHOP
The main scope of the workshop will be to maintain and service the medical equipment for
patient monitoring, X-ray and laboratory equipment, diagnostic and OT-equipment. The second
group of equipment is related to refrigeration sterilization, laundry and kitchen. The workshop
team will also be responsible for engineering facilities for power supply, standby power supply,
air-condition, water supply and disposal. The overview of in-house maintenance and services
which shall be provided from external sources is enclosed in ANNEX 7.2.
The maintenance unit shall have a role in commissioning of new equipment, preparation on
specification, evaluation of equipment functions, ordering of spare parts and development of
maintenance budget and policy.
The unit shall be responsible for the establishment of external maintenance contracts and
supervise the execution of such contracts. Repair work required from external sources shall be
approved, guided and controlled by the maintenance unit.
The administrative duties shall include upkeeping of the equipment records from the purchase up
to the disposal of the equipment, recording of all maintenance work executed and collect data on
the respective repair-work and spending for each of the hospitals. Equipment audit, performance
reports, standard proforma shall be prepared and circulated.
Training for biomedical engineering will be established in Bangalore which will be financed by the
World Bank. Special equipment related training for technicians will be set up at the teaching
hospital workshop. This workshop will also organize equipment related user training. ANNEX
7.3 describes the staff category which shall be trained on certain equipment.
5.
PROCEDURES FOR MAINTENANCE AND REPAIR
With the set up of the maintenance facilities, the unit shall organize an inventory of all medical
equipment and installation for all relevant hospitals. All new equipment provided by the project
shall be registered with the maintenance unit. The unit shall produce a card or form for each of
the equipment. For all new equipment, a complete history shall be maintained.
Requisition forms for repair should be available at all hospitals. At the time of failure or apparent
damage, a request shall be made to the maintenance unit and the repair staff will repair and if it is
not possible in their capacity, the relevant external agencies shall be organized. If the repair
amount exceeds certain cost levels then approval should be obtained.
MAINTENANCE APPROACH
4
ANNEX?
Equipment record card shall form the key reference to all service functions. The unit will establish
and maintain required service and repair documents. For all service and repair work, a record
shall be established which indicates for each procedure time spent, spare part and material used.
A computerized maintenance information system shall be implemented in each of the workshops
and will be pending on the overall concept which will be finally implemented in all respective
hospitals in Karnataka.
6.
BUDGET REQUIREMENT FOR MAINTENANCE
Besides the cost tor the operation or the workshop which will be mainly staff salary (the total
operational cost tor each workshop will be approximately Rs 500,000 per year)
It will be necessarv to a;.o<.\re in amount for maintenance As <in indication it
be o>.p'cd
that the amount required tor each hospital bed per year is approximately Rs 5 000 ^assuming the
investment cost per hospital bed is Rs 250,000 and the maintenance amount per veir is
For
CHC this amount will be less and for general hospitals and district hospitals it may be above
Rs 5,000. On average each district operates about 2,000 hospital beds which means that for each
district Rs 10.0 million maintenance budget is to be allocated. From the budget «0% shall he
dedicated to the district level and only 20% of the maintenance budget shall be administered by
the DHFW mainly for major repairs and for unforeseen circumstances.
7.
COMMITMENT FROM THE GOVERNMENT OF KARNATAKA
For the successful implementation of the maintenance concept, the Government of Karnataka
assures that the fol owing changes will be implemented in the first two years of the project:
•
•
•
•
The workshop will be established at the district hospital level and the responsibility of the
workshop will be to undertake maintenance work for all hospitals including CHCs within the
district.
The District Surgeon will be responsible for the workshop and the utilization of the
maintenance budget spent in the district.
The DHFW will implement the respective directive relating to the responsibility and
organizational procedures for the handling of the maintenance related to medical equipment
and engineering installation. The directive shall also cover the responsibility of DHFW for the
maintenance of building.
The DHFW is committed to provide at least 50% of the required amount (indicated in clause
6) for maintenance.
The DHFW will sanction the required post in clause 3 and provide the operational budget to
operate the workshop.
MAINTENANCE APPROACH
5
ANNEX 7
8.
PROJECT BUDGET FOR MAINTENANCE
Within the project, building facilities, workshop equipment, initial spare parts and user training
will be financed. The workshop will be established at the teaching hospital in Gulbarga and at the
three district hospitals in Bidar, Bellary and Raichur.
• Building Facilities
The workshop in Gulbarga will require 200 sqm and each of the three district hospital workshops
need 150 sqm. In total 650 sqm of new building space will have to be built. Based on building
cost of Rs 4,000 per sqm the total cost for building will be Rs 2.6 million.
• Equipment Cost and Vehicles
Similar to the building cost, the workshop equipment including tools for Gulbarga Division will
be Rs 900,000 and for the three district workshops Rs 600,000. Each workshop will be provided
with a jeep at the cost of Rs 250,000 each. The total amount for equipment and vehicles will be
Rs 3.7 million.
• Initial Spare Part Supply
Initial supply for the maintenance workshop will comprise standard spares for medical equipment
and consumables which will be defined at a later stage. The amount reserved for each workshop
will be Rs 300,000 each amounting to Rs 1.2 million.
•
User Training
The user training will be established jointly with the World Bank project and Rs 500,000 will be
allocated to cover transport allowance and cost for trainer.
MAINTENANCE APPROACH
6
ANNEX?
•
Summary For Maintenance Workshop
The TABLE below summarizes the budget for the implementation of the maintenance component
in the first phase.
in Rs
2.600,000
2,700,000
1,000,000
1,200,000
500,000
Building cost
Equipment cost
Vehicles
Spare parts
Training
TOTAL
8,000,000
MAINTENANCE APPROACH
7
ANNEX 7.1
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4.00
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WORKBENCH
CARPENTER’S
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ELECTRONIC WORKBENCH
2
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VEHICLE
ACCESS
VEHICLE
ACCESS
TYPICAL LAYOUT for a WORKSHOP
1:60 MTS.
0
V
1
3
METERS
ANNEX 7.2
MAINTENANCE ARRANGEMENTS
First-line maintenance by in-house
technical staff
Minor attention by in-house staff
(other work contracted-out locally )
500mA X-ray system
300mA X-ray system
100mA X-ray system
i Ches: stand. X-ray
60mA mobile X-ray system
Dental X-ray system
Ultrasonic scanner, linear
I U/sonic scanner, linear sector
Defibrillator (with recorder)Endoscope, fibre-optic
| Operating microscope
I Ventilator, adult
I Emergency resuscitation kit
j Acute Medical Care system
t Denta: Chair
j Aerotor (turbine & compressor)
J Ultrasonic dental scaler
Dental lab. i bath, motor etc
I Operating table, hydraulic
j pH meter
Glucometer
I Blood-gas analyser
Tables (vanous)
Beds (various)
Foo: steps
Beside screen
Stools (various.1
Saline stano
Wheel char
Emergency/recovery trolley
Stretcher on trolley
Oxygen cylinder stand/trolley
Height measuring stand
Cots (vanous)
Beside locker
Trolleys (vanous)
Cabinets (various i
Traction system
Chairs (various;
Racks (vanous)
Steel cupboard
Wooden bench
I
I
i
; Generators (various)
I Incinerators <
Hot water systems (solar) c
Gas regulators & flowmeters
| Sewing machine
I
I
_______
—
Fully contracted out services
Anaes. m/c (with FloTec)
Anaes. m/c (without FloTec)
Pulse Oximeter
Oxygen cylinder
Nitrous oxide cylinder
Ambulance
Hearse
Pick-up
Typewriter
Photocopier
Roneo m/c
Intercoms
Fax machine
Telephones
Fire extinguishers
j!
j________ _
i
1
ANNEX 7.3
oifEfMeEReTnt cadres
MENT TRA,N,NG programmes FOR
APWP c
Member 1993 Wort<shop whlch revised
equipmen( nonns fQr
A WP Communrty (30-50 bed). Area (75-100 bed) and D.stnct (200-350+bed) hosprtals
w'H
e necessary to ensure that all users of technology and plant Installed in APWP
n
thirties can meet their obligations as spelt out in the policy paper.
==s=”====.
TABLE 2 : EQUIPMENT TRAINING FOR OPERATION
Doctors only
Audiometer
Endoscope, fibre-optic
Operating microscope
! Cryo Surgery, basic
Cryo Surgery, de-luxe
Ventilator, adult
Anaesthetic m/c (with FloTec)
Anaes.m/c (without FloTec)
Pulse Oximeter
Opthlamoscope
Slitlamp with table
Retinoscope
Perimeter
Pulse air tonometer
Dental unit
Otoscope
Universal bone drill
& SIMPLE CARE
Doctors & Nurses
Cardiac monitor
Defibrillator (with recorder)
Phototherapy unit
Radiant heater, 4KW
S-Wave electro-physio unit
Emergency resuscitation kit
Sigmoidoscope, rigid, adult
Acute Medical Care equipment
Oxygen masks, with regulator
B.P. machine
Oxygen cylinder
Nitrous oxide cylinder
Gas regulators & flowmeters
Ambu-bag
Laryngoscope(adult & child)
1
i
Table 1 (confd)
Full maintenance and repair by in-house technical staff
ECG machine (12-lead)
Cardiac monitor
Audiometer
Phototherapy unit
Radiant heater
I Cryo Surgery systems
! S-W electro-physio unr.
Opthlamoscope
Slitlamp with table
Retinoscope
Perimeter
Sigmoidoscope, rigid, adult
Pulse air tonometer
Dental unit
Operating table, ordinary
I Autoclave HP (various)
i Shaoowless lamp, OT. mobile
I OT lights, ceiling(shadowless)
Focusing lights. OT (mobile)
Suction m/c (high vacuum MTP)
Suction apparatus, electrical
Foot suction apparatus
Vacuum extractor
Steriliser, instrument
Electro-surgery machine
Cautery set, electric (Gynae)
Automist (OT fumigator)
Microscope, binocular
Chemical balance,analytical
Simple balance
Photo-electric colorimeter
Flame photometer
Spectrophotometer
Micro Pippette
Water bath
Hot air ovens
Incubator, laboratory
Water still
Centrifuge (electrical)
Centrifuge (haematocrit)
Hot plate, laboratory
Rotor/shaker (laboratory)
Haemocytometer
Haemoglobin meter
Microtome
Oven, wax-embedding
Tissue Processor
Lovibond comparator
Refrigerators (various)
Air conditioner w.'stabiliser
Water cooler, 60/120 litres
2-body mortuary (cold store)
Oxygen masks, with regulator
Torch light
Surgical instruments
X-ray viewing box
Developing tanks (various)
Safelight, X-ray darkroom
Cassettes, X-ray. various
Intensifying screen, various
Lead protection screen
B.P. machine
Weighing scale, adult
Weighing’scale, infant
Infra-red lamp (Physiotherapy)
Ambu-bag
Angle-poise lamp
Hot plate, domestic
Emergency lamp
Laryngoscope (adult & child)
Otoscope
Universal bone drill
i
i
Nurses onty
Operating table, hydraulic
Autoclave. HP. (honz.& vert.)
Autoclave, electncal.
Shadowless lamp. OT. mobile
OT lights.ceiling (shadowless)
Focusing lights, OT (mobile)
Suction (high vacuum MTP)
! Suction apparatus, electnca!
' Foot suction apparatus
I Vacuum extractor
i Steriliser, instrument
Electro-surgery machine
Cautery set. electric (Gynae.i
i Automist (OT fumigator)
I Weighing scale, adult
Weighing scale, infant
Infra-red lamp (Physiotherapy)
: Emergency lamp
I Fire extinguishers (various)
l Biochemists, Lab Technicians &
L
Operating Theatre Assistants
n
All surgical instrument packs
Operating table, hydraulic
Autoclave. HP. (honz.S vert.)
Autoclave, electrical.
Shadowless lamp. OT. mobile
OT lights.ceiling (shadowless)
Focusing lights. OT (mobile;
Suction (high vacuum MTP)
Suction apparatus, electrical
Foot suction aooaratus
Vacuum extractor
Steriliser, instrument
Electro-surgery' machine
Cautery set. electric (Gynae)
Automist (OT fumigator)
Weighing scale, adutt
Weighing scale, infant
i
i
I
i
Radiographers & Darkroom
Attendants
Assistants
Microscope, binocular
Chemical balance, analytical
Simple balance
Photo-electric colorimeter
Flame photometer
Spectrophotometer
Micro Pippette
Water bath
Hot air oven
Incubator, laboratory
Water still
Centrifuge (electrical)
Centrifuge (haematocrit)
Hot plate, laboratory
Rotor/shaker (laboratory)
Haemocytometer
pH meter
Glucometer
Haemoglobin meter
Microtome
Oven, wax-embedding
Tissue Processor
Blood-gas analyser
Lovibond comparator
500mA X-ray system
300mA X-ray system
100mA X-ray system
60mA mobile X-ray system
Dental X-ray system
Radiation protection
Ultrasonic scanner, linear
U/sonic scanner, linear sector
ECG machine (12-lead)
X-ray viewing box
Developing tanks (various)
Safelight, X-ray darkroom
Cassettes. X-ray. various
Intensifying screen, various
Chest stand, X-ray
I
Drivers
Ambulance
Hearse
Pick-up
| Plant attendants
■ Generators (various)
Incinerators
Hot water system (solar)
L
Office staff
Photocopier
Roneo m/c
Intercoms
Fax machine
Telephones
Tailors
Sewing machine
ANNEX 8
PROJECT MANA CEMENT
ANNEX 8
1.
THE PROJECT MANAGEMEiNT STRUCTURE
The project management shall be based on the following principles:
•
•
•
•
•
The project management team will be at division and district level
All required design, engineering and supervision will be tendered and provided by the private
sector
All civil works and engineering works will be tendered at district level
All supply of equipment will be tendered locally
An independent project manager will be appointed by the government to assist the project
management team at division level in the execution of the project.
For the implementation of the project, three project bodies will be formed. At the APEX of the
project management structure, the “Project Governing Board” headed by the Chief Secretary will
be constituted. The project management Steering Committee will be formed which will be
headed by the Secretary to the Government, Health and Family Welfare Department. The
“Project Committee” headed by the Additional Director, Projects which is in-charge for all
special projects in the state will handle all project overall relevant issues. At working level, the
Divisional Project Management will be installed. The principle project structure is indicated in
CHART 1.
CHART 1: PROJECT MANAGEMENT STRUCTURE
GOVERNING BOARD
(Chief Secretary to the Government)
STEERING COMMITTEE
(Secretary to the Government HFWD)
ADDITIONAL PROJECTS
(Additional Director Projects)
__________ J_____________
DIVISION PROJECT MANAGEMENT
(Joint Division Director)
(External Architects, Engineers and Monitoring)
District
implementation
I
District
Implementation
I
District
Implementation
PROJECT MANAGEMENT STRUCTURE.
I
District
Implementation
1
ANNEX 8
The Governing Board for the project will consist of the following:
1)
2)
3)
4)
5)
6)
7)
8)
The Chief Secretary to the Government
Representative of the Government of India
The Secretary to the Government, Finance Department
The Secretary to the Government, HFWD
The Secretary, Planning Department
Additional Secretary HFWD
The Director of HFWD
The Additional Director (Projects)
Chairman
Member
Member
Member
Member
Member
Member
Secretary
The Governing Board will meet twice a year if necessary. The board will make required policy
decisions and appoint personnel in the other project bodies. The board will be assisted by the
Steering Committee which will furnish reports from time to time to the Governing Board for
ratification of action if taken. The Steering Committee shall consist of the following Members:
1)
2)
3)
4)
5)
6)
The Secretary to the Government, HFWD
The Secretary to the Government, Finance Department
The Secretary, Planning Department
The Director of HFWD
The Additional Director of HFWD
Project Director
Chairman
Member
Member
Member
Member
Member
The Steering Committee shall meet as often as necessary but at least once in every three months.
The Steering Committee shall generally administer, execute and evaluate the project and in
particular exercise the following function:
•
•
•
•
Review the progress of the project, including construction of building and supply of
equipment and ensure that the project is implemented in accordance with the terms of
Agreement between the Government of Karnataka and KfW.
Review of reports furnished by the Project Director from time to time and issue such
directions as are necessary for implementation of the project.
Take all policy decisions and other steps which may be required for a successful project
implementation.
Approval of the annual budget.
The Additional Director Projects, is in-charge of all special projects within the DHWF in the state
and provides the overall technical assistance to the project and is coordinating all project
activities relating to policy.
The responsibility for the implementation of the project rests with the Division Project
Management which will be located at Gulbarga Division. The project team will be headed by the
Project Director who will be nominated by the government and will be responsible for all relevant
PROJECT MANAGEMENT STRUCTURE
2
ANNEX 8
activities related directly to the project and he will be assisted by the DHO of the respective
districts. A member of the Public Works Department will coordinate all activities related to the
department (approvals and documentation). The Project Team will consists of
0 Division Director for Gulbarga Division Project
2) Health services consultant
Public Works Department
4) Architect
5) Civil Engineer
6) Medical equipment engineer
7) Mechanical and electrical engineer
8) Draftsman
9) Project accountant
10) District Health Officer
H) Clerks
v
Project Director
Perman. Member
Temper. Member
Perman. Member
Perman. Member
Perman. Member
Perman. Member
Perman. Member
Perman. Member
Tempor. Member
Perman. Member
The Division Project Management Team will consists of Members from the Government at
Division Level and experts or consultants from the private sector. The following activities will be
handled by the Divisional Project Management Team:
•
•
•
•
•
•
•
•
Detailing project components in consultation with the Additional Director (Projects).
Development of terms of reference for external architects, engineers for each district and for
the project monitors and submit proposals for appointing the external architects, engineers.
Tendering of all works and supply in accordance with the guidelines of KfW and prepared by
the external project team.
Verifying of all tender evaluation and approval of all contracts up to a value of Rs 5.0 million.
Contracts above Rs 5.0 million have to be approved by the Additional Director (Project).
Releasing of all payment in relation to the project and respective contracts.
Preparation of annual and quarterly budget.
Monitoring of progress of all activities for each project component.
Providing feed back to the Additional Director (Projects) and preparation of monthly reports
in respect of project progress and financial utilization.
The external project team recruited from the private sector will be appointed by the Government
and will consist of:
1)
2)
3)
4)
Architects
Civil Engineers
Mechanical and Electrical Engineers
Medical Equipment Consultants
for each distnet
for each district
for each district
for the project
Architects and Engineers will be nominated for each district and the equipment consultant will be
responsible for the total project scope.
PROJECT MANAGEMENT STRUCTURE
3
ANNEX 8
Besides the design and engineering (basic design, detailed design and all relevant professional
services) the external team will also be responsible for the following:
FOR CONSTRUCTION and ENGINEERING WORKS
The civil and engineering works will be based on the prepared concept development. The
necessary activities are listed below:
<
•
•
•
•
•
<
•
B)
Preparation of design and engineering for each of the facilities including obtaining all relevant
approvals.
Preparation of construction plans and details necessary for bidding, specification for buildings
and engineering works, materials, technical installation, interior finishing as well as site
installation, external works and landscaping.
Preparation of all Tender documents ( condition for bidding and terms of contract)
Evaluation of tender by assessment of bidder and bidder track record and tender price
analysis.
Confirmation of tender evaluation and preparation of contract documents
Construction supervision by review of the construction programme and all relevant contract
details
Approval of drawings and specifications prepared by the contractors including preparation of
site diary
Preparation of quarterly reports
FOR SUPPLY
The supply for the project includes vehicles, medical equipment and other medical supplies.
•
•
•
•
•
•
•
•
•
Preparation of the final list of quantities for all supply categories for the project period of
three years.
Definition of quantities delivered to each of the district hospitals per year
Preparation of specification for medical equipment, medical consumables
Elaboration of cost estimation for each supply category and development of budget schedule.
Development of procurement procedures and logistic framework for each of the supply items
Preparation of principle tender document in accordance with the guidelines for procurement
of KfW and definition of bidding procedures.
Monitoring of evaluation of offers with respect to technical and financial aspects and
competitiveness.
Verifying tender evaluation and submission of proposal
Monitoring of execution of contracts including provisional and final acceptance.
PROJECT MANAGEMENT STRUCTURE
4
ANNEX 8
The Division Project Team will be assisted by an external Monitoring Team which will also be
appointed by the Government and will be in-charge of
•
•
•
•
•
2.
Certification of all tender evaluation
Certification of contracts to be awarded for construction and engineering works
Certification of contracts to be awarded to suppliers
Certification of all payment released to contractors
Overall monitoring of project progress and preparation of quarterly reports.
METHODS OF TENDERING
The methods of tendering will be based on the procurement guidance .of KfW for local
competitive bidding which includes the following steps:
•
•
•
•
•
•
•
3.
Notification (Prequalification)
Issue of bidding documents (terms of bidding, terms of contract, quantity and quality of
supply)
Submission of bids
Public opening of bids
Evaluation and selection of lowest evaluated bid based on qualification criteria
Contract award
Contract performance
PROJECT MANAGEMENT FACILITIES
For the project implementation, facilities will be established in the Gulbarga Division for the
Division Project Management comprising of:
•
•
•
Project office of approximately 200 sqm
Office equipment including furniture, computer, printer, drawing facilities and copy machine
Office infrastructure such as telephone and fax
The Division Project Team will be supported with three cars to ensure a proper project
coordination and implementation.
PROJECT MANAGEMENT STRUCTURE
5
ANNEX S
4.
MID-TERM REVIEW
third ye,ar ofthe Project. a mid-term review will take place. The main scope of the midterm review will be to evaluate the project implementation in respect of:
•
•
•
•
•
•
Project costing
Project schedule
Quality of work
Staffing of facilities which have been upgraded
Utilisation of facilities
Implementation of cost sharing measurements
In addition, the mid-term review will evaluate the principle requirement of upgrading and
renovations of district hospital and other secondary healthcare facilities which have not been
included in the first phase.
As part of the mid-term review, a [project proposal for the second phase shall be developed
including the cost estimation and project schedule.
The mid-term review will be executed by an independent consulting team which will be engaged
based on an international tender tendered by KfW.
5.
PROJECT MANAGEMENT BUDGET
The project management budget does not include the fees for design, engineering and supervision
which is incorporated in the cost of upgrading.
• Manpower
The Division Project Management Team will be paid from the project management budget. The
salary will only be provided for the permanent team members.
in IR
No.
1
1
2
2
2
5
5
2
6
MEMBER OF PROJECT TEAM
Project Director
Health Services Consultant
Architect
Civil Engineer
Medical Equipment Engineer
Mechanical and Electrical Engineer
Draftsman
Project Accountant
Clerks
TOTAL
TOTAL SALARY
600,000
500,000
1,000,000
800,000
800,000
2,000,000
900,000
500,000
900,000
8,000,000
PROJECT MANAGEMENT STRUCTURE
6
ANNEX 8
*
Office and Equipment
This cost item includes rental tor a 200 sqm office space with all necessary facilities for the
operation of the project such as furniture, computers, printer, drawing facilities, copy machine
and infrastructure (telephone, fax, generator). The amount for equipment is calculated at
Rs 1,000,000.
•
Office Operation And Travel Expenses
This item also comprises the cost for office operation such as <cost of energy, petrol, travel
expenses and office stationary. The cost is assumed at Rs 20,000 per month which amounts to
Rs 960,000.
Vehicles
For the project execution, 8 vehicles will be supplied at the cost of Rs 250,000 each amounting to
a total of Rs 2.0 million.
• Project Monitoring
The project monitoring team will be formed from independent experts for procurement,
supervision of construction and medical equipment planning. For the budget it has been assumed
that 36 man-months of local consultant and 12 man-months of foreign consultants have been
foreseen. The total amount for monitoring is indicated in the table below and amounts to
Rs 22,360,000.
in Rs
ITEM
72 man-month local consultant
24 man-month foreign consultant
Local travel expenses
International travel expenses
TOTAL
cost_______
2,160,000
13,200,000
1,000,000
___________ 6,000,000
22,360,000
• Mid-term Review
The mid-term review will be conducted by external and local consultants and will be for a
duration of 2 months. The amount estimated for this mid-term review is Rs 5,000,000.
PROJECT MANAGEMENT STRUCTURE
7
ANNEX 8
•
Total Project Management Cost
The total cost for the project management amounts to Rs 39,320,000 which is equivalent to
DM 1,787,000.
Summary Project Management
MANPOWER
OFFICE EQUIPMENT
OFFICE OPERATION AND TRAVEL EXPENSES
VEHICLES
PROJECT MONITORING
MID-TERM REVIEW
TOTAL
in iR
8,000,000
1,000,000
960,000
2,000,000
22,360,000
5,000,000
39,320,000
PROJECT MANAGEMENT STRUCTURE
8
U1
ANNEX 9
SELECTION OF FA CILITIES FOR UPGRADING AND
RENOVATION
ANNEX 9
THE SELECTED FACILITIES
The basis for the selection of facilities for upgrading are described herewith by district and
taluka. It should be noted that selection was confined to data and other information that were
provided by the state or district health authorities. The information was verified by the survey
team at each of the sites. In accordance with the survey team’s findings, the scope of
services for upgrading was changed in some cases. Thus, the final report may differ from the
Stage Report submitted beginning of May 1995 as the survey will be completed at the end of
May 1995.
Although the upgrading is described in terms of bed capacity, it must be noted that bed
capacity corresponds with other facilities, such as number of professional staff including
medical specialists and range of services offered.
In the following section, the socio demographic indicators and data related to existing beds
may differ from data in the previous section. The information provided in the section below
are the most recent figures from district statistics which were collected within this year.
SELECTION OF FACILITIES
1
ANNEX 9
1.
BID AR DISTRICT
Bidar District located in the far north of the State of Karnataka is an important centre for
pilgrims who are devotees of Guru Nanak. The total population of 1,255,799 is the smallest in
comparison with the districts in the Gulbarga Division and is divided into 5 talukas. The urban
population is only about 10% and as in all other districts in this Division, the majority of the
population is comprised of agricultural workers.
i
TABLE 1: Socio Demographic Indicators Bidar District
BIRTH
/ DEATH
' RATE
RATE
LITERACY
District Bidar
n.a.
n.a.
n.a.
TK Bidar
27.4
8.8
50.96
TK Aurad
27.6
8.5
39.50
TK Bhalki
29.5
8.8
46.47
TK Humnabad
28.2
8.7
42.87
TK Kalyani
28.3
8.9
42.95
IMR .
n.a.
71.0
72.0
72.1
72.0
72.3
MMR
n.a.
1.8
1.8
2.4
2.1
2.0
POPULATION :
1,255,799
223,436
210,040
196,042
201,378
______ 203,592
Although the literacy level in the district is above the Division average, the birthrate is one of
the highest in comparison with all districts in the state.
Within the first phase of the project scope, four hospitals will be upgraded and an additional
140 beds provided. The CHC in Mannekahalli will be renovated in the second phase. Besides
Raichur, Bidar District has the lowest ratio of population per secondary level hospital bed in
Karnataka. The ratio of population per bed will be reduced from the present 2,970 to 2,230.
The distribution of secondary level hospital beds is shown in TABLE 2 below.
TABLE 2: Health Services Facilities Bidar District
District Bidar
TK Bidar
TK Aurad
TK Bhalki
TK Humnabad
TK Kalyani
PHC's_____
NO, ■
BEDS
36
268
6
58
7
62
8
40
7
52
8
56
ACTUAL
__ CHC’s/GH’s
NO.
BEDS
7
423
2
283
1
20
1
30
2
60
1
30
NEW
BEDS
NO.
140
30
70
20
20
FUTURE
CHCs/GH’s
NO.
BEDS
7
563
2
283
1
50
1
100
2
80
1
50
The district map is shown in the opposite page which indicates the location of the health care
facilities.
SELECTION OF FACILITIES
2
ANNEX 9
Himmabad Tciluka
This taluka, located in the south bordering Gulbarga District, has a population of 201,378.
The birth rate, maternal mortality rate and female literacy are less favourable compared to the
state average.
At present, there is one 30 bed CHC in Mannekahalli where the buildings are in good
condition but inadequately provided with medical equipment. The renovation of the CHC only
applies for medical equipment. The 30 bed GH located in Humnabad, the taluka headquarters
with a town population of 25,200 will be upgraded to a 50 bed sub district hospital. The total
number of secondary level hospital beds in this Taluka will increase from 60 to 80 beds.
•
Aurad Taluka
Aurad Taluka (population 210,040) is located in the north of the district bordering the states
of Andhra Pradesh and Maharashtra. The female literacy rate here at 39.5% is the lowest in
Bidar district and among the lowest in the state. Most of the other socio demographic
indicators are also below the average of the state.
It is proposed that the only existing GH in the taluka headquarters of Aurad wich presently has
20 beds will be upgraded and further 30 beds with all required hospital facilities will be added.
The upgrading to a 50 bed sub district hospital will provide health care services to a large area
in the north of the taluka and the secondary health care facilities in this taluka will have a total
of 50 beds in comparison with the present 20 beds.
•
Bidar Taluka
Bidar taluka has a population of 323,436. The literacy rate (51%) of this area is the highest
among the five talukas and higher than the average for Karnataka. The total number of beds of
283 consists of a 50 bed maternity hospital and the 233 bed district hospital. The renovation of
the district hospital will be considered for the second phase of the project.
•
Bhalki Taluka
The population of this taluka is 196,042. Bhalki appeal's to have the highest birth rate and
maternal mortality rate in the district.
Only one secondary level facility is presently established. The GH in Bhalki (population of
26,860) is provided with 30 beds. Since Bhalki is located in the centre of the district the
hospital is also serving neighboring talukas and the occupancy rate is one of the highest in the
taluka. It is proposed to upgrade the GH Bhalki to a 100 bed sub-district hospital which will
increase the total nuber of beds from the present 30 to 100 beds.
SELECTION OF FACILITIES
3
ANNEX 9
•
Kalyani Taluka
In Kalyani taluka, with a population of 203,592, the upgrading of the taluka headquarters,
hospital in Basavakalyan (population of 42,750) is proposed. The hospital is sanctioned as a
50 bed sub district hospital but only 30 beds are available at present. In the scope of
. upgrading, an additional 20 beds including the required functional modification will be
provided. With the implementation of the project, the total number of hospital beds will
increase from the present 30 to 50 beds.
SELECTION OF FACILITIES
4
ANNEX 9
RAICHUR DISTRICT
Raichur district is bordering the districts of Gulbarga (in the north) and Bellary (in {he south).
The district population of 2.3 million has the highest ratio of population per bed in the state of
Karnataka. The district with 78% comprising of rural population is one of the poorest and is
typical for the region, with the majority of the population working as agricultural labourers.
The literacy levels for all talukas in this district are lower than the state average.*”
TABLE 3: Socio Demographic Indicators Raichur District
BIRTH
DEATH
RATE
_________ CAdT
fate
LITERACY
District Raichur
26.2
8.5
35.96
TK Devandurga
24.0
8.8
21.61
TK Gangawati
21.0
8.4
36.25
TK Koppal
21.5
8.6
42.39
TK Kushtagi
26.3
8.8
35.34
TK Lingsugur
20.9
8.5
35.19
TK Manavi
24.7
8.9
29.14
TK Raichur
21.2
8.3
43.62
TK Sindhnur
20.5
8.8
34.48
TK Yelbarga
24.4
8.1
39.10
1MR
73
79
71
70
72
72
81
69
72
71
MMR
3.61
4.26
3.71
3.13
3.79
3.27
4.19
3.89
3.58
3.75
POPULATION
2,309,887
176,889
255,551
207,111
189,.891
211,096
241,193
201,295
240,383
______ 196,080
Within the first phase of the project scope, six hospitals will be upgraded and an additional 237
beds provided. Raichur District has the lowest ratio of population per secondary level bed in
Karnataka. The ratio of population per bed will be reduced from the present 5,420 to 3,620.
The distribution of secondary level hospitals is shown in TABLE 4 below.
There are plans to build a 500-bed district hospital financed by the OPEC Fund. However,
However,
the construction work has not begun yet. With the establishment of the OPEC financed
hospital the ratio of population per bed will be further reduced to 2,030.
TABLE 4: Health Services Facilities Raichur District______
District Raichur
TK Devandurga
TK Gangawati
TK Koppal
TK Kushtagi
TK Lingsugur
TK Manavi
TK Raichur
TK Sindhnur
TK Yelbarga
PHC's____
NO. ;
BEDS
69
414
5
30
10
60
9
54
6
36
10
60
9
54
6
36
8
48
6
36
ACTUAL
___ CHC’s/GH’s
NO.
BEDS
13
425
1
30
3
42
1
17
1
30
2
56
1
30
1
130
1
30
2
60
NEW :
BEDS
NO,
213
20
70
33
20
50
20
FUTURE
CHC’s/GH’s
NO,
BEDS
13
638
1
50
3
112
1
50
1
50
2
106
1
30
1
130
1
50
2
60
The district map is shown in the opposite page which indicates the location of the health care
facilities.
SELECTION OF FACILITIES
5
ANNEX 9
•
Devadurga Taluka
Devadurga, with a population of 176,889, is served by a 30 bed GH at the taluka headquarters
in Devadurga town with a population of 14,959. Based on the available data, this taluka has
one of the highest IMR, MMR and the lowest literacy level in the district and state.
No other secondary level facility is available in this taluka. Thus, the GH in Devadurga will be
converted to a 50 bed sub district hospital.
•
Gangawati Taluka
This taluka has the highest population in the district (255,551). There is one GH with 30
beds at the taluka headquarters in Gangawati with a population of 64,843 In the taluka two
facilities are sanctioned as CHCs in Kanakagiri and Kortgi but presently still serving as PHCs
with 6 beds.
Gangawati one of the main towns in Raichur District with a steadily increasing population and
will require upgrading to a 100 bed sub district hospital. This will improve the total number of
beds in the taluka from 42 to 112 beds.
• Manvi Taluka
This taluka with a population of 241,193 is one of the most populated talukas in the district.
The data shows that Manvi is the most disadvantaged in terms of I MR, MMR and literacy in
the district.
The CHC in Manvi (population 28,080) serves as the taluka secondary health care facility.
Manvi is located close to Raichur and patients are using the district hospital. The present
utilization of the hospital does not demand upgrading but the hospital should be renovated in
the second phase.
•
Koppal Taluka
In contrast to Manvi, Koppal has more favourable IMR, MMR and literacy rates in the
district. The population of 207,111 is served by a 17 bed GH in the taluka headquarters.
Koppal town has a population of 44,602 which also serves as a sub-district centre. An
additional 33 beds (total 50 beds) has been sanctioned with the building renovations not
started yet. The GH will be upgraded to a 50 bed sub district hospital. The total number of
secondary level facilities in this district will be 50 beds.
SELECTION OF FACILITIES
6
ANNEX 9
•
Kushtagi Taluka
With a population of 189,891, the GH at the taluka headquarters provides only 30 beds.
Kusthagi has a relatively small population (14,650) but located on two main roads the
hospital will require improvement to a 50 bed sub district hospital. The final total number of
secondary hospital beds in this taluka will be 50 beds.
•
Lingsugur Taluka
The population of the taluka is 211,096. Lingsugur located in the central part of the district
has a population of 21,330. There are two hospitals in the taluka, one GH in Lingsugur and
one sanctioned CHC in Mugal which is not upgraded yet and serves as a PHC. The GH in
Lingsugur will be converted to a sub district hospital with 50 beds. The total number of beds
will be raised to 56 beds from the present 36 beds.
• Raichur District
Raichur town with a population of 170,580 represents 75% of the population of the Raichur
Taluka. The district hospital with only 130 beds is one of the smallest in the state of
Karnataka. The building of a new 250 bed hospital financed by OPEC is in the preparatory
stage but no final agreement between the Government and Opec has been achieved. The
renovation of the existing district hospital will take place in the second phase.
•
Sindhmir Taluka
Sindhnur is the second largest taluka in the district (population 240,383). In terms of IMR,
MJvIR and literacy, this taluka fares about average for the district. Birth rate, on the other
hand, is lower.
The GH in Sindhnur (population 44,380) is the only secondary health care facility that will be
extended to a 50 bed sub-district hospital. The central location of this town makes for a
suitable referral centre for other areas in the taluka. Based on the upgrading of the hospital the
capacity will increase from 30 to 50 beds.
SELECTION OF FACILITIES
7
ANNEX 9
•
Yelbarga Taluka
Yelbarga Taluka located in the south of the district has a population of 196,080. The CHC
Kuknoor (30 beds) is providing secondary health care. The GH in the taluka headquarters
sanctioned as a 30 bed GH which was completed last year is proposed to be upgraded to a 50
bed sub-district hospital. The supply of equipment will be in the second phase. The CHC in
Kuknoor shall be renovated in the second phase of the project.
SELECTION OF FACILITIES
8
*
ANNKY9
BELLARY DISTRICT
Bellary District located in the south of the Gulbarga division has a population of 1,890,000. In
comparison to the other districts in the division, Bellary' is the most advanced district. Most of
the socio demographic indicators are above the division level. The urban population comprises
approximately 35 % and is the highest in the division.
s
TABLE 5: Socio Demographic Indicators Bellary District
BIRTH
DEATH
RATE
_
RATE
LITERACY
District Bellary
n.a.
n.a
n.a.
TK Bellary
TK Hadagalli
TK
27.8
8.6
36.4
Hagaribommana.
25.0
8.0
40.0
TK Harpanahalli
27.5
6.2
41.9
TK Hospet
26.0
9.0
45.0
TK Kudligi
TK Sandur
30.0
8.9
39.3
TK Siruguppa
IMR
n.a.
MMR
n.a.
60.0
85.2
79.0
4
79.0
2
POPULATION
140,280
146,778
312,788
4
198,635
In Bellary, there is a teaching hospital with 210 beds and the district hospital is also a medical
college with 512 beds at present. Six facilities have been selected for renovation or upgrading
and the conversion of four GH to 50 bed sub-district hospitals. Two hospitals will be
renovated whereby the sub-district hospital with 94 existing beds will be the largest hospital to
be renovated in the first phase. The total number of new beds is 96 as described in TABLE 6
below. The ratio of population per bed will improve from 1,870 to 1,710 after the first phase.
TABLE 6: Health Services Facilities Bellary District___________
District Bellary
TK Bellary
TK Hadagalli
TK Hagaribommanahalli
TK Harappanahalli
TK Hospet
TK Kudligi
TK Sandur
TK Siruguppa
PHC's_____
NO.
BEDS
72
260
18
42
8
20
6
28
13
48
9
32
8
36
4
20
6
54
ACTUAL .
;•
CHC's/GH's
NO.
BEDS
10
1,009
2
722
1
30
1
30
1
34
1
94
2
69
1
30
1
20
NEW
BEDS
“no.
96
20
R
1R+26
20
30
FUTURE
CHC’s/GH's
NO,
BEDS
10
1,105
2
722
1
50
1
30
1
34
1
94
2
95
1
50
1
50
The district map is shown in the opposite page which indicates the location of the health care
facilities.
SELECTION OF FACILITIES
9
ANNEX 9
•
Bellary Taluka
As mentioned above, Bellary (town population of 245,400) has one teaching
t
hospital and the
district hospital has a total of 722 beds. The very urgent renovation of the district hospital will
take place in the second phase of the project.
*
a
Hagaribommanahalli Taluka
In this taluka with a population of 140,280 only one GH is available. Although sanctioned as a
30 bed GH, this facility in Hagaribommanahalli ( population 15,000) has only 10 beds. It is
proposed to renovate this facility and to add the remaining 20 beds and is planned for the
second phase.
•
Huvinna Hadagali Taluka
This taluka located in the south-west has a population of 250,560. The 30 bed GH at the
taluka headquarters (population 18,700) is fully functional. As the only facility in the taluka,
the hospital will be extended to a 50 bed sub-district hospital.
•
Hospet Taluka
This taluka, in the central part of the district, has a large population (312,788). Hospet (town
population 134,800) is an important town with railway and state highway connections to other
areas. It is in close proximity to the Tungrahadra Dam, one of the largest irrigation dams in
South India. The hospital is well utilized but with the upgrading of hospitals in the
neighbouring talukas the renovation of this facility will be sufficient.
•
Sirugupa Taluka
Sirugupa taluka is located in the northern comer of the district and has a population of
198,635. The GH at the taluka headquarters (population 31,400) is only provided with 20
beds. Within this project, the GH will be upgraded to a 50 bed sub-district hospital.
'•
Kudligi Taluka
In Kudligi, south of Hospet, one GH at taluka headquarter and one CHC in Chikkajogihalli is
established. The GH in Kudligi is only provided with 24 beds but will be upgraded to a 50 bed
sub-district hospital. The CHC in Chikkajogihalli (a small town) is sanctioned with 50 beds
and 45 beds are existing. This facilitiy, which is in unsatisfactory condition, shall be renovated
in the first phase. This raises the number of secondary level hospital beds from 69 to 95 beds.
SELECTION OF FACILITIES
10
ANNEX 9
•
Sandur Ta Iuka
Sandur (town population 9,800) is located between Bellary and Kudligi. This district is not a
highly populated district and is provided with a 30 bed GH. It is proposed that the facility will
be renovated and if necessary upgrading will be planned for the second phase.
t
• Harappanahalli Taluka
Harappanahalli Taluka with a population of 146,800 boardering the Chitradurga District is
provided with a 34 bed GH. This hospital which is well utilized, is located at the taluka
headquarter (population 34,150). The present utilization rate is average and the renovation or
upgrading shall take place in the second phase of the project.
r
SELECTION OF FACILITIES
11
ANNEX' 9
4.
GULB ARGA DISTRICT
The Gulbarga district, headquarters of the division is the largest and most populated district
(2,582,000). Gulbarga is similar to Bellary District and is one of the more urbanised districts in
the state but workers in the agricultural sector are the majority in the distict.
TABLE 7: Socio Demographic Indicators Gulbarga District
DEATH
A-:' A-A A:-:; ?
E.:? RATE
RATE
LITERACY
District Gulbarga
32.3
9.2
34.2
TK Aland
33.1
9.1
29.9
TK Afzalpur
30.0
10.0
25.5
TK Chincholi
33.0
10.5
36.4
TK Chitapur
32.5
10.0
24.7
TK Gulbarga
30.0
9.0
30.3
TK Jevargi
32.0
9.0
25.7
TK Sedam
33.0
10.0
24.5
TK Shahapur
33.3
10.0
33.0
TK Shorapur
32.5
9.2
44.4
TK Yadgir
33.0
9.1
30.6
a
IMR
73.0
73.0
74.0
73.5
74.0
71.0
72.0
73.0
73.0
74.0
73.5
MMR
POPULATION
3.3
2,582,169
3.0
234,270
3.6
150,856
2.9
189,161
2.7
234,015
2.7
219,845
3.0
188,707
3.1
139,885
3.1
208,417
3.0
247,079
3.0 _____
216,742
The main district hospital in Gulbarga with 750 beds also serves as a teaching hospital. In
Gulbarga, five facilities have been selected for upgrading and another four hospitals for
renovation. The total number of new beds proposed is 154 as shown in TABLE 8 below. The
ratio of population per hospital bed will be reduced from 2,290 to 2,020.
TABLE 8: Health Services Facilities Gulbarga District
ACTUALS
PHC’s_____
CHC's/GH’s
NO,
BEDS
NO,
BEDS
District Gulbarga
83
529
17
1,126
TK Aland
11
66
3
36
TK Afzalpur
6
36
1
6
TK Chincholi
9
54
2
60
TK Chitapur
7
72
4
57
TK Gulbarga
8
48
1
751
TK Jevargi
8
48
1
30
TK Sedam
4
25
2
56
TK Shahapur
9
54
1
50
TK Shorapur
9
54
1
30
TK Yadgir
12
72
1
50
NEW
BEDS
NO.
154
20+1R
44
20
2R
20
1R
50
FUTURE
CHC's/GKs
NO. .
BEDS
17
1280
3
56
1
50
2
80
4
57
1
751
1
50
2
56
1
50
1
30
1
100
The district map is shown in the opposite page which indicates the location of the health care
facilities.
SELECTION OF FACILITIES
12
t
ANNEX 9
Aland Taluka
t
Aland taluka, with the second largest population of 234,270 is located in the north-west of the '
district. Two CHCs are sanctioned but only one CHC in Madanahippargi is provided with 30
beds. The other CHC in Nimbarga has only 6 beds existing. One GH with 30 beds is presently
available in Aland (town population 26,560) which is proposed for upgrading to a 50 bed sub
district hospital.The CHC in Madanahippargi will be renovated. The capacity of secondary
level beds will increase from 66 to 86 beds.
•
Afzalpur Taluka
In Afzalpur taluka (population 150,856), one GH at the taluka headquarters has been
sanctioned as a 30 bed GH but only has six beds at present wherby the building for the 30 bed
hospital is in existence. This facility will be upgraded to a 50 bed sub-district hospital. The
total number of beds will increase from 6 to 50 beds to serve the western region of this
district.
Chincholi
The taluka located in the far north-east of the district with a population of 189,161 is one of
the most populated.
Presently, one CHC in Gaddakeshwar with 30 beds and one GH with 30 beds in Chincholi
town (population 10,580) are present. It is proposed to upgrade the GH at the taluka
Headquarter to a 50 bed sub-district hospital which will increase the total number of beds from
60 to 80. The CHC in Gaddakeshwar will be renovated if necessary in the second phase.
•
9
Chitapur Taluka
One of the larger talukas in the central region of the district, Chitapur has a population of
234,015. Four facilities are sanctioned as secondary level hospitals. The GH in Chitapur has 8
beds, the CHC in Hebbal (21 beds), the CHC in Kalgi (8 beds) and the CHC in Shahbad (20
beds). The GH in Chitapur which only has 8 beds is under renovation financed by the state.
The CHC in Kalgi and the CHC in Shahbad will be renovated and the required functional units
added. The CHC in Hebbal will be renovated in the second phase.
Sedam Taluka
The taluka of Sedam (population 139,885) is on the railway line to Hyderabad. The town of
Sedam (town population 23,270) is thus an important stop-over. The 50-bed sub-district
hospital is presently well utilized and the condition of the facility does not need urgent
renovation. The renovation or upgrading will take place in the second phase. In addition to
SELECTION OF FA CUTTIES
13
ANNEX 9
this sub-district hospital, the taluka is also served by a CHC in Mudhol which is foreseen for
renovation in the second phase.
'■h
•
Shahapur Taluka
In the southern region, Shahapur has a population of 208,417. It is served by the 50 bed sub
district hospital at the taluka headquarters (town population 24,740). The hospital is proposed
for renovation.
i
• Shorapur Taluka
Also in the south, Shorapur has only one GH with 30 beds at the taluka headquarters with a
population of 30,590. Presently construction is in progress and therefore no provision is made
within the first phase of this project.
• Jevargi Taluka
The taluka located in the centre of the district with a district population of 188,000 is served
by a 30 bed GH at the taluka headquarter. The facility needs urgent upgrading to a 50 bed
sub-district hospital.
•
Yadgir Taluka
Yagdir taluka in the south east of the Gulbarga district has a population of 216,000. Two
facilities are providing secondary level health care. The CHC in Gurumatkal is sanctioned as a
30 bed hospital but the implementation has not taken place yet. The sub-district hospital in
Yadgir has 50 beds and is presently well utilised The hospital will be upgraded to 100 beds.
i
SELECTION OF FACILITIES
14
&
ANNEX 10
DELEGATION OF ADMINISTRATIVE
AND FINANCIAL POWER
J .
»lx
*
5
ANNEX 10
DELEGATION OF ADMINISTRATIVE AND FINANCIAL POWERS
Description of Powers_____________________
Description Powers
__________________
1.
To approve the list of candidates for
training Radiographers, Health Inspectors and
other Categories subject to the number of
Candidates and rates of stipends fixed by
Government
________________________
2.
(a) To depute the staff of the Maximum
pay of whom and below for Service under local
bodies under the foreign services rules
KC.S.R.s. to Commercial under takings.(1 )ln
place of Rs.2175/- the current maximum pay of
the related post i.e., Class-I Junior Scale/Grade
is replaced).
_______________________
(b)
To depute for Training within India, for
Course not exceeding Ninety Days (Both
Gazetted Staff and Non-Gazetted Staff)._______
3.
To Sanction the Deputation of NonGazetted staff on Temporary Duty within the
state.
4
(a) To appoint Part-Time Teachers
and other staff against sanctioned part- time
posts.
(b)
To appoint during epidemics when
there is urgent necessary and there is no time to
obtain sanction of Govt. Medical Officer with a
Peon for each Officer of sanctioned scale of pay
& Allowance plus an appointment being sent to
Government simultaneously.________________
(c)
To appoint wardens & Asst., Wardens
of Hospitals.
5.
To Sanction Expenditure on (a)
Funeral Expenses as per Scale Laid Down
(b)
Public Lectures & Demonstrations
(c)
Demmurage and welfare charges
provided they are not caused by the negligence of
any Govt, servant.________________________
(d) ______ Purchase of X-Ray Photo Films______
(e)
Maintenance of frogs, rabbits, dogs,
rats, white rats and other animals required for
experiments in Medical Colleges and other
institutions. ____________________________
D_____
Existing
Proposed
Full Power
Full power
(subject
ratification by
DHS& ADHS.
Full Power
Full Power
Full Power
Rs.3000/- each
time________
Rs.2500/- each
time
Rs.50/-each
time________
Rs. 150/- each
time
Rs.500/- each
time________
Rs.2000/- each
time
Rs.50/- each
time________
Rs. 100/- each
time
Rs.500/- each
time._______
Rs.500/-each
time.
Full Power
Rs.10,000/each time
Full Power
Rs.2500/- each
time
Full Power
Rs.5000/- each
time
Full Power
Full Power
C_____
B_______
Existing
Full Power
Proposed
Full Power
Three Year
(Non-Gazetted)
Three Year
(Non-Gazetted)
Six
Month (Tech. St
aff)
Full Power
Six Post at a
Time Subject to
ratification of
Govt, thereafter
Full Power
A_______
Existing
Full power
Proposed
Full Power
Three Years
Three Years
Full Power
Full Power
One year
One Year
Full Power
Full Power
Six post at a
time Subject to
ratification of
Govt,
thereafter.
Existing
Nil
Proposed______
Full
Power(Subject to
Approval)
Six
months(Tech.S
taff)
Full Power
One Month
One Month
Four Posts at a
time (Subject to
ratification by
Govt.,
thereafter).
Nil
2 Posts
Full Power
Full Power
Full Power
Nil
Full Power
Full Power
Full Power
Full Power
Rs.500/-each
time_______
Full Power
Rs.5000/-each
time________
Full power
Rs.300/- each
time_______
Rs.750/- each
time
Full Power
Full Power
Full Power
Full Power
Full Power
Rs. 10,000/each time
DELEGATION OF ADMINISTRATIS AND FINANCIAL POWERS
1
••
*
ANNEX 10
i) Rs.250/-for
each pair of
shoes per
inmate.
ii) Rs.15O/- for
each pair of
chappal per
inmate_____
Full Power
i) Rs.100/-for
each pair of
shoes per
inmate
ii) Rs.40/- for
each pair of
chappal per
inmate_____
Rs.5000/-
i) Rs.200/- for
each pair of
shoes per
inmate.
ii) Rs.15O for
each pair of
chappal per
inmate_____
Rs.10,000/-
i)Rs.100Z- for
each pair of
shoes per
inmate.
ii) RS.4O/- for
each pair of
chappal per
inmate_____
Rs.2,500/-
Rs.250/- for each
pair of shoes per
inmate.
ii)Rs.150/- for
each pair of
chappal per
inmate
5.
Measures for control of Plague & other
under the following heads: ^Construction &
repairs of segregation camps & Hospitals.
ii)Purchase & carriage of Medicines iii)Dietary
Charges, iv)Disinfection chary—. v)Bedding and
clothing. vi)Other incidental expenditure in plague
camps
6.
To sanction the purchase of the
following without reference to the Stores
Purchase Department but following the purchase
rules and purchasing from Govt., under takings
wherever available:_______________________
(a)
Diet articles
i) Rs.100/-for
each pair of
shoes per
inmate.
ii) Rs.4O/- for
each pair of
chappal per
inmate_____
Full Power
Full Power
Full Power
Full Power
Full Power
Rs.10,000/- per
annum
Rs. 10,000/- per
annum
Rs.3,000/-per
annum
Rs.3,000/- per
annum
Linen.Bedding & Clothing
Full Power
Full Power
Full Power
Full Power
(c)
Utensils & crockery and other
equipment items._____________________
(d)
Photographic materials/Exhibition
materials:___________________________
(e)
Medicines & Drugs not suitable in
Medical Stores or Rate Contract and required
urgently. ___________________________
(f)
Instruments, furniture & other
equipment required urgently. i)Colleges and
teaching Institutions___________________
ii)
Other Institutions
Full Power
Full Power
Full Power
Full Power
Rs.20,000/each time
Rs.15 lakhs per
annum
Rs.25,000/- per
annum_______
Rs. 10,000/- per
annum_______
Rs. 15,000
each time
Rs.50,000/- per
annum_______
Rs.20,000/-per
annum_______
Rs.5 lakhs per
annum
Rs.50,000/-per
annum_______
Rs. 10,000/- per
annum,______
Rs.2,500/- per
annum_______
Rs. 5,000
each time
Rs.1.0 lakh per
annum_______
Rs.25,000/- per
annum_______
Rs. 10,000/- per
annum_______
Rs.2 lakhs per
annum
Rs. 10,000/- per
annum_______
Rs.3,000/- per
annum_______
Rs. 1,000/- per
annum_______
Rs.2,500/each time
Rs. 10,000/- per
annum_______
Rs.5,000/- per
annum_______
Rs.1,000/- per
annum_______
Rs.1 lakh per
annum.
Rs.40,000/each time
Rs.15 lakhs per
annum
Rs.20,000/each time
Rs 5 lakhs per
annum
Rs.2,500/each time
Rs.2 lakhs per
annum
Rs. 100/- each
time
Rs.1 lakh per
annum
Rs.25,000/each time
Full Power
Rs.50,00/each time
Full Power
Full Power
Full Powers
Rs.2,500/each time
Rs.500/- each
time________
Rs. 1,000/each time
Rs.3,000/each time
limited to
Rs.15,000/- pr
annum
Rs. 10,000/- each
time__________
Rs.5,000/- each
time__________
Rs.5,000/- each
time__________
Rs.5,000/- each
time limited to
Rs.50,000/- per
annum
Rs.5,000/- per
annum.
Full Powers
Rs.25,000/each time
Rs.25,000/each time
Rs.25,000/each time
Rs.25,000/each time
Rs.500/- per
annum
Full Power
Rs.10,000/each time
Rs. 10,000/each time
Rs. 10,000/each time
Rs. 10,000/each time
Rs.250/- each
tune limited to
Rs. 1,500/- per
annum
Rs. 1,000/each time
limited to
Rs.5,000/- per
annum.
(f)
Supply of shoes to the inmates of
Mental Hospital, TB & CD Hospital and Leprosy
Institutions per year.
(b)
(g)
Herbs and other Pharmacy
necessaries.__________________________
(h)
Other items of Hospital necessaries.
7.
Glassware, Chemicals & Acids & other
Laboratory "necessaries" i) Colleges
T
i)Rs.100/- each
pair of shoes
per inmate
ii)Rs.4O/- for
each pair of
chappal per
inmate
Rs.5000/-
DELEGA TION OFADMINISTRA FIVE AND FINANCIAL POWERS
i) Rs.25O/- each
pair of shoes
per inmate.
ii) Rs.15O/- for
each pair of
chappal per
inmate
Rs.1000/-
2
*
* *
ANNEX 10
Rs.5,000/each time
limited to
Rs.30000/- per
annum______
Rs.50,000/each time
Rs.10,000/each time
limited to
Rs.50000/- per
annum______
Rs.1 lakh each
time
Rs.25,000/each time
Rs.50,000/- each
time
Rs .1,000/each time
Rs. 1,000/each time
limited to
Rs.5000/- per
annum_____
Rs.5,000/each time.
Full Powers
Rs. 10,000/each time
Rs.20,000/each time
Rs.5,000/each time
Rs. 10,000/- each
time
Rs. 1,000/each time
Rs.2,500/each time
Full Power
Full power
Rs.2,000/each time
Full Powers
Full Powers
Clothes and Time Pieces
Full Power
Full Powers
Full Powers
Rs.25,000/each time_____
Rs.50,000/(vide Rule 55 of
MCE)_______
Full Powers
8.
To accept gifts & donation from Public
or Institutions for institutions under the control of
the Department.________ _________________
9.
To sanction expenditure out of poor
funds of Hospitals.
_________________
10.
To get forms etc., not supplied by
Govt., Press printed by Private Presses_______
11.
To sanction subscription to daily
newspaper._____________________________
12.
To condemn Time-barred drugs and to
order their disposal.
Full Power
Full Powers
Full Powers
Full powers
Full Power
Full Powers
Full powers
Full powers
Full Power
Full Powers
Full Power
Full powers
Rs. 10,000/each time
Full Powers
Full Power
Full Powers
Rs.10,000/-
Full power
Full Powers
Full power
Full power
Full Powers
Full Powers
To sanction expenditure on fixing replacement of
parts and servicing or repairs of: (a)X-Ray &
other machines
______________ _____
(b)
Sterilisers, Microscopes & other
equipment /Refrigerators.
Full Power
Full Powers
Full Powers
(c)
Bedding / Clothing / Cots / Lockers /
Equipment________________ __________
(d)
Repairs of Buildings/Furniture etc.,
ii)
(e)
Other Institutions
13.
To refund fees paid by stipendaries
who have been awarded full free-ships & half
freeships claimed during the same or the
following year as per rules_______________
Supply of uniform as per prescribed
14.
scales
15.
Issue of Essentiality certificate for
going abroad at ones own cost for Medical
Treatment.
Rs.5,000/- each
time limited to
Rs.20000/- per
annum
Rs. 1,000/each time
Rs.5.000/-
Rs. 10,000/- each
time__________
Rs.30,000/-(vide
rule 55 of MCE)
Rs. 100/- each
time_______
Full Powers
Rs. 1000/- each
time_________
Full powers
Rs. 100/- each
time________
Full powers
Rs.500/- each
time_______
Full powers
Rs. 1000/- each
time__________
Rs.10.000/-each
time__________
Full Powers
Rs.50/- each
time
Rs.25,000/each time
Full powers
Rs.500/- each
time_______
Rs.5,000/each time
Full powers
Rs. 100/- each
time________
Rs. 1000/-
Full powers
Full powers
Full powers
(Proposed full
powers to the
extent of the
powers to
purchase these
items)_______
Full powers
Full power
Full power
Full power
Full power
Full Power
Full power
Full power
Full power
Full power joint
Director
(Medical) &
Divl.Jt.DH &
FWS
Full power
Joint Director
(Medical) &
DM. Jt. DH &
FWS
Full power
DELEGA TION OF ADMINISTRA TIVE AND FINANCIAL POWERS
I
3
' t
*
ANNEX 10
16.
To condemn linen which have become
unservicable by their fair wear and tear and to
order their disposal.
17.
To condemn books, instruments
equipment, furniture, glassware etc.,________
18. _____ Medical Journals (Library)_________
19.
To depute staff for instruction
Seminar, work shops, training or any
course:(within the state)
______________
(b)______ Outside the state within India.______
20.
Purchase of production of films 16 or
35 mm.
21. _____ Production of Video film/Print_____
22.
Exhibition i.e.,/Mysore Dasara Major
Exhibition programme:________________
23. _____ Condemn of vehicles__________
24.
Printing of
Forms/Publicationreports/Manual/guidelines
25.
Financial Assistance provisional
organisation & scientific like,IMA
Full powers to
the extent of
the powers to
Purchase these
items.
Full power
Full power
Full power
Full power
25,000/- p.a
Full power
5.0 lakhs
3.00 lakhs per
annum______
Full power
Rs.1 lakh p.a
Full power
Full power
Rs.50,000/- p.a
Rs.50,000/- p.a
Full power
Full
power
Full power
Full power
Full power
Full power
Full power
Rs.50,000/- p.a
Rs.50,000/each time
Explanatory Notes:
A
B
C
D
Director of Health & Family Welfare Services/Director of Medical Education/Adi. Director (FW & MCH)
Joint Director/Divisional Joint Director/Principal of Medical/Dental Colleges, Superintendent of teaching Hospitals/Chief Admin.
Officer/ Director Minto) R.I. Optalmology, Joint Director, GMS/Joint Director, Vaccine Institute, Belgaum, Joint Director, PHI
Bangalore, Joint Director TB, Bangalore.
Deputy Director/Dist. Health & Family Welfare Officer/Dist. Surgeon/Dy.CMO/Senior Specialist)/Principal of Health & FW
Training Centre/College of (Nursing)/Administrative Officers, Deputy Director (NMEP)/Deputy Director/Health Officer (SSI
Unit)/Medical Officer (Leprosy Hospital)
Heads of Institutions of General Hospital/Primary Health Centre/Primary Health Units/Senior Medical Officer Specialist/Duty
Medical Officer Specialist/Duty Medical Officer/Dist.Lep.Unit Specialist/Lay Secretaries, Gazetted Assistant/DLO/Dist. T.B.
Centre.
DELEGATION OFADMINISTRA TIVE AND FINANCIAL POWERS
4
*
y
ANNEX 11
y
I
>
I
r
CONTACT ADDRESSES OF
DEPARTMENT HEALTH AND FAMILY WELFARE
Contact Address of Department Health & Family Welfare
C
1
1.
Mr. B. Eswarappa I.A S.
Secretary to Government,
Department of Health & Family Welfare,
Government of Karnataka,
Multi Storey Building,
Bangalore -560 001, India.
Tel : 2265324
2.
2
Dr. S. Subramanya I. A S.
Project Administrator, KHSDP & E/o
Additional Secretary to Government,
Department of Health & Family Welfare,
Government of Karnataka,
PHI Building, Seshadri Road,
Bangalore -560 001, India.
Tel : 2277391
3.
Dr. M.T. Hema Reddy,
Director,
Directorate of Health & Family Welfare Services,
Bangalore -560 009, India.
Tel: 3364541
4.
Dr. Krishnaswamy,
Additional Director I/c, KHSDP,
Government of Karnataka,
Seshadri Road, K.R. Circle,
Bagalore -560 009, India.
Tel: 2276356
2
>
i
5.
Dr. Gundappa,
Additional Director,
KSLHCF (KFW), Gulbarga
6.
Dr. D V. N. Sarma,
Centre for Symbiosis of Technology,
Environment and Management (STEM)
35, 17th Main, VI Block,
Koramangala,
Bangalore -560 095, India.
Tel: 80-5533664
Fax: 80-5533358
- Media
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