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RF_COM_H_69_SUDHA
Chapter 2
Organisational Reform, Project management, monitoring
and research
" God grant me the serenity
To accept the things I cannot change:
The courage to change the things I can:
And the wisdom to know the difference:"
- Reinhold Niebuhr.
2.1
Reforms in Administration
The current structure of health services has evolved over the years, with differing emphasis on
the preventive and curative aspects at various points of time. There is a need for the
reinstitution of a strong public health element in health services. This element, which was
the foundation on which these sendees were instituted, has virtually disappeared due to
changing approaches towards the content of these services, mainly from a preventive
approach to a curative approach. It is evident that even in current times the absence of the
public health element has resulted tn skewed services, de-emphasizing fundamental issues
such as sanitation and prevention. What would seem essential is to reconstitute the system to
have a fair balance between both preventive and curative approaches.
The proposed re-structuring of health sendees has been indicated by the Task force in its
Final Report. The current posts have been redistributed / redesignated. For example, the
Maintenance Engineering Division now included tn the Directorate is the transfer, in effect,
of the one that is now part of the Karnataka Health Systems Development Project. Also, the
posts at all levels have been redistributed..
The posts indicated do not include supporting staff. It would also be necessary to take into
consideration the current levels and numbers tn the professional cadres while putting in place
the proposed structure with the revised positions and designations. The Task Force has kept
the following main principles in view while considering the changes to be made in the
structure of health services:
The emphasis on Public Health should be revived and its essentiality recognized;
Separate cadres would be constituted for Public Health and Medical (clinical)
responsibilities of the Department;
3. Common functions such as 1EC and publicity, supplies and maintenance would be
integrated to avoid duplication and lack of internal coordination;
4. The Divisions would be reorganized on the basis of integrated responsibilities and
current needs;
5. The cadres should be reorganized so that all health personnel up to the district level
fonn District Cadres, selection being the mode for filling up higher posts. The latter
would constitute State Cadres;
6. The State Cadres would constitute the Karnataka Health Service.
1.
2.
The availability of services at PHC and taluk levels should be ensured through
administrative means, including institution of special pay, a team at taluk level, etc;
8. All national programmes which now function in vertical fashion would be integrated
into the system so that local supervision and management of these programmes is at
District level;
9. The structures for implementing Externally Aided Projects (EAP) would be more
directly integrated into the structure of the Directorate of Health Services;
10. Discipline and control measures would be strengthened while, at the same time
building up both expertise and morale through nurturing enhancement of skills and a
transparent transfer policy;
11. A Commission on Health would be constituted as a mechanism for interaction with
professionals and to assist in policy formulation.
7.
2.2
Strengthening Institutions and Capacity Building
A key element in the process of restructuring the Department is in making various units in the
organisation functionally empowered and accountable. In specific terms this will imply the
following:
The Directorate of Health and Family Welfare has a large number of very senior
officers. However, there is hardly any delegation of powers to them. As a result they
are not made accountable and responsible for their sphere of work. Additional
Directors need to be given powers of minor heads of department and made fully
accountable in their sphere of work. Some autonomy has been given in the
functioning of the RCII project to the Project Director, but here too the unit clearly
needs to take greater initiative and become more accountable. Two new positions of
Additional Directors have been put in place to look after Primary Health Centres and
Communicable Diseases and they have been recently given job responsibilities.
However, these two vitally important offices arc yet to be given clear budgets and
responsibility in implementation of programmes.
The role and responsibilities of the Commissioner has now been more clearly spelt
out. There is need to delegate greater financial and administrative powers to the
Commissioner so that routine programme implementation goes on unimpeded. This
matter is currently under examination in the Government.
Over a period of time the Secretariat and Us field organisation, the Directorate has
become distanced. With the creation of the position of the Commissioner some
administrative restructuring is called for to ensure speedy decision-making and
avoidance of duplication of work. Apart from delegation, introduction of reforms
such as “single file system" and “desk officer system” arc under consideration of
government. The Administrative Reforms Commission has also recommended these
changes.
Clarity of roles, responsibilities and specific accountability upto Joint Director level
need to be worked out. Internal decentralization mechanisms for Joint Directors and
District level functionaries need to be put in place with adequate powers. Freedom
anil accountability systems need to be developed.
»
Rapid communication systems and mechanisms need to be established. Modem facilities
of fax. email, and internet access need to be provided below district level at Taluka and
PHC level also.
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Karnataka Health Service
2.2
All posts that constitute the State level cadre could be constituted into a service called the
“Karnataka Health Service”. This would contribute to morale building and create a sense of
common identity. The major advantage of constituting such a Service would be that young
professionals would, through a process of selection, rise to occupy middle level management
positions fairly early. This would ensure that officers with a reasonably long tenure would, in
due course, hold senior positions so that stability in management is ensured at higher levels.
Often, officers are promoted to senior positions when they have very short periods (a few
months) of tenure remaining before they are due to retire. The main features of this Service
would be as follows:
1.
2.
3.
4.
5.
6.
2.3
The Service would consist of all posts above the District Cadres and would include
both the Public Health and Medical Cadres;
Posts in the Service would be filled through two methods:a. Promotion from the District Cadres on the basis of merit cum seniority; and
b. Through a process of direct induction from the District Cadres.
Appropriate proportions of the posts of the State Cadre, in both Public Health and
Medical Cadres, would be reserved for promotion and for induction from the District
Cadres. It has been recommended by the Task Force that this proportion be 50 per
cent each;
All officers in the District Cadres who have the necessary qualifications and satisfy
such other criteria as may be specified, including minimum period of experience,
would be entitled to apply and compete for the posts reserved in the Health Service
for recruitment through this method
All officers appointed to the Karnataka Health Service will, on appointment, be
trained in administration and management.
In public interest, if officers who satisfy the stipulations of the Cadre and Recruitment
Rules arc not available for appointment to posts at any level in the Service, and for
such time as they are not available, such posts may be filled by induction of suitable
persons, with the stipulated qualifications, laterally, on contract basis.
District Cadre and Zilla Panchayats
The cadres, both Public Health and Medical, up to the District level would be District Cadres
coming under the management of the Zilla Panchayat.
With the institution of Constitutional local governments at the village, tahika and district
levels, it would be necessary' to consider how. in the long run, social services, including health
services, appropriate mechanisms could be established to ensure community participation and
management of social sendees, including health sen ices at the district level.
All health sendees at all area levels are now dcpartmentally organized and managed. The
revised structure envisages all health services within a district being managed by the Zilla
Panchayat. The health services assigned to the ZP would be those currently offered by PHCs
(and Sub Centres), CHCs and Tahika Hospitals. All specialized institutions would continue to
be under the Department.
In effect, the ZP, and at the lower area levels, the other panchayat organizations would be
responsible for management of the health services in their local areas. The ZP would be the
nodal agency and would oversee the working of these services in the talukas and at village
level. Such an arrangement is already partly in existence, but what is envisaged in the revised
structure is assigning full responsibility to the ZP and including all health services and
programmes within the ambit of its responsibilities, ft need hardly be mentioned that financial
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allocations commensurate with these responsibilities would have to be allocated, to that extent
reducing the allocation to the Departmental budget.
The revised structure would imply that all posts of health and medical officers from the
village level up to and including the district level, excluding nil district level posts such as the
DHO / DMO and equivalent, would be part of the establishment of the ZP. The recruitment,
control, postings within the district and related matters would be entirely within the
competence of the ZP. It must be emphasized that this would not at all mean the absence of
Government control, supervision and monitoring. The ZPs would function within guidelines
and other stipulations specified by Government with regard to all matters relating to health
services. The DHO / DMO, as at present, would continue to represent Government. In effect,
a distinct cadre of health personnel would have to be constituted for each district, with
common features.
It is recognized that the structure suggested here is a radical departure from the current one.
However, it has the merit of ensuring that local persons find employment within their
districts, which would reduce the difficulty of filling rural posts. It would also mean that the
community, through their elected bodies, takes full responsibility for the adequacy,
accessibility and quality of the health services in their district. The Department would then be
responsible for overseeing and monitoring of the health sendees and not have direct
administrative responsibility for these services. Ils energies would then be better spent in
ensuring the efficiency and effectiveness of these services and setting standards through more
intensive inspections and reviews.
2.4
Commission on Health
The health sendees must be responsive to the expectations of the public and must meet
current needs. The working of the Department should be transparent and the structure should
be able to induct outside expertise as and when necessary' for special studies or consultancies.
It would be desirable to create a mechanism for general overseeing of the health system which
would assist (he Government and for providing policy inputs. The facility of lateral advice
being tendered at the highest level would assist in ensuring both transparency and public
confidence. For this purpose, it is recommended that a Commission on Health be established
by Government consisting of both senior officers and non-official professionals. •
Commission on Health
Chairperson
Principal Secretary of Health and FW
Members
Secretary (Medical Education), Project Administrator of EAP,
Director of Health Services, Director of Medical Services,
Director of Medical Education, Director, State Institute of
Health and Family Welfare, Director, Indian Systems of
Medicine and Homeopathy, Drugs Controller, Vice Chancellor,
RGL'IIS. 8 to 10 eminent persons from professionals, NGOs
and prominent persons.
Member Secretary
Commissioner of H & FW
The functions of the Commission would include:
I.
Preparation of the Perspective Plan for health services;
2.
Monitoring inter-sector issues and recommending corrective appropriate measures;
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3.
Monitoring implementation of Plan programmes, externally funded projects and
Central Schemes and general management of health services;
4.
Ensuring that public health is an important component of the health services;
5.
Suggesting such studies or consultancies that arc found to be necessary from time
to time;
6.
Reviewing all such aspects of health sendees as it may consider necessary for
ensuring improvement of such sendees.
The Commission would not be concerned with the administration of the Department,
or with disciplinary' cases. The Planning and Monitoring Division could serve as the
secretariat of the Commission.
2.5
Review and Amendment of Cadre and Recruitment Rules
The structure suggested would need considerable amendments to the existing Cadre and
Recruitment Rules.
Recommendations have been made with regard to introducing mandatory tenures of service in
rural areas and selection criteria being introduced for certain posts. Also, elsewhere in this
Report, there are recommendations that have implications for the C & R Rules. It would,
therefore, be necessary to review these rules to take into consideration the recommendations
made herein and to bring them up to date. In particular, the rules should identify posts which
for which selection criteria should apply such as Joint Directors and above, introduce
stipulations regarding tenure in rural postings for entitlement to confirmation / promotion. It
is recommended that a Committee for Review of the C & R Rules be set up, with the
Commissioner as Chairman, and the Director of Health Services, Joint Secretary', Health
Department and a representative of the Law Department as members.
It is recommended that the new structure should be in place within the next one year, with
recruitment and cadre choice to new recniits being as suggested above.
2.6
Corruption and enforcement of discipline
The prevalence of conniption in the health services is a serious issue. Corruption in any
official agency is deplorable and must be eliminated. However, its presence in an essential
social sector such as health is particularly obnoxious because it increases the costs of the
services the public is entitled to and quite often determines both availability and quality of the
sendees provided. It is pernicious and pervasive and operates at different levels in different
manner. It could range from (a) demanding payment for services which are free or even paid
for and for carrying out the legitimate duties of the personnel involved, (b) direct diversion of
supplies meant for patients or from hospital supplies, (c) carrying on private practice when
this is prohibited, (d) deliberately treating patients outside stipulated hours and charging
personal fees for such services, and (e) diverting patients to private clinics with which one is
associated and charging fees or obtaining commissions. In particular, corruption in
government hospitals has a serious effect on the availability of medical services to the poor.
How to eliminate corruption
I hat corruption exists, (he various methods adopted in its practice and points at which it is
practiced are well known. The issue is the mechanisms for its detection and elimination. The
detection of conniption is dependent on the cooperation of the public and the internal
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mechanisms for this purpose. In this context, it is admittedly difficult for the public to
complain of corruption in a situation where medical services are required because, unlike
other official contacts, the need for these services cannot be postponed. However, the system
should encourage complaints being received even after the event. Secondly, the consideration
of complaints and completion of enquiry proceedings must be quick and thorough. The latter
is particularly important to avoid enquiries being deemed as improperly conducted on
procedural issues, as is quite often the case.
The current mechanisms inhibit quick enquiry. In particular, the procedures where major
punishments are proposed to be imposed are complicated and invariably tend to delay
enquiries beyond reasonable periods of time. It would, therefore, be vital for these procedures
to be reviewed so that, without taking away constitutional rights io justice, enquiries could be
completed within two to three months. It is recommended that the Commissioner of I I & FW
evaluate the current procedures to determine how they could be modified to ensure quick
completion of enquiries.
In the majority of cases, under the current procedures, officers of a senior level are appointed
as enquiry officers in individual cases. Such assignments are invariably viewed as an
additional burden and given very low priority. There is rarely a sense of urgency and quite
often enquiries have dragged on indefinitely. This results in a feeling of complacency in the
corrupt that the-system is incapable of dealing with them while, at the same lime, reducing the
morale of the honest and hardworking. The mechanisms for enquiry being within the
Department would also seem to inhibit quick enquiry and strong action.
The enquiry into corruption cases, depending on the nature and content of the complaint, arc
either dealt with by the Vigilance Commissioner or within the Department by the appointment
of an enquiry officer. There is. however, no institutional mechanism for detection of
corruption. It is recommended that such a mechanism be set up on the lines similar to the
Food Cell or Forest Cell. In the latter, a senior police officer on deputation is independently
assigned the responsibility of follow up of complaints on corruption, carrying out test checks
and the like. This cell should be preferably under the Principal Secretary or under the
Commissioner for Health and not an adjunct of the DHS. The specific role and duties of the
Cell could be defined. It should be empowered to investigate and take action against
corruption and absenteeism. An appeal procedure would have to be provided but time limits
must be fixed for disposal of such appeals.
The public should be aware of the services they are entitled to in the Sub Centres, the PHCs,
at the Tahika and District levels and in Government Hospitals. Prominent boards should be
put up indicating what services are free and the fees for services for which charges are levied.
The officer who should be contacted if money is demanded should be indicated and an
assurance held out that corruption charges would be investigated. The hospital Visitor system
should be strengthened and one of the functions should be to enquire about harassment and
demands of money, particularly from the poorer patients. Wide and constant publicity should
also be made of measures taken promptly. All complaints of corruption should be
acknowledged against corruption.
2.7
Centrally Funded Projects and integration of vertical programmes
A number of Centrally Sponsored Schemes have been implemented, at various points of time,
as part of the successive Plans. These include programmes relating to control of blindness,
malaria, AIDS, tuberculosis, leprosy and goitre, and enhancement of nutrition. The general
principle of funding has been that for the Plan period these arc funded either fully or partially
by the Central Government, with the financing being taken over by the State at the end of the
Plan period. I here have, of course, been some exceptions to the latter.
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The main issue is not so much the funding or the content of these schemes, since they all deal
with important aspects of health services. It is the structural aspects that need consideration
since separate hierarchies, with Programme Officers, were established under each such
scheme for a specific purpose. This has created vertical hierarchies of a specialized nature
within the Department. Also, it has complicated the reporting system by requiring different
streams of reporting within the Department and to the Government of India. Such a structure
does not lend itself to cost effective use of personnel or coordinated management of services.
The difficulty of control and management of such separate vertical hierarchies for some
activities is particularly noticeable at the district level. It is at this level that management and
coordination need to be clear and effective. The relative seniorities between the DI IO and the
Programme Officers have added to the problems of coordination.
The vertical programmes must be reviewed to determine the mechanisms of eliminating the
concept of independent vertical hierarchies, better utilization of the professionals in the
Department, and establishing only one focal point of administration of personnel,
management of services and reporting at the district level. It must be emphasized that this can
be done without in anyway diminishing attention to these important programmes. As in most
activities of the Department, designated officers would be responsible for specific activities.
What is desirable is to eliminate vertical hierarchies that are under-utilized and give rise to
loose administrative practices. Such integration is possible at all levels, including the senior
posts at headquarters. It may. al this point be mentioned that a revised structure for the
Department has been suggested later. T he review of the vertical programmes would be part of
this new structure.
2.8
Externally Aided Projects
There are a number of externally aided projects tn operation in the State. In the health sector,
the Karnataka Health Systems Development Project and the India Population Project are the
major externally funded projects. These projects deal with specific health issues and arc not
experimental in nature. They operate independent of the DHS though they are very much
concerned with health issues in terms of objectives, structure and content. The management
structure of these projects is independent of the DHS and so devised as to ensure efficient
performance. Special officers are placed in charge of such projects, with officers of various
specializations on deputation, and the induction of outside expertise is often assured through a
system of appointment of consultants. Decision-making in these projects is expeditious
because the high power Project Governing Board and the Standing Committee are delegated
with full powers. The conventional system of seeking sanctions, administrative and financial,
with many layers of official scrutiny and many departments to be consulted, is absent. There
are no financial constraints and performance is intensively monitored by both external and
internal agencies. In view of the structure and management independence, these projects are
successful and appear as islands of excellence in governance of health services.
These projects are successful because they have well defined objectives, with leadership not
generally available in other activities of government, selected competent staff and with
operational independence. They provide lessons in management of the health services and
innovative structures of delegation of authority and of monitoring and internal control and
review systems. However, experience would indicate that once the project is over and the
maintenance phase commences, the same perfonnance levels rapidly disappear and the work
gets “routinised”. While the projects definitely add to both assets and experience, there are
fundamental issues that need to be considered if full and, more importantly, permanent
advantages have to accrue to the health system from the implementation of such projects.
These are (a) how one transplants the work culture of these projects into the larger, parent
organization, namely (he Health Department, (b) how the tempo and efficiency of the project
implementation period could be sustained, (c) how the assets created are maintained for
effective use, (d) how the human resources created could continue to be used effectively and
99
productively and (e) how is adequate funding to be ensured for these purposes, in short, the
issue is one of sustainability ox er time of both the organizational and professional advantages
of these projects and building them into the culture of the department itself.
2.9
Sustainability
The issue ts essentially one of sustainability of the projects objectives and systems. It would
be difficult to integrate the project structure in toto into the departmental structure at the end
of the project period, nor would this be necessary. However, the main difficulty would be that
the project leadership would no longer be available and the Director of Health' Services would
have been only generally associated with the project '. If integration of project activities in
the maintenance phase has to be effective, it would be necessary to ensure that the project is
built into and implemented within the departmental structure from the start. While a separate
wing or division could be considered desirable because of the special needs of the project and
the need to complete it within a fixed period, this wing I division should be a part of the
Department; an exclusive project division within the Department should implement such a
project. This would ensure that the Director is not merely involved in the project but is also
responsible for its efficient implementation. It is recognized that this could limit the choice of
officers for being appointed as project administrators but the Project Governing Board and the
Steering Committee of the project should be able to enhance their supervision / monitoring to
ensure effective implementation. Also, the Commission on Health, suggested as part of the
restructuring of the Department, could also be empowered to monitor I review the
implementation of the project. The present practice of establishing a separate but temporary
project administration structure outside the Department should be given up and the special
unit created for implementation of such projects should be placed within the department, even
while maintaining its separate identity, with the appropriate structure and operational
freedom, for expeditious and efficient completion of the project. The Director should be
responsible for not merely fostering the work culture of the project but also for the spread of
such a work culture in the other divisions of the Department.
2.10
Transparency / morale building
The Department of Health Sen ices is one of the larger administrative organizations of the
State. Its importance both in terms of size and responsibilities dictate that the morale of the
officers and staff should always be high. It should be managed in such a manner that
administration is not accused either of favouritism or lack of direction. Morale building
would depend on the personnel having a conviction of fair dealing in matters such as
postings, selection for postgraduate courses, promotions and quick redressal of grievances. At
present, unfortunately, there would appear to be no internal guidelines or traditions for many
of these aspects.
2.11
Transfer Policy
Transfers arc admittedly necessary in the department for manning vacant posts, on promotion
or for other reasons. However, the system of routine transfers that are made every year has
virtually deteriorated into a scramble for “good" postings or for postings in Bangalore, with
pressures and pulls of all sorts having free play. In particular, it is most unfortunate that
political pressures predominate. This works to the disadvantage of those who adhere to the
rules or who have no political backing, and encourages indiscipline and inefficiency. It would
be necessary to formulate and adopt a transfer policy under which the transfers would be
transparent and unassailable.
100 '
2.12
Delegation of duties and powers
Morale and functional efficiency are also dependent on the ability to exercise powers
appropriate to each level in the hierarchy. Currently, there are orders delegating both
administrative and financial powers various levels. In particular, the powers of the senior
officers are well defined to permit them to function with adequate independence. However, in
practice, these powers do not seem to be exercised fully because traditions have been built up
that favour centralization of decision-making or excessive caution operates in exercising
them. This is reflected in complaints of inability to cany out adequate touring, delays in
processing of even simple requisitions, etc. The adequacy of the delegations and. more
importantly, the processes through which they are exercised would need review.
There is need to carry out a review of the administrative and financial powers delegations in
the Department to 1.
2.
2.13
Evaluate their adequacy and determine if any further delegations are necessary;
Examine the procedures of exercising of the delegated powers to determine if there
are any procedural factors that reduce their effective use.
Ensuring Overall Responsibility on Health Matters in Urban Areas
The administration of health services in urban areas is largely the responsibility of the local
administrations such as the municipalities and Municipal Corporations. The staff in the larger
cities are appointed and managed by the Corporations. While the administration of the
services in these areas and the management of the staff would be the responsibility of the
municipal body, it would be necessary to ensure that the Commissioner, the Director of
Public Health and Director of Medical Services have overall responsibility for the technical
aspects of these services so as to ensure quality and availability. The Directors should have
the right of inspection and monitoring. Such general authority would be specially important in
periods of outbreak of diseases and emergency situations. In particular, the public health
aspects of urban areas, including water quality and the like, should be reviewed by the
Director of Public Health.
2.14
Inter-sectoral Coordination
Health should not be viewed in isolation. While, for pragmatic administrative purposes, the
DHS is in charge of health services, the success of the latter depends on the successful
implementation of many other programmes. The latter include programmes relating to
nutrition, sanitation and water supply, meeting minimum housing needs, literacy,
transportation, communication, and the like. It is also dependent, in a larger sense, on social
policies, as for example, raising the age of marriage of girls. More specifically, the health
services are closely associated with the ICDS and school health programmes.
It is evident that health services would need to be ci ordinated with activities of the
programmes referred to. Such coordination would be n< cessary both with regard to the
relevant elements of these programmes and with the implementing agencies. The
establishment of an effective coordination mechanism would also ensure more optimum use
of the funds invested in the health services and these programmes. The establishment of a
high level mechanism for coordination would develop synergy among these activities. It is
recommended that a High Power Coordination Committee be set up with the Development
Commissioner as Chairperson, and members being the Commissioner of Health and EW,
Director of Health Services, Principal Secretary and Director of Primary' / Secondary
Education. Principal Secretary', Woman and Child Welfare Department and Director ICDS,
Principal Secretary Rural Development and Panchayati Raj, and officers in charge of rural
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water supply ami sanitation programmes. Other officers could be co-opted if necessary.
Representatives of prominent NGOs could also be inducted as members. Similar coordination
mechanisms must be established at the district and tahika levels.
2.15
Coordination with other institutions
There are autonomous specialty institutions, which include the Kidwai Memorial Institute of
Oncology, Sri Jayadeva Institute of Cardiology, Sanjay Gandhi Accident Hospital and
Research Institute, and others Gin eminent is represented on the management of these
institutions and. therefore, mechanisms arc present for ensuring coordination. The links
permit review of performance, monitoring of activities and also provide for an active role of
intervention if necessary.
2.16
Contracting out non-clinical services
The KHSDP has identified 28 non-clinical services, which could be performed by private
sector agencies on contract. The advantages are obvious. Large number of staff need not be
on the permanent payroll of government. Services are likely to be performed better because
penalty clauses could be enforced, which would not be easy in the case of government
employees. It would allow more time and effort to be invested in health and medical issues. It
is recommended that this system of contracting out non-clinical services could be extended to
as many hospitals as possible.
In the context, the view that general services cannot be contracted out under the laws relating
to abolition of contract labour would seem to be of doubtful validity. In the arrangement
contemplated, the contract would be with service firms and not individuals.
2.17
Improving Registration of Births and Deaths
The importance of improving the system of registration of births and deaths cannot be
overemphasized. The data provided by the system, if complete in coverage and valid in
recorded information, would provide information at regional, sub-regional and micro level on
health parameters.
The placement of the system of reporting would seem to need consideration. Currently, it is
monitored by the Director of the Bureau of Economic and Statistics, with a network of
notifiers and registrars at the field level. The latter are revenue officials. The system merits a
review for its reorganization and vitalization. It is recommended that this be examined in
consultation of the Departments involved. The Government of India would also have to be
consulted al the final stages.
2.18
Planning and monitoring
Health services must meet current needs and the management must have the capacity to adapt
them to such needs. Any modifications or expansion of services have implications in terms of
staff, training, and financial outlay. It is therefore necessar to have an in-built ability for
carrying out such reviews and in the preparation of perspecth plans. Tthe Department should
also have a strong, unified system of reporting as part of the Health Management Information
System. This would necessarily have to form part of the planning and monitoring structure of
the Department. These activities would call for the establishment of a Planning and
Monitoring Division.
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Present structure
There is, al present, a Joint Director in the office of the Di IS in charge of planning. The post
is currently designated as Joint Director (Health and Planning). The JD (I I & P) is assisted by
a Deputy Director (Planning) with supporting staff. The functions of this post include
preparation of the annual plans, five -year plans, and preparation of the monthly monitoring
reports (MMR) which deals with financial and physical progress and the Karnataka
Development Plan which deals with staff and organizational issues, that are submitted to
Government. An important function is the preparation of the Annual Report of the
Department. The Preparation of these reports involves obtaining information from all units in
the Directorate, including the Programme Officers on a monthly basis. Coordination and
constant interaction with the other Divisions and sections in the office of the DHS are
essentia! elements of the post. The JD (H & P) is concerned with the preparation of only
schemes relating to the Plan. Non-Plan elements are prepared by the Chief Accounts Officer
cum Financial Adviser. This is because the latter are more concerned with staff and
maintenance issues. However, information on the latter is incorporated in the reports
mentioned above. The JD (I I & P) is also in charge of the Bureau of Health Intelligence.
Role of the Planning and Monitoring Division
The planning process in the office of the DHS is restricted in scope and serves the immediate
administrative needs of routine reporting. The process of preparation of Plan schemes is also
fairly well established, as well as statistical reporting in specified formats. These are essential
activities in themselves but the constant internal monitoring of performance, particularly the
sensitive appraisal of available information, is near absent. The Planning Unit, which should
be designated as the Planning and Monitoring Division in view of its importance, should play
a more central role in the management of information systems within the Directorate. It
should be responsible for all information flows, appraisal of such information and feed back
of such appraisal to the functional divisions concerned. Currently, the appraisal of
performance is within the functional divisions concerned, which would render it routine.
Also, a total appreciation of the functioning of the Directorate would not be available to the
Director.
The reporting system is envisaged as common to the Department and not in sectional
components, more related to individual programmes, as at present. With this change in the
structure and focus of the HMIS, it would be logical to place its management under the
Planning and Monitoring Division.
Functions of the Planning and Monitoring Division
1. Coordination of all reporting activity as part of the unified system of the HMIS and
providing the information that other Divisions would require on the basis of the unified
HMIS:
2. Coordination of all statistical activity in the Department, at various levels, including
ensuring of quality of data, and processing and analysis of such data in the presenbed
manner as may be required for various purposes;
3.
Production of the Annual Report, periodic reports such as the Monthly Monitoring
Reports. Karnataka Development Plan, and such other prescribed reports. The reports of
the projects such as IPP and KI 1SDP should be incorporated so that there is one report for
the entire health department;
4.
Monitoring progress in implementation of Plan programmes and schemes each month to
enable mid-course corrections to be made;
103
5.
Preparation of Annual Plans and Five year Plans of the Department, coordinating with the
other wings such as Medical Education, Stale Institute of Health and Family Welfare and
the like;
6.
Preparation of a perspective plan for the Health Sector and its updating at appropriate
intervals.
7.
Organization and management of the Geographical Information System that is
recommended for establishment;
8.
Organization and management of the Computer System that is recommended for
establishment;
Structural changes in the Statistical System
The statistical system within the Department has developed in a rather ad-hoc manner. The
statistical and reporting system at headquarters could be said to consist of three distinct wings •
as follows:
a)
I he Bureau of I lealth Intelligence (Bill)
b) The Demography and Evaluation Cell (D & E Cell)
c)
Ihe statistical units / personnel attached to some Divisions on an independent
basis.
The Bill is the unit that generates the Annual Administration Report and all statistical reports,
excluding those relating to the RCH programme. It is also responsible for collection and
collation of information on health indicators, including the macro indicators from the RCH
programme. One important responsibility of the BHl is collection and processing of data
relating to morbidity and mortality.
It would be evident that if the planning process in the health sector has to be unified, as
indeed it should, it would be necessary to recognize the need for basic structural changes. ■
Such changes would include (a) unifying the statistical functions at all levels and of the
various units, (b) the inclusion of the reports of distinct projects such as the IPP and KHSDP
within the unified reporting system, and (c) coordination within the Department with the
Chief Accounts Officer / Financial Advisers of the Department itself and of the special
projects.
The distribution of the posts in the various statistical / reporting units, as would be seen from
the table above, is very' uneven. There is no uniformity in the work load and the levels of
posts seem to have been determined more by what was acceptable to the sanctioning
authorities than any rational considerations of work load, position in the hierarchy, etc.
The efficiency of the HMIS and GIS, the ensuring of quality of data, the management of the
computerized system of maintenance and analysis of data and production of monitoring
reports for better management would depend on the structure of the reporting and statistical
system. If the system has to perform at peak efficiency and be able to serve its purpose, it
would be necessary to consider certain structural changes.
In principle, it would be desirable to have a unified statistical and reporting system so that the .
planning and monitoring requirements are adequately met. The Planning unit in the office of
104
the DHS may be designated as the Planning and Monitoring Division, as suggested earlier, '
and assigned a central role of information management and appraisal, with the functions
indicated.
Structural changes at Headquarters
The Planning and Monitoring Division should be constituted with the following sections:
•
The Reporting and Monitoring Section for production of reports based on the
analytical statements generated by the Computer Section, and for preparation of all
monitoring reports required by Government or needed for internal management:
•
The Computer Section for information processing
•
The G1S Section for assisting in monitoring and planning
•
A Perspective Planning Section which would formulate the Five Year Plans and the
annual plans, monitor plan implementation, prepare and continuously update the
perspective plan of the Department and monitor implementation of the Health and '
Population Policy of the State.
This Division should be responsible for the following:
•
•
•
•
Strategic Planning of activities of the entire health system, including long term
planning;
Coordination with the Zilla Panchayats to ensure that the health plans of the districts
are formulated, including tahika and Gram Panchayat plans, and integrate them into
the State Health Plan;
Assess budget resources for cunent and future needs, taking into consideration
population, level of services, nonns for services and other relevant parameters;
Assess human resources and all material resources on a continuing basis.
All statistical and reporting functions in the headquarters should be unified. The various
wings and units referred to earlier would fonn part of the Planning and Monitoring Division.
These would include the Bill and the D & E Cell. There is a senior officer of the rank of Joint
Director on deputation from the Directorate of Economics and Statistics, who heads the D &
E Cell. This officer could be the Joint Director in charge of HIMS, the GIS and all statistical
reporting within the Directorate. This Joint Director could be designated as Joint Director.
Health Information System. This officer would be the Chief Statistical Officer and Head of
the HIMS / Monitoring Section.
Structural changes at District level
Strong statistical units would have to be established in the offices of the DUO / DMO and all
reporting and statistical functions in the district should be placed under them so far as their
jurisdictions are concerned. A computer cell in their offices would also have to be set up.
These cells would generate reports in standardized formats, which would be sent to
Headquarters for consolidation and analysis. However, analysis at the district level would also
be carried out so that monitoring by the DHO / DMO is possible at the district level. The
Programme Officers of the district would get the reports in the formats they need from this
cell
The central role <>/ the Planning and Monitoring Division
105
The role of the Planning and Monitoring Division, as envisaged herein, is much wider than
what it is at present and its responsibilities are much heavier. It is the Division that plans for
and monitors the performance of the Department. In view of this expanded role, the
Planning and Monitoring Division may be headed by an Additional Director. This Division
would function as the secretariat for the Commission on Health that has been recommended to
be established. The division will use an evidence-based approach & hence have close links
with the HMIS & Surveillance system. It will need to establish good inter-sectoral linkages
with departments dealing with nutrition, water supply and sanitation, education, Panchayati
Raj, etc. The unit needs to develop multidisciplinary capacities in Epidemiology, Health
Planning and Management. Health Economics, Bio-statistics, Anthropology, Social Sciences
etc.
Strengthening the capacity for Strategic Planning had been identified as a key objective under
KHSDP. However, mechanisms to ensure that Strategic Planning begins to take place arc yet
to get institutionalized. There is an immediate need to fill up the newly created positions in
the Strategic Planning Cell (SPC) so that studies, research, and planning functions can start
taking place. These initiatives planned under KHSDP need to be carried forward in to the
present project as well.
2.19
Project implementation and integration
Earlier experience with national health programmes, and more recently with externally aided
projects, teach us that;
a)
Basic objectives and strategies, even if explicitly outlined in policy documents/ project
proposals, are often re-interpreted or forgotten, in such major ways that expected
outcomes are not achieved.
b)
The focus of attention and activity tends to be on construction, purchase of
equipmcnt/consumablcs and appointments. ‘Softer’ service issues such as quality of
care, access to care, establishment of referral services, surveillance and health
management information system etc have not yet become functional. Training of health
personnel has been undertaken but outcomes ol this activity have been variable.
c)
The Department of Health, as a whole, docs not manifest a sense of ownership of
important health programmes. Responsibilities and systems have become fragmented
with vertical programmes and specific projects.
Hence, during the next five years, the PRIMARY FOCUS of this project will be to ensure,
IMPLEMENTATION and INTEGRATION, particularly at the critical point of interface
between the public and service provider at sub-centres. PHCs, CHCs, schools, anganwadi
centres. Mahila sanghas and hospitals at different levels.
Special planned efforts will be made to internalise and embed processes and factors that
ensure implementation, into the institutional functioning of the system.
2.20
a.
Safeguards to ensure implementation
Involvement of credible and knowledgeable NGOs, people’s movements, academic
institutions, i.e. representatives of civic society in the steering committees. The choice of
representatives is critical, as the objective is to bring in openness, transparency,
accountability, knowledge of field realities and alternative expertise. It will also enhance
collaboration, cooperation and a joining together of forces if appropriately facilitated.
106
b.
Make public the annua! statements of income and expenditure of the project. Explanatory
notes to be given for non-utilization of funds.
c.
The Annual Report of the Di IFW, under which achievements of the different programmes
and projects are given, need to be more widely disseminated. The DHFW could also have
a Website on which reports arc made available. With increasing computerization of the
Department these reports will be easily available to peripheral/ all health institutions and
their stall'.
d.
The supervisory and senior management staff to take responsibility and be accountable
for implementation at all levels. For this there needs to be adequate delegation of
authority and financial powers - i.e. a decentralization within the department. This is
separate from decentralization under Panchayati Raj.
e.
Supervisory’ staff to pror ide technical guidance, problem solving advice and
encouragement, rather than focusing on fault finding and inspection. Maintaining
motivation, morale and job satisfaction of field staff is an important responsibility of
senior staff.
f.
DHFW staff needs to be given strong feedback on the wide gap between the people's
expectations and the health services. At the same time, the good committed and
competent work by several government personnel needs to be recognised and appreciated.
Recognizing that this factor is critical to implementation, the department will introduce a
series of measures to facilitate behaviour change, c.g. sessions on group dynamics,
personal growth, interpersonal relations, and management techniques. The Task Force on
Health has also recommended steps to be taken to reduce corruption and political
interference in appointments, transfers, and promotions.
g.
While taking steps to provide a good working atmosphere, the DHFW will also tighten its
administrative functioning by taking disciplinary action, as per the rules; clarifying job
responsibilities and ensuring that they are carried out; keeping to time frames.
2.21
Project management structure
The KHSDP has built up a fairly extensive management structure, headed by a super-time
IAS officer. Another super-time officer is heading the project team dealing with IPP VIII and
IX. The government has recently also put in place the post of Commissioner, who is also a
very senior. Secretary-rank IAS officer. A team of senior Doctors and Engineering staff
supports both the KHSDP as well as IPP projects. Given the nature of the project which is
very ambitious both in size and scope, and the limited capacity, at the present moment, within
the Directorate, there is need to have a strong management team to lead the project. Multidisciplinarity. and management capacity will need to be part of the long-term leadership
structure in the health sector. The experience of KHSDP has been that the presence of a
dynamic leadership is able to give the necessary momentum to the project. At the same time,
in view of the large size and scope of the civil works and equipment procurement
requirements, the project team is unable to give the required attention to service delivery and
some other “software components’. The KHSDP staffing structure will be continued at the
end of the project and integrated into the health system as a dedicated, specialised,
professional management support agency of the department for all civil works construction
and maintenance, equipment procurement and maintenance, and other specified "hardware
components". This wing will continue, as at present, to be headed by a senior IAS officer.
This wing will also manage all the civil works and procurement components of the new
project. This will free the project director, who is proposed to be a full time super-time IAS
officer to concentrate on actual service delivery. He will lead a project team that will work
107
closely with the Commissioner and the Director and directly with the slate programme
officers so that there is hill integration from the commencement of the project.
A dedicated management structure will also be put in place for the special project initiatives
proposed for the backward category C districts of the state.
2.22
Project Governing Board, Project Steering Committee and Project Implementation
Committee
The Project Governing Board constituted under the KHSDP with the Chief Secretary as
Chairperson has worked well and it is proposed to retain the same structure for the proposed
Project. Similarly, the Project Steering Committee has also provided a structure that has
facilitated quick decision-making. In addition to these two structures there is need Io ensure
that decisions taken at the Project Steering Committee are implemented and there is constant
monitoring in respect of all components of the Project. There is also need to integrate the
Project management structure with the DI IS. It is therefore proposed to have a Project
Implementation Committee under the Chairmanship of the ( ommissioner I lealth and Family
Welfare.
2.23
Local project consultancies
The project has several new uncharted thrust areas, such as in the area of women's health,
health promotion, and community participation, HMIS etc. where the services of experienced
NGOs and other professionals will be required from the commencement of the Project. They
will support not only the project team but more critically be asked to directly work with the
State Programme Officers to ensure that the department has a feeling of “oneness’ with this
external team and vice versa. Their main role will be in providing both expertise as well as
elements of “capacity building” into the department.
2.24
Capacity building for programme implementation
Cadre ofprofessional managers
Over time the DHFWS has created at Taluka, District and State level an adequate number of
positions to supervise and implement various National Health and Family Welfare
programmes. In recent years, it has been noticed that at all levels the Taluka Health Officers,
DHOs, as well as Deputy Dircctors/Joint Directors have very short tenures and are unable to
spend time on management of national health programmes.
In many States and in several countries around the world health programme managers and
hospital managers arc non-medical professionals in public health, and hospital administration.
The Project therefore seeks to develop a cadre of professional managers to help in programme
management at the district level, state level and to help in hospital management. It is proposed
to recruit young graduates, preferably with post-graduatcs/diploma in management. Hospital
administration, Masters in Social Work (MSW), Masters in Economics, Masters in Nutrition/
Communication and related disciplines to function as Assistant Programme Managers at the
District level, in major Hospitals, and at the State level. These officers will be recruited at the
Group B level and will have opportunities for career advancement based on their performance
and merit. They will be recruited through a very transparent system based on their qualifying
marks and a Common Entrance Test and will undergo specialized training for six months
before being assigned any responsibilities. About 150 posts will be created for this purpose.
To ensure management teams including this new cadre become effective, there will also be a
need to develop manuals on integrated health care responsibilities for different institutional
levels and various programmes.
HIS ■
Introducing merit and competence in respect ofsom e crucial posts
Currently all senior positions are filled by seniority, except the post of Director. There is
therefore no incentive for good performance or any system to reward good work. Private
sector structures need to be brought in at least to man crucial positions at the district and State
levels. Meritocracy and transparency would be introduced and seen in the overall context of
good governance. A study has been commissioned by the I'ask Force to review the
organisational structure and design job responsibilities. The DHFWS is a very large
organisation in terms of manpower and responsibilities, with about 60,000 personnel of which
more than 4700 are grade A officers. There arc several levels of technical expertise. The
study makes a systematic effort to identify requirements at various levels & to develop job
responsibilities. The Task Force final recommendations and study findings will be
incorporated to the project proposal.
Engineering wins'
Under the K.11SDP an Engineering Wing has been established v hich is exclusively dedicated
to designing, constructing and maintaining all the facilities taken up under the Project. A
Chief Engineer heads the Engineering wing while a Deputy Chief Architect heads the Design
wing. These positions are supported by the necessary complement of supporting staff. All
these positions will require to be continued to support the Civil Works in the present Project.
The present proposal envisages the renovation of a large number of primary health institutions
scattered throughout the rural parts of the State. There is a need to prepare detailed estimates,
design renovation, for each of the over 1000 buddings proposed for renovation/expansion in
the project.
There is also need to ensure that the major civil works component is taken up and completed
quickly so that more substantive programme components get full attention during the project.
IPP VIII has successfully demonstrated capacity to take up construction of a large number of
small institutions in quick time by employing the services of a consultancy agency on a “turn
key” basis. There is need to identify an appropriate Civil Works consultancy Agency to
survey all the institutions, make detailed estimates for renovation and expansion well in
advance of the Project start, as a pre-project activity. The Agency can be selected through a
bidding process.
Routine maintenance of sub-centres, PHCs and Taluka hospitals will have to continue to be
looked after by the Zilla Pajichayat engineering divisions and the engineering divisions.
Enabling work environment
One reason for poor work culture at the state and district levels is due to the shabby physical
environment in which the offices are maintained which is also an expression of work culture.
It is expected that an integrated office complex for all health programmes, including for the
Project staff will be constructed under KHSDP. The building will require maintenance
expenditure etc. Similarly provisions will require to be made for the DIIOs office buildings,
including the seven new districts.
2.25
Implementation challenges and strategies of the integrated health project
Karnataka has had mixed experience in implementation of health programmes and services.
Health programmes so far have largely used a top -down problem centred approach, that is
largely rational (focusing on major decisions), linear and prescriptive. Implementation has
been on the whole hierarchical and techno managerial, attempting measurable outputs and
compliance, with people often seen as target groups or objects. Evaluations of several
109
programmes report big implementation gaps even in programmes and projects with well
thought out health goals, objectives and strategies. In Karnataka this is seen in the National
Tuberculosis Programme (NTP and RNTCP), the Reproductive and Child Health (RCH)
programme, the National Programme for Control of Blindness (NPC'B). the National AIDS
Control Programme etc. The Karnataka Task Force on Health has raised poor implementation
capacity as an issue of serious concern by senior government officials and. The public have
expressed a lack of confidence and tnist in the sendees through elected representatives,
through peoples health dialogues conducted as a part of the peoples health assembly process,
and through increasing protest as recorded by the media. It is imperative that implementation
processes are given importance and viewed as being as critical as decision-making, resource
allocation and proposal writing. It is what happens between front line implementators and the
public that really determines policy.
Current opportunities and strengths
It is therefore suggested that using the same policy and programme / project management
approach may not improve functioning of the system adequately.
Achieving good quality
performance or implementation should be the key strategic objective or mantra of the entire
Department of Health during the next five-year phase. There is a window of opportunity
presently open with government showing signs of greater political commitment to health;
with the participatory processes already initiated by the Karnataka Task Force on I lealth: with
a small but critical mass of good leadership at the top; and with the possibility of augmenting
financial and technical resources through a healthy process of dialogue with partner donor
agencies. Therefore a slightly different approach will be utilized in this implementation plan.
It will build incrementally on the several good initiatives of the past decade including the
mechanisms and management systems that arc functioning well II will use the learning points
and evidence gathered from studies already undertaken and then planned
Broad approach
It will use the bottom up integrative approach that is process orientated, recognizing the
political, iterative, interactive and evolutionary dimensions of policy process. This will
require a major change in mindset, through regular workshops and training programmes. It
will consciously build motivation, capacity, work strategies, work culture and ethics of
implementors, especially at front line and different levels.
It will increase
interorganizational and inter-departmental interaction. People and communities will be given
opportunities to become active participants in decision-making and in becoming change
agents of health services and of their own health status.
The social construction and complexity of disease, ill health, poorly functioning health
services and programmes are accepted, including underlying iniquitous social relations and
issues of power and conflict. Hence, no magic or perfect solutions are offered, nor miraculous
changes expected. However, planned, systematic efforts that arc responsive to ground
realities will be made, to use public health policy to move towards some leveling of social
inequity.
Specifics
Some of the (actors important for implementation arc:
Health policy so far has not been explicit but has developed in an ad hoc. add on manner,
often driven by national health programmes or by externally aided projects. A Comprehensive
Integrated Draft Health Policy has been recently written by the Karnataka Task Force on
110
Health and published for wide discussion within the government health sector by the
Government of Karnataka (KHSDP) and with others. After modification and adoption this
will provide a cohesive framework for the next five-year period.
Developing leadership at state district, taluka and local levels. State leadership for all
components should have the ability and acumen to mobilise power, political, financial and
other resources for health and to positively influence implementation Leadership that
nurtures encourages and supports its teams to perform better. Leadership that is open to
questioning, demands and pressures from the public and civil society organizations, seeing
these as a positive sign of interest and support and not as a threat. Leadership that looks
ahead, beyond and is inspirational. Leadership that is sometimes willing to follow. Selection
of leadership will necessarily need to depend on competence and capacity and will have to be
free of political interference. Leadership for district and state level will depend on track
record of past performance, with seniority coming as the lower criteria.
This is a complex project and selection of the Project Director (PD) is critical. The PI) will
require having good management skills, good interpersonal skills, a firm administrative hand.
and an understanding of the project goals and objectives, especially the technical, health
aspects. It is advisable that the PD is available to steer the project for a period of 5 years.
Develop a core implementation team working with the Commissioner and Director of
Health and the Project Director: with a mandate to see that implementation of all key aspects
outlined above occurs on time, maintaining quality. Members of the Project Preparation
Committee who have been active will continue in the Implementation Team.
Taking forward the Task Force recommendations - The recommendations of the Task
Force, especially Health Systems Management and on Implementation will influence all
programmes. Mechanism for implementation of recommendations will be initiated in 2001
and will carry over into the integrated health project being proposer!. The preliminary steps in
brief suggested by the Task Force are:
a)
b)
c)
d)
e)
Formation of a small core group to process, prioritize and set lime
frames for implementation of recommendations;
Formation of an Implementation Committee (lor health system
reform and reorganization);
Formation of Subject Matter Sub-Committee reporting to the
above;
Formation of a small secretariat or cell to support the
Implementation Committee and follow up on action points: this
function to be taken over by the Planning and Monitoring division or
unit:
Formation of a Commission for Health.
The Task Force recommendation broadly fall into four categories:
a)
b)
Structural changes to re-institutionalise public health and primary
health care, with district and state cadres and increased professional
capacities in public health, management and administration, primary
health care and curative care:
Governance issues - transparent appointment and transfer policies;
mechanisms for motivation and morale building: personal appraisal
systems; supervisory systems; monitoring finances and performance;
relationship with elected Panchayal bodies; access of the public lo
information; feedback systems from the public and patients;
improving ethical and legal aspects of work;
111
c)
d)
Building of institutional capacity through training and continuing
education; good intra and inter-organizational communication
systems; partnerships with NGOs and private sector: developing
administrative and management skills at PI K’s. CHCs. taluka and
district hospitals; assessment of need and impact through studies and
research;
Those relating to equity, quality, integrating access and to
technical aspects.
The department will be taking action on the recommendations that arc accepted by the
government. Mechanisms evolved will link with the project.
The KHSDP and IPP IX systems for construction and procurement will be integrated into
the department and will be utilized for this project. Maintenance functions will be allocated
to the same unit. Minor repair and maintenance work will be undertaken locally upto a
specified financial level. Annual maintenance contracts for equipment may be made with
companies concerned after studying the cost effectiveness of such arrangements.
Good communication systems will be evolved to keep all functionalics 01 team incmheis ol
the Dept, of Health (DOH) informed on a monthly (or two monthly basis to start with) of the
process and activities in the project and the department. The public should also be kept
informed through information boards in each institution and through the mass media,
especially the radio and press. Specific communication systems for specific aspect, such as
surveillance and referrals, make use of faxes, telephone, and emails. These systems w ill have
to be introduced. Rapid and free flow of information is important for optimal functioning.
112
nf2'
ACTIVITIES AT VILLAGE LEVEL (AND SUB-CENTRE)
(Approx. Population 1000 - 3000)
TRAINED /
UNTRAINED DAIS
ANM
1.
1.
2.
Delivery- of New Born Babies (NBB)
and training of dais (OJT)
Immunization of NBB
- of Infants
- of Under 5’s
- PPI's, Measles etc
3. Recording of Births, Deaths and
Marriages
4. Basic curative services
5. Family Planning activities
6. Maternal and Child Health
ANC, PNC. Care of Newborn
Training of Dais
Prevention and treatment of
Anemia
Well baby clinic
7. Health Education. IEC. HNE
8. Identification of Cataract and Night
Blindness
Children
Pregnant Women
9. School Health
SCHOOL
TEACHERS
1.
2.
3.
4.
5.
2.
3.
4.
Inform and Assist in Delivery of NBB
or actual Home delivery.
Inform of Births. Deaths, Marriages.
Bring cligibles for FP.
Assist .ANM in MCI I services.
ANGANWADI
WORKER (AWW)
1.
Assist in Imunization of
- Infants
- Under 5's
- PPI's Measles, etc
2. Health Education, IEC, HNE.
3. Distribution of Nutrition Supplements
and Micronutrients
- Weaning foods (where applicable)
- Under 6yrs
- Pregnant & Lactating mothers
- Adolescent girls (who will also assist
the AWW)
4. Medical check-up of children by PHC
doctor.
5. Maintenance of Growth chart.
6. Basic curative services (ORS, Fever,
Deworming, cuts, etc)
Health Education. HNE. IEC.
School Health.
Adolescent girls.
Reach the dropouts
Toilets and drinking water in
school.
OTHERS
(SHE group leader, AH department,
NGO representatives, PP, AW
helper)
1.
2.
Assist in di fferent activities as
per their capabilities.
Women’s empowerment.
HEALTH WORKER
MALE/FEMALE
Collection of Water samples from
drinking water sources and
chlorination.
2. Collection of blood slides of fever
cases and treatment.
3. Notification of Communicable
disease outbreak.
4. Ilealth Education, IEC, HNE.
5. Basic curative services.
6. Assist in outdoor activities .
7. Reporting to PHC’s.
8. Liaison with Private Practitioners
Surveillance
Provision of Health Care
9. Arrangements for tpt of seriously ill,
emergency cases including EmOC.
10. Environment sanitation vector
control.
11.
Male involvement in FP, in other
health issues.
1.
GRAM
PANCHAYAT
MEMBERS
Arrangement for tpts.
Community participation.
Coordination, Monitoring of various
activities in the village.
4. Environmental Sanitation of the
village.
- Garbage disposal / Refuse
collection.
- Toilets
- Water collections
- Piggery
5. Inclusion of Marginalised in all
activities.
6. Social issues - Alcoholism, violence
against women, etc.
1.
2.
3.
ACTIVITIES AT VILLAGE LEVEL (AND SUB-CENTRE)
(Approx. Population 1000 - 3000)
TRAINED /
UNTRAINED DAIS
ANM
I.
I
2.
3.
4.
5.
6.
7.
8.
9.
Delivery of New Bom Babies (NBB)
and training of dais (OJT)
Immunization of NBB
- of Infants
- of Under 5's
- PPI's, Measles etc
Recording of Births. Deaths and
Marriages
Basic curative services
Family Planning activities
Maternal and Child Health
ANC, PNC. Care of Newborn
Training of Dais
Prevention and treatment of
Anemia
Well baby clinic
Health Education, IEC, HNE
Identification of Cataract and Night
Blindness
Children
Pregnant Women
School Health
2.
3.
4.
ANGANWADI
WORKER (AWW)
1.
2.
3.
4.
SCHOOL
TEACHERS
I.
2.
3.
4.
5.
Inform and Assist in Delivery of NBB
or actual Home delivery.
Inform of Births, Deaths. Marriages.
Bring eligibles for FP.
Assisi ANM in MCI! services.
5.
6.
Assisi in Imunization of
- Infants
- Under 5’s
- PPI’s Measles, etc
Health Education, IEC, HNE.
Distribution of Nutrition Supplements
and Micronutrients
- Weaning foods (where applicable)
- Under 6yrs
- Pregnant & Lactating mothers
- Adolescent girls (who will also assist
the AWW)
Medical check-up of children by PHC
doctor.
Maintenance of Growth chart.
Basic curative services (ORS, Fever.
Deworming, cuts, etc)
Health Education. HNE. IEC.
School Health.
Adolescent girls.
Reach the dropouts
Toilets and drinking water in
school.
OTHERS
(SHE group leader, Al I department,
NGO representatives, PP, AW
helper)
1.
2.
Assist in diffcrent activities as
per their capabilities.
Women’s empowerment.
HEALTH WORKER
MALE/FEMALE
1. Collection of Water samples from
drinking water sources and
chlorination.
2. Collection of blood slides of fever
cases and treatment
3. Notification of Communicable
disease outbreak.
4. Health Education. IEC, HNE.
5. Basic curative services.
6. Assist in outdoor activities .
7. Reporting to PHC’s.
8. Liaison with Private Practitioners
Surveillance
Provision of Health Care
9. Arrangements for tpt of seriously ill,
emergency cases including EmOC.
10. Environment sanitation,vector
control.
11. Male involvement in FP, in other
health issues.
GRAM
PANCHAYAT
MEMBERS
1. Arrangement for tpts.
2. Community participation.
3. Coordination, Monitoring of various
activities in the village.
4. Environmental Sanitation of the
village.
- Garbage disposal / Refuse
collection.
- Toilets
- Water collections
- Piggery
5. Inclusion of Marginalised in all
activities.
6. Social issues - Alcoholism, violence
against women, etc.
Medium Term Fiscal Plan for the Health Sector, Karnataka
Indicators ami Targets
i Indicator
1 Present position
I Target in 2007
! Crude birth rate
i Infant mortality rate
i Maternal mortality rate
22 per 1000 population
58 pcrlOOO Live births
195 per 100,000 live births
1 17
I 40
| 150
1 Severe malnutrition
1
! Moderate malnutrition
6.2%
3%
45.4%
| 30%
I Immunisation coverage
■ with maintenance of cold
i chain
Safe deliveries with access
to emergency obstetric care
TB case detection and cure
• rates
1 HTV/AIDS prevalence
60%
85%
51%
>80%
60% and <40%
75% and 85%
1% of adult population
< 3% of adult population
Hospital utilization
N.A.
25% above current level
Client satisfaction
N.A.
25% above current level
Note: Refinement of indicators is currently going on.
Monitoring
The indicators listed above will be monitored through Sample Registration Surveys, RCH
Surveys, National Family Health Survey, and Special Surveys commissioned once in 3
years by tire department In addition disaggregated monitoring at district and sub-district
levels will be strengthened through a comprehensive and improved Health MIS -and
strengthening of tire Civil Registration System.
Resources as per Medium term Fiscal Plan
The Resources as per tire Medium Term Fiscal Plan indicated by the Finance department
is shown at Table 1.
Table 1: Resources as per MTFP indicated by Finance Department
(Rs. crore)
CategoryA’ear
2000-01 2001-02
Projection
BE
Health
1069
606
373
90
Salaries
Non-wagc O&M
Capital
1304
688
529
88
2002-03
Projection
2003-04
Projection
2004-05 |
Projection i
1464
728
619
117
1666
770
709
187
2026
815
815
396
j
i
The above resource projections include the resource flows from the proposed Karnataka
Integrated Health Nutrition Family Welfare Services Project (KIHNFWP) to be
substantially funded by the World Bank and estimated at SI70 million (approx. Rs. 800
crore). The Project is slated to commence in 2002-03 and continue till 2006-07. The
proposed Karnataka Integrated Health Nutrition, and Family Welfare Services Project
will address all the key health sector issues. It will have three major components, viz.
L
Management development and institutional strengthening;
II.
Improving access, service quality and effectiveness; and,
HI.
Innovations to enhance partnerships with communities and private sector.
The ycar-wisc projected Resource flows through this Project is indicated below at Table
2.
Table 2: Resource flows through the Karnataka Integrated Health, Nutrition and
Family Welfare Services Project (KIHNFWP)
(Rs. crore)
Category/Year.
2000-01 2001-02 2002-03 2003-04 2004-05 2005-06 2006-07
Proj.
Proj.
Proj.
Proj.
BE
Proj.
Proj
KIHNFWP
80
150
215
175
175
Salaries
15
20
25
30
35 «
50 "
Non-wagc O&M
15
30
40
45
Capital
____
50
100
150
90
;
100
The Health sector comprises the following departments/dfvisions: i) Health ii) Family
Welfare iii) Medical Education iv) Indian Systems of Medicine & Homeopathy v) Drug
Controller vi) Karnataka Health System Development project and vii) EPP VUI and IX.
The MTFP needs to adequately reflect the priorities and needs of each of the above
departments/divisions. A detailed exercise with each department/division has been
undertaken. Based on this exercise tlie MTFP has been slightly modified in terms of
the projected flows for different components, keeping the overall projections within
tlie amounts indicated by the Finance Department Tire modified projections may be
seen in Table 3 below. The projected resource flows through the KEHNFW Project has
been included. Committed liabilities and essential expenditures to be continued at tlie end
of die KHSDP (ends in March 2002) and at die end of IPP VIII and IX (ends in
December 2001) have also been included.
Table 3: Resources as per MTFP now proposed by the Health and Family Welfare
Department
(Rs crore)
Category/Year
2000-01
RE
1025
Health
550
Salaries
Non-wage O&M . 275
200
Capital
2001-02
Projection
2002-03
2003-04
2004-05
Projection Projection Projection
1304
650
475
180
1464
700
574
190
1666
770
676
220
2026
840
840
346
Health Sector Issues
Human Resource Development — All vacant posts in die Department must be filled
up to eliminate shortage of qualified staff. Simultaneously, capacity'- building measures
must be initiated to increase accountability and efficiency of the existing staff. This
requires an ongoing system of training based on a broad range of principles of public
hcaldi management. There is also need to further increase transparency in die selection,
posting and transfer of health personnel, and to introduce a system of performance rating
and incentives for medical staff to work in remote areas.
Governance - The planning, administration, monitoring and evaluation systems of the
health sector must be improved do increase accountability at all levels. All vertical
programmes of health, nutrition and family welfare services must be integrated at die
primary health centre, rather than implemented piece-meal, as is die current practice.
Such integration will result in greater programme effectiveness, and accountability to the
communities for whom they are intended. Convergence of programmes at the PHC level
must also be accompanied with a well functioning referral system. There is also need to
improve inter-sectoral coordination and increase partnerships with general practitioners,
traditional hcaldi providers, voluntary organizations, civic society and the private sector.
Funding — The sectoral share of funds for the hcaldi sector must be increased. In
addition, systems to improve efficiency in the utilisation of funds must to be redesigned,
perhaps with greater decentralization and devolution of powers, ensuring however, that
primacy in funding of the primary and secondary health sectors is maintained. The
funding of essential non-wage O&M costs such as on essential drugs, maintenance of
buildings, vehicles, etc. requires to significantly improve. There is also need to look at
alternative sources of financing, including community financing, insurance and a
judicious application of user charges, which ensures exemption to the poor.
Equity, Regional Disparities and Quality - Regional disparities require to be
adequately addressed. Gender and caste inequities also need to be given increased
aitcmion. There has also been inadequate attention to establishment and maintenance of
quality of care standards.
Programme and project issues
During the coming years die focus will be on key health system issues that deal widi die
concerns identified in die previous section. These will be addressed bodi through regular
programme funding as also through the proposed Karnataka Integrated Health, Nutrition
and Family Welfare Services Project. In specific terms die issues identified for attention
arc spelt out below.
Access, quality and effectiveness of Primary Health care Services - Access to
die poor, especially to women and SC/ST will be fully ensured. Through more effective
use of existing resources as well as Project funding, die State will put in place an
integrated and responsive primary health care system supported by a well functioning
referral system. Maintenance of quality standards in health care will receive special
attention.
Institutional Strengthening — The organizational structure will be thoroughly
revamped to provide for a more responsive health system. These efforts will also include
improved planning, programme management, human resource development, a modem IT
based HMIS, and an improved surveillance system.
Reduction in Regional Disparities —Policies and programmes, including project
funding will focus on reducing rcgipnal equities; districts widi poor health indicators will
receive increased attention and priority. •
Improving Governance, forging partnerships and community partnerships Measures introduced recently to improve transparency in selections, postings and
transfers will be further enhanced. All key health personnel posts will be filled up.
Performance monitoring will be introduced and incentives provided to motivate health
personnel to work in remote rural areas. Partnerships with the private sector and NGOs
will be forged. Community empowerment and participation in tire implementation of all
health programmes will be encouraged and supported.
Improving nllocative efficiency — In addition to striving for increasing the share of
tlie health sector, the share of tlie primary and secondary sectors within the health sector
will be maintained and further enhanced. Oilier innovative mechanisms such as
community based financing mechanisms linked with health insurance will be introduced.
India
Karnataka Integrated HNP Sendees Development
j7f\r n i
Project Concept Document
South Asia Regional Office
Country Department
Date:
Country ManagerZDirector: Edward Lim
Project ED:
Lending Instrument: Specific Investment Loan
Project Financing Data
[X] Loan
[] Credit
For Loans/Credits/Others:
Total Project Cost (USSm)
Total Bank Financing (USSm)
[] Grant
Team Leader: Tawhid Nawaz
Sector ManagerZDirector: Richard Lee Skolnik
Sector: HY - Other Population, Health & Nutrition
Theme(s): HealthZNutrition/Population
Poverty Targeted Intervention:
[X] Yes
[]
[] Guarantee
Cofinancing:
Borrower Government of Karnataka
Guarantor Government of India
Responsible agency: Department of Health and Family Welfare Services
Project implementation period:
Implementing Agency:
Contact person:
Address:
Tel'
Fax:
E-mail:
OCS PCD Ferm: October 15. 1998
[] Other [Specify]
No
A: Project Development Objective
1.
Project development objective: (see Annex 1)
The objectives of the proposed project are:
2.
♦
to improve efficiency in the allocation of health resources through policy and institutional
development
♦
to enhance performance of the health systems^?the primary level?)
Key performance indicators: (see Annex 1)
♦
Increased public resources to health sector, with increased share ^primary and secondary levels
of care
■—
♦
Increased referral between levels of care, between health, family welfare, and nutrition programs,
and between private and public sectors
♦
Increased utilization of primary health services, especially by the poor
•
Increased patient and community satisfaction with primary health services
Cj/f
r
B: Strategic Context
1.
Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1)
Document number:
Date of latest CAS discussion:
The objectives of this proposed project reflect the goals and priorities identified by the CAS and India’s
Ninth Five-Year Plan and National Population Policy, 2000. The CAS recommends focusing Bank-Group
financed investments on states that are undertaking economic restructuring programs and supporting
sectoral policy reform. Karnataka is one of the states that have initiated important fiscal, sectoral, and
governance reforms. Furthermore, it supports the CAS objectives by strengthening institutional capacity,
improving governance, engaging the private sector, expanding access to services, upgrading effectiveness
and quality of services and enhancing community participation and empowerment. Furthermore, the
project’s objective to meet the health needs of under-served populations, such as the poor, scheduled
castesand tribes (SC’STs), women, and children, is at the core of poverty reduction strategies in India.
2.
Main sector issues and Government strategy:
HNP Sector Issues in India
India has made considerable progress in improving the health status of its population over the past fifty-'
years. The State of Karnataka reflects some of this gain, standing slightly above average in improvements
in life expectancy and declines in fertility, infant mortality, maternal mortality, and severe and moderate
malnutrition. Despite these broad favorable trends in both the country and the state, a significantly high
proportion of the population, particularly those living in poverty, continue to suffer and die from
preventable infections, pregnancy- and childbirth-related complications, and under-nutrition. An
epidemiological transition is also taking place in which there are simultaneously high rates of
communicable and non-communicable diseases and where rapid urbanization is resulting in new health
problems. Furthermore, disparities between regions, men and women, and the poor and non-poor
continue to widen.
Experience with project implementation and findings of the sector work indicate that the principal
constraints in the health, nutrition, and population (HNP) sector in India include: (i) inadequate
institutional arrangements and weak program management; (ii) limited financial resources; (iii) poor
governance; (iv) low quality of HNP services in both the public and private sectors; (v) limited access to
health services for the poor; and (vi) inadequate framework for engaging the private sector.
Inadequate institutional arrangement and weak program management The existing fiscal and
administrative set up is complex, thereby hindering effective financing and accountability for
decentralized management of health facilities and deterring effective coordination across the health,
population, and nutrition sectors. More field level integration of the various health programs and
coordination of HNP services at the primary level are critical to improving health outcomes. In addition,
management skills at all levels are poor.
Limitedfinancial resources. Overall spending on HNP sen ices in India is sizeable, albeit lower than in
comparable countries, and far less than the amount recommended to provide basic services. Spending on
preventive and promotive primary care services has not kept up with the growing need for services,
particularly for people below the poverty line. In addition to overall revenue constraints, weak
mechanisms for reallocating resources according to priorities, particularly operating and maintenance
expenditures, impede the delivery of effective public HNP services.
Poor governance. A major problem related to governance, which affects the performance of Karnataka’s
public sector in HNP is a lack of accountability and transparency in areas such as management of human
resources, particularly with respect to staff recruitment, appointment and transfer.
Low quality ofhealth services. Most Indians expect little, and receive little, from their health services.
Health facilities are often in disrepair, poorly equipped, and under-supplied, reflecting the low levels of
health spending. They are further constrained by,staffing limitations, particularly in poor and remote
areas, by inappropriate skill-mix as well as by shortages of drugs and supplies and lack of attention to
supervision and maintenance. In both the public and private sectors, there are few standards and quality
improvement systems in place. Quality private health services are inaccessible for the poorest and most
vulnerable sections of society, and they do not address public health issues of national significance. As a
result, substantial gaps remain in the effective delivery of health care services that are provided to the
population, especially for the poor and vulnerable populations.
Limited access for the poor. Those comprising the most vulnerable sections of society suffer the deepest
from the inadequacies of the public health system, ^.ural populations'', women, children, the disabled, and
people belonging to the scheduled tribes and scheduled castes have the worst health outcomes, are
allocated the least resources, and receive the fewest sendees to compensate for their increased risks. The
poor also pay relatively more for health care and receive worse care.
Inadequate frameworkfor engaging the private sector. The private sector in India accounts for about 80
percent of overall health expenditures, one of the highest proportions of private expenditure on health in
the world. Services provided by the private sector are highest for primary health care, such as visits to
formal and informal health providers, and are financed almost entirely by out-of-pocket sources, placing a
disproportionate burden on the poor. The private sector, however, remains largely neglected in the
government’s policy formulation and program implementation. Appropriate policies to engage the
private sector, particularly with respect to providing information,(licensing^ and regulations to protect and
empower consumers, especially poor consumers, need to be clearly articulated and implemented.
i an-t n
Government of India
India has made substantial progress in improving the health status of its population over the past two
decades. GOI has determined that public investments in health are critical for the sustainability of
development and poverty alleviation in India. Health is one of the six priority areas identified in the
Ninth Plan (1997-2002) which emphasizes successful preventive and promotive activities, better control
of communicable and non-communicable diseases, strengthened community and beneficiary
participation, and improved surveillance and systemic efficiency. The Central Council of Health and
Family Welfare has noted the importance of linking preventive and promotive care with selective aspects
of curative care as well as highlighted the importance of a well functioning referral system. Since the
states are largely responsible for the financing and implementation of health programs, these issues need
to be addressed at the state level.
Government of Karnataka
The Government of Karnataka (GOK) has had a long standing commitment to human development and
public health. In 1999 the GOK, prepared its first Human Development Report outlining developmental
disparities based on gender, income and region, as well as bringing to the fore issues of access and equity.
Building on the report, in early 2000 the Chief Minister of Karnataka commissioned a review of the
health system to ensure “Health for All”, with an emphasis on equity and quality. In order to ensure a
participatory process, a Task Force on Health consisting of key stakeholders in the government and civil
society was formed. The Task Force has developed a proposal outlining priorities for the health sector.
The priorities include developing an integrated health, nutrition and population project for the State
building on the gains of the existing Health System Development project, improving the existing primary
health care system with a special emphasis on equity' and quality, increasing the health sector’s
responsiveness to the needs of populations with special needs, strengthening management, and developing
a comprehensive health management information system.
3.
Sector issues to be addressed by the project and strategic choices:
Achieving health and nutritional goals set by the Government of Karnataka —reduced infant and maternal
mortality, reduced malnutrition, control of communicable diseases—will require concerted action from
the health sector, as well as from other sectors such as education, water, sanitation, and rural and social
development. Important determinants of poor health and nutritional status include extreme poverty, low
educational status of women, lack of access to clean water and sanitation, and gender and caste-based
inequities; these factors cannot be adequately or directly addressed by interventions in the health sector.
To assist the GOK in reaching the state’s desired health and nutritional outcomes for its people, the Bank
has adopted a systemic and broad based approach to addressing the health system and has financed
projects and programs which include centrally sponsored disease control, nutrition, and family welfare, as
well as state health system development that focuses on increasing efficiency of resources and enhancing
the performance of health systems at the secondary level of health care.
The proposed project will establish an integrated and responsive primary health care system supported by
a well functioning referral. It will build upon and expand the inxestment operation financed by the Bank,
Karnataka State Health Systems Development Project (KHSDP). and integrate delivery of health services
with family welfare services and disease control at the primary level. Furthermore, it will complement
fiscal and governance reforms planned under the economic restructuring program, which is also supported
with the Bank assistance.
The project will address the key sector issues in the following way:
Strengthening institutional arrangement and program management. The project will address institutional
problems through improving overall planning and management, manpower development, procurement of
Page 5
r
drugs and equipment, referral, HMIS, surveillance, and training. Furthermore, the project will strengthen /
institutions to enable integration and coordination between health, nutrition, and family welfare services,/>'
as well as to work with the private sector at the primary care level.
/
Increasingfinancial resources. The project will supplement ongoing efforts by the Bank-financed
investment KHSDP, to (i) ensure adequate budgetary allocations to the health sector, (ii) increase the
share of health sector resources provided to the primary and secondary levels; and (iii) allocate adequate
resources for drugs, essential supplies, and operations and maintenance. In addition, under the fiscal
reforms supported by the Bank, Government of Karnataka (GOK) Medium Term Fiscal Plan envisages
increased spending on priority social sector programs, of which health is one. The project will also
address regional (intra-state) disparities in allocation of resources within the health sector, by intensifying
interventions in under-served areas.
Improving governance. GOK has initiated measures to improve governance, such as civil service reform
and human resource management, which will be expanded under the Bank’s structural adjustment
program. Within the health^ector KHSDP has already made considerable progress in increasing
transparency in the iraiisfefofmedical personnel and contracting out non-clinical services at secondary'
level hospitals to private agencies. The proposed project will also adopt measures to improve governance
in the health sector, such as providing incentives for medical personnel to work in remote areas and with
vulnerable populations, mechanisms to establish merit-based selection and increase transparency in the
performance rating of personnel, and promoting the role of the public in monitoring health services.
Enhancing quality of health services. The project will support policies and activities to improve the
quality of health services through supply-, as well as demand-side interventions. Supply side
interventions include upgrading primary health care facilities, putting in place service norms, and
addressing manpower gaps and skills mismatches, and strengthening linkages between public and private
providers. Furthermore, this project will empower communities with information and mechanisms for
redress and quality improvement. The role of the community in increasing accountability' of the health
systems will also be strengthened.
Expanding access for poor and vulnerable populations. The project will increase access by expanding
services in areas where poverty is concentrated, and health status poor. The project will intensify
; interventions with respect to physical infrastructure, staffing. IEC, and community' involvement in the
j northern districts of Karnataka, which have suffered from neglect and therefore, exhibit the lowest human
\development. Furthermore, NGOs and community based organizations (CBOs), in addition to local
private practitioners, will be engaged to deliver clinical and non-clinical services, such as IEC and
outreach, to communities difficult to access by the public health system.
Partnering with the private sector. The proposed project will promote private sector participation
through innovative schemes to involve traditional healers, NGOs, and other private practitioners in areas
such as referral, training, health financing, development of accountability and transparency' measures, and
monitoring and evaluation.
C: Project Description Summary
1.
Project components: (see Annex 1)
The project consists of three main components:
1. Management development and institutional strengthening component would consist of (i)
strengthening management and implementation capacity, in the areas of financial management,
procurement, technical management, and monitoring and evaluation; (ii) strengthening disease
surveillance and management information system; and (iii) improving institutional framework for policy
;----------------------
- - -
X
Pages
development. The component would finance professional services, local training, vehicles, equipment,
including computers, furniture, studies, fellowships, workshops, operational expenses, and salaries of
incremental staff on a declining basis. This component
2. Improving access and service quality and effectiveness component would consist of (i) upgrading
primary health care facilities; (ii) improving human resource development and management, and curative,
preventive and support services; (iii) strengthening referral system between levels of care, between HNP
programs, and between public and private sectors; and (iv) expansion of health services in underserved
areas. The component would finance civil works, professional sendees, furniture, medical and other
equipment, local training, workshops, vehicles (purchase, hire, and maintenance), EEC, operational
expenses, and salaries of incremental staff on a declining basis.
3. Innovations to enhance partnership with communities and private sector component would
consist of (i) strengthening community capacity’ to identify health needs and solutions and to monitor and
evaluate health services; (ii) piloting community driven schemes in the areas of health, financing and
health promotion; and (iii) piloting.public-private partnership schemes. It would finance professional
services, NGOs, local training, EEC^.workshops, studies, vehicles (purchase, hire, and maintenance),
operational expenses, and salaries of incremental staff on a declining basis.
Slndicativ.ee?
T^SectoryS;
1. Management development and
Institutional strengthening
S&Banlgg; g®.°7o,of.i^:
^ofy- ^financing- gliBan'k'ir
£Tqtal|
•^fjn anejn
«2(US$M)X
9
2. Improving access and service
quality and effectiveness at the
primary care level
3. Innovations to enhancing
partnership with communities
Total
Total Project Costs
Interest during construction
Front-end fee
Total Financing Required
2.
0
0
0
0
Key policy and institutional reforms to be sought:
Many of the following key policy' and institutional reforms have been initiated by GOK with the support
of KHSDP. The Task Force on Health and Family Welfare has also commissioned studies, financed by
KHSDP, to help inform these policy decisions and reforms. In addition to increasing support for current
efforts, the proposed project would expand particularly in the areas affecting primary care and
involvement of communities to improve health servicesand financing.
I
•
Increasing financing and improving resource allocation to the health sector, in particular primary and
secondary' levels
1
•
•
Developing policy and strategy to promote public-private partnerships, including traditional health
care providers
Improving manpower policy and procedures within the health sector by improving recruitment,
deployment, transfer, training, performance appraisal, sanctions, and incentives
Improving technical efficiency by developing and strengthening management systems in the areas of
planning and budgeting, finance, information, manpower, equipment procurement, and maintenance
Strengthening institutions to better manage and deliver integrated health, family welfare, and nutrition
services at the primary level
Improving financial protection for the poor Q/1
Enhancing role of community based organizations (CBOs) in health promotion, service delivery, and
monitoring and evaluation
>
Enhancing public involvement ana accountability of health services and financing
3.
Benefits and target population:
■
•
■
•
•
Add
4.
Institutional and implementation arrangements:
Institutional arrangements are currently under preparation. Our experience from implementing health
systems development projects indicates the following arrangements. The top of the proposed structure
would be composed of Project Governing Board, chaired by the Chief Secretary and including other
Principal Secretaries from other concerned departments of GOK-—Health and Family Welfare, Women
and Child Development, Indigenous Medicine, Education, Sanitation (and possibly representatives from
the private sector, consumer groups, and NGOs), which would have responsibility for overall project
coordination and policy. A Project Steering Committee (PSC), led by the Secretary, Health and Family
Welfare Services, and composed of high level managers from the State Health and Family Welfare
Directorates, would be the second tier. The PSC would supervise and guide the implementation of the
project, in addition to coordinating with other health sector projects. The next tier would be the Project
Management Unit (PMU) to be headed by the Project Director. The Unit would consist of Financial
Management Wing, Equipment Procurement and Maintenance. Engineering and Architectural Wing,
Quality Improvement Cell, HMIS Cell, Community Empowerment Cell, and Training Cell, all composed
of professionals. The PMU situated at the Department of Health and Family Welfare Services, would
work with Directorates of Health, Medical Education, and Family Welfare and would be responsible for
day-to-day project implementation.
D: Project Rationale
1.
Project alternatives considered and reasons for rejection:
The major alternatives considered include:
(a) Focus on selected parts of the State. Implementing exclusively in selected parts of the state would
be politically infeasible, and would miss the opportunity to address key state-wide policy issues such as
increasing financing and improving resource allocation in the health sector, allocating adequate resources
for drugs, essential supplies and operations and maintenance, and institutional strengthening such as
rationalized service norms, referral mechanism, health care waste management system, equipment
management system, HMIS and surveillance of major diseases, procurement and financial management
arrangements. By addressing needs in only parts of the state, this alternative would not address the health
needs in a coherent and effective manner. Experience in the six states where State Health Systems
Page 8
Development projects are currently being implemented indicates that the broad-based approach is the
appropriate mechanism to address systemic health sector issues.
(b) Leave the provision of basic services entirely to the private sector. There are several rationale for
undertaking this operation through the public sector: (i) the private sector provides mainly curative care,
and does not provide the most appropriate services to those in greatest need; (ii) both sector work and
beneficiary' assessment studies in several states in India indicate that more than 60% of the beneficiaries
belong to the poorest sections of society and much of the remaining 40% are marginally above the
poverty line. They are unable to afford the costly fees for private services, which are paid almost entirely
from out-of-pocket sources. Since this project wishes to address the needs of the poor leaving the
provision of services to the private sector will fail to In addition, public health measures and essential
interventions is an important priority for government financing.
(c) Use an Adaptable Program Loan (APL). The advantage of the APL is that it encourages progress
against defined benchmarks, adds flexibility', cuts down on subsequent preparation time by' focusing on
implementation and monitoring, signals a long-term commitment to assisting on long-term problems,
while keeping the whole problem under consideration in a phased manner. Due to limits on program
loans in the overall lending program, Regional Management prefers to use flexible lending instruments
such as the APL for sectors which are more conducive to phased reform monitoring, such as the power
sector (?).
(d) Use a Sector-Wide Approach (SWAp) was considered but rejected as a feasible alternative due to
the GOK's weak institutional capacity to implement disparate elements of health sector operations under
one umbrella program. The GOK has clearly outlined as its’ main priority in the health sector to build its’
own technical and managerial capacity and strengthen the existing health system. The government has
opted for a systems development approach within the framework of a broad based sector dialogue.
2. Major related projects financed by the Bank and/or other development agencies (completed,
ongoing and planned):
Sector issue
Pr 0je ct‘ - 'y?' i
'A-
- >.
Latest Siiperyisjon'(Form 590)
Ratingsyiyrj• -“ T-- ,.r " ’ w'f (Bank-financed projects only)
Development
Implementation
Objective (DO)
Progress (IP)
T
T
Bank-financed
Population VIII
Population IX
Reproductive and Child Health
Immunization Strengthening
State Health Systems II
Andhra Pradesh First Referral Health System
Orissa Health Systems Development
Maharashtra Health Systems Development
Utter Pradesh Health Systems Development
National HIV/AIDS Prevention and Control
Cataract Blindness Control
Malaria Control
Tuberclosis Control
s
s
s
s
s
s
s
s
s
s
U
Secondary Health Development (Gulbarga)
IP/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory)
KfW
S
S
s
s
s
s
s
s
s
s
s
s
u
ijlil
■
ft
Other development
agencies
S
S
Page 9
3.
Lessons learned and reflected in proposed project design:
The project design takes into account key lessons learned from implementation of social sector projects in
India, and specifically four State Health Systems Development Projects currently under implementation
in six states, findings from sector work, and evaluations from Operations Evaluation Department (OED) .
Lessonsfrom implementation ofState Health Systems Development Projects', (i) maintain continuity in
project management and key project actors; (ii) empower Project Management Unit and Project manager
appropriately to ensure timely and adequate flow of funds, especially when the project is implemented by
a government line department; (iii) strengthen project management by providing greater autonomy with
respect to management and supervision, adequate staffing of key project management personnel and
improving management procedures; (iv) pay attention to quality aspects of the project through
development of staffing and technical norms, referral mechanism, clinical and management training
programs, incentives for medical personnel, staff selection based on merit, and addressing skill-mix
during preparation; (v) emphasize software aspects, such as EEC. quality, and referral, to be implemented
in conjunction with hardware; (vi) improve HMIS to facilitate policy and institutional strengthening and
ensure information collected through M & E be used for management decision-making; (vii) use
independent agency in areas of M & E and EEC; and (viii) undertake early preparation of procedures and
mechanisms to select and monitor NGOs and other private agencies contracted by the project.
Findings from sector work'.
Keys lessons from implementation of social sector and other HNP projects in India: (i) ensure timely
and adequate flow of funds to the project entity; (ii) undertake advanced preparation of hardware and
software aspects of the project prior to approval; and (iii) speed up implementation and increase
supervision by strengthening implementation capacity' of the line agency to resolve problems in
procurement and disbursement early in the project cycle, and de\elop detailed implementation plans prior
to appraisal.
Key recommendations from OED: (i) place greater emphasis on institutional development and
governance issues in order to make a greater impact on development; (ii) engage in policy development
and debate; (iii) tackle the personnel problems and incentives structures in the sector; (iv) support
integration of referral system; (v) engage the private sector; and (vi) introduce performance-based
budgeting.
4.
Indications of borrower commitment and ownership:
Political commitment and ownership for the project are high. The commitment of GOK to health sector
reform is reflected in the constitution of the Task Force on Health and Family Welfare, which is
composed of prominent persons in the field of medicine and public health from academia, and the private
and NGO sectors. The principal responsibility of the Task Force is to provide strategic vision and
formulate recommendations for improving the health care system in the State. Furthermore, Karnataka is
one of the states partnering with the Bank to undertake broad reform measures, mainly fiscal, sectoral,
and governance changes to strengthen the enabling environment for poverty reduction.
5.
Value added of Bank support in this project:
IDA is best suited to provide funds to complement the medium and long-term policy initiatives of the
government. IDA’S approach to policy dialogue, which includes up front, and long-term engagement, are
useful in supporting the types of changes envisaged. The project would help consolidate the investment
made by a number of other IDA and donor-supported projects in the health, nutrition, and population ’
Page 10
sector, and provide a critical link to these investments. The project would also strengthen EDA's strategy
of poverty reduction in India through its focus on the poor and under-served populations.
E: Issues Requiring Special Attention
1.
Economic
[ ] Summarize issues below (e.g., fiscal impact, pricing distortions)
[ ] To be defined (indicate how issues will be identified)
[ ] None
Economic evaluation methodology:
[ ] Cost benefit
[X] Cost effectiveness
[X] Other [specify]
The following economic analysis will be completed by appraisal and will contribute to project design (i) a
public expenditure review in the health sector addressing financial sustainability and the ability to
increase resources and protecting non-salary recurrent items, (ii) an analysis of private sector provision
and financing to assure that public investments are not simply trying to substitute for private services, and
to examine who is benefiting from the proposed investments.
2.
Financial
[X] Summarize issues below (e.g., cost recovery, tariff policies, financial controls and accountability)
[ ] To be defined (indicate how issues will be identified) [ ] None
Project preparation will pay special attention to the fiscal impact of the proposed project as it relates to the
medium term expenditure framework and to issues relating to financial controls, accountability, and
sustainability, including (i) recurrent cost implications of the project, with the understanding that the
project would finance recurrent costs on a sliding scale (ii) an assessment of the resource flows into the
health sector. This analysis will examine issues of sustainability and the ability of the state to finance
incremental recurrent costs of the proposed project as well as the sustainability of IPP VIII, IPP IX and
the Karnataka Health System Development Project.;(iii) mechanisms to ensure adequate flow of funds;
(iv)an assessment of financial control mechanisms to identify' capacity, to collect and analyze financial
information, handle cash flow/disbursement issues, procure goods, and contract services. The assessment
will examine staffing and systems development and the need to develop financial management capacity to
better understand and manage public budgets, and improve financial accountability and controls. There
will also be an analysis conducted to outline feasible alternatives for health financing that will be piloted
during the project.
3.
Technical
[X] Summarize issues below (e.g., appropriate technology, costing)
[ ] To be defined (indicate how issues will be identified) [ ] None
Technical issues to be analyzed by project preparation include (i) integration of the health, family welfare
and nutrition services at the primary health care level, supported by a well functioning referral system, (ii)
the development of a comprehensive management information system (iii) human resource management
particularly in the area of skill mismatch, disruptive staff vacancies, performance based rewards and
incentives. A series of workshops and consultations will be held to clarify these issues. These workshops
will build on the workshops on staffing and service norms conducted under the State Health Systems
Development Project II
Page 11
4.
Institutional
[X] Summarize issues below (e.g., project management, M&E capacity, administrative regulations)
[ ] To be defined (indicate how issues will be identified) [ ] None
An institutional assessment is being planned to provide guidance on how to implement the proposed
institutional reforms for the project. An analysis of the existing relationship between the public and
private sectors will be conducted to better identify and plan how the government can work with the
private sector in the area of referral, quality improvement and disease surveillance. As well, a study will
be conducted to examine the institutional arrangements needed to increase community involvement and
increase the community’s capacity to provide feedback and monitor and evaluate the health system.
Executing agencies:
The project will build on existing arrangements developed through the Karnataka Health Systems
Development Project
Project Management
The project will build on existing arrangements developed through the Karnataka Health Systems
Development Project
Procurement Issues
As a result of the existing KHSDP project, the GOK is well versed in the Bank procurement guidelines
thus there are no foreseen problems in this area.
Financial management issues
As a result of the existing KHSDP project, the GOK is well versed in the Bank procurement guidelines
thus there are no foreseen problems in this area.
5.
Social
[ ] Summarize issues below (e.g., significant social risks, abiIity to target low income and other
vulnerable groups)
[ ] To be defined (indicate how issues will be identified) [ ] None
One of the key issues to be addressed in this project is how to overcome socio-economic and cultural
barriers, as well as gender discrimination and thereby increase access for vulnerable populations.
Additionally, an assessment of the potential impact of the project and any changes in health policy on the
various stakeholders will be conducted. A special focus will be on the poor, SC/ST, women, disabled
groups and under-served districts in North-East Karnataka. A mapping exercise will also be conducted in
these under-served areas. The project preparation will also review the evaluation of the Yellow-Card
Scheme implemented under KHSDP to expand access to the scheduled tribes.
6.
Environmental
a. Environmental issues:
[ ] Summarize issues below (distinguish between major issues and less important ones)
[ ] To be defined (indicate how issues will be identified) [ ] None
Other:
b.
Environmental category:
c.
Justiflcation/Rationale for category rating:
V
[)
A
[]
B
[X]
C
Page 12
The project is expected to have no adverse environmental impact given that the project only involves
upgrading of existing facilities. With regards to waste management, the project will ensure that it
complies with WHO standards
d.
e.
Status of Category A assessment:
EA start-up date:
Date of first EA draft:
Current status:
t
Proposed Actions:
f. Status of any other environmental studies: Government has conducted audits of each secondary level
facility.
g.
Local groups and NGOs consulted (list names): Not Applicable
h.
Resettlement Not Applicable
[ ] Summarize issues below (e.g., resettlement planning, compensation)
[ j To be defined (indicate how issues will be identified) [ ] None
i.
Borrower permission to release EA:
j.
Other remarks:
7.
Participatory Approach:
[
]Yes
[
] No
[
] N/A
a. Primary beneficiaries and other affected groups:
[X] Name and describe groups (how involved, and what they have influenced or may influence.)
[ ] Not applicable (describe why participatory approach not applicable with these groups)
End beneficiaries, community groups, NGOs, private providers and local government officials, will
participate in the preparation phase through consultation workshops, exit interviews at health facilities,
and focus group discussions to define performance indicators and plans for monitoring and evaluation
during the course of the project, to identify needs and barriers to obtaining quality care and expanding
access. Monitoring of use by end beneficiaries, and of patient and community satisfaction with the health
sendees will be incorporated into the HMIS and will be used for local planning and management and
performance assessment of the project.
MOH will prepare the Project Implementation Plan (PIP)
b. Other key stakeholders:
[X] Name and describe groups (how involved, and what they have influenced.)
[ ]Not applicable (describe why participatory' approach not applicable with these groups)
Local academic groups will be involved in the design and preparatory studies and in advising technical
elements of the drafting of the PIP. NGOs, and other technical agencies, WHO and KfW will be
consulted in the design phase and their inputs will be coordinated and shared.
Page 13
8.
Checklist of Bank Policies
a. Safeguard Policies (check applicable items):
^^l^kipfjN:o.niCpnTpl i a n c ej(
v/
Environmental Assessment (OP 4.01)
Natural Habitats (OP/BP/GP 4,04)
Forestry (OP 4,36)
Pest Management (OP 4,09)
Cultural Property (OPN 11.03)
Indigenous Peoples (OD 4,20)
Involuntary Resettlement (OP 4.30)
Safety of Dams (OP 4.37)
Projects on International Waterways (OP 7.50)
Projects in Disputed Areas (OP 7.60)
b. Business Policies (check applicable items):
Financing of recurrent costs (QMS 10.02)
Cost sharing above country 3-yr average (OP/BP/GP 6.30)
Retroactive financing above normal limit (OP/GP/BP 12.10)
Financial management (OP/BP 10.02)
■V
Involvement of NGO’s (GP 14.70)
Other (provide necessary details)
c.
Describe issue(s) involved, not already discussed above:
F: Sustainability and Risks
1. Sustainability:
Financial, social, technical, and managerial sustainability is being addressed in the design and preparation
of the project. The economic analysis and monitoring of expenditures will determine whether the
incremental costs of the project are affordable, and whether they will remain so as the program develops.
Institutionalizing a process to justify' major capital investments is intended to maintain a sustainable
program. Social sustainability is addressed by instituting mechanisms to increase the involvement and
voice of consumers in the design of the project, and in routine provision of health services in both public
and private sectors. Updating the technical paradigms, streamlining services and integrating the referral
chain, working with the private sector, and focusing on management training and systems are steps taken
to ensure that the system is more technically and managerially sustainable than before the project.
Page 14
2. Critical Risks: (reflecting assumptions in the fourth column of Annex 1)
From Outputs to Objective
Institutional arrangements are not effective in
integrating centrally sponsored health and
family welfare and state health concerns (M)
Productive institutional linkages with the
private sector are not established (G,M)
Competent staff and managers are not placed
in project management units and health
facilities (M)
Provider behavior cannot be changed (S,O)
Strategic approach to behavior change
communication will not increase demand for
and accountability of health services (S)
From Components to Outputs
Flow of funds from GO1 to State project are
inadequate
Staff and consultants are not assigned in a
timely manner
Key staff and managers are not retained for
sufficient time
Procurement is not managed in a timely
manner
Funds are not made available for non-wage
recurrent expenditures, especially drugs and
mobility’
Institutional strengthening will be
emphasized in the proposed project.
Financing would be linked to
performance
Information sharing, pilot studies, and
self-regulation will be encouraged.
Financing would be linked to
performance.
Address through Letter of Health Sector
Development Program, appoint key
personnel prior to negotiations
Emphasize consumer feedback and
provider incentives as part of the project
design
Use research-based communications and
monitor results carefully
Address through Letter of Health Sector
Development Program, and financial
monitoring
Appoint key staff prior to negotiations
Include provision at negotiations to retain
well-performing staff
Develop robust procurement plans and
appoint key staff prior to negotiations
Address through Letter of Health Sector
Development Program, and continued
monitoring of health expenditures.
Link financing to performance
Overall Risk Rating:
Risk Rating - H (High Risk). S (Substantial Risk). M (Modest Risk). N (Negligible or Low Risk)
G: Project Preparation and Processing
1. Has a project preparation plan been agreed with the borrower: (see Annex 2 to this form)
[X] Yes, date submitted: NLM/DD/YY
2.
[] No, date expected: MM/DD/YY
Advice/consultation outside country department:
[V] Within the Bank:
[
3.
] Other development agencies:
Composition of Task Team: (see Annex 2)
Tawhid Nawaz (Team Leader-Task Manager)
David Peters (Sr. Public Health Specialist)
Sadia Chowdhury (Sr. Public Health Specialist)
I
Page 15
Preeti Kudesia (Sr. Public Health Specialist)
Hnin Hnin Pyne (Public Health Specialist)
Maj-Lis Voss (Economist)
Abdo Yazbeck (Economist)
Tazim Mawji (Health Specialist)
Rajat Narula (Financial Management Specialist)
Mam Chand (Procurement Specialist)
(Legal Officer)
Vijay Rewal (Architect)
Shrelata Rao (Social Scientist)
Pradeep Kakkar (IEC)
4.
1
Quality Assurance Arrangements: (see Annex 2)
External Peer Reviewers:
Internal Peer Reviewers
5.
Management Decisions:
Total Preparation Budget:
Cost to Date: (USSOOO)
[
(USSOOO)
] GO
Bank Budget: (USSOOO)
] NO GO
(signature)
Team Leader: Tawhid Nawaz
(signature)
Sector Manager/Director: Richard L. Skolnik
(signature)
Country Manager/Director: Edwin R. Lim
Trust Fund: (USSOOO)
Further Review [Expected Date]
Annex 1: Project Design Summary
India: Karnataka Integrated HNP Services Development
rchy^oftQ Eject!vesJ2 5‘KeylE.erforrn a n.c ell 5'dic.a to.rs.i i M o n i to rjiTgfa n.djEyal u atid.n ’£ ^sSC.ritical2Assucnp.ti.ons£-!:
Sector-related CAS Goal:
Sector Indicators:
Health and nutritional status of
Karnataka’s population,
particularly the poor, women,
children, and schedule castes and
tribes, is improved.
Decline in infant mortality
Decline in maternal mortality
Decline in malnutrition
Decline in anemia
Increase in immunization coverage
Increase in TB case detection and
cure
Project Development Objective:
Improve efficiency in the
allocation of health resources
through policy and institutional
development
Performance of health system
strengthened through
improvements in quality,
effectiveness, and coverage of
primary health care services
Outcome 1 Impact Indicators:
1. Increased public resources to
health sector, with increased share to
primary and secondary levels of care
2. Increased utilization of primary
health facilities, esp. by the poor and
*
SC/STs
3. Increased patient and
community satisfaction with
primary health services
*
4. Increased referral between
levels of care, programs, and private
and public providers)
Sector / Country Reports:
(from Goal to Bank Mission)
Focusing on reforming states and
human development will
contribute to poverty reduction in
India
Improving quality of life and
health and nutritional status will
increase opportunities and
productivity
Project Reports:
(from Objective to Goal)
Political commitment continues
Continuing investment in other
sectors, such as water and
sanitation, and education, affecting
health and nutritional status
Continuing support for centrally
sponsored programs, currently
assisted by the Central
Government, the Bank, UN
agencies, and bilaterals
Continuing support for improving
quality, effectiveness and coverage
of secondary level care, currently
financed bv the Bank
—————- --
Indicators need further input: QQ1
Uu-.put from each component:
Access to primary health
^services expanded, particularly in
under-served districts and tribal
areas.
2. Etiectiveness and quality of
primary' health services improved
>
Output Indicators:
1.1. Increased awareness of primary
health services offered, particularly
among SC/STs, women, and poor
*
1.2. Increased number of primary
health care facilities (functioning
according to service and staff
norms) in underserved districts and
tribal areas
*
1.3. Increased number of NGOs
contracted to conduct outreach and
deliver services in tribal and remote
*
areas
3.1. Increased referral between
levels of care
3.2. Increased referral between HNP
programs
3.3. Increased referral between
private and public providers
-1. Human resource development
and management capacity a: the
primary level strengthened
4.1. IT system developed
4.2. FM system in place
4.3. Manpower gaps filled, esp.
vacancies in underserved areas
4.4. Transparency in transfer of
medical staff (% of counseling used
for transfer)
4.5. Incentives system in place
5. Communities involved and
empowered to demand better
ices and to identify' health
needs and problems
5.1. Mechanisms/channels for
communities to voice complaint and
demand for better services ??
5.2. Involvement of CBOs in M&E
(rating of services, etc.)
5.3. Training of CBOs and
community leaders in identifying
health problems/needs and barriers
to access
Inputs: (budget for each
component)
1. Management development and
institutional strengthening
2. Improvements in access and
service quality and effectiveness
3. Innovations to enhance
partnership with communities and
private sector
(from Outputs to Objective)
Competent staff and managers arc
placed project management units
and health facilities, particularly in
remote areas
Synchronization of project inputs:
flow of.funds, provision of
training, development of norms
and contractual arrangements.
Timely start-up of civil works,
training programs, and other soft
ware components, such as IEC anc
HMIS, and procurement of drugs
and equipment
2.1. Number of primary health care
facilities rehabiliated, equipped
versus planned
2.2. Percentage of facilities meeting
staffing, equipment, and medicines
norms
2.3. Increased number of medical
staff trained (clinical, management,
patient-provider communication,
MIS, referral, waste management)
2.4. Use of disease surveillance and
HMIS
3. Well functioning referral
system (between levels of care and
between programs) in place
Project Components/Subcomponents:
Project Reports:
Project Reports:
(from Components to Outputs)
Flow of funds from GO! to State
project are inadequate
Staff and consultants are not
assigned in a timely manner
Annex 2
Page 1 of 2
Project Preparation Plan
A project preparation plan is normally discussed and agreed in principle with the borrower during the
identification mission. A one-two page summary of the plan is attached to the PCD as Annex 2 (see sample developed by
the LAC Region in page 2 of this annex). The plan should cover the following:
Role, responsibility and staffing of the borrower for project preparation, including designation of a project preparation team (Bank and
Borrower).
Bank assistance to be provided during project preparation.
*
.Arrangements for local/foreign consultant inputs.
*
Outline of Project Implementation Plan (see Attachment) to be prepared by the borrower.
Timetable for project preparation (including deadline for submission of the PIP).
Milestones for progress review and any discussions by the Bank.
Key outputs of project preparation, e.g. technical/economic feasibility studies; environmental assessments; institutional, beneficiary,
social analyses; tariff studies; financial models.
^pth of analysis required for each specialist area, e.g., cost benefit analysis, skills/gap analysis.
Issues to be addressed in parallel with project preparation (parallel track or likely loan conditions).
Modalities of project preparation and analytical tools, e.g., beneficiary participation in project design, beneficiary surveys, use of
logical framework
The proposed public consultation/participation process
Items indicated above that are covered elsewhere in the main text of the PCD can be omitted from the summary but
should form part of the project preparation plan agreed with the borrower.
‘Costs arc reflected in the project preparation budget (see Annex 3). ■
wf
KARNATAKA INTEGRATED HEALTH. NUTRITION AND FAMILY
WELFARE SERVICES DEVELOPMENT PROJECT
TERMS OF REFERENCE FOR FORMULATING AN INFORMATION SYSTEM
STRATEGY PLAN.
1.
BACKGROUND:
The Government of Karnataka has received a TA grant in response to preparation
of an integrated Health, Nutrition and Family Welfare Services Development
Project (P 071160) The proposed PHRD fund are primarily to finance key
studies required in finalization of the project.
Amongst the six studies envisaged, information technology strategy plan needs to
be formulated. Karnataka is well known in the field of IT An integration of
Health. Family Welfare and Nutrition Services requires careful monitoring and
synthesis of the various information systems from existing vertical programmes
Apart from strengthening the health information system, the project will establish
a system that facilitates sharing and utilizing information, as well as validating of
data emanating from the field
2.
•
•
•
•
•
•
OBJECTIVES:
The objective of the study is to develop a Health Management Information System
(HMIS) strategy plan.
To review the existing HMIS in the state and National level (and literature of HMIS
system in developing and developed countries) and work out modalities of
strengthening the system in the state.
To the state work out strategies to validate all data emanating from the sub-centre
level to District level and upwards to the state.
To establish a system or careful monitoring and synthesis of various information
systems from existing vertical National Health Programmes.
To establish a system of feedback or sharing and utilization of information to the
sources of information as well as all'concerned agencies.
To improve management and increase staff productivity thereby enhancing health
care delivery and services.
3. OUTLINE OF THE TASK TO BE CARRIED OUT AND TIME LINES.
•
•
•
Appointment of three consultants who are experts in the field of Information
Technology, Epidemiology / Public Health and Health Management and familiar with
the existing system in the State Health Services.
- 1 month.
Review of the HMIS at state level, National level and literature available of HMIS in
developing and developed countries.
- 1 month.
Preparation of a detailed plan of implementational study, activity, month and costings
wise
- 2nd month.
•
Preparation of a monthwise programme for each consultants for office work weeks
and field tour weeks
- 2nd month.
•
Develop a comprehensive information systems strategy plan, define short-term and
long-term requirements of the sector, recommend technology architecture and prepare
system implementation.
- 3rd -5th month.
•
Preparation plan for procurement of equipment, connectivity, Internet, based
technologies, local area networks (LAN) and computer/ server, fax-machines,
modems and other hardware and software required for a comprehensive HMIS.
- 3rd -5th month.
•
Develop detailed information schedules / proforma for disease surveillance, National
Health Programmes and information feed back required for a comprehensive data
base & HMIS.
- 3rd -5th month.
•
Develop in-built monitoring and evaluation system especially with regard to
validation of data in the field and also to disseminate information to all concerned at
all levels.
-3rd-5th month
Develop a strategy to recruit and train staff to operate the HMIS effectively at all
- 5th -7th month
levels.
- 5th month.
Submission of draft interim report.
- 8Ih month.
Submission of final report.
•
•
•
4. OUTPUTS:
•
•
•
•
•
•
•
Inception report.
Information schedules / proforma.
Plan for procurement of equipment, hardware and software.
Plan for a comprehensive HMIS.
Plan for monitoring, evaluation and validation of data.
Strategy for training staff.
Monthly reports, interim reports, draft final report and final report.
5. REVIEW COMMITTEE:
HNP Pre-project studies review committee will consist of
Chairman - Commissioner of Health and Family Welfare, GOK.
Members - Director of Health F&W services.
Demographer of Director of H & FW services.
- One member of KTF on Health (Dr. C.M. Francis)
Joint Director Communicable Diseases, Director of H&FW.
6. INPUTS FROM THE CLIENTS:
-
Existing HMIS proformas, protocols of National Health Programmes.
Details of SC’s, PHC’s Taluk Hospital, District Hospitals and Channel of
communication.
HM1S inputs and surveillance activities from KHSDP.
7.
STUDY PROGRESS MONITORING:
There will be a monthly meeting of all the key consultants with the Commissioner
for monitoring the progress of the studies as per the time schedules.
8. COSTING AND PAYMENT SCHEDULE:
Total INR-33.12 lacs.
The agency will be paid 4Qiof the contacted amount on signing of the agreement.
40% on submission of the draft final report and 20% when final report is
accepted.
*
ftKIND ATTN: MR. SANJAY KAUL, I.A.S
23 January 2001
Pre- Project Studies and Activities
List of Pre-Project studies/activities which may be required to be conducted is given
below. It is reiterated that,
•
•
•
No external consultants will be required, as qualified consultants are available
locally.
It is also mentioned that S 6,80,000 (PHRD grant) would be required for carrying
out the studies.
Setting up of a Research Advisory Group to brainstorm and monitor the pre
project studies.
.■.j
../'L a) Facility Survey for repair and renovation of 1000 Primary Health Centres
(PHCs) and SCs, as well as staff quarters, including preparation of
implementation documents and manuals.
b) Siting and developing architectural designs for 100 new building for PHCs
(preference to Category C districts).
"
c) Selection of 100 PHCs for upgradation into FRUs (First level referral
units).
'T. Study of health care financing in private and voluntary sector in urban and
rural areas in Karnataka .
t<3. Patient satisfaction (OPD and in-patient) surveys for public and private /
voluntary sector and utilization (beneficiary assessment).
4.
Institutional analysis / management capacity.
Information technology strategy plan including validation of data emanating
from the field.
6.
Evolving a health promotion strategy.
X7. Availability of EmOC (Emergency Obstetric Care), EssOC (Essential
Obstetric Care) in rural areas.
x8. Evaluation of nutrition interventions in rural areas and evolution of strategy to
improve service delivery.
NOTE:No funds would be required to formulate a Comprehensive Health Nutrition and
Family Welfare policy for Karnataka as the same is already being carried out
under the Karnataka Task Force on Health.
A. Facility survey for repair and renovation of 1000 Primary Health Centres
(PHCs) as well as staff quarters including preparation of implementation
documents and manuals.
B. Siting and developing architectural designs for 100 new buildings for PHCs
(preference to category C districts).
C. Selection of 100 PHCs for upgradation into First level referral units (FRUs).
Facility survey will not merely be an engineering exercise. Specific selection of
institutions for renovation with objective of increased access and quality of care.
Therefore it has to relate to institutional capacity including staffing and past record of
work done there e.g. surgeries if there is an OT, deliveries, tubectomies, and family
planning procedures, cataract surgery etc.
Siting- selection of site not just on availability of free land. It is better to purchase land in
a locality where people can reach the facility conveniently. Focus group discussions with
communities particularly Dalits and women would help in siting. Use of community
mapping exercise for selection (as in water supply &sanitation in Maharashtra with DFID
support).
Therefore this exercise will need social perspective,
public health and health
management inputs. The selected group to do this possibly in collaboration with others,
with research advisory group, and survey teams should have all these components. There
is need for constant interaction with the Commissioner, the HNP project team and the
Health Directorate.
FRUs - What happens to PHC activities, staff and accommodation for additional staff.
Assess a sample of upgraded FRUs/ CHCs- are they playing the referral role they are
supposed to, are they adequately staffed and equipped for the purpose. Do they have
mobility and communication facilities.
Estimates need to be detailed and need to reflect expected rise in prices during the five
year period. Accountability at different levels needs to be fixed.
Agencies- TOR Steel
MECON
L&T
Zila Parishad Engineering Divisions
Study of Health Care Financing in private and voluntary sector in urban and rural
areas in Karnataka.
To study options for community financing, analyzing experiences in social health
insurance in India. These have been largely in the voluntary sector and have been studied
by CEHAT, Mumbai and others. A literature review and some field visits have to be
carried out. Health co-operatives e.g. in Mallur, Kolar district to be studied. Some
experimental work maybe initiated as in the UNDP initiative in T. Narsipur.
To study community pre-payment schemes and other forms of insurance.
To study out of pocket expenditure particularly the poor in different districts in
Karnataka.
Agencies: ISEC
Kaveri Bopaiah
Gita Sen
Centre for Budget Studies
Dharwar Institute of Management
Patient Satisfaction (OPD and in-patient) Surveys for Public & Private I Voluntary
Sector and Utilization (beneficiary assessment).
Stratified sample for gender, age, social class, language groups in different districts in
Karnataka, (for public, private and voluntary sector)
OPDWaiting time
Staff attitude and behaviour
Availability of Doctors and staff
Investigations
Feed back on user fee
Feed back on informal payments, private practice linkages
Referral for investigations, prescriptions
Feed back on physical facilities - water, toilet, electricity, chairs etc.
Any form of discrimination
Referral system functioning
Selection - choose patients suffering from diseases covered by National Health
Programmes - TB, HIV/AIDS, Malaria, MCH and minor ailments
Cost per visit - direct, indirect (loss of wages, accompanying person)
In- patients
Average duration of stay
Nurses on duty - 24 hours or not
Number of doctors visits
Agencies:
Population Research Centre
Ratnesh Kanbargi
PAC
ISEC
Institutional Analysis and Management Capacity
Will be prepared after discussions with CM Francis and Ravi Narayan
Agencies:
RN, CMF
IIM
X1ME
Ferguson
Information Technology Strategy Plan including validation of data emanating from
the field.
Technical aspects
Connectivity
Electrical Connections
Requirements - physical
Staff- training at di fferent levels
Data Quality- validating
Training of field staff
Supervision
Analysis
Discussion regarding data analysis at institutional level for decision
making
Communication facilities and systems including maintenance at different levels - district,
taluk, CHC, PHC (telephone, fax, cell phones for DHOs, beepers/pagers for key hospital
personnel)
Costing of the above per unit/institute per district and at state level
Phased planning.
Agencies:
BPL Innovision
NICNET
Evolving Health Promotion Strategy (make use of Dr. Bassappa’s study report to
Karnataka Task Force on Health and Family Welfare)
Action research
Costing
Strategy for different groups- urban, rural, women, children in/out of school etc.
Formation of expert group/think tank
Capacity building of directorate staff (identifying and sending competent staff for
training)
Revision of school curriculum - for different age groups
Converging different health education activities of different agencies
Ongoing assessment including accountability
Agencies:
Institute of Communications- Ahmedabad ( MICA?)
IUHE
VOICES
Madhyam
Jayashree Ramakrishnan
Dr. Neela Patel
Wigan & Leigh
Availability and Utilization of Emergency & Essential Obstetric care in rural areas
with recommendations / strategies to reduce maternal morbidity and mortality
Assessment of existing approaches
Developing district specific strategies
Belaku study - Dr. Saraswati Ganapathy
Developing indicators for rapid / on going district based assessment of MMR
Reasons for decline in developed countries (literature review)
Tackling women’s empowerment, health education, referral, transportation
Extent of illegal abortions
Measuring maternal mortality - impact indicators, sisterhood surveys, reproductive age
mortality study, maternal death review etc.
Agencies:
Medical Colleges
Dr. S.K. Krishnan
Evaluation of Nutrition Interventions in Rural Areas and Evolution of Strategy to
improve service delivery.
Quality & effectiveness of nutrition education
Impact of feeding of under fives.
Iron and folic acid supplementation
Vitamin A deficiency prevalence studies
Anthropometry
1CDS - operational aspects
Weaning foods - costing, delivery, logistics, methods
Efficiency of NGO programmes
Agencies:
Dr. Padmasini Asuri (with Dr Sabu George & Dr. Anup Radhakrishnan)
N1N
CFTRI
NIPCCD
KIND ATTN* Mli. SANJAV KAUL, I.A.«
18 January 2001
Pre- Project Studies smd Activities
1 isl of Pre-Project studies/activities which may' be required to be conducted is given below, fi is
reiterated that no external consultants will be required, as qualified consultants are available
locally. It is also mentioned that $ 6,80.000 (PHRD grant) would be required for carrying out the
studies.
To <2
Facility Survey for repair aud renovation of 1000 Primary Health Centres (PHCs) and
S€s. as well as staff quarters, including preparation of implementation documents
and manuals.
B.
Siting and developing architectural designs for 100 new building for PHCs
(preference to Category' C districts).
C.
Selection of 100 PHCs for upgradation into FRUs (First level referral units).
d7
Urban health facility survey and urban health needs assessment.
Distribution (including qualifications and work practices) of private sector general
practitioners.
-pc
Study' of health care financing in private and voluntary' sector in urban and rura
areas in Karnataka
—p
.
.
.
:R&.
Patient satisfaction (OPD and in-patient) surveys for public and private / voluntary — ;
sector and utilization (beneficiary' assessment).
pfi
—
Institutional analysis / management capacity. — T-XH
Xj. ri ri
Information technology strategy plan including validation of data emanating from the
field.
Evolving a health promotion strategy.
Study of women’s health needs.
L.
tv<>iv;ngTncchrmisms-andsysle.ms
M.
Evaluation of nutation interventions m rural areas and evolution of strategy to
improve service delivery.
Costing and modalities of hiring vehicles for health sendees.
Study of Regional Disparities.
Development of curriculum towards school health/ health education in schools.
NOTE:No funds would be required to formulate a Comprehensive Health Nutrition and Family
Welfare policy for Karnataka as the same is already being carried out under the
Karnataka Task Force on Health.
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Dear Mr.Sanjay Kaul,
Forwarded herewith are the draft TORs for HNP Project.
Thanking you,
Yours sincerely,
Dr. Sampath K. Krishnan
CHC
Attachment of type application/msword name
TOR,doc
please download the attachment
KARNATAKA INTEGRATED HEALTH, NUTRITION & FW
SERVICES DEVELOPMENT PROJECT.
TERMS OF REFERENCE FOR:
c)
Facility survey for repair and renovation of 1000 Primary Health Centres
(PHCs) as well as staff quarters, including preparation of implementation
documents and manuals.
Siting and developing architectural designs for 100 new buildings for PHC's
(Preference to category 'C districts).
Selection of 100 PHC's for upgradation into FRU's (First level referral units).
1.
BACKGROUND
a)
b)
The Government of Karnataka has received a TA grant in response to preparation
of an Integrated Health, Nutrition and Family Welfare Services Development
Project (P 071160). The proposed PHRD fund is primarily to finance key studies
required in finalisation of the project
Amongst the six studies envisaged Facility survey and preparation of
implementation manuals is required so that preparatory work on procurement can
be done in advance. Improving quality of services and increasing utilization will
involve renovating and upgrading of PHC's, labs and equipments. The study will
concentrate on the access of services to the poor and vulnerable populations
2.
OBJECTIVES
•
Identifying ways to improve quality of services and optimum utilisation of facilities.
•
Identification, upgradation and renovation of Primary Health Centres and their
equipment.
•
To indicate, pattern of utilisation of services and barriers to access.
•
Identify reasons for preference of private and public sector health services.
•
Concentration of efforts to reach far-flung areas, women, scheduled castes and tribes,
marginalised and below poverty line population.
To prepare the implementation manuals (Architectural and Engineering) for the new
buildings after identifying 100 PHC's which do not have buildings.
3.
OUTLINE OF THE TASK AND TIME LINES
•
Appointment of six consultants with expertise in Health, Planning, Management,
Engineering and Architecture.
— 1st month.
•
Preparation of a detailed plan of implementational study, activity. Month and costings
wise
—— 2nd month.
•
Preparation of a month-wise programme for each consultant for office work weeks
and field tour weeks.
— 2nd month.
•
Facility survey of all PHC's to short-list 1000 functional PHC's which require repair /
renovation and construction of staff quarters
— 3rd-5th month
•
Identification of 100 PHC’s which require new buildings (preference to Category ‘C’
districts and other poorly served areas)
— 3-5lh month
•
Selection of 100 PHC’s for upgradation to FRU’s.
—— 3rd-5,h month.
•
Collection of data on use of professional Health Services and peoples access to
primary health care
—— 3rd-5lh month.
•
Assessment of the effectiveness of FRU’s and functioning of their areas of referral
— 6lh month.
•
Preparation of engineering documents and manuals for buildings (1st phase).
— 7th month.
•
Preparation of procurement plan of the project for equipment, transport (limited) and
drugs.
-— 7th month.
4.
•
•
•
•
•
•
•
5.
OUTPUTS
Inception reports.
Facility survey report of 1000 PHC’s.
Selected list of 100 new buildings for PHC’s.
Selected list of 100 PHCs to be upgraded to FRU’s.
Engineering documents (including Blueprints) and manuals for buildings.
Procurement plan for equipment, drugs and transport.
Report on the studies carried out on use of professional health services and
effectiveness of FRU’s.
REVIEW COMMITTEE
HNP Pre-project review committee will consist of'
Chairman
- Commissioner of H & FW, GOK.
Member
- Director of H & FW Services
- Chief Engineer KHSDP.
- Member of KTF on Health
- Joint Director of Primary Health Care.
6.
•
•
•
•
7.
INPUTS FROM THE CLIENTS
List of all PHC’s and FRU’s, taluk-wise and District wise.
Map of each taluk showing outreach villages and boundaries of each PHC’s and Sub
Centres
List of essential drugs and equipment identified by KTF on Health.
Status of vehicles taluk wise.
STUDY PROGRESS MONITORING
There will be monthly meeting of all the consultants with the Commissioner for
monitoring the progress of the studies as per the time schedules.
8.
COSTINGS AND PAYMENT SCHEDULE
Total INR 92.9 lacs.
The agency will be paid 40% of the contract amount on signing of the agreement.
40% on submission of the draft final report and 20% when the final report is
accepted.
NOTE:No funds would be required to formulate a Comprehensive Health Nutrition and
Family Welfare policy for Karnataka as the same is already being carried out
under the Karnataka Task Force on Health.
A.
Facility survey for repair and renovation of 1000 Primary Health Centres
(PHCs) as well as staff quarters including preparation of implementation
documents and manuals.
B.
Siting and developing architectural designs for 100 new buildings for PHCs
(preference to category C districts).
C.
Selection of 100 PHCs for upgradation into First level referral units (FRUs).
Facility survey will not merely be an engineering exercise. Specific selection of
institutions for renovation with objective of increased access and quality of care.
Therefore it has to relate to institutional capacity including staffing and past record of
work done there e.g. surgeries if there is an OT, deliveries, tubectomies, and family
planning procedures, cataract surgery etc.
Siting- selection of site not just on availability of free land. It is better to purchase land in
a locality where people can reach the facility conveniently. Focus group discussions with
communities particularly Dalits and women would help in siting. Use of community
mapping exercise for selection (as in water supply &sanitation in Maharashtra with DFID
support).
Therefore this exercise will need social perspective,
public health and health
management inputs. The selected group to do this possibly in collaboration with others,
with research advisory group, and survey teams should have all these components. There
is need for constant interaction with the Commissioner, the HNP project team and the
Health Directorate.
FRUs - What happens to PHC activities, staff and accommodation for additional staff.
Assess a sample of upgraded FRUs/ CHCs- are they playing the referral role they are
supposed to, are they adequately staffed and equipped for the purpose. Do they have
mobility and communication facilities.
Estimates need to be detailed and need to reflect expected rise in prices during the five
year period. Accountability at different levels needs to be fixed.
Agencies- TOR Steel
MECON
L&T
Zila Parishad Engineering Divisions
In- patients
Average duration of stay
Nurses on duty - 24 hours or not
Number of doctors visits
Agencies:
Population Research Centre
Ramesh Kanbargi
PAC
ISEC
Institutional Analysis and Management Capacity
Will be prepared after discussions with CM Francis and Ravi Narayan
Agencies:
RN, CMF
UM
XIME
Ferguson
Information Technology Strategy Plan including validation of data emanating from
the field.
Technical aspects
Connectivity
Electrical Connections
Requirements - physical
Staff- training at different levels
Data Quality- validating
Training of field staff
Supervision
Analysis
Discussion regarding data analysis at institutional level for decision
making
Communication facilities and systems including maintenance at different levels - district,
taluk, CHC, PHC (telephone, fax, cell phones for DHOs, beepers/pagers for key hospital
personnel)
Costing of the above per unit/institute per district and at state level
Phased planning.
4
Agencies:
BPL Innovision
NICNET
Evolving Health Promotion Strategy (make use of Dr. Bassappa’s study report to
Karnataka Task Force on Health and Family Welfare)
Action research
Costing
Strategy for different groups- urban, rural, women, children in/out of school etc.
Formation of expert group/think tank
Capacity building of directorate staff (identifying and sending competent staff for
training)
Revision of school curriculum - for different age groups
Converging different health education activities of different agencies
Ongoing assessment including accountability
Agencies:
Institute of Communications- Ahmedabad (MICA?)
IUHE
VOICES
Madhyam
Jayashree Ramakrishnan
Dr. Neela Patel
Wigan & Leigh
Availability and Utilization of Emergency & Essential Obstetric care in rural areas
with recommendations / strategies to reduce maternal morbidity and mortality
Assessment of existing approaches
Developing district specific strategies
Belaku study - Dr. Saraswati Ganapathy
Developing indicators for rapid / on going district based assessment of MMR
Reasons for decline in developed countries (literature review)
Tackling women’s empowerment, health education, referral, transportation
Extent of illegal abortions
Measuring maternal mortality - impact indicators, sisterhood surveys, reproductive age
mortality study, maternal death review etc.
Agencies:
Medical Colleges
Dr. S.K. Krishnan
KARNATAKA INTEGRATED HEALTH, NUTRITION AND FAMILY
WELFARE SERVICES DEVELOPMENT PROJECT
TERMS OF REFERENCE FOR FORMULATING AN INFORMATION SYSTEM
STRATEGY PLAN.
1.
BACKGROUND:
The Government of Karnataka has received a TA grant in response to preparation
of an integrated Health, Nutrition and Family Welfare Services Development
Project (P 071160). Tire proposed PHRD fund are primarily to finance key
studies required in finalization of the project.
Amongst the six studies envisaged, information technology strategy plan needs to
be formulated. Karnataka is well known in the field of IT. An integration of
Health, Family Welfare and Nutrition Services requires careful monitoring and
synthesis of the various information systems from existing vertical programmes.
Apart from strengthening the health information system, the project will establish
a system that facilitates sharing and utilizing information, as well as validating of
data emanating from the field.
2.
•
•
•
•
•
•
OBJECTIVES:
The objective of the study is to develop a Health Management Information System
(HMIS) strategy plan.
To review the existing HMIS in the state and National level (and literature of HMIS
system in developing and developed countries) and work out modalities of
strengthening the system in the state.
To the state work out strategies to validate all data emanating from the sub-centre
level to District level and upwards to the state.
To establish a system or careful monitoring and synthesis of various information
systems from existing vertical National Health Programmes.
To establish a system of feedback or sharing and utilization of information to the
sources of information as well as all concerned agencies.
To improve management and increase staff productivity thereby enhancing health
care delivery and services.
3.
OUTLINE OF THE TASK TO BE CARRIED OUT AND TIME LINES.
•
Appointment of three consultants who are experts in the field of Information
Technology, Epidemiology / Public Health and Health Management and familiar with
the existing system in the State Health Services.
- 1 month.
Review of the HMIS at state level, National level and literature available of HMIS in
developing and developed countries.
- 1 month.
•
Preparation of a detailed plan of implementational study, activity, month and costings
wise
- 2nd month.
Preparation of a monthwise programme for each consultants for office work weeks
and field tour weeks
- 2nd month.
Develop a comprehensive information systems strategy plan, define short-term and
long-term requirements of the sector, recommend technology architecture and prepare
system implementation.
- 3rd -5th month.
Preparation plan for procurement of equipment, connectivity, Internet, based
technologies, local area networks (LAN) and computer I server, fax-machines,
modems and other hardware and software required for a comprehensive HMIS.
- 3rd -5th month.
Develop detailed information schedules / proforma for disease surveillance, National
Health Programmes and information feed back required for a comprehensive data
base & HMIS.
- 3rd -5th month.
Develop in-built monitoring and evaluation system especially with regard to
validation of data in the field and also to disseminate information to all concerned at
all levels.
-3rd-5th month
Develop a strategy to recruit and train staff to operate the HMIS effectively at all
- 5 th -7th month
levels.
Submission of draft interim report.
Submission of final report.
— 5th month.
- 8th month.
4.
OUTPUTS:
o
•
•
•
•
•
•
Inception report.
Information schedules / proforma.
Plan for procurement of equipment, hardware and software.
Plan for a comprehensive HMIS.
Plan for monitoring, evaluation and validation of data.
Strategy for training staff.
Monthly reports, interim reports, draft final report and final report.
5.
REVIEW COMMITTEE:
HNP Pre-project studies review committee will consist of
Chairman - Commissioner of Health and Family Welfare, GOK.
Members - Director of Health F&W services.
Demographer of Director of H & FW services.
One member of KTF on Health (Dr. C.M. Francis)
Joint Director Communicable Diseases, Director of H&FW.
6.
INPUTS FROM THE CLIENTS:
-
7.
Existing HMIS proformas, protocols of National Health Programmes.
Details of SC’s, PHC’s Taluk Hospital, District Hospitals and Channel of
communication.
HMIS inputs and surveillance activities from KHSDP.
STUDY PROGRESS MONITORING:
There will be a monthly meeting of all the key consultants with the Commissioner
for monitoring the progress of the studies as per the time schedules.
8.
COSTING AND PAYMENT SCHEDULE:
Total INR-33.12 lacs.
The agency will be paid 40%of the contracted amount on signing of the
agreement. 40% on submission of the draft final report and 20% when final
report is accepted.
5KK
"To
TERMS OF REFERENCE FOR THE INSTITUTIONAL ANALYSIS
AND BENEFICIARY7 ASSESSMENT
STUDY
FOR
THE
KARNATAKA INTEGRATED HEALTH, NUTRITION AND FAMILY
WELFARE SERVICES PROJECT
1.0
Background
1.1. The Government of Karnataka has received a TA grant from the PHRD fund for
preparation of an integrated Health. Nutrition and Family Welfare Services
Development Project (Po7l 160). The proposed is primarily to finance key studies
required tor the finalisation of the project.
-^-7"
* n u.a>-~~
1.2. The Government of Karnataka has builtp0' a vast primary health care and first referral
network in the State comprising 1676 Pinnary Health Centres, 582 Primary Health Units
and 359 Community Health Centres. Under the Woild Bank assisted Karnataka Health
Systems Development Project (KHSDP) there have been major improvements made to
the first referral infrastructure. Despite these improvements, the Task Force on Health
set-up by the Government of Karnataka has identified many lacunae in the functioning
of the primary health care and first referral institutions. The primary health care system
is expected to delivery a wide range of services including maternal and child health and
nutrition services, geneiai curative car?, management of communicable diseases, and
health education & promotion''/fmajor gap in the System is poor quality of delivery of
primary' health care services. The level of utilisation of the infrastructure already built up
is uneven in the State. 1 he system is also somewhat alienated from its clientele, the
y* ' beneficiaries, making it unresponsive to beneficiary needs. It is therefore, essential to
niid<?anG?bJective institutional analysis of the Primary Health care system. including the
referral structure and cany out a beiieficlary assessment. This analysis and assessment
will identify' cost effective investments with s view to increasing utilisation of (he
existing facilities, improving both access and quality of services, as well as making the
more responsive to the poor and vulnerable sections of the population, especially
women, SC/ST gioups and children. The Study will also provide a base-line, on the
basis of which future benchmarking can take place.
B
2.
Objectives of the Study
2.1 *
(Kcy
o
bjcctives:
Against the above background, the key objectives of the study will be
a) An objective institutional analysis on the utilisation and quality of the pimary health
care system;
„
A?
b) A ber+efmiaiwmes^Trassessinent of the various beneficiary groups, especially the
RnAf
c)
UWnAh
CC/'C F „nrt r-hfl/trAn
: IL.
A set of- rftcninmerided .strategies tn improve the level of utih.sation , mrpmvv the
quality of service. and=i
*»fsEfttee
the responsiveness of the primary health care
system.. '
2.2 Specific objectives: Within the broad objectives enumerated in 2.1 above, the specific
objectives will be to:
a) Identify critical institutional strengths and weaknesses in the present primary health
care system;
t>) Identify inherent institutional differences, if any,_between the Primary' health.system
as it exists in the identified backward dfstl+eas arid the remaining dfer+ets and the
reasons for such differences.
t<— e^c
>, i
c) Measure the levels of utilisation of the primary health infrastructure built up,
including the PHCs, PHUs, sub-centres as well as the first level referral system in
terms of inpatients, out patients, bed utilisation rates, usage of lab facilities, usage
of equipment, and other standard criteria; “t----- d) Assess the quality of services in terms of availability of doctors and para medical
staff such us ANMs and male health workers, the utilisation of residential quarters,
the quality of diagnosis, rational use of drugs, quality of referrals, level of upkeep
and maintenance of facilities and other standard criteria.
e) Assess the quality' ef services with respect to the delivery of National and State
Health and Family Welfare programmes, specifically, RCH services, TB control,
HIV/AIDS prevention and management, RTI-'STD management, malaria, other
communicable diseases.
f) Make an assessment of the availability' and quality of services as perceived by
different groups of beneficiaries - women, SC/ST and poor.
g) Assess the percentage of beneficiaries who access the Government facilities for
various types of ailments and the percentage who first contact other health service
providers such as private allopathic doctors, practitioners practicing Indian Systems
of medicine and homeopathy, traditional unqualified practitioners, and quacks,,
h) Indicate whether is any significant variation in beneficiary assessment as between
Assess the degree and extent of corruption in the delivery of primary health care
and in the referral system at various levels and at different levels of health
providers.
j) Assess the work load among various health functionaries, Doctors, lab technicians,
pharmacists, male health workers, clerical and ether PHC staff, and health
educators.
k) Assess the qualify of supervision and management capacities among various levels
of health providers.
1) Recommend a set of strategies^ to strengthen and improve the primary health care
system and make it more responsive. This could include Citizens charters, steps to
i)
beneficiaries, enhance community participation etc. (Plans to improve and maintain
the physical infrastructure and equipment as well as training are being separately
addressed, and therefore these aspects will need nor be specifically addressed in
this Study).
3.0
THE TASKS
The selected agency will be expected to constitute a core full time Project team
3.1
COiiipi liiug ti Siu 1 <-■£,iaL'[Jv,idI Wuik spci.ia liil dllj u Public ] Ivdllll llldJldgcl
•’
3.2
that will function until the Agency submits its Final Report. This team will be
rnnnnnniiiln fn» thn rlnnirmiiin nul imnlniin'iiiinfiiiii nil rlia nntmiiiiii nmitrunnInt rri
in the study.
The Agency will carry out the institutional analysis through visits of Study teams
to atlcast 2% , of the Primary Health centres, PHUs, CHCs and other first refer ral
units in the State. In addition the Study teams will also visit 50 sub-ccntrcs both
3.3
3.4
3.5
3.6
4.0
with, buildings and those without. The institutions will be randomly selected and
will include a sizeable number in the backward districts of the State.
The Agency will carry out its beneficiary assessment study through
questionnaires, interviews and focus group discussions. The questionairre will be
addressed to both health care providers as well as to different beneficiary' groups
including women, SC/ST and the poor. In addition the questionnaire will be
addressed to Grama Panshayat members, members of self-help croups and
members of Mahila Swasthya Sanghas. Interviews will be both structured as well
as unstructured.
The Agency will conduct 4-5 Workshopsjn various parts of the State to discuss
institutional
strengthening,
strengthening
of management
capacities,
improvements in the quality of services, and measures to make the system more
responsive. The participants could be “mixed” or different Workshops could be
held for health providers, local elected representatives and NGOs.
Tho queotionnairoc, intoruiowo, foouo group dicuussirjr.u and the Werltshsps will
be properly tabulated and documented.
The data from the Study visits, questionnaires, interviews, focus group
discussions, and the Workshops will be collectively utilised for developing a set
of strategies for improving the primary health care system.
DELIVERABLES
The Facility Survey should result in the following reports, which should be presented to s
to the Review Committee at various stages of the Study.
4.1
A Status Report containing an Institutional Analysts for each type of facility,
via. PHCa./PfrUL'CHCc/subc<ntr«<:
4.2
4.3
4.4
5.0
A Statin Rep jit eontaining ai\ Aitiiysis and paifb.mimic
Iwd and e«cl.
type of health care provider, Dorters, ANMs, male health worker, lab
toohnieinns, health educator^ pb.nimaaista. etc.
A Beneficiary Asse.MVicnl Ilepoit cvAemig .ill
nl il.c Punmij. IIc.dll.
Care system and identified gaps between expectations and performance.
A set of Recommendations containing workable, and cost effective strategies
addressing the key concerns brought out by the Reports and analysis covered
Resource support and review
5.1
5.2
The consultants will receive assistance and support from a Working Group of
knowledgeable individuals drawn from the various functional areas of the
Karnataka Health., Nutrition & Family Welfare Services units.
A Review Committee of the Karnataka Health, Nutrition & Family Welfare
Services will be responsible for lite review, supervision, and approval of the
Flans, t his committee will be chaired by tne commissioner o: Health <s Family
Welfare and consist of senior government officials.
,3
f.
The. c.r.nuilfrmt.s will hr. prr.vidr.d nr.r.>-.w,ry n’Mst.-.iw from the. Il-.nllh & Family
Welfare Department for smooth conduct of the Study.
6.0
Work Plan
A tentative schedule of the Work Plan is presented below. Once approved by the
Review C.rimmitte.e the. .schedule will itiquiie tn be anhe.ic.il tn slricliy.
18:11
FPOH:
P:<4
7.0
Review Committee:
The review committee will consist of
Chairman: Commissioner of Health &Family Welfare.
Members:
• Project Director tPP IX
• Additional Director PHC
* Project Director RCH
» Demographer
• Joint Director (Planning)
71. Selection criteria
Selection of the Agency will be through National Competitive bidding on the basis of
quality based selection, providing for negotiating with the highest ranked bidder.
hKLIi:
Nome of the
Activity
Description Of the Activity
,A.p;n iiiilinnil
lipimii.fiiiMt r,f .1 rnrr PrnjrtM
team
Dellverabliw
Time
Finnic
of core Project
team
Fb.nih.
MaiiiplinC,
design
•vi...
.. i.... .. „;n
me sampling design, structure
of questionnaires, interviews,
focus group disouccionc and
Cnr.i Innm in hu
i wuh
appointed and
approved by review
Committee.
J l.lliultu
Study dc’ji^.n mid
time-phasing
workshops.
Identify Tasks
Prepare
Sntdy
a
Listing uf nil ihc tanks that
come uudci the purview of the
study.
Prepare document that will list
the
responsibilities.
Activity list
3 woekc
MOU
3 weeks
Workshop formats
and workshop time
tabic
Approved
Study
teams
3 weeks
dvlivniublv^ juJ time frnnvci;
Duouniuiu
Finalisation of
Workshop
design
Appointment
of Study teams
Conduct
workshops
of
conduct
Survey
identified
facilities
of
of
Conduct
of
beneficiary
assessment
Finalisation of
Recommendati
ons
in short an MOI 1
This v/ill be done in close
consultation
with
the
Department
Appointment of full time
Study teams comprising of two
social
work/public
health
specialists,
including
one
woman specialist.
Workshops along with medical
officers,
NGOs,
elected
representatives and health staff
On site visits to randomly
selected insdtutiuiis
The
asscssu'iCnt
will
be
conducted
through
questionnaires,
interviews,
focus group discussions, and
Workshops
An
approved
set
of
recommendations
and
strategies.
3 weeks
Workshop Reports
8 weeks
Iil'sliiuliiimil
Analysis Reports
16 YYiTh-?
Dcnfiviury
Assessment Report
16 we tike
Final
Report
including Analysis,
Bunficiary
Assessment
and
Recommendations
18 weeks
MOP-UP POLIO IMMUNISATION OPERATION IN BIJAPUR DISTRICT DURING 2001
(OCTOBER-14, 15,16 - 2001 )
TALUKA-WISE PLAN OF ACTION
( POPULATION, ESTIMATED CHILDREN, NO. OF H-t-H TEAMS AND MAN POWER REQUIRED)
SI.
No.
Population
Taluka
Estimated Children undec
5 YearsfAs per M arch-01
Mop_up Coverage)
Estimated Hc'.’ses
(As per March-61 Mop_up
Coverage)
Total No. of Booths
Total No. H-t-H Teams
Manpower Required
(4 peraonsIBooth)
Rural
Urban
Total
Rural
Urban
Total
Rural
Urban
Total
Rura
I
Urban
Total
Rural
Urban
Total
Rural
Urban Total
No. of Sqrervisors
(1 Supervised
5 Booths)
Rural
Urban Total
1
B.Bagewadi
274632
28582
303214
38893
5470
44363
48712
5309
54021
156
22
178
312
44
356
624
88
712
31
4
35
2
Bijapur
315574
252807
568381
45642
34138
79780
89182
46064
135246
183
137
320
366
274
540
732
548
1280
37
27
64
3
Indi
325285
31483
356768
45643
5463
51106
56375
5504
61879
183
22
205
366
44
410
732
88
820
37
4
41
4
Muddebihat
199207
54953
254160
28517
8291
36808
38057
11113
49170
114
33
147
228
66
294
456
132
588
23
7
30
5
Sindagl
29B592
27748
326340
44271
3771
48042
55095
4616
59711
177
15
192
354
30
384
708
60
76B
35
3
38
1413290
395573
1808863
202966
57133
260099
287421
72606
360027
813
229
1042
1626
458
2084
3252
916
4168
163
45
208
Total
District Health & F.W. Officer,
BIJAPUR
56
RCHMOP.UPOl
REGULAR IMMUNIZATION PERFORMANCE IN BIJAPUR DISTRICT DURING 2001-02
UP TO AUGUST-2001
SI.
No.
Item
Achievement
Annual
Target
2001-02
April-01
May -01
June-01
July-01
Aug-01
Total
%age to
annual
Target
1
BCG
43737
3250
2902
3562
3858
4308
17880
40.80
2
DPT
43737
3256
3097
3340
3431
3634
16758
38.30
3
Polio
43737
3255
3183
3338
3446
3637
16859
38.50
4
Measles
43737
3168
3018
3502
3517
3478
16683
38.10
5
D&T
48223
59
279
267
1978
9118
11701
24.20
6
T.T. 10 Years
46415
257
608
565
2506
7232
11168
24.00
7
T.T. 16 Years
42352
268
583
855
1100
4256
7062
16.20
8
T.T. Mothers
45206
3435
3558
3950
4557
4098
19598
43.30
Remarks
District Health & F.W. Officer,
BIJAPUR
57 RCH MOP_UP 01
MOP-UP IMMUNISATION OPERATION 2001 IN BIJAPUR DISTRICT
TALUKA WISE AFP CASES OCCURRED FROM 1992 TO AUGUST-2001 IN BIJAPUR DISTRICT
1995
Jan to
Dec
1996
Jan to
Dec
1997
Jan to
Dec
1998
Jan to
Dec
1999
Jan to
Dec
2000
Jan to
Dec
2001
Jan to
August
1992 to
2001
Total
Cases
25
0
0
3
7
4
2
4
63
10
29
2
0
1
3 .....
0
3
5
72
33
5
5
0
0
3
0
4
1
1
52
Muddebihal
3
2
17
3
0
2
3
2
0
1
33
Sindagi
14
2
34
3
1
3
2
]
1
1
62
84
22
110
8
1
12
15
11
' 7
12
282
1992
1994
1993 Jar
Jan to
Jan to
to Dec
Dec
Dec
SL
No.
Taluka
1
B.Bagewadi
15
3
2
Bijapur
19
3
Indi
4
5
District
Total
District Health & F.W. Officer.
DI T IDI1D
19
RCHMOPJIPOI
ANNEXURE
ACTIVITIES AND EXPENDITURE (APRIL-2001TO AUTUST-2001) DISTRICT BIJAPUR
sit
PARTICULARS
1
Number and place of the CHCs in the district
2
a) Number and Place ofthe MNP PHCs identified for B.Bagewadi Taluka
contractual appointment of Doctors. (19 MNP PHCs)
1. B.Bagewadi
3
Major civil works - No. and name of NMP PHCs
identifioed for construction of O.T. and labour room
2. Muddebihal
3. Sindagi
4. Kalagi
5. Talikoti
6. Tadavalga
5. K.Salawadagi
1. Kolhar
2. Ronihal
3. Golasangi
4. Wadavadagi
Bijapur Taluka
1. Kanamadi
2. Mamadapur
3. Nagathan
4. Kannur
Indi Taluka
1. Horti
2. Tamba
3. Atharga
4. Agarkhed
Muddebihal Taluka
1. Madikeshwar
Sindagl Taluka
1. D.Hipparagi
2. Moratagi
3. Aski
4. Yankanchi
1. Kolhar
2. Ronihal
3. Golasangi
b) Vacancy position of contractual doctors with name B.Bagewadi Taluka
ofthe MNP PHCs
REMARKS
Bijapur Taluka
1. Mamadapur
Indi Taluka
1. Atharga
Muddebihal Taluka
1. Madikeshwar
Sindagl Taluka
1. D.Hipparagi
B.Bagewadi Taluka
1. Ronihal
Bijapur Taluka
1. Kannur
Indi Taluka
Muddebihal Taluka
Sindagl Taluka
1. Horti
5. Chandkawate
11 Doctors
appoinement
2. Agarkhed
2. Yankanchi
is under process
3. Chandkawate
4. Aski
2. Tamba
1. Madikeshwar
1. D.Hipparagi
District Health &F.W. Officer,
Bijapur
RCH_Temp Sheet2
a/13018:13 PM
MONTH WIS^CTMTIES AND EXPENDITURE (APRIL-2001 TcWjTUST-2001) DISTRICT BIJAPUR
SI.
No.
PARTICULARS
4 a) Number of SM Clinics and
Apr-01
May-01
Jun-01
Jul-01
Aug-01
Sept-01 up to
12-09-01
Total
-
-
-
-
-
-
-
-
-
-
-
-
Remarks
number of beneficiaries
a) Expenditure incurred
5 a) Number of Beneficiaries who
-
-
-
-
-
-
-
-
utilized Anaesthetist Services.
b) Expenditure incurred
6 a) Number of Contractu cal Doctors
-
-
-
-
-
-
-
8
8
8
8
8
8
8
Rs. 14.904
Rs. 44,731
Rs. 30,000
Rs. 42,000
25
25
25
25
Rs. 87,400
Rs. 87.400
Rs. 15.200
Rs. 74.541
5
67
working
b) Expenditure incurred
7 a) Number of Contractu cal Staff
83.000
Rs.
25
Rs.
12,000
Rs. 226,635
25
25
Nurses working
b) Expenditure incurred
5 Staff Nurses appointment
is under process
8 a) Number of women who utilized
152.000
Rs.
-
-
-
-
-
234/49
231/47
141/60
Rs.
148.808
Rs. 565,349
20
92
Referal Tansport for safe delivery
b) Expenditure incurred
9 a) Total No. of Deliveries in PHCs
Rs.
1.000
252/35
Rs. 13,400
Rs.
4,000
327/16
Rs.
18,400
1185/207
and number of night deliveries
DC bills prepared and
submitted by MOs for
counter signature to DHO
b) Expenditure incurred
10 a) No. of vehicles hired every month
-
-
-
-
-
-
■-
6
7
7
All 19 MNP
All 19 MNP
submitted to ZP for counter
PHCs
signature
-
office
3 Months vehicles hired
payment bill is prepared and
15 PHCs
b) Name of PHCs utilized vehicles
Except Bijapur PHCs
taluka 4 PHCs
—
c) Expenditure incurred
-
-
11 a) Number of AWWs utilized
60
60
Rs.
75.000
Rs.105.000
Rs. 105,000
Rs. 285,000
AWWs honorarium of June.
July & August will be paid in
b) Expenditure incurred
12 a) IEC activities through ZSS
Rs. 15.000
Sept-2001
Rs. 15,000
Not applicable
b) expenditure incurred
RCH_Temp Sheet3
District Health & F.W. Officer.
Bijapur
1'13/01
Cold Chain Planning Form for areas undertaking Booth plus House-to-House Stareagy or Exclusive House to House Stareagy.
SN1D. Name of the District - Koppal. Round / October - 2001
Vaccine
canies
Name of the area
Taluk
Ice peaks
For Vaccine
carries
Additional
cold chain
equipment
Cold boxes
Ice peaks
for cold
box
ILRS
Function
Deep
ing
freezens
Function
ing
Vaccine
distribution
center
Req.
A.
Able
Req.
A.
Able
Req.
A.
Able
Req.
A.
Able
Req.
A.
Able
14
—
281
—
896
—
—
—
13
__
_ _
15
13
13
—
244
—
1129
—
—
—
25
_
__
13
12
09
—
247
—
1153
—
—
_
17
_
__
10
10
13
—
215
—
899
—
_
—
18
__
__
12
11
49
—
987
—
4077
—
—
—
73
—
—
50
46
KOPPAL
GANGAVATI
KUSTAGI
V ELBURGA
TOTAL
Daily
ICE
Required
(KG)
Number
days
ICE is
required
Total
ICE
required
(KG)
for each
rounds
—
—
—
—
—
—
—
—
—
—
—
—
—
—
—
V Dist. HealtJi^F.W.Officer.
v
Koppal
Comments
(Availability
of power
supply
stabilizers
thennometry
ect).
:: 2
9
10
11
Total No of mobile team
members
118
Urban
Rural
20
98
24
Urban
Rural
04
20
238178
40486
197692
11910
2026
9884
Total No of Supervisors for
transit & mobile teams
Total OPV Doses required
Urban
Rural
12
Total OPV Vial Required
Urban
Rural
13
Total No of General Hospital
04
14
Total No ofPHC’s
38
Urban
01
Rural
37
15
Total No of PHU’s
01
16
05
17
Total No of Community
Health Centers
Total No of Sub - Centers
172
18
Total No of Jr H.A. (Female)
134
19
Total No of Jr H.A. (Male)
72
20
Anganawadi
883
21
Total No of Community
Health Guides
517
F.W.OITicer,
Koppal,
®ID PROGRAMME GENERAL INFORMATION
KOPPAL DISTRICT.
SI.NO
1
2
3
4
5
6
7
Particulars
Total Estimated Population
Numbers.
1209734
Urban
Rural
209934
999800
179078
Urban
Rural
30438
148640
2419^6
Urban
Rural
41987
199959
Urban
Rural
1934
335
1599
1288
Total Estimated 0-5 Years
Children
Total Estimated Houses
Total No of House-to-House
team
Total No of House-to-House
team members available
Urban
Rural
224
1064
644
Urban
Rural
112
532
129
23
106
10
Total No of House-to House
teams available
Total No of Supervisors
Urban
Rural
8
Total No of Transit team
members
Urban
Rural
10
—
form I A
p BOGRAMI®
FORM 2,
INTENSIFIED PUL® POLIO IMMUNIZATION P HO GRAMM?
CO IE CHAIN PLANNING FORM
For areas undertaking Booth Plus House-to -house Staategy or exclusive House-to-house Statergy
Round (Ci role): October 2001.
Nam of Di st/Block/Urban Ansa: Gulbarga.
Si.
NO.
Name of the
AWfi.
Vaccine
Dlstri
but! on
Centres.
Vaccine Carriers Ice-packs for Additional
Cold Boxes
ILRs Dapp Daily No.ofTotal
ICE Packs
Reoul- Aval LnVaccine
Cold chain
Func Freze Ice Days Ice
RequiAvai<
for Cold
“vallaCarriers.
equipment
tions rs
requ-Jce requ
Boxes.
He qui-^Avalla
He qui-'
Avai*
r8d*lable.
-------uX©
““.. ..............
." 1"1 KSOTS
ired
‘ ing. func-iied is
JteguAvai
ble •
red.
lable.
requ Kg,
tuni KG,
led.
lable
ired.
ng.
1
2
3
4
5
6
7
1.
Afzalpur
8
98
82
392
348
2.
Aland
12
199
129
796
3.
Chineholi
10
174
142
4. Chitapur
11
223
5.
8
5
106
10
6. Jevargi
8
7. Sedan
8
9
1®
11
12
13
-
10
3
5
75
125
646
-
65
7
6
175
150
OB
696
610
OB
36
5
6
125
150
ob
203
892
812
<9
40
2
8
500
200
ob
*
144
424
576
O»
ob
5
6
155
150
«o
330
40
1714
OB
197
10
17
250
425
■a
156
108
624
492
ea
30
4
6
100
150
OB
7
150
90
600
480
<=>
60
2
6
50
150
-
«•
OB
Shahapur
11
249
189
996
846
cs
45
6
6
150
150
OB
OB
9. Shorapur
10. Yadgir
10
222
126
888
—
143
892
5
8
8
125
200
200
200
OB
223
45
50
8
14
594
672
OB
Dist.Total
104
1810
1686
7240
7790
578
57
82
1425
2050
Gulbarga(R)
Gulbarga(U)
8.
OB
OB
15
14
16
17
18
OB
«B
-
OB
OB
M
OB
OB
M
SB
ob
*
BB>
<BB:
OB
OB
SB
*
OB
«B
OB
OB
OB
OB
OB
OB
OB
SB
SB
•
OB
OB
OB
OB
*
SB
'SB
SB
«
•»
SB
-
«■
*
OB
•
••
OB
1
DIST. HLALTH& F.W.OFFIQSR
.
GULBARGA.
-
•
OB
?
OB
-.
o»
SB
INHERITED PUL® POLIO IMMUNIZATION PiOraMJE
FORM I
A
FANPOWER AND VACCINE PLANNING FORM
For Areas Undertaking Booth plus House-to-House Stategy.
Name of the District/Block/Urban ireaj Gulbarga Round (CLrcle)s October 2001.
SI. Name of the
No. Aiea
Population 2001
^provisional)
®rfcah
<®ial
io tai
Estimated Vaccina
Children
tion
below fiyrs.Booths
@ 14% of
Populn.
Booth
Supervi
sors f or
Team
Members Booth/
Requi
Teams
required.
red.
Transit Mobile Super
Total
Team
OPV,
Team
visors
members members for
Doses
required;. Re qui- transit Requi
ed.
& mobile red.
Total
OPV Via:
Bequire<
Required
A
1. Afzalpur
B
160702
C
19114
D
179816
25175
E
F
90
360
G
18
I
H
4
J
1
2. Aland
259530
35308
294838
41275
164
656
33
8
«■
3. Chincholi
206319
17158
223477
31285
158
632
32
4
•
K
L
33483
1675
1
54896
2745
1
41610
2080
12
1
68250
3412
■a
1
46018
2301
12
12
1
80086
4004
4. Chitapur
238766
127758
366524
51315
213
852
42
12
5.Gulbarga( R)
- ^7 Hi
24«161
34600
125
500
25
4
Gulbarga(U)
430108
247161M 3o/oS
430108
60215
170
680
34
6. Jewargi
215651
19174
234825
32875
132
528
26
8
OB
1
43724
2186
7. Sedan
155974
40113
196087
27450
120
480
34
8
a*
1
36509
1826
1
52888
2645
8. Shahapur
249683
34347
284030
39765
219
876
44
10
«■>
9. Sborapur
293098
43591
336689
47135
174
696
35
12
12
1 ■
62690
3135
10. Yadgir
250051
75729
325780
45610
183
732
37
12
am
1
60662
3033
Di st. Total
2276935
842400
3119335
436700
174£
69 92
350
94
36
11
580816
29041
MACRO PLAN OF ACTION OF PPI (SNID + NID) OF RAICHUR DISTRICT 2001 - 2002
Name of the
Taluka
Raichur
Devodurga
Manvi
Lingasugur
Sindhnoor
Total
Estimated
Eligible
children
Below
5 years
No of
Booths
72061
Vaccinators
Supervisors
Vaccine Carriers
Vehicles
Avai
lable
Req
Hired
Total
Avail
Able
Requ
ired
Total
Avail
able
Requ
ired
Total
Avail
able
Requ
ired
Total
289
64
1092
1156
36
22
58
364
214
578
15
56
71
32842
130
38
482
520
18
8
26
123
137
260
03
40
43
50657
203
54
758
812
25
16
41
134
272
406
01
65
66
48144
191
62
702
764
25
15
40
167
215
382
05
61
66
56226
220
57
823
880
20
25
45
154
286
440
04
60
64
259930
1033
275
3857
4132
124
86
210
942
1124
2066
28
282
310
01) Estimated eligible children have been taken as per the performance report of NID January 2001.
02) No of Booths calculated at the rate of one booth per 250 childrens.
03) Vaccinators 4/booth - they shall break into two batches for H-t-H
04) 9800/- Ice packs are available. No. V.C. 4 I P - 624, V.C. 2 I. P. 138. Required V.C. 4 IP / 2 IP 1124.
05) As many of the Govt. Sister departmental vehicles will be reported as sick or some are the other repairs. Hence it may be permitted to
utilize hired vehicles.
06) IEC materials to be supplied at the earliest - minimum 15 days prior to the SIND I NID.
07) All reporting formats, tally sheets, and supervisors check list etc., be supplied well in advance. So that during the training of personnel
they can be explained.
08) Gention Violet I Marker pens be supplied when in advance. So that they shall reach the teams in time.
09) H-t-H teams are 2066. Hence the number of vaccine carriers is calculated as one per H-t-H Team.
COLD CHAIN WORKING STATUS IN RAICHUR DISTRICT
SI.
No.
Equipment
MONTH AUGUST 2001
Total Nos.
Supplied
Total Nos
Installed
Total Nos
Working
No of
Repairable
Units
—
—
—
—
-
-
—
—
Beyond repairs due to internal gas leak
Total Nos Replaceme
Replacement
nt Received
till date
required
Action Taken
WITH C.F.C.
01
Electrollux TCW 1151
VEST FROST
02
SB 300 / 303 / 304
4
4
3
1
—
—
—
—
03
MK 300 / 302 / 304
2
2
2
—
—
-
—
—
04
SB 140/ 142/ 144
44
44
33
—
11
—
11
-
05
MK 140/142/144
63
63
59
--
4
8
4
—
—
-
-
—
—
-
INDIAN MAKE
06
FREEZS 130 LIT
1
1
1
—
07
FREEZA 225/300LIT
6
6
5
1
TOTALS:
120
120
103
2
15
8
15
—
6
6
5
1
—
-
-
-
13
13
12
1
-
—
—
—
—
-
—
—
—
—
—
—
—
—
—
-
—
NON C.F.C.
01
ELECTROLUX TCW 1990
VEST FORST
02
ILR (SMALL)
03
ILR (LARGE)
3
3
3
04
D.Fr. (SMALL)
29
29
29
05
D.Fr. (LARGE)
02
02
02
—
—
TOTALS:
53
53
51
2
-
STATUS OF WIC /
WIF WITH C.F.C. MACHINES
—
-
INTENSIFIED PULSE POLIO IMMUNIZATION PROGRAMME
Form 2
COLD CHAIN PLANNING FORM
For areas undertaking booth plus House-to-House Strategy or exclusive House-to-House Strategy
Round (circle): October 2001 / December 2001 / January2002
Q—
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ro
3
0
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Required
Available
Required
Available
ILRs functioning
Deep Freezers
functioning
Daily Ice Required (Kg)
Number of Days Ice is
required
20
70
620
60
65
63
2500
3
Required
Available
Required
Available
Ice packs for Additional
Ice packs
Vaccine
cold chain
for cold
carriers
equipment cold Boxes
boxes
Total Ice Required (kg)
for each round
Available
400 950 12600 3550 30ILR 128
30DF
Vaccine
Carriers
Required
Name of the Area
Bellary Dist
Vaccine Distribution
Centers
:
Name of the District / Block / Urban Area:
Comments
(Availability of
power supply,
stabilizers, thermom
eters.etc)
Stabilizers 40
2500
Thermometers 50
required
MICRO PLAN FOR MOP-UP IMMUNISATION
District: Bellary
SI.No.
1
Name of the Taluk
Bellary
Urban
300000
Population
Rural
340000
Total
640000
Eligible Children
95000
2
Siruguppa
61000
170000
231000
32000
3
Sandur
200000
200000
27000
4
Hospet
152000
382000
53000
5
Hagari Bommanahalli
165000
165000
6
Hadagalli
179500
7
Kudligi
30000
197745
Total
| 621000
1404245
230000
No of House Teams
Urban
Rural
Total
157
201
358
112
144
100
100
101
221
20000
80
80
179500
35500
98
98
227745
41500
14
130
144
304000
323
822
1145
| 2025245
32
120
District Health &
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Bellary
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Cold Chain Planning Form
for areas undertaking Booth plus House-to-House Strategy or exclusive House-to-House Strategy
Name of District I Block / Urban Area: 136) AUYO7~
Total
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R eq u ired
——
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336 I5~ 'A
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Total Ice req u ired (kg)
for each ro u n d
u
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for cold
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N um ber of D ays Ice is
R eq u ired
73 ' /3^'
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Daily Ice R eq u ired (kg)
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£>4
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o3
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for vaccine
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R eq u ired
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Name of the Area
VIA-./
R eq u ired
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S
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3
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Comments
(Availability of power
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thermometers, etc)
FORM No.: 4.8/1
MUSTER ROLL FOR PARTICIPANTS (MRF)
Details of Training / Workshop / Meeting : SNID Strategy Planning Meet
Purpose
; Microplanning for SNID’s
Location
; Directorate of Health F/W Services, Bangalore
Date
: 15/09/2001
Participant Signature in
Confi ation of Attendance
Designation
Name of Participant
(L&0,
&L ff- ■ o^l J
Field Unit Office : Bangalore
Approved Budget Proposal for
for TWM Ref. : Yes
Zp.
o$‘
6 fc'- J •
&
t )
5. p/VL-AOfy
hie.
fecH- Ca
Signature; DR. RADHA.R.:
Surveillance Medical Officer
(i /find
Signature : DR. PAVANA MURTHY
Regional Coordinator - South
,
FORM No.: 4.8/
MUSTER ROLL FQR PARTICIPANTS TOIB
Field Unit Office : Bangalore
Approved Budget Proposal for
for TWM Ref.: Yes
Details of Training / Workshop / Meeting : SNED Strategy Planning Meet
Purpose
: Microplanning for SNID’s
Location
: Directorate of Health F/W Services, Bangalore
Date
: 15/09/2001
SI.
No.
Name of Participant
IS
- c. S.
/G
Participant Signature in
Confirmation of Attendance
Designation
.
O) -WO
.................................
(JJY'—
Cj
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Signature; DR. RADHA.R.:
Surveillance Medical Officer
Signature : DR. PAVANA MURTHY
Regional Coordinator-South
~~T
GOVERNMENT OF KARNATAKA
D1WCTORATE OF HEALTH & FAMILY WELFARE SERV1CES~ANGALORE-560009
MONTHLY EPIDEMIOLOGICAL SITUATION REPORT FOR THE MONTH OF JUNE 2001
NATIONAL ANTI FAALARIA PROGRAMME (Revised Proforma)
PROGRESSIVE TOTAL Upto June
DURING THE MONTH
SI. No
i
DISTRICT
1
Bangalore (U)
2
Sangalore (R)
3
Kolar
4
Tumkur
5
Ch’rtradurga
I
I
6
I
>
I
i
!
I
I
Davanagere
Shimoga
8
Bclgaum
9
Bijapura
10
Bagalkot
11
Dharwad
12
Gadag
13
Haven
14
U.Kannada
Pf Cases
YEAR
Mr 4 june 01 (RP)
No. of Malaria cases
P.F.CAScS
Confirmed Deaths
Malaria Cases
BJs Collected
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2001
2000
2901
Confirmed Deaths
15654
18393
2274S
27812
3S105
3527S
91918
78991
43539
54534
21541
29849
18682
27722
48543
50500
25569
26426
25399
26816
16729
22820
14324
16236
25508
27679
17041
19160
8/s Collected
3/s Examined
15654
16308
22746
27812
38105
31382
91918
72025
43539
54584
21541
26590
18682
27458
48543
50500
25569
26426
25399
26816
16729
22820
14324
16236
25508
27679
17041
19160
F emalo
Total
17
24
42
52
279
319
1496
1826
93
3766
5
30
10
120
29
44
199
218
319
190
4
20
17
21
7
5
1
7
42
69
83
113
761
656
3360
4033
3152
8143
16
100
38
272
373
113
465
440
620
393
18
42
42
54
18
21
616
Female
T eta!
5
10
1
11
48
103
.155
463
10
1116
13
22
4
8
131
148
348
939
337
2412
2
11
2
26
5
5
22
9
17
27
2
2
0
3
0
0
0
0
3
37
9
49
68
15
53
27
34
86
1
5
2
1
0
1
3
1
Femals
0
1
27s Examined
Total
0
1
Female
89081 ■
93886
135359
130955
198943
192635
298341
357295
191042
261019
100137
136750
105886
125770
296444
275803
136811
128399
132926
148719
98731
116959
87550
90007
149974
157113
98492
102084
89081
91801
135359
130955
198943
188741
298341
350329
191042
261019
100137
133491
105886
125506
296444
275803
136811
128399
132926
148719
98731
116959
87550
90007
149974
157113
98492
102084
T otal
42
146
180
63
85
201
116
294
1993
738
1276
2449
7313
2652
5648 13800
1874
6917
13166 33145
45
16
119
366
144
43
634
273
1336
442
553
243
1114
2578
1564
760
715
2118
754
1612
32
75
59
147
39
154
186
67
76
19
132
12
20
82
25
97
Female
Total
F emaJ
*
15
26
17
19
154
341
351
1315
301
3403
4
36
16
57
131
41
142
73
80
141
6
8
4
6
0
0
2
1
55
68
49
32
417
594
1021
3116
952
8495
7
113
54
123
362
95
276
159
254
332
9
21
23
11
1
7
12
5
1
0
0
0
0
0
0
1
0
0
0
0
0
1
1
0
1
0
0
0
0
0
0
0
0
0
0
0
Total
1
0
0
0 “I
0
0
1
1
0
1
0
0
1
1
1
0
1
0
0
0
0
0
0
0
0
0
0
0
|
[999
1
35
1
704 |
224|
25181
95691
10/91
560!
125
J~ V N £~
2921
459|
2141
1
702j
687
5543!
I
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23S57 I
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11854 |
1
2752
979 I
____ 42
40
69
1
1
N u m b e r of C um ula-tive
cases
num ber
of cases
tre a te d
d u rin g
treated
the m o n th
upto date
MALARIACLINICS
23
____
Fever Treatment Depots
1
62
655
143l
1
1921
28
26
25
62
29
586
426 I ___ 29
291
!
1231
161
1
N um ber o f C um ula-tive
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num ber
tre a te d
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d u rin g
tre a te d
the m o n th
u p to date
____
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[K__
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|97
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13981
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15104
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09
C um ula
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Drug Distribution Centres
N um ber of
cases
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the m o n th
1
1511
467
1
27703|
38511
1
1556|
594
6205
2181
2521
861|
1
1
305!
1
238
282
355
461
1-27
1
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DISTRICT
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ET
GOVERNMENT OF KARNATAKA
NO:CMD/DSU/109/2001-02
TO,
OFFICE OF THE MEDICAL OFFCIER
DIST. SURVEILLANCE UNIT
KOLAR DIST. DATED: 18-8-2001
THE DEPUTY DIRECTOR
AND OFFICER I/C N.I.C.D,
PLAGUE SURVEILLANCE UNIT,
BALLARY ROAD,
BANGALORE.
Sub:- Out break report of suspected Dengue fever In
Two villages of Kolar taluk
jfcrjr «tn}t
I
While drawing your attention towards the Dengue out breaks in Kolar taluk. 1 would like to inform
you that the surveillance team of Kolar has investigated in the following two villages immediately after
getting an early warning signal of fever Myalgia etc... the details are as follows
Village
PHC
Population
Houses
No. of fever cases
No. of screened B/S for MP
Results
No. of samples sent for Serology
Thotly
Sugatur
1402
249
83
83
Negative
10
Results
Total no. of Thottyes in the village
Total no. of Thottyes found larva
No. of deaths
Awaited
83
56
Nil
Settyhalli
Vemagal
734
151
18
18
Negative
The date of onset of fever is only 2 days
back hence no samples collected but Ades
Aegypti larive are found in 4 houses
—
63
04
Nil
Action takes;
In both villages all containment measures including IEC are taken up meticulously and fever is under
control. The concerned Gramapanchayaths are gearedup to taken action on their part by maintained}^
sanitation and clean of water storages etc.. Fogging is at present not possible because both villages are
rearing silk worms.
Note: Please fax this to N.I.C.D. Delhi, the weekly reports
Will follow in the concemned formates
Yours faithfully,
MEDJCAL OFFICER,
DIST. SURVEILLANCE UNIT
KOLAR DISTRICT
Weekly Report of NSFCD
1.
Week Starting
JJL - g - jLocJ.
2.
Week Ending
_LS - s . JLooJ.
3.
OutBreak
u U>o
oii^petL.cL
KoUrr -EAAt-
(A)
(B)
No: ©
Nature:
??
*
g°
S-3>
Ss dSBecl
VuLQ^ve, _lo stood
<3..l2v^
u4p- ’tAuite.
4.
5.
idhuU W
Co
News Paper Cutting—y
' *’.Se~- -J*c>4,eve..- 8 g.lX«a ig £>boi S<
*vt.<vrf>
°
-f-or.- ■
- r o.u-jI J ptiwA rvc ^tAtve.
—-------- Mil-----------u
0
J
Report of Epidemiological Investigations.
-to .N.X.CD
iw k <^pLcU.
lf\L~ Aqsyvcl. oJovvci JcnlFC I.K»kSe.aux£t to N«T. O..33. Ta .,Lk:
m/dIcal. officer
District Surveillancs Um
Kolar District
KOLAR-S631&1
No. of fever cases
No. of screened B/S for MP
Results
No. of samples sent for Serology
83
83
Negative
10
Results
Total no. of Thottyes in the village
Total no. of Thottyes found larva
No. of deaths
Awaited
83
56
Nil
18
18
Negative
The date of onset of fever is only 2 days
back hence no samples collected but Ades
Aegypti larive are found in 4 houses
—
63
04
Nil
Action taken:
In both villages all containment measures including IEC are taken up meticulously and fever is under
control The concerned Gramapanchayaths are gearedup to taken action on their part by maintained?^
sanitation and clean of water storages etc.. Fogging is at present not possible because both villages are
rearing silk worms.
Note: Please fax this toN.I.C.D. Delhi, the weekly reports
Will follow in the concernned formates
Yours faithfpLJy,
MEDICAL OFFICER,
DIST. SURVEILLANCE UNIT
KOLA R DISTRICT
<
nicdpsu
From:
To:
Sent:
Attach:
S u bject:
Director, NICD <dirnicd@bol.net.in>
NICD.RJY <patnaiks@hd2.dot.net.in>; NICD, Varanasi <mrai89@satyam.net.in>; NICD,
Coonoor <ajpurty@tr.dot.net.in>; NICD, Bangalore <nicdpsu@kar.nic.in>; NICD, Alwar
<nicdalwr@jp1.dot.net.in>; NDSP-Orrisa state lab <prof_hodmicrobiology@123india.com >;
NDSP-Kottayam-Nodal Off. <ndspktym@md5.vsnl.net.in>; NDSP-Hyd nodal officer
<dhsh@pol.net.in>; NDSP-E. Godavari -DMHO <dmho_egdt@pol.net.in>; NDSP, Satara CDHO <epcell@vsnl.net>; NDSP, Jamnagar - CDHO <surendranagar@yahoo.com>; NDSP,
Goa - State Epid. <ssygoa@goatelecom.com>; NDSP - Secretary Health
<Secyhlth@mohfw.delhi.nic.in>; NDSP - JS(BT) <jsbt@nb.nic.in>; NDSP - Dr. Vijay Kumar
<vijayk@whosea.org>; NDSP - Dr. Kim Farley, WR <wrindia@whoindia.org>; NDSP - Dr. Ira
Ray, AddlDG <iraray@nb.nic.in>; NDSP - AS(PR) <nacodel@vsnl.com>; NDSP - AS(H) - P
<asp@nb.
Wednesday, August 22, 2001 6:00 PM
ATT00113.txt
Todays News - Outbreak Watch-21 -8-2001
L' —
Nationai institute of communicable Diseases
22-Shamnath Marg, Delhi -110 054
National Surveillance programme for communicable Diseases (NSPCD)
Outbreak News -Weekending 21 August 2001
in the pilot districts under NSPCD
During the week under report, the following districts reported outbreaks of communicable
diseases. The details are as follows:
1)
Bijapur district (Karnataka) An outbreak of Acute Gastroenteritis was noted in
village Hanchinal, Bijapur Taluk, by the district surveillance team. The rapid
response team is carrying out the investigation
The detail information about the cases in respect of their age, gender and other risk
factor may be provided. The results of the outbreak investigation along with the
laboratory results and present status of the outbreak may also be provided.
2)
Dhuie district (Maharashtra): An outbreak of gastroenteritis noted in village,
Chilane, Taluka Shindkheda on 15th August. A total of thirteen cases were detected
in a village with a population of 13,934. The investigation revealed the cause of
outbreak as contaminated hand pump water.
The information in respect of age, sex and other related variables for the notified
cases may be provided. The laboratory results of the investigation may also be
provided
8/24/01
L»>o>'i3i©IHiftrait:por‘ pfetrict (Himachal Pradesh): An outbreak of acute diarrhoea reported in
' Punjab Kesri newspaper. The outbreak affected the village, Chatrail under PHC
Bhareri on 10.8.2001. The rapid response team of the district investigated the
episode. A total of 15 cases were detected by house-to-house search. It affected
person of all age groups. Further investigation revealed the cause of outbreak as
contaminated well water.
The detail information about the cases in respect of their age, gender and other risk
factor may be provided. The results of the outbreak investigation along • with the
laboratory results and present status of the outbreak may also be provided.
8/24/01
DISEASE SURVEILLANCE
Meeting with Dr Shyamal Biswas Dy Director XICD Bangalore & Sohanlal on 27 Aug 01.
NSPCD (National Surveillance Programme for Communicable Diseases) started about 5
years ago in 45 pilot Districts in the country. Has been effective in Karnataka since past two
years in 3 Districts - Bellary, Bijapur & Kolar. Surveillance is carried out for
21 communicable diseases.
Weekly report (covering period Monday to Sunday) is sent by Fax on Mondays. Supposed
to be sent by all MO PHC’s to DHO. (25% compliance only). DSO compiles and sends to
XICD & DHS. Xil report also sen (.(photocopy of Kolar enclosed). Very simple format
designed by XSPCD and also includes newspaper reports. PHC conducts immediate
investigation and forwards report along with lab samples for confinnation of diagnosis and
initiates control measures.
Weekly Outbreak Watch Report is then prepared and circulated to all pilot districts (by
e-mail post, photocopy attached).
All districts also send a monthly compiled report (copy attached). Private Hospitals.''
practitioners not presently involved in the surveillance.
Training : Training in Surveillance conducted by XICD in all three districts to all PHC
MO’s for five days who in turn trained their staff (Budget given by XSPCD). Additional
budget given for telephone. Fax. Reagents, training not yet utilised by the State.
Discussed other aspects of Surveillance:
Basically XICD is conducting lab diagnosis of Plague and Leptospirosis (reagent for
leptospirosis not available since June from NICD Delhi. Dr Nagraj of ROHFW confirms by
Matt test). Presently outbreak reported from Shimoga district with two deaths.
Is of the view that district labs should be able to conduct most tests (except for plague &
viral). NIX’ Bangalore and some private hospitals like Manipal Hospital also arc diagnosing
dengue infections.
Stated that he and Dr Murgendrappa had prepared the detailed surveillance plan for KHSDP
including duties of each category of staff.
Agrees that action is usually taken after a death and/or the outbreak is reported in the media
which emphasizes surveillance failure.
Endorsed that many MO’s have been trained in what lab samples are required,
methodology, preservation, transportation precautions and which referral lab to be sent
clarified.
Confirmed that the three months course in Epidemiology conducted at NICD is
continuing and presently one MO PHC is currently attending the course.
Comments:
Reporting formats should be as simplistic as possible.
Monitoring of reporting units (RU's) by frequent visits by DSO vital and he should cover
each RU once in three months. Action against non-reporting must be taken or the
surveillance system collapses ( pattern followed by NPSP should be followed).
DSO should not be chair bound but always mobile.
Surveillance failure ( report in the press, etc.) should be identified and measures to improve
surveillance constantly updated.
hi case of occurrence of case/ cases MO should not wait for weekly report but report
immediately, followed by daily report till epidemic tapers off.
Spot Map and Line List imperative and all MO's trained in preparation of the same.
Importance of proper collection of samples, preservation, transportation to referral labs, is
vital for confinnation of diagnosis.
Training of Junior Health Assistants (Male & Female) is the only way to improve quick
reporting.
Suitable payment for collection, transportation of samples should be in-built in the system.
(if /£
uaie: inu. zo Aug zuui id:10:1^
Frnm* ?{T>.-‘^-pnacs»n Plr NT ,: <RFV A D A ‘s A NT\J^?i\vhnip(-hpi.nro>
the ci
as
i rcir.K cnac usarnataKa nas a wxs nealth system development project
Sc that is the current state or surveillance. It there are anv rurther
emeries - kindlv do feel free to ask:. And if vou feel the need for me to
1 of]
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IN Skvs
DRAFT NATIONAL HEALTH POLICY - 2001
■NTRODlCTORY
A National Health Policy was last formulated in 1983 and since then, there have been
. ery marked changes in the determinant factors relating to the health sector. Some of the
policy initiatives outlined in the NHP-1983 have yielded results, while in several other
L.eas. the outcome has not been as expected.
1.2 The NHP-1983 gave a general exposition of the recommended policies required in
he circumstances then prevailing in the health sector. The noteworthy initiatives under
that policy were
i. A phased, time-bound programme for setting up a well-dispersed network of
comprehensive primary health care sendees, linked with extension and health
education, designed in the context of the ground reality that elementary health
problems can be resolved by the people themselves;
ii. Intermediation through ‘Health volunteers’ having appropriate knowledge, simple
skills and requisite technologies;
iii. Establishment of a well-worked out referral system to ensure that patient load at the
higher levels of the hierarchy is not needlessly burdened by those who can be
treated at the decentralized level;
iv. An integrated net-work of evenly spread speciality and super-speciality services;
encouragement of such facilities through private investments for patients who can
pay, so that the draw on the Government’s facilities is limited to those entitled to
free use.
A
.3 Government initiatives in the pubic health sector have recorded some noteworthy
successes over time. Smallpox and Guinea Worm Disease have been eradicated from the
country; Polio is on the verge of being eradicated; Leprosy, Kala Azar, and Filariasis can
be expected to be eliminated in the foreseeable future. There has been a substantial drop
in the Total Fertility Rate and Infant Mortality Rate. The success of the initiatives taken
in the public health field are reflected in the progressive improvement of many
demographic / epidemiological / infrastructural indicators over time - (Box-I).
" Box-1 : Through The 'S ears - 1951-2000Achievements
Indicator
1951
1981
2000
Life Expectancy
36.7
54
64.6(RGI)
Crude Birth Rate
40.8
33.9(SRS)
26.1(99 SRS)
Crude Death Rate
25
12.5(SRS)
8.7(99 SRS)
146
110
70 (99 SRS)
Demographic Changes
' IMR
I
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Epidemiological Shifts
I
Malaria (cases in million)
i 75
Leprosy cases per 10.000
population
3S.1
■ 2.7
1
i 57.3
Small Pox (no of cases)
>44,887
Eradicated
i 2.2
3.74
Guineaworm ( no. of cases)
>39.792
Eradicated
Polio
29709
265
57,363
1,63,181
Infrastructure
SC/PHC/CHC
725
(99-RHS)
Dispensaries &Hospitals( all)
9209
23,555
43,322
(95-96-CBHI)
Beds (Pvt & Public)
117,198
569.495
8,70,161
(95-96-CBHI)
Doctors(Allopathy)
61,800
2,68.700
'
5,03,900
(98-99-.MCI)
Nursing Personnel
18,054
1,43.887
7,37,000
(99-INC)
1.4 While noting that the public health initiatives over the years have contributed
significantly to the improvement of these health indicators, it is to be acknowledged that
public health indicators / disease-burden statistics are the outcome of several
complementary' initiatives under the wider umbrella of the developmental sector,
covering Rural Development, Agriculture, Food Production, Sanitation, Drinking Water
Supply, Education, etc. Despite the impressive public health gains as revealed in the
statistics in Box-I, there is no gainsaying the fact that the morbidity and mortality levels
in the country are still unacceptably high. These unsatisfactory health indices are, in turn,
an indication of the limited success of the public health system to meet the preventive
and curative requirements of the general population.
1.5 Out of the communicable diseases, which have persisted over history, incidence of
Malaria has staged a resurgence in the 1980s before stabilising at a fairly high prevalence
level during the 1990s. Over the years, an increasing level of insecticide-resistance has
developed in the malarial vectors in many parts of the country, while the incidence of the
more deadly P-Falciparum Malaria has risen to about 50 percent in the country as a
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whole. In respect of TB, the public health scenario has not shown any significant decline
in the pool of infection amongst the community', and, there has been a distressing trend
in increase of drug resistance in the type of infection prevailing in the country. A new
and extremely' virulent communicable disease - HIV/AIDS - has emerged on the health
scene since the declaration of the NHP-1983. As there is no existing therapeutic cure or
vaccine for this infection, the disease constitutes a serious threat, not merely to public
health but to economic development in the country. The common water-borne infections
- Gastroenteritis, Cholera, and some forms of Hepatitis - continue to contribute to a high
level of morbidity' in the population, even though the mortality rate may have been
somewhat moderated. The period after the announcement of NHP-83 has also seen an
increase in mortality through ‘life-style’ diseases- diabetes, cancer and cardiovascular
diseases. The increase in life expectancy has increased the requirement for geriatric care.
Similarly, the increasing burden of trauma cases is also a significant public health
problem. The changed circumstances relating to the health sector of the country since
1983 have generated a situation in which it is now necessary to review the field, and to
formulate a new policy framework as the National Health Policy-2001.
1.6 NHP-2001 will attempt to set out a new policy framework for the accelerated
achievement of Public health goals in the socio-economic circumstances currently
prevailing in the country.
2.
CURRENT SCENARIO
2.1
FINANCIAL RESOURCES
The public health investment in the country over the years has been comparatively low,
and as a percentage of GDP has declined from 1.3 percent in 1990 to 0.9 percent in 1999.
The aggregate expenditure in the Health sector is 5.2 percent of the GDP. Out of this,
about 20 percent of the aggregate expenditure is public health spending, the balance
being out-of-pocket expenditure. The central budgetary allocation for health over this
period, as a percentage of the total Central Budget, has been stagnant at 1.3 percent,
while that in the States has declined from 7.0 percent to 5.5 percent. The current annual
per capita public health expenditure in the country is no more than Rs. 160. Given these
statistics, it is no surprise that the reach and quality of public health services has been
below the desirable standard. Under the constitutional structure, public health is the
responsibility of the States. In this framework, it has been the expectation that the
principal contribution for the funding of public health services will be from States’
resources, with some supplementary input from Central resources. In this backdrop, the
contribution of Central resources to the overall public health funding has been limited to
about 15 percent. The fiscal resources of the State Governments are known to be very
inelastic. This itself is reflected in the declining percentage of State resources allocated
to the health sector out of the State Budget. If the decentralized pubic health services in
the country are to improve significantly, there is a need for injection of substantial
resources into the health sector from the Central Government Budget. This approach,
despite the formal Constitutional provision in regard to public health, is a necessity if the
State public health services - a major component of the initiatives in the social sector are not to become entirely moribund. The NHP-2001 has been formulated taking into
consideration these ground realities in regard to the availability of resources.
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EQUITY
2.2
2.2.1 In the period when centralized planning was accepted as a key instrument of
development in the country, the attainment of an equitable regional distribution was
considered one of its major objectives. Despite this conscious focus in the development
process, the statistics given in Box-Il clearly indicate that attainment of health indices
have been very uneven across the rural - urban divide.
Box II : Differentials in Health Status Among States
Sector
Population
BPL (%)
I MR/
<5Mort-ality
Per 1000
per 1000
(NFHS II)
Live Births
(1999-SRS)
1
Malaria
+ve
Cases in
vear
2000 (in
Leprosy
cases per
Weight I MMR/
For AgeLakh
(Annual
% of
Report
Children
2000)
Under 3
years
10000
popula-tion
thousands)
(<-2SD)
India
26.1
70
94.9
47
408
3.7
Rural
27.09
75
103.7
49.6
-
-
-
Urban
23.62
44
63.1
38.4
■
-
-
Kerala
12.72
14
18.8
27
87
0.9
5.1
Maharastra
25.02
48
58.1
50
135
3.1
138
TN
21.12
52
63.3
37
79
4.1
56
i
-
2200
Better
' Performing
States
: Low
Performing
States
1
1
1 Orissa
47.15
97
104.4
54
498
7.05
483
Bihar
42.60
63
105.1
54
707
11.83
132
i Rajasthan
15.2S
81
114.9
S'
607
0.8
53
i UP
1 .
31.15
84
122.5
52
707
4.3
99
1 MP
37.43
90
137.6
55
498
3.83
528
;
i
1
1
Also, the statistics bring out the wide differences between the attainments of health goals
in the better- performing States as compared to the low-performing States. It is clear that
national averages of health indices hide wide disparities in public health facilities and
health standards in different parts of the country. Given a situation in which national
averages in respect of most indices are themselves at unacceptably low levels, the wide
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inter-State disparity implies that, for vulnerable sections of society in several States.
access to public health services is nominal and health standards are grossly inadequate.
Despite a thrust in the NHP-1983 for making good the unmet needs of public health
sendees by establishing more public health institutions at a decentralized level, a large
gap in facilities still persists. Applying current norms to the population projected for the
year 2000, it is estimated that the shortfall in the number of SCs/PHCs/CHCs is of the
order of 16 percent. However, this shortage is as high as 58 percent when disaggregated
for CHCs only. The NHP-2001 will need to address itself to making good these
deficiencies so as to narrow the gap between the various States, as also the gap across the
rural-urban divide.
2.2.2 Access to, and benefits from, the public health system have been very uneven
between the better-endowed and the more vulnerable sections of society. This is
particularly true for women, children and the socially disadvantaged sections of society.
The statistics given in Box-Ill highlight the handicap suffered in the health sector on
account of socio-economic inequity.
Box-Ill : Differentials in Health status Among Socio-Economic Groups
Indicator
Infant
Mortality/! 000
Under 5
Mortality/1000
% Children
70
94.9
47
Scheduled Castes
83
119.3
53.5
Scheduled Tribes
84.2
126.6
55.9
Other Disadvantaged
76
103.1
47.3
i Others
|
61.8
82.6
41.1
India
1
Underweight
Social Inequity
i
1
2.2.3 It is a principal objective of NHP-2001 to evolve a policy structure which reduces
these inequities and allows the disadvantaged sections of society a fairer access to public
health sendees.
2.3
DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
2.3.1 It is self-evident that in a country as large as India, which has a wide variety of
socio-economic settings, national health programmes have to be designed with enough
flexibility to permit the State public health administrations to craft their own programme
package according to their needs. Also, the implementation of the national health
programme can only be carried out through the State Governments’ decentralized public
health machinery. Since, for various considerations, the responsibility of the Central
Government in finding additional public health services will continue over a period of
time, the role of the Central Government in designing broad-based public health
initiatives will inevitably continue. Moreover, it has been observed that the technical and
managerial expertise for designing large-span public health programmes exists with the
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Central Government in a considerable degree; this expertise can be gainfully utilized in
designing national health programmes for implementation in varying socio-economic
settings in the states.
2.3.2 Over the last decade or so, the Government has relied upon a ‘vertical’
implementational structure for the major disease control programmes. Through this, the
system has been able to make a substantial dent in reducing the burden of specific
diseases. However, such an organizational structure, which requires independent
manpower for each disease programme, is extremely expensive and difficult to sustain.
Over a long time-range, ‘vertical’ structures may only be affordable for diseases, which
offer a reasonable possibility of elimination or eradication in a foreseeable time-span. In
this background, the NHP-2001 attempts to define the role of the Central Government
and the State Governments in the public health sector of the country.
2.4
THE STATE OF PUBLIC HEALTH INFRA-STRUCTURE
2.4.1 The delineation of NHP-2001 would be required to be based on an objective
assessment of the quality and efficiency of the existing public health machinery in the
field. It would detract from the quality of the exercise if, while framing a new policy, it
is not acknowledged that the existing public health infrastructure is far from satisfactory. 4)
For the out-door medical facilities in existence, funding is generally insufficient; the
presence of medical and para-medical personnel is often much less than required by the
prescribed norms; the availability of consumables is frequently negligible; the equipment
in many public hospitals is often obsolescent and unusable; and the buildings are in a
dilapidated state. In the in-door treatment facilities, again, the equipment is often
obsolescent; the availability of essential drugs is minimal; the capacity of the facilities is
grossly inadequate, which leads to over-crowding, and consequentially to a steep
deterioration in the quality of the services. As a result of such inadequate public health
facilities, it has been estimated that less than 20 percent of the population seeks the OPD
services and less than 45 percent avails of the facilities for in-door treatment in public
hospitals. This is despite the fact that most of these patients do not have the means to
make out-of-pocket payments for private health services except at the cost of other
essential expenditure for items such as basic nutrition.
2.5
EXTENDING PUBLIC HEALTH SERVICES
2.5.1 While in the country generally there is a shortage of medical manpower, this
shortfall is disproportionately impacted on the less-developed and rural areas. No
incentive system attempted so far, has induced private medical manpower to go to such
areas; and, even in the public health sector it has usually been a losing battle to deploy
medical manpower in such under-served areas. In such a situation, the possibility needs
to be examined for entrusting some limited public health functions to nurses, paramedics
and other personnel from the extended health sector after imparting adequate training to
them.
2.5.2 India has a vast reservoir of practitioners in the Indian Systems of Medicine and
Homoeopathy, who have undergone formal training in their own disciplines. The
possibility of using such practitioners in the implementation of State/Central
Government public health Programmes, in order to increase the reach of basic health
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care in the country, is addressed in the NHP-2001.
2.6
ROLE OF LOCAL SE .F-GOVERNMENT INSTITUTIONS
2.6.1 Some States have adopted a policy of devolving programmes and funds in the
health sector through different levels of the Panchayati Raj Institutions. Generally, the
experience has been a favourable one. The adoption of such an organisational structure
has enabled need-based allocation of resources and closer supervision through the
elected representatives. NHP- 2001 examines the need for a wider adoption of this mode
of delivery of health services, in rural as well as urban areas, in other parts of the
country.
2.7
MEDICAL EDUCATION
2.7.1 Medical Colleges are not evenly spread across various parts of the country. Apart
from the uneven geographical distribution of medical institutions, ,the quality of
education is highly uneven and in several instances even sub-standard. It is a common
perception that the syllabus is excessively theoritical, making it difficult for the fresh
graduate to effectively meet even the primary health care needs of the population. There
W is an understandable reluctance on the part of graduate doctors to serve in areas distant
from their native place. NHP-2001 will suggest policy initiatives to rectify these
disparities.
2.7.2 Certain medical discipline, such as, molecular biology and gene-manipulation,
have become relevant in the period after the formulation of the previous National Health
Policy. Also, certain speciality disciplines - Anesthesiology. Radiology and Forensic
Medicines - are currently very scarce, resulting in critical deficiencies in the package of
available public health services. The components of medical research in the recent years
have changed radically. In the foreseeable future such research will rely increasingly on
such new disciplines. It is observed that the current under-graduate medical syllabus
does not cover such emerging subjects. NHP-2001 will make appropriate
recommendations in this regard.
2.8
NEED FOR SPECIALISTS IN ‘PUBLIC *
HEALTH AND ‘FAMILY MEDICINE'
£ 2.8.1 In any developing country with inadequate availability of health.services, the
requirement of expertise in the areas of ‘public health’ and ‘family medicine’ is very
much more than the expertise required for other specialized clinical disciplines. In India,
the situation is that public health expertise is non-existent in the private health sector,
and far short of requirement in the public health sector. Also, the current curriculum in
the graduate / post-graduate courses is outdated and unrelated to contemporary
community needs. In respect of ‘family medicine’, it needs to be noted that the more
talented medical graduates generally seek specialization in clinical disciplines, while the
remaining go into general practice. While the availability of postgraduate educational
facilities is 50 percent of the total number of the qualifying graduates each year, and can
be considered adequate, the distribution of the disciplines in the postgraduate training
facilities is overwhelmingly in favour of clinical specializations. NHP-2001 examines
the need for ensuring adequate availability of personnel with specialization in the ‘public
health’ and ‘family medicine’ disciplines, to discharge the public health responsibilities
in the country.
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URBAN HEALTH
2.9.1 In most urban areas, public health senices are very meagre. To the extent that such
services exist, there is no uniform organisational structure. The urban population in the
country is presently as high as 30 percent and is likely to go up to around 33 percent by
2010. The bulk of the increase is likely to take place through migration, resulting in
slums without any infrastructure support. Even the meagre public health services
available do not percolate to such unplanned habitations, forcing people to avail of
private health care through out-of-pocket expenditure. The rising vehicle density in large
urban agglomerations has also led to an increased number of serious accidents requiring
treatment in well-equipped trauma centres. NHP-2001 will address itself to the need for
providing this unserved population a minimum standard of health care facilities.
2.10
MENTAL HEALTH
2.10.1 Mental health disorders are actually much more prevalent than are visible on the
surface. While such disorders do not contribute significantly to mortality, they have a
serious bearing on the quality of life of the affected persons and their families. Serious
cases of mental disorder require hospitalization and treatment under trained supervision.
Mental health institutions are perceived to be woefully deficient in physical
infrastructure and trained manpower. NHP-2001 will address itself to these deficiencies
in the public health sector.
2.11
INFORMATION, EDUCATION AND COMMUNICATION
2.11.1 A substantial component of primary health care consists of initiatives for
disseminating, to the citizenry, public health-related information. Public health
programmes, particularly, need high visibility at the decentralized level in order to have
any impact. This task is particularly difficult as 35 percent of our country’s population is
illiterate. The present IEC strategy is too fragmented, relies heavily on mass media and
does not address the needs of this segment of the population, it is often felt that the
effectiveness of IEC programmes is difficult to judge; and consequently, it is often
asserted that accountability, in regard to the productive use of such funds, is doubtful.
NHP-2001, while projecting an IEC strategy, will fully address the inherent problems
encountered in any IEC programme designed for improving awareness in order to bring
about behavioural change in the general population.
2.11.2 It is widely accepted that school and college students are the most receptive
targets for imparting information relating to basic principles of preventive health care.
NHP-2001 will attempt to target this group to improve the general level of health
awareness.
2.12
MEDICAL RESEARCH
2.12.1 Over the years, medical research activity in the country has been very limited. In
the Government, such research has been confined to the research institutions under the
Indian Council of Medical Research, and other institutions funded by the States/Central
Government. Research in the private sector has assumed some significance only in the
last decade. In our country, where the aggregate annual health expenditure is of the order
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of Rs. 80.000 crores, the expenditure in 1998-99 on research, both public and private
sectors, was only of the order of Rs. 1150 crores. It would be reasonable to infer that
with such low research expenditure, it would be virtually impossible to make any
dramatic break-through within the country, by way of new molecules and vaccines: also,
without a minimal back-up of applied and operational research, it would be difficult to
assess whether the health expenditure in the country is being incurred through optimal
applications and appropriate public health strategies. Medical Research in the country
needs to be focused on therapeutic drugs/vaccines for tropical diseases, which are
normally neglected by international pharmaceutical companies on account of limited
profitability' potential. The thrust will need to be in the newly-emerging frontier areas of
research based on genetics, genome-based ding and vaccine development, molecular
biology, etc. NHP-2001 will address these inadequacies and spell out a minimal quantum
of expenditure for the coming decade, looking to the national needs and the capacity of
the research institutions to absorb the funds.
2.13
ROLE OF THE PRIVATE SECTOR
2.13.1 Considering the economic restructuring underway in the country, and over the
globe, since the last decade, the changing role of the private sector in providing health
care will also have to be addressed in NHP 2001. Currently, the contribution of private
health care is principally through independent practitioners. Also, the private sector
contributes significantly to secondary-level care and some tertiary care. With the
increasing role of private health care, the need for statutory licensing and monitoring of
minimum standards of diagnostic centres / medical institutions becomes imperative.
NHP-2001 will address the issues regarding the establishment of a regulatory
mechanism to ensure adequate standards of diagnostic centres / medical institutions.
conduct of clinical practice and delivery of medical services.
2.13.2 Currently, non-Govemmental service providers are treating a large number of
patients at the primary level for major diseases. However, the treatment regimens
followed are diverse and not scientifically optimal, leading to an increase in the
incidence of drug resistance. NHP-2001 will address itself to recommending
arrangements, which will eliminate the risks arising from inappropriate treatment.
2.13.3 The increasing spread of information technologt raises the possibility of its
adoption in the health sector. NHP-2001 will examine this possibility.
2.14
ROLE OF THE CIVIL SOCIETY
2.14.1 Historically, the practice has been to implement major national disease control
programmes through the public health machinery of the State/Central Governments. It
has become increasingly apparent that certain components of such programmes cannot
be efficiently implemented merely through government functionaries. A considerable
change in the mode of implementation has come about in the last two decades, with an
increasing involvement of NGOs and other institutions of civil society. It is to be
recognized that widespread debate on various public health issues have, in fact, been
initiated and sustained by NGOs and other members of the civil society. Also, an
increasing contribution is being made by such institutions, in the delivery of different
components of public health services. Certain disease control programmes require close
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inter-action with the beneficiaries for regular administration of drugs: periodic carrying
out of the pathological tests; dissemination of information regarding disease control and
other general health information. NHP-2001 will address such issues and suggest policy
instruments for implementation of public health programmes through individuals and
institutions of civil society.
2.15
NATIONAL DISEASE SURVEILLANCE NETWORK
2.15.1 The technical network available in the country for disease surveillance is
extremely rudimentary and to the extent that the system exists, it extends only up to the
district level. Disease statistics are not flowing through an integrated network from the
decentralized public health facilities to the State/Central Government health
administration. Such an arrangement only provides belated information, which, at best,
serves a limited statistical purpose. The absence of an efficient disease surveillance
network is a major handicap in providing a prompt and cost effective health care system.
The efficient disease surveillance network set up for Polio and HIV/AIDS has
demonstrated the enormous value of such a public health instrument. Real-time
information of focal outbreaks of common communicable diseases - Malaria, GE,
Cholera and JE - and other seasonal trends of diseases, would enable timely
intervention, resulting in the containment of any possible epidemic. In order to be able to
use an integrated disease surveillance network, for operational purposes, real-time
information is necessary at all levels of the health administration. NHP-2001 would
address itself to this major systemic shortcoming in the administration.
2.16
HEALTH STATISTICS
2.16.1 The absence of a systematic and scientific health statistics data-base is a major
deficiency in the current scenario. The health statistics collected are not the product of a
rigorous methodology. Statistics available from different parts of the country, in respect
of major diseases, are often not obtained in a manner which make aggregation possible.
or meaningful.
2.16.2 Further, absence of proper and systematic documentation of the various financial
resources used in the health sector is another lacunae witnessed in the existing scenario.
This makes it difficult to understand trends and levels of health spending by private and
public providers of health care in the country, and to address related policy issues and
formulate future investment policies.
2.16.3 NHP-2001 will address itself to the programme for putting in place a modem and
scientific health statistics database as well as a system of national health accounts.
2.17
WOMEN'S HEALTH
2.17.1 Social, cultural and economic factors continue to inhibit women from gaining
adequate access to even the existing public health facilities. This handicap does not just
affect women as individuals; it also has an adverse impact on the health, general
well-being and development of the entire family, particularly children. NHP 2001
recognises the catalytic role of empowered women in improving the overall health
standards of the community.
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2.18
MEDICAL ETHICS
2.’ S.l Professional medical ethics in the health sector is an area, which has not received
much attention in the past. Also, the new frontier areas of research - involving gene
manipulation, organ/human cloning and stem cell research impinge on visceral issues
relating to the sanctity of human life and the moral dilemma of human intervention in the
designing of life forms. Besides these, in the emerging areas of research, there is an
un-charted risk of creating new life forms, which may irreversibly damage the
environment, as it exists today. NHP - 2001 recognises that moral and religious dilemma
of this nature, which was not relevant even two years ago, now pervades mainstream
health sector issues.
2.19
ENFORCEMENT OF QUALITY STANDARDS FOR EOOD AX'D PRI GS
2.19.1 There is an increasing expectation and need of the citizenry for efficient
enforcement of reasonable quality standards for food and dings. Recognizing this need,
NHP - 2001 makes an appropriate policy recommendation.
2.20
REGULATION OF STANDARDS IN PARA MEDICAL DISCIPLINES
2.20.1 It has been observed that a large number of training institutions have mushroomed
particularly in the private sector, for several para medical disciplines - Lab Technicians.
Radio Diagnosis Technicians, Physiotherapists, etc. Currently, there is no
regulation/monitoring of the curriculum, or the performance of the practitioners in these
disciplines. NHP-2001 will make recommendations to ensure standardization of training
and monitoring of performance.
2.21
OCCUPATIONAL HEALTH
2.21.1 Work conditions in several sectors of employment in the country are
sub-standard. As a result of this, workers engaged in such activities become particularly
prone to occupation-linked ailments. The long-term risk of chronic morbidity is
particularly marked in the case of child labour. NHP-2001 will address the risk faced by
this particularly vulnerable section of the society.
2.22
PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
2.22.1 The secondary and tertiary facilities available in the country are of good quality
and cost-effective compared to international medical facilities. This is true not only of
facilities in the allopathic disciplines, but also to those belonging to the alternative
systems of medicine, particularly Ayurveda. NHP-2001 will assess the possibilities of
encouraging commercial medical services for patients from overseas.
? M IMPACT OF GLOBALIZATION ON THE HEALTH SECTOR
2.23.1 There are some apprehensions about the possible adverse impact of economic
globalisation on the health sector. Pharmaceutical drugs and other health services have
always been available in the country at extremely inexpensive prices. India has
established a reputation for itself around the globe for innovative development of
original process patents for the manufacture of a wide-range of drugs and vaccines
within the ambit of the existing patent laws. With the adoption of Trade Related
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Intellectual Property (TRIPS), and the subsequent alignment of domestic patent laws
consistent with the commitments under TRIPS, there will be a significant shift in the
scope of ’ e paran ters regulating the manufacture of new drugs/vaccines. Global
experience has shown that the introduction of a TRIPS-consistent patent regime for
drugs in a developing country, would result tn an increase in the cost of drugs and
medical sendees. NHP-2001 will address itself to the future imperatives of health
security in the country, in the post-TRIPS era.
2.24
NON - HEALTH DETERMINANTS
2.24.1 Improved health standards are closely dependent on major non-health
determinants such as safe drinking water supply, basic sanitation, adequate nutrition,
clean environment and primary education, especially of the girl child. NEIP-2001 will
not explicitly address itself to the initiatives in these areas, which although crucial, fall
outside the domain of the health sector. However, the attainment of the various targets
set in NHP 2001 assumes a reasonable performance in these allied sectors.
2.25
POPULATION GROWTH AND HEALTH STANDARDS
2.25.1 Efforts made over the years for improving health standards have been neutralized £
by the rapid growth of the population. Unless the Population stabilization goals are
achieved, no amount of effort in the other components of the public health sector can
bring about significantly better national health standards. Government has separately
announced the 'National Population Policy - 2000’. The principal common features
covered under the National Population Policy-2000 and NHP-2001, relate to the
prevention and control of communicable diseases; priority to containment of H1V/AIDS
infection; universal immunization of children against all major preventable diseases;
addressing the unmet needs for basic and reproductive health services; and
supplementation of infrastructure. The synchronized implementation of these two
Policies - National Population Policy - 2000 and National Health Policy-2001 - will be
the very cornerstone of any national structural plan to improve the health standards in
the country.
2.26
ALTERNATIVE SYSTEMS OF MEDICINE
2.26.1 Alternative Systems of Medicine - Ayurveda, Unani, Sidha and Homoeopathy - a
provide a significant supplemental contribution to the health care services in the country, w
particularly in the underserved, remote and tribal areeas. The main components of
NHP-2001 apply equally to the alternative systems of medicine. However, the policy
features specific to the alternative systems of medicine will be presented as a separate
document.
3. OBJECTIVES
3.1 The main objective ofNHP-2001 is to achieve an acceptable standard of good health
amongst the general population of the country. The approach would be to increase access
to the decentralized public health system by establishing new infrastructure in deficient
areas, and by upgrading the infrastructure in the existing institutions. Overriding
importance would be given to ensuring a more equitable access to health services across
the social and geographical expanse of the country. Emphasis will be given to increasing
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the aggregate public health investment through a substantially increased contribution by
t1'? Central Government. It is expected that this initiative will strengthen the capacity of
ti.e public health administration at the State levy. to render effective service delivery.
The contribution of the private sector in providing health services would be much
enhanced, particularly for the population group, which can afford to pay for services.
Primacy will be given to preventive and first-line curative initiatives at the primary
health level through increased sectoral share of allocation. Emphasis will be laid on
rational use of drugs within the allopathic system. Increased access to tried and tested
systems of traditional medicine will be ensured. Within these broad objectives,
NHP-2001 will endeavour to achieve the time-bound goals mentioned in Box-IV.
Box-IV: Goals to be achieved by 2000-2015
1
o Eliminate Leprosy
2005
...
2005
• Eliminate Kala Azar
2010
• Eliminate Lymphatic Filariasis
2015
• Achieve Zero level growth of HIV/AIDS
2007
• Reduce Mortality by 50% on account of TB, Malaria
and Other Vector and Water Borne diseases
2010
• Reduce Prevalence of Blindness to 0.5%
2010
• Reduce IMR to 30/1000 And MMR to 100/Lakh
2010
• Improve nutrition and reduce proportion of LBW
Babies from 30% to 10%
2010
. Increase utilisation of public health facilities from
current Level of <20 to >75%
2010
. Establish an integrated system of surveillance, National
Health Accounts and Health Statistics.
2005
• Increase health expenditure by Government as a % of
GDP from the existing 0.9 % to 2.0%
2010
. Increase share of Central grants to Constitute at least
25% of total health spending
2010
. Increase State Sector Health spending from 5.5% to 7%
of the budget
2005
= Eradicate Polio and Yaws
1
1
2010
Further increase to 8%
4. NHP-2001 - POLICY PRESCRIPTIONS
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FINANCIAL REf PURGES
The paucity of public health investment is a stark reality. Given the extremely difficult
fiscal position of the State Governments, the Central Government will have to play a key
role in augmenting public health investments. Taking into account the gap in health care
facilities under NHP-2001 it is planned to increase health sector expenditure to 6 percent
of GDP. with 2 percent of GDP being contributed as public health investment, by '. ;
year 2010. The State Governments would also need to increase the commitment to le
health sector. In the first phase, by 2005, they would be expected to increase the
commitment of their resources to 7 percent of the Budget; and. in the second phase, by
2010, to increase it to 8 percent of the Budget. With the stepping up of the public health
investment, the Central Government’s contribution would rise to 25 percent from the
existing 15 percent, by 2010. The provisioning of higher public health investments will
also be contingent upon the increase in absorptive capacity of the public health
administration so as to gainfully utilize the binds.
4.2
EQUITY
4.2.1 To meet the objective of reducing various types of inequities and imbalances inter-regional: across the rural - urban divide: and between economic classes - the most
cost effective method would be to increase the sectoral outlay in the primary health
sector. Such outlets give access to a vast number of individuals, and also facilitate
preventive and early stage curative initiative, which are cost effective. In recognition of
this public health principle, NHP-2001 envisages an increased allocation of 55 percent of
the total public health investment for the primary health sector; the secondary and
tertiary health sectors being targetted for 35 percent and 10 percent respectively.
NHP-2001 projects that the increased aggregate outlays for the primary health sector will
be utilized for strengthening existing facilities and opening additional public health
service outlets, consistent with the norms for such facilities.
4.3
DELIVERY OF NATIONAL PUBLIC HEALTH PROGRAMMES
4.3.1 NHP-2001, envisages a key role for the Central Government in designing national
programmes with the active participation of the State Governments. Also, the Policy
ensures the provisioning of financial resources, in addition to technical support,
monitoring and evaluation at the national level by the Centre. However, to optimize the
utilization of the public health infrastructure at the primary level, NHP-2001 envisages
the gradual convergence of all health programmes under a single field administration.
Vertical programmes for control of major diseases like TB, Malaria and HIV/AIDS
would need to be continued till moderate levels of prevalence are reached. The
integration of the programmes will bring about a desirable optimisation of outcomes
through a convergence of all public health inputs. The policy also envisages that
programme implementation be effected through autonomous bodies at State and district
levels. State Health Departments’ interventions may be limited to the overall monitoring
of the achievement of programme targets and other technical aspects. The relative
distancing of the programme implementation from the State Health Departments will
give the project team greater operational flexibility. Also, the presence of State
Government officials, social activists, private health professionals and MLAs/MPs on
the management boards of the autonomous bodies will facilitate well-informed
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decision-making.
4.4
THE STATE OF PUBLIC HEALTH INFRASTRUCTURE
4.4.1 As has been highlighted in the earlier part of the Policy, the decentralized Public
health service outlets have become practically dysfunctional over large parts of the
country. On account of resource constraint, the supply of drugs by the State
Governments is grossly inadequate. The patients at the decentralized level have little use
for diagnostic services, which in any case would still require them to purchase
therapeutic dings privately. In a situation in which the patient is not getting any
therapeutic dings, there is little incentive for the potential beneficiaries to seek the
advice of the medical professionals in the public health system. This results in there
being no demand for medical services, and medical professionals, and paramedics often
absent themselves from their place of duty. It is also observed that the functioning of the
public health sendee outlets in the four Southern States - Kerala, Andhra Pradesh, Tamil
Nadu and Karnataka - is relatively better, because some quantum of drugs is distributed
through the primary health system network, and the patients have a stake in approaching
the Public health facilities. In this backdrop. NHP-2001'envisages the kick-starting of the
revival of the Primary Health System by providing some essential drugs under Central
Government funding through the decentralized health system. It is expected that the
provisioning of essential drugs at the public health service centres will create a demand
for other professional services from the local population, which, in turn, will boost the
general revival of activities in these service centres. In sum, this initiative under
NHP-2001 is launched in the belief that the creation of a beneficiary interest in the
public health system, will ensure a more effective supervision of the public health
personnel, through community monitoring, than has been achieved through the regular
administrative line of control.
4.4.2 Global experience has shown that the quality of public health services, as reflected
in the attainment of improved public health indices, is closely linked to the quantum and
quality of investment through public funding in the primary health sector. Box-V gives
statistics which show clearly that the standards of health are more a function of accurate
targeting of expenditure on the decentralised primary sector (as observed in China and
Sri Lanka), than a function of the aggregate health expenditure.
Box-V: Public Health Spending in select Countries
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1
%Population
with income of
<S1 day
Infant
Mortality
Rate/1000
%Health
Exnenditure to
GDP
%Public
Expenditure
on Health to
Total Health
Expenditure
India
44.2
70
5.2
17.3
China
IS.5
31
2.7
24.9
Sri Lanka
6.6
16
3
45.4
UK
-
6
5.S
96.9
USA
-
7
13.7
44.1
Indicator
Therefore. NHP-2001, while committing additional aggregate financial resources, places
strong reliance on the strengthening of the primary health structure, with which to attain
improved public health outcomes on an equitable basis. Further, it also recognizes the .
practical need for levying reasonable user-charges for certain secondary and tertiary
public health care services, for those who can afford to pay.
4.5
EXTENDING PUBLIC HEALTH SERVICES
4.5.1 NHP-2001 envisages that, in the context of the availability and spread of allopathic
graduates in their jurisdiction, State Governments would consider the need for expanding
the pool of medical practitioners to include a cadre of licentiates of medical practice, as
also practitioners of Indian Systems of Medicine and Homoeopathy. Simple
services/procedures can be provided by such practitioners even outside their disciplines.
as part of the basic primary health services in under-served areas. Also, NHP-2001
envisages that the scope of use of paramedical manpower of allopathic disciplines, in a
prescribed functional area adjunct to their current functions, would also be examined for
meeting simple public health requirements. These extended areas of functioning of
different categories of medical manpower can be permitted, after adequate training and
subject to the monitoring of their performance through professional councils.
4.5.2 NHP-2001 also recognizes the need for States to simplify the recruitment
procedures and rules for contract employment in order to provide trained medical
manpower in under-served areas.
4.6
ROLE OF LOCAL SELF-GOVERNMENT INSTITUTIONS ■
4.6.1 NHP-2001 lays great emphasis upon the implementation of public health
programmes through local self Government institutions. The structure of the national
disease control programmes will have specific components for implementation through
such entities. The Policy urges all State Governments to consider decentralizing
implementation of the programmes to such Institutions by 2005. In order to achieve this,
financial incentives, over and above the resources allocated for disease control
programmes, will be provided by the Central Government.
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4.7
MEDICAL EDUCATION
4.7.1 In order to ameliorate the problems being faced on account of the uneven spread of
medical colleges in various parts of the country, NHP-2001. envisages the setting up of a
Medical Grants Commission for funding new Government Medical Colleges in different
parts of the country. Also, the Medical Grants Commission is envisaged to fund the
upgradation of the existing Government Medical Colleges of the country, so as to ensure
an improved standard of medical education in the country.
4.7.2 To enable fresh graduates to effectively contribute to the providing of primary
health services. NHP-2001 identifies a significant need to modify the existing
curriculum. A need based, skill-oriented syllabus, with a more significant component of
practical training, would make fresh doctors useful immediately after graduation.
4.7.3 The policy emphasises the need to expose medical students, through the
undergraduate syllabus, to the emerging concerns for geriatric disorders, as also to the
cutting edge disciplines of contemporary medical research. The policy also envisages
that the creation of additional seats for post-graduate courses should reflect the need for
i more manpower in the deficient specialities.
4.8
NEED FOR SPECIALISTS IN ‘PUBLIC HEALTH' AND ‘FAMILY MEDICINE'
4.8.1 In order to alleviate the acute shortage of medical personnel with specialization in
‘public health’ and ‘family medicine’ disciplines, NHP-2001 envisages the progressive
implementation of mandatory nonns to raise the proportion of postgraduate seats in
these discipline in medical training institutions, to reach a stage wherein ‘A th of the seats
are earmarked for these disciplines. It is envisaged that in the sanctioning of
post-graduate seats in future, it shall be insisted upon that a certain reasonable number of
seats be allocated to 'public health’ and 'family medicine’ disciplines. Since, the 'public
health' discipline has an interface with many other developmental sectors, specialization
in Public health may be encouraged not only for medical doctors but also for
non-medical graduates from the allied fields of public health engineering, microbiology
and other natural sciences.
4.9
URBAN HEALTH
4.9.1 NHP-2001, envisages the setting up of an organised urban primary health care
structure. Since the physical features of an urban setting are different from those in the
rural areas, the policy envisages the adoption of appropriate population norms for the
urban public health infrastructure. The structure conceived under NHP-2001 is a
two-tiered one: the primary centre is seen as the first-tier, covering a population of one
lakh, with a dispensary providing OPD facility and essential drugs to enable access to all
the national health programmes; and a second-tier of the urban health organisation at the
level of the Government general Hospital, where reference is made from the primary
centre. The Policy envisages that the funding for the urban primary health system will be
jointly borne by the local self-Govemment institutions and State and Central
Governments.
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4.9.2 The National Health Policy also envisages the establishment of fully-equipped
‘hub-spoke’ trauma care networks in large urban agglomerations to reduce accident
mortality.
4.10
MENTAL HEALTH
4.10.1 NHP - 2001 envisages a network of decentralised mental health services for
ameliorating the more common categories of disorders. The programme outline for such
a disease would envisage diagnosis of common disorders by general duty medical staff
and prescription of common therapeutic drugs.
4.10.2 In regard to mental health institutions for in-door treatment of patients, the policy
envisages the upgrading of the physical infrastructure of such institutions at Central
Government expense so as to secure the human rights of this vulnerable segment of
society.
4.11
INFORMATION, EDUCATION AND COMMUNICATION
4.11.1 NHP-2001 envisages an IEC policy, which maximizes the dissemination of
information to those population groups, which cannot be effectively approached through
the mass media only. The focus would therefore, be on inter-personal communication of
information and reliance on folk and other traditional media. The IEC programme would
set specific targets for the association of PRIs/NGOs/Trusts in such activities. The
programme will also have the component of an annual evaluation of the performance of
the non-Govemmental agencies to monitor the impact of the programmes on the targeted
groups. The Central/State Government initiative will also focus on the development of
modules for information dissemination in such population groups who normally, do not
benefit from the more common media forms.
4.11.2. NHP-2001 envisages priority to school health programmes aiming at preventive
health education, regular health check-ups and promotion of health seeking behaviour
among children. The school health programmes can gainfully adopt specially designed
modules in order to disseminate information relating to ‘health’ and ‘family life’. This is
expected to be the most cost-effective intervention as it improves the level of awareness,
not only of the extended family, but the future generation as well.
4.12
MEDICAL RESEARCFI
4.12.1 NHP-2001 envisages the increase in Government-funded medical research to a
level of 1 percent of total health spending by 2005; and thereafter, up to 2 percent by
2010. Domestic medical research would be focused on new therapeutic drugs and
vaccines for tropical diseases, such as TB and Malaria, as also the Sub-types of
HIV/AIDS prevalent in the country. Research programmes taken up by the Government
in these priority areas would be conducted in a mission mode. Emphasis would also be
paid to time-bound applied research for developing operational applications. This would
ensure cost effective dissemination of existing / future therapeutic drugs/vaccines in the
general population. Private entrepreneurship will be encouraged in the field of medical
research for new molecules / vaccines.
4
18 of 22
13 ROLE OF THE PRIVATE SECTOR
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4.13.1 NI 1P-^OO1 envisages the enactment of suitable legislations for regulating
it imum infrastr
ture raid quality standards by '.003, in clinical
establishments, medical institutions; also, statutory guidelines for the conduct of linical
practice and delivery of medical services are to be developed over the same period. The
policy also encourages the setting up of private insurance instruments for increasing the
scope of the coverage of the secondary and tertiary sector under private health insurance
packages.
4.13.2 To capitalize on the comparative cost advantage enjoyed by domestic health
facilities in the secondary and tertiary sector, the policy will encourage the supply of
services to patients of foreign origin on payment. The rendering of such services on
payment in foreign exchange will be treated as ‘deemed exports’ and will be made
eligible for all fiscal incentives extended to export earnings.
4.13.3 NHP-2001 envisages the co-option of the non-governmental practitioners in the
national disease control programmes so as to ensure that standard treatment protocols are
followed in their day-to-day practice.
£ 4.13.4 NHP-2001 recognizes the immense potential of use of information technology
applications in the area of tele-medicine in the tertiary health care sector. The use of this
technical aid will greatly enhance the capacity for the professionals to pool their clinical
experience.
4.14 ROLE OF THE CIVIL SOCIETY
4.14.1 NHP-2001 recognizes the significant contribution made by NGOs and other
institutions of the civil society in making available health services to the community. In
order to utilize on an increasing scale, their high motivational skills, NHP-2001
envisages that the disease control programmes should earmark a definite portion of the
budget in respect of identified programme components, to be exclusively implemented
through these institutions.
4.15 NATIONAL DISEASE SURVEILLANCE NETWORK
a 4.15.1 NHP-2001 envisages the full operationalization of an integrated disease control
" network from the lowest rung of public health administration to the Central Government,
by 2005. The programme for setting up this network will include components relating to
installation of data-base handling hardware; IT inter-connectivity between different tiers
of the network; and, in-house training for data collection and interpretation for
undertaking timely and effective response.
4
16 HEALTH STATISTICS
4.16.1 NHP-2001 envisages the completion of baseline estimates for the incidence of the
common diseases - TB, Malaria, Blindness - by 2005. The Policy proposes that
statistical methods be put in place to enable the periodic updating of these baseline
estimates through representative sampling, under an appropriate statistical methodology.
The policy also recognizes the need to establish in a longer time frame, baseline
estimates for : the non-communicable diseases, like CVD, Cancer, Diabetes; accidental
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1
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: juries: and othe communicable diseases, like Hepatitis and JE. NHP-2001 envisages
lat. ith access to such reliable data on the incidence of various diseases, the public
.eahi: system would move closer to the objective of evidence-based policy making.
4.16.2 In an attempt at consolidating the data base and graduating from a mere
estimation of annual health expenditure, NHP-2001 emphasis on the needs to establish
national health accounts, conforming to the ’source-to-users’ matrix structure. Improved
and comprehensive information through national health accounts and accounting
systems would pave the way for decision makers to focus on relative priorities, keeping
in view the limited financial resources in the health sector.
4.17
WOMEN'S HEALTH
4.17.1 NHP-2001 envisages the identification of specific programmes targeted at
women’s health. The policy notes that women, along with other under privileged groups
are significantly handicapped due to a disproportionately low access to health care. The
various Policy recommendations of NHP-2001, in regard to the expansion of primary
health sector infrastructure, will facilitate the increased access of women to basic health
care. NHP-2001 commits the highest priority of the Central Government to the funding
of the identified programmes relating to woman’s health. Also, the policy recognizes the
need to review the staffing norms of the public health administration to more
comprehensively meet the specific requirements of women.
4.18
MEDICAL ETHICS
4.1S. 1 NHP - 2001 envisages that, in order to ensurethat the common patient is not
subjected to irrational or profit-driven medical regimens, a contemporary code of ethics
be notified and rigorously implemented by the Medical Council of India.
4.18.2 NHP - 2001 does not offer any policy prescription at this stage relating to ethics
in the conduct of medical research. By and large medical research within the country is
limited in these frontier disciplines of gene manipulation and stem cell research.
However, the policy recognises that a vigilant watch will have to be kept so that
appropriate guidelines and statutory provisions are put in place when medical research in
the country reaches the stage to make such issues relevant.
4.19
ENFORCEMENT OF QUALITY STANDARDS FOR FOOD AND DRUGS
4.19.1 NHP - 2001 envisages that the food and drug administration will be progressively
strengthened, both in terms of laboratory facilities and technical expertise. Also, the
policy envisages that the standards of food items will be progressively tightened at a
pace which will permit domestic food handling / manufacturing facilities to undertake
the necessary upgradation of technology so as not to be shut out of this production
sector. The policy envisages that, ultimately food standards will be close, if not
equivalent, to codex specifications; and drug standards will be at par with the most
rigorous ones adopted elsewhere.
4.20
REGULATION OF STANDARDS IN PARAMEDICAL DISCIPLINES
4.20.1 NHP-2001 recognises the need for the establishment of statutory professional
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councils for paramedical disciplines to register practitioners, maintain standards of
training, as well as to monitor their performance.
4.21
OCCUPATIONAL BEA..TH
4.21.1 NHP-2001 envisages the periodic screening of the health conditions of the
workers, particularly for high risk health disorders associated with their occupation.
4.22
PROVIDING MEDICAL FACILITIES TO USERS FROM OVERSEAS
4.22.1 NHP-2001 strongly encourages the providing of health services on a commercial
basis to sendee seekers from overseas. The providers of such services to patients from
overseas will be encouraged by extending to their earnings in foreign exchange, all fiscal
incentives available to other exporters of goods and services.
4.23
IMPACT OF GLOBALISATION ON THE HEALTH SECTOR
4.23.1 NHP-2001 takes into account the serious apprehension expressed by several
health experts, of the possible threat to the health security, in the post TRIPS era, as a
result of a sharp increase in the prices of drugs and vaccines. To protect the citizens of
the country from such a threat, NHP-2001 envisages a national patent regime for the
future which, while being consistent with TRIPS, avails of all opportunities to secure for
the country, under its patent laws, affordable access to the latest medical and other
therapeutic discoveries. The Policy also sets out that the Government will bring to bear
its full influence in all international fora - UN. WHO, WTO. etc. - to secure
commitments on the part of the Nations of the Globe, to lighten the restrictive features of
TRIPS in its application to the health care sector.
5,
SUMM ATION
5.1 The crafting of a National Health Policy is a rare occasion in public affairs when it
would be legitimate, indeed valuable, to allow our dreams to mingle with our
understanding of ground realities. Based purely on the clinical facts defining the current
status of the health sector, we would have arrived at a certain policy formulation; but.
buoyed by our dreams, we have ventured slightly beyond that in the shape of NHP-2001
which, in fact, defines a vision for the future.
5.2 The health needs of the country are enormous and the financial resources and
managerial capacity available to meet it, even on the most optimistic projections, fall
somewhat short. In this situation, NHP-2001 has had to make hard choices between
various priorities and operational options. NHP-2001 does not claim to be a road-map
for meeting all the health needs of the populace of the country'. Further, it has to be
recognized that such health needs are also dynamic as threats in the area of public health
keep changing over time. The Policy, while being holistic, undertakes the necessary risk
of recommending differing emphasis on different policy components. Broadly speaking,
NHP - 2001 focuses on the need for enhanced funding and an organizational
restructuring of the national public health initiatives in order to facilitate more equitable
access to the health facilities. Also, the policy is focused on those diseases which are
principally contributing to the disease burden - TB, Malaria and Blindness from the
category of historical diseases; and HIV/AIDS from the category of‘newly emerging
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.
*
diseases’. This is not to say that other items contributing to the disease burden of the
country will be ignored: but only that, resour s as also e trincipal focus of the public
heaidi administration, will rec agnize certain ;e.alive prio.iti's.
5.3 One nagging imperative, which has influenced every aspect of NHP-2001. is the
need to ensure that ‘equity’ in the health sector stands as an independent goal. In any
future evaluation of its success or failure, NHP-2001 would like to be measured against
this equity norm, rather than any other aggregated financial norm for the health sector.
Consistent with the primacy given to ‘equity’, a marked emphasis has been provided in
the policy for expanding and improving the primary health facilities, including the new
concept of provisioning of essential drugs through Central funding. The Policy also.
commits the Central Government to increased under-writing of the resources for meeting
the minimum health needs of the citizenry. Thus, the Policy attempts to provide
guidance for prioritizing expenditure, thereby, facilitating rational resource allocation.
5.4 NHP-2001 highlights the expected roles of different participating group in the health
sector. Further, it recognizes the fact that, despite all that may be guaranteed by the
Central Government for assisting public health programmes, public health services
would actually need to be delivered by the State administration, NGOs and other
institutions of civil society. The attainment of improved health indices would be
significantly dependent on population stabilisation, as also on complementary efforts
from other areas of the social sectors - like improved drinking water supply, basic
sanitation, minimum nutrition, etc. - to ensure that the exposure of the populace to health
risks is minimized.
Suggestions on the draft policy are welcome. Kindly mail your suggestions to aeaboo4mb.nic.in within
30 days.
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.223.61
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85,86,504.00
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o
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8
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1,20,540.00
8
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2,50,600.00
l,15,74,341.a|/
2,58,300.00
6,30,000.00
U,
1.1
&
13
£
^3
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3,82,032.00
3,00,812.00
2^4^
Supplementary Note
From 1987 till end of August 2000, 613 persons are reported to be suffering
from AIDS. Out of this 106 people have been died due to AIDS. The HIV cases are
reported from Voluntary Testing and Counselling Centres. These centres serve as
surveillance centres. The State conduct sero-surveillance on a regular basis at five
voluntary testing centres. In addition, every year for a period of three month from
August to October sentinel surveillance is carried out at 14 sites. This gives trend of
increase of HIV infection in high risk groups as well as general population.
District arise details are below:
SI.
No.
Division/ Districts
HIV +Ve
AIDS Cases
Death due
to AIDS
2685
178
156
170
117
33
150
100
9
11
29
7
7
11
28
4
1
2
2
0
2
122
3
272
743
437
11
81
103
10
1
18
16
120
2
11
9
5
0
5
9
10
1
2
2
BANGALORE DIVN.
1 Bangalore ( U )
2 Bangalore ( R )
3 Tumkur
4 Shimoga
5 Chitradurga
6 Davanagere
7 Kolar
MYSORE DIVN.
8 Mysore
9 Chamaraj anagara
10 Mandya
11 Mangalore
12 Udupi
13 Madikeri
14 Chickmangalore
15 Hassan
BELGAUM DIVN.
16 Belgaum
17 Bijapur
18 Bagalkote
19 Dharwad
20 Haveri
21 Gadag
22 Karwar
GULBARGA DIVN.
23 Gulbarga
24 Raichur
25 Bidar
26 Bellary
27 Koppal
KARNATAKA TOTAL
85
114
9
268
23
12
171
9
0
3
119
13
4
35
0
0
0
4
1
0
5
63
144
7
508
18
6682
4
11
2
9
2
562
3
5
2
0
0
93
Other States
Foreigners
GRAND TOTAL
509
15
7206
47
4
613
9
4
106
1.
2.
HIV testing procedures are followed as per the National HIV testing policy of
Government of India. Hence unlinked anonymous testing procedures are followed to
keep the result confidential. The testing procedure will be done by giving pre and post
test counselling to the client on getting explicit consent and the result will be revealed
to the patient or his close relatives since stigma and sensitivity is attached to the
disease. In view of this the testing centres are providing only the age, sex and the
district to which the case belong and the names and addresses are kept confidential.
As per the current estimates the HIV infection in the State may be upward of 2
lakhs though exact estimates are not available.
To control AIDS disease, National AIDS Control programme is being
implemented in the State. This is a 100% centrally sponsored scheme. The activities
under this programme are being implemented as per the guidelines of National AIDS
Control Organisation, Ministry of Health & Family Welfare, Government of India with
World Bank assistance. The main objective of this programme is to prevent the spread
of HIV transmission in the community and to create awareness on HIV/AIDS. The
activities under the programme are being implemented as per the guidelines of National
AIDS Control Programme, Government of India. In view of this and to enable the time
bound implementation of activities the Karnataka State AIDS Prevention Society is
established during 1997.
Objectives:
1.
2.
To reduce the spread HIV infection in Karnataka State
To strengthen Karnataka State's capacity to respond to HIV/AIDS on long term
basis.
Project interventions’.
To keep HIV prevalence rate below 3% of adult population in Karnataka.
To reduce blood bome transmission of HIV to less than 1%.
To attain awareness level of not less than 90% among the youth and others in the
reproductive age group.
d) To achieve condom use of not less than 90% among high risk behavior groups.
a)
b)
c)
Programme components:
Sl.No
1
Component No.
Component -1
2
3
4
5
Component - II
Component - III
Component - IV
Component - V
Description
Targetted Intervention, STD/RTI Services
including & Condom Promotion
IEC, Blood Safety & VTC
Institutional Strengthening
Low Cost Care & Capacity Building
Intersectoral Collaboration including AIDS
Education in Schools.
Financial statement:
(Rs.in Lakhs)
Year
Approved action
plan by NACO
1999-2000
2000-2001
Rs. 1067.70 lakhs
Rs.700.00 lakhs
Releases by
NACO + unspent
balance amount of
previous year
Rs.950.28 lakhs
Rs.584.00 lakhs
Expenditure
Balance
Rs.556.942 lakhs
Rs. 318.00 lakhs
Rs.393.34 lakhs
Rs.266.00 lakhs
NGO involvement in targetted intervention in Karnataka through Karnataka State
AIDS Prevention Society:
18 Non-governmental organizations have received the grants to take up targetted
interventions programmes among high risk groups such as Commercial Sex workers,
Truck drivers, Migrant labourers and Street children's etc., to bring behavioral
communication change.
Rs.16,21,695.00 (Sixteen lakhs twenty one thousand six hundred ninety five
only) have been released 18 non-governmental organisation for the year 2000-2001.
To control AIDS and to take up preventive measures the following five voluntary
blood testing centres are established.
1. Victoria Hospital, Bangalore
2. National Institute of Mental Health and Nuerosciences (NIMHANS)
3. Kasturba Medical College, Manipal
4. Karnataka Institute of Medical Sciences (KIMS), Hubli
5. Vijayanagara Institute of Medical Sciences (VIMS), Bellary
In these centres HIV testing facility is provided and to know the tense of
infection surveillance activities are undertaken.
To ensure blood transfusion safety
ten voluntary blood-testing centres are established in the blood banks of the following
hospitals.
1. K. C.General Hospital, Bangalore
2. HSIS Gosha Hospital, Bangalore
3. KIDWAI Memorial Institute of Oncology, Bangalore
4. Airforce Common Hospital, Bangalore
5. Karnataka Institute of Medical Sciences (KIMS), Hubli
6. Vijayanagara Institute of Medical Sciences (VIMS), Bellary
7. J.N. MedicalCoIlege, Belgaum
8. M.R.Medical College, Gulbarga
9. Kasturba Medical College, Mangalore
10. Kasturba Medical College, Manipal
All blood banks are linked to these zonal blood-testing centres for HIV testing.
A total of 52 blood banks in the State are being modernized in a faced manner. District
level blood banks are being provided with HIV rapid test kits to take up testing during
emergencies.
30 STD (Sexually Transmitted Diseases) clinics attached to major
hospitals and district level hospitals are being strengthened in addition to treatment
advice on safe sexually practices are given.
To create awareness on AIDS disease in the community, information, education
and communication activities are being implemented. Guidelines are being issued to all
hospitals to use properly sterilized syringes, needles and other equipments. In addition
to implementation information, education and communication activities other medias
like All India Radio, Doordarshan and leading Daily news papers are also utilised for
release of advertisements and documentary films "NIRDHARA" and "BELAGAGUVA
TANAKA" and TV spots on HIV/AIDS with the involvement of religious leaders are being
advertised through Doordrshan. Video and Audio cassette are produced and provided
to District Health and Family Welfare Officers, Information and Publicity Department
and Field Publicity Department, Government of India to take up publicity activities. In
addition to this street plays are also being takenup. Every year to create awareness on
a intensified way National Voluntary Blood Donation Day is being observed on 1st
October, World AIDS Day is being observed on 1st December in the State. During the
year 1999-2000 Family Health Awareness Campaign was conducted in 14 districts and
during the year 2000-2001 the Family Health Awareness Campaign was observed from
1st to 15th July 2000 in. all the 27 districts as a special event.
During Family Health Awareness Campaign awareness activities on HIV/AIDS
and Sexually transmitted diseases prevention are taken up in both Urban and Rural
areas. And treatment facility for STD cases and reproductive tract infection cases were
provided at all governmental hospitals and primary health centres. The health workers
were entrusted with the work of identification and motivation of the sexually
transmitted infections and reproductive tract infections cases to avail the facility of
treatment during the primary stage. Priority targetted intervention programmes on
HIV/AIDS control are being taken up in high-risk groups (vulnerable groups for HIV
infection with the involvement of non-governmental organization.
For the year 2000-2001 the Government of India have provided an amount of
Rs.223.61 lakhs out of this as of 30th September 2000 Rs. 115.74 lakhs is spent for
awareness creation activities. Details as follows:
§
W
A
*
H
(amount in Rs.)
10,45,553.00
85,86,504.00
2,58,300.00
6,30,000.00
3,82,032.00
3,00,812.00
1,20,540.00
2.50,600.00
4^
World Health Day
Family Health Awareness Campaign
All India Radio
Doordarshan
CCTV
Blood Donation Day
Audio Cassettee
TV Spots
»-»
1
2
3
4
5
6
7
8
Project Director,
Karnataka State AIDS Prevention Society &
Commissioner, Health & Family Welfare Services
GOVERNMENT OF KARNATAKA
KARNATAKA S TA TE AIDS PREVENTION SOCIETY®
No.13, 5‘" Main, 1 O'11 Cross. 12':' Block, Kutnara Park (West). Behind BDA, Bangalorc-20
<-(■> OSO 33-19057 ,3349142 Fax No. 080 /3349142_
4 th Seplembei 2000
NO/KAP&AIDS/S IC/05/98-99
\
TO.
DR.P.L.JOS11I
JOINT DI RECTOR(TECH)
NATIONAL AIDS CONTROL ORGANISATION
MINISTRY OF HEALTH & FW.GOVT.OF INDIA.
NIRMAN BHAVAN, NEW DELHI-! 10 001
,
Sir,
Sub.-Monthly report of HIV/AIDS for the month of July 2000
Please Find in herewith enclosed the monthly update report along with Lite surveillance report
for the month of July 2000 for your reference.
Yours faithfully,
Sd/Additiona! Project Director (TI),
Karnataka state AIDS Prevention Society, Bangalore.
Copy to
1. Dr P.SALEEL. Joint Director (Blood Safety) National Aids Control Organisation,
Ministry of Health, &F\V.C-jvt. of India , Nirman Bhavan New Delhi -110 001.
2. Regional Director .Regional Offce of Health & FW Govt.of India , II Floor (F Wing) Kendriya Sadana
Koramangala, Bangalore-560 034.
AdditionahPfojectThrector (TI),
Kamataka state AIDS Prevention Society, Bangalore.
nfl1
GOVERNMENT OF KARNATAKA
____________ KARNATAKA S TATE AIDS PREVENTION SOCIE TY®
No. 13, 5'1' Main, 10,h Cross. I21!1 Block. Kutnnra Park (West), Behind BDA, Bangalore -20
ft OSO 3349057 ,3349142
NT)J<.\I‘S/AlixS/SIC/O5/93-99 '
TO.
DR.P.L.JOSH1
JOINT DIRECTOR(TECH)
NATIONAL AIDS CONTROL ORGANISATION
MINISTRY OF HEALTH & FW.GOTT.OF INDIA.
NIRMAN BHAVAN, NEW DELHI-! 10 001
Fax No. 080 Z3349142
’
’
’
’’
4 (Il Scpleinixi ?0<K>
iT.'lV J k
'
.
Sir,
Sub:- Monthly report of HIV/AIDS for the month of July 2000
Please find in herewith enclosed the monthly update report along with die surveillance report
for the month of July 2000 for your reference.
Yours faithfully,
SelfAdditional Project Director (T1),
Karnataka state AIDS Prevention Society, Bangalore.
Copy to :1. Dr P.SALEEL. Joint Director (Blood Safety) National Aids Control Organisation,
Ministry of Health, &FW.C-ivt. of India , Nirman Bhaean New Delhi -110 001.
2. Regional Director .Regional Office of Health & F\V Govi.of India , II Floor (F Wing) Kendriya Sadana
Koramangala, Bangalore-560 034.
Additional
Karnataka state AIDS Prevention Society, Bangalore.
govi:i<nmi:ni or Karnataka
KARNATAKA STATE AIDS PREVENTION SOCIETY ®
No. 13. 5th Main, 10th Cross, 121’1 Block, Kumara Pari (West), Behind B1)A,
Bangalore - 560 020
MONTHLY UPDATE ON HIV INFECTION IN KARNATAKA
(based on reports received at KSAPS)
(subject to retrospective corrections on receipt of more accurate data from centres)
1.
JULY 2000
Period of report upto end of
From 1987
To June 2000
2. SERO SURVEILLANCE REPORT
i. total number of samples screened
ii. number confirmed by second test
:
:
4,24,538
6,860
Cummulative total HIV + ve
:
7,051
iii.Sero-positivity rate(per thousand) :
16.51
iv.AIDS cases
a) Karnataka
b) Other states
c) Foreigners
July. 2000
2,560
191
F
83
4
M
450
41
4
Total
533
45
4
582
Breakup of scro-positives
- Hetro sexuals promiscuent & others
: 2625
37.23
-
Homosexuals
-
Blood Donors
:
588
08.34
-
Antenatal Mothers
:
91
1.29
-
Suspected AIDS/ ARC cases
: 3729
52.88
-
Foreigners
:
14
0.20
I . V . Drug users
:
04
0 .06
-
Total
: 7051
100 .00 %
4. Year Wise Blood sample screened for IIIV +Ve
Year
1987
19S8
19S9
1990
1991
1992
1993
1994
1995 •
1996
1997
1998
1999
July 2000
TOTAL
Blood
Samples
913
2,264
25,928
48,348
66,828
1,02,336
76,237
24,209
11,583
8,877
15,452
15,912
16,702
11,509
4,27,098
Blood samples found
IIIV +Ve
0
6
32
58
86
168
868
425
439
697
847
1,023
1,319
1083
7,051
AIDS cases
0
2
1
1
1
2
9
15
12
22
58
44
200
215
582
Death due
to AIDS
0
2
1
1
1
2
9
13
12
7
17
12
20
6
103
The report received from Voluntary Blood Testing Centre, Kasturaba Medical College Manipal
&. Vijayanagar Institute Medical Sciences Bellary on HIV Cases , AIDS Cases & Death due to AIDS
during the month of March 2000 & June 2000 .which was related the year 1999 is compiled accordingly.
NATIONAL AIDS CONTROL PROGRAMME
AIDS CASES SURVEILLANCE REPOR T
Name of the State
Reporting Month
KARNATAKA
I.Morbidity & Mortality Data
During the Month
F
M
10
36
No of AIDS Cases
TOTAL
46
July 2000
During the Year (from January)
M
F
TOTAL
170
45
215
No.of AIDS Deaths
1
0
1
5
1
6
Children
0
0
0
0
1
1
Adults
1
0
1
5
0
5
II. AGE/SEX Distribution of AIDS Cases
Male
Age in Years
0-5
6-14
15-19
20-29
30-39
40-49
50-59
60 +
Not Specified
Total
0
2
0
7
12
6
4
5
0
36
Female
Not specified
Total
0
0
0
3
4
2
1
0
0
10
0
0
0
0
0
0
0
0
0
0
0
2
0
10
16
8
5
5
0
46
III. Risk/Transmission Categories
Adult
Children
- Sexual Route
- Through Blood & Blood products
- Through infected syringes & needles
- Others
- Not specified
- Perinatal
- Through Blood & Blood products
- Others
- Not specified
Male
33
0
0
0
1
1
0
1
0
Female
10
0
0
0
0
0
0
0
0
Total
43
0
0
0
1
1
0
1
0
VI. Frequency of Presenting Sign and Symptoms
Sl.No.
1.
2.
3.
4.
5.
6.
7.
Presenting Sing / Symptoms
Weight loss
Diarrhoea
Fever ( Low grade )
Asthenia,Fatique &Malaise
Caugh
Presistent Generalized lymphadenopathy
Others, Specify
Male
7
7
21
5
12
5
3
No. of Cases
Female
2
3
6
2
5
0
0
Total
9
10
27
7
17
5
3
V. Opputunistic Infections
Sl.No.
1.
2.
3.
4.
5.
6.
7.
8.
9.
Opputunistic Infections
M. Tuberculosis
Candiadiasis
P.C.P
Cryptosporidium
Toxoplasma
Herpes
Kaposi Sarcoma
Parasitic Infections
Othres /Cryptococcal Meningitis
TOTAL
Date 31-08 -2000
Place:- Bangalore
Male
16
3
0
2
1
3
0
5
3
33
Additional
Karnataka state AIDl
No. of Cases
Female
6
0
0
0
0
1
0
3
0
10
Total
22
3
0
2
1
4
0
8
3
43
TI),
iety, Bangalore.
NATIONAL AIDS CON TROL PROGRAMME
MONTHLY REI’OR'I - BLOOD TESTING CENTRES
Name of the STATE:-
KARNATAKA
S
Number of Blood Testing in the State:-
Number of Reporting Centres :-
Month :- July
Year:-
5
1. Diagnosis of Clinically Suspected
2000
HIM/ AIDS Cases
1.1 Route of Transmission
During the Month
Cumulative since January
Route of Transmission
Samples
Screened
Samples
-Hive
Samples
Screened
Samples
■Hive
Sexual Route
765
104
4892
565
Through Blood & Blood
Products
Through Infected Syringes
And Needles
Perinatal Transfusion
22
1
186
9
11
0
112
4
18
1
159
25
Other (Specified)
50
5
407
45
Total
866
111
5756
648
1.2 z\ge <& Sex Distribution of HIV/AIDS Cases
Age Group in
During the Month
Years
Male
Female
Total
0-14
3
0
3
15-29
30-44
45 & above
Total
17
43
13
76
17
14
4
35
34
57
17
111
Cummulative
Male
Female
Total
18
138
257
54
467
9
92
58
22
181
27
230
315
76
648
2.Voluntary 111Testing
Age Group in
~ Years
Durin'.’ the Month
Samples 1'este.l
No. found -t-Vc
0-1-4
4
35
31
10
80
26
1391
171
106
1694
15-29
30-44
45 & above
Total
Cummulative
Samples Tested
No.found -l-Vc
126
3599
1502
526
5753
18
190
179
48
435
3.Counselling Services
i. Number of counselors Working
12
ii. Counseling Services
Male
No.of Persons
Counseled
Date 3 1 - 08 - 2000
Place Bangalore
1483
During the Month
female
Total
971
2454
Cummulative since January
Male
Female
Total
5934
5156
11090
AdditionalProjcpr'Direttqr (TI)
Karnataka state AIDS Prevention Society, Bangalore.
5. DISTRICT WISE HIV+VE CASES , AIDS CASES, DEATH DUE TO AIDS.
1987 to June 2000
July 2000
SI.
Division /
Cuinu
No. 1 Districts
Death HIV
-latixe
HIV
AIDS
AIDS
Death
Cases
due to
AIDS
2596
172
148
169
115
32
147
98
9
11
28
7
6
11
28
4
1
2
2
0
2
50
2
~7|
122
2
268
742
396
8
77
100
10
1
18
16
107
1
11
9
5
0
5
9
8
1
2
2
0
0
3
0
21
3
2
82
113
6
210
19
8
164
6
0
1
71
9
2
31
0
0
0
2
1
0
5
1
1
1
33
3
2
63
138
7
436
15
6355
4
10
2
9
1
489
490
15
6860
+Ve
BANGALORE DIVN.
1. Bangalore ( U)
2. Bangalore (R)
3. Tuinktir
4. Shinioga
5. Chitradurga
6. Davangere
7. Kolar
MYSORE DIVN.
8. Mysore
9. Chaniarajnagar
10. Mantlya
11. Mangalore
12. Udupi
13. Madikeri
14. Chickntangalore
15. Hassan
BELGAUM DIVN.
16. Bclgaunt
17. Bi jap nr
18. Bagalkote
19. Dharwad
20. Havcri
21. Gadag
22. Kanvar
GULBARGA DIVN.
23. Gulbarga
24. Raichur
25. Bidar
26. Bellary
27. Koppa!_________
KARNATAKA TOTAL
1.
2.
Other States
Foreigners
GRAND TOTAL
■
+Ve
Cases
due to
AIDS
2
0
0
0
0
1
0
0
0
0
0
0
0
0
2646
174
155
169
116
33
150
0
0
0
0
7
1
0
0
0
0
0
0
0
0
0
0
122
2
271
742
417
11
79
101
3
1
0
1
23
3
2
2
0
0
0
1
0
0
0
S3
114
7
243
22
10
167
3
5
2
0
0
89
0
4
0
43
0
185
0
1
0
0
0
44
0
0
0
■ 0
.0
1
63
142
7
479
15
6540
43
4
9
4
6
0
2
0
0
0
496
15
536
102
191
46
1
7051
0
1
~T|
3
1
(-.ACE
Age
Years
1 -10
11-20
21-30
31-40
41-50
51 & >
TOTAL
SEX WISE HIV POSITIVE CASES,AIDS CASES.DEATJI DUE TO AIDS
__________________ 1 ROM 1987 TO JULY 200(1_________________
Death due to AIDS
AIDS Cases
HIV + VE
Male
Female
Trial
Male
Female
Total
87
171
2416
1794
518
121
72
262
1052
394
134
30
159
433
3468
2188
652
151
11
9
199
194
56
26
7
5
39
21
7
8
18
14
215
63
34
1
0
33
36
13
2
1
2
8
5
0
2
2
2
41
41
13
4
5107
1944
7051
495
87
582
85
18
103
Male
Female
Total
238
Additionai-Pre;ect Dirccton (TI).
Karnataka state AID.J 7~\ention Socictv, E.anealorc.
( 0' '
*
£>-S’LL
GOVERNMENT OE KARNATaA
No. CMP/ m 2-98^»,
Office of the Dist.Hea]th & F'/7 Off i—
—Ends:
^zJcv/—cer, Kolar DLst, Kolar, Date;
To,
The Static tic al Officer,
B.H.I. (Section)
Dir®ctoraxo of Health & F. W. Services,"
Bengal or e-560009,
Sir,
Sub;
Submission of Monthly Progress report
for the Month of CAu Lv. ,
. W&-^2_
I am herewith submitting the Monthly Progessd report of
Healty. Condition report for the Month of
per-
taining to Kolar District for your kind information and needful-
U ClA<D^pD.t| pi]
p Cop
tours faithfully,
. L^£ey ^/c /V-Q • C -J). p
Sty c'/'
]3>cdtay^ R.oact
'
9-m h' vt
r a j/-
■
n*-
D^TOOkQ^^Roff i cer
KRiJtajet SH-rg^illnK^qJl
District
Sii\AKOlJAR-5331JJ
MONTHLY STATEMENT-’SHNOING INSTITUTION
CASES AND DEATHS DUE TO COMMUNICABLE DISEASES
>
’.in
Name of the District:
2.
' Mcrth/yearr.".~7v; vi ....
3.
Total Numbers of existing
Instifutiohs in Di'st'.
4
Total■Number of repopting
institutions in the month
ih-.Dist‘fict/U-T;
r
.Total'Number of Defaulting
.institutions in the month
Reported cases and. deaths-due to communicable diseases;
J
----!
3
Accute diarrhoel dieases
(including) Gastro inteit.
es ehd cholera.
(DCO
—
5
—
i
1
1
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<>
' I
try
4, Tetanus other than neonata.’
Name, of the District; .(.QW. ,
i • •
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1
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1
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.
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of the Diseases
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ed' disaases-'*I«,i.> . .
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8.‘ Date of .Japanese ;encephal'i'tieSpghoul^.’baliy^y^th':'’ '. furnish to national Maia^a‘:'fiiad^e^'^ph‘^i^^^mme\
9 J/l5ate ias ;yaccine preveme^tabie/^j'i^s.^sp's •«'hoiiip!‘ tally
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04 Sep 2001
Ref: CHC/M^-/2001
To,
Dr. N Devadasan,
National Surveillance Coordinator,
World Health Organisation,
New Delhi.
Subject: Disease Surveillance
Dear Dr. Devadasan,
Greetings from CHC!
Thank you for your prompt reply with the relevant information. The KHSDP (WB funded) has a
HM1S (State to taluk level, not including the PFIC’s) and rudimentary' surveillance but is yet to
develop fully.
I have spoken to the NICD regional office regarding the NSPCD and some of my comments arc
enclosed.
I feel that for effective disease surveillance, surveillance for symptoms (e.g. fever with rash for
smallpox and AFP for polio) is of paramount importance, if cases arc not to be missed. Also,
proper epidemiological investigation (preliminary and final), prompt reporting (including nil
reporting) and lab confirmation are essential/vital for any successful surveillance programme.
(Some of my rough jottings for surveillance arc enclosed for your valuable comments).
We would like to receive any further information regarding the integrated disease surveillance
programme (WB funded) which you have mentioned, and will definitely take you up on your
offer to involve you in future discussions with the state Government when it is scheduled.
I am also sending a copy of the final report of the Task Force on Health- GOK
Best regards to you, Roopa and the children, from all of us at CHC.
Thanking you.
Yours sincerely,
.s'"
D^Sruwpath K Krishnan
D.
Teltow (Training & Health Promotion)
P.01
I for ..
days-i ■
i ;■ ig . abler? I'raining wo kshop(fit nr 7.8.2000 to 9,8.2000 both■. Health md Famil) Welfare Fiaird . Centre, Magadi Road,
j.bc
Iji K.H.S.D.P.
A>;;sS a:id objectives ui the 3 days workshop are:-
7 j 1’ran on District Surveillance Officei and one Senior Laboratory Technician
each ;>.■ 2~ disinris {Tc-al 54 partiC’Ccnis) ir. laboratory investigation /
pox.T.du’-esobK;it p.-iruaiy rlealtl: Ceuire iTTlC) Latxjratories.
'? "op-.;: coriViV'.n.'ation t:;id supei visorv skills,
5 o enabfe tlv -i. i-.' i'ai-i
ulted laboratory rechnicians of their respective
PARTICULARS OF TRAINING PROGRAMMES PLANNED TO BE CONDUCTED FOR
VARIOUS CATEGORY OF HEALTH PERSONNELS IN THE STATE
1) Foundation Training to Medical Officers who are going to be
Recruited every year:In the Department on an average 200-300 Doctors being
recruited every year due to Superannuation and Voluntory
Retirement of Officers, etc.,
As they are coming fresh from
the Medical Colleges, they will not be aware of Administration
and Management Matters.
Further, they also need Orientation
towards all the on going National Health Programmes.
Hence,
it is desired to conduct Foundation Training to the Newly
Appointed Medical Officers for a period of six months.
This
six months Training includes 3 months of theory classes at
State -Institute of Health and Family Welfare and 3 months of
Field work at selected PHCs/Sub-Centres in the State.
The 3 months theory classes will be conducted at State
Institute of Health and Family Welfare, by the Faculty of State
Institute of Health arid F.W. and expert Guest Faculty from the
Department and outside.
During 3 months of Field work Medical Officers will work
at different levels as follows:-
a)
Sub-Centre Level:-
One week to get familiarised
with the workincr of Jr.H.A.(K
b)
F) .
At PHC Level:- They will work at PHC Level as
Sr.H.A.(F) for one week, Sr.H.A.(M) for one week
and R.H.E. two we^ks to g-=t acguanted with the
supervisory and guiding role of above said
Category of Staff (total 4 we^ks).
c)
He will also undergo Training in
p.H.C.
Adminis
tration and Managem'-nt for one month staying at
PHC with Administrative Medical Officer.
d)
At District Level:-
He will work at District
Laboratory for one week for skills of various
Laboratory tests.
2 :—
He will also work at District Hospital for acquiring
Knowledge and Skills in dealing with Medico-legal ' cases
including post mortem for two weeks.
These Newly Appointed Doctors will be attached to
State Institute of Health and F.W., Bangalore and the pay
and allowances will have to be drawn by State Institute of
Health and F.W.
The approximate pay and allowances of each
Newly Recruited Doctors at present rate will be around
Rs.12,000/-.
The total expenditure for 300 Doctors for
6 months will be Rs.12,000 x 6 months x 300 = 2,16,00,000/-
(Two hundreden sixteen Lakhs only).
As these 300 Doctors have to work at field for 3 months .
Their t.A during field duty will be at the rate of Rs. 500/the
approximate/person, so for:300 Doctor total, T.A. Expenditure
will be Rs. 1,50, 000/-. (Rs. One lakh fifty thousand only)
The daily allowances payable during these 90 days at
the rate of Rs. 200
per day(at current rate)will be Rs. 54, 00, 000/-
3 :Inservice Training for Medical Officers of less than
II.
6 years of Service at Health and F.W.Training Centres
for one month:Inservice Doctors need Re-Orientation Training in
Health
various National1Programmes periodically to up-date their
and
knowledge: skill so that the Programmes are Implemented
effectively.
Hence, it is desired to have one month Inservice
Training fbr above Category of Staff at Health and F.w.
Training Centres once in every five years.
At present
total strength of General duty Doctors is approximately
about 2000 and every year about 400 Doctors are to be
Trained.
There are 4 Health and F.W.Training Centres in
the State and each Health and F.W.Training Centres has
to train about 100 Doctors every year.
They will have to
conduct about 3 batches in a year in batch size of 30 each.
The total cost per batch will be 3s. 2,70,000
approximately
and total cost for Training of 2000 Doctors at 04 Health and
F.W.Training Centres in 70 batches will be' 3s. 1', 39,00,000.
details are enclosed in an AnnexureIII.
Hospital Management and Programme Management Training
2 weeks each to Specialists and Sr.Specialists:A. There are about 1500 Specialists(6 to 13 years service)in
the State-They need re-orientation Training once in 5 years in
Hospital Management and Programme Management of 2 weeks each
(totally 4 weeks).
These 1500 Specialists have to be trained
at 04 Health and F.W.Training Centres at the 'rate of about
400 Specialists per Health and F.W.Training Centres during
5
years period.
The total batches per year per Health and
F.w.Training Centres will be about 3 of 30 persons.
cost per batch is Rs. 1,35,000
The
and the total cost for 50
batches for 5 years period will bo b.
67,50,000.
4
4
There are about 1500 Sr.Specialist(13 years and above
B.
service) in the Department.
They need Re-orientation
Training once in 5 years in Hospital and Programme and
:2
Management of:weeks each(total 4 weeks).
These 1500
Sr.Specialists have to be trained at State Institute of
Health and F.w., Bangalore in 50 batches over a period of
5
years.
Each year 10 batches will have to be trained.
The cost per batch will be Is. 1,35,000
and cost for total
50 batches pver a period of 5 years will be Rs. 15,00,000.
IV.
Orientation Training in Administration and Programme
Management to District Health and F.W.Officers/Dist.
Surgeons and Dy.Directors for a period of 3 weeks at
State Institute of Health and F.w,:There are about 100 Officers in the above Category.
They are holding key posts of Administration at District
and State Level and also they are the main Implementing
Officers of the Programmes.
Hence, they need Orientation
Training in Administration and Programme Management for a
period of 3 weeks at State Institute of Health and F.W.,
once in 5 years.
Each year one batch consisting of 20
persons will be trained.
The cost per batch is Rs. 1,66,000
and for all 5 batches is Rs. 8, 30, 000.
Trainer of Training(TOT) in Training Technology for
Faculty of State Institute of Health and F.W./’
Health and F.W.Training Centre/District Training
Centre/L.H.V.Training Centre/A.N.M.Training Centres:The Faculty of above said Training Centres are involved
in imparting Training to various Category of Staff.
need for enhancing the teaching and Training
skills
There is
of
these Staff.
The teaching faculty of State Institute of Health and F.W.
and Health and F.W.Training Centre have to be trained outside
the State in Nationalyrecognised Training Institutions and
also some at Abroad.
5
5 :V(B) .
Similarly, Faculty of District Training Centres, L.H.V.
Training Centres and A.K,M.Training Centres have to be trained
at State Institute of Health and F.W.
There are 19 District
Training Centres, 19 A.N.M.Training Centres and 4 L.H.V.
Training Centres in the State and the total Faculty will be
about 150 in these Training Centres.
5 batches in one year itself.
They will be trained in
The cost per batch is Rs.72,500,
and for 5 batches is Rs. 3,62,500.
y
VI.
'
Specialised Skill Based Training in Specialities
like Cardiology, Endoscopy, Trauma Care, I•C.C.U.,Etc.,:-
There are about 600 Specialists with P.G.Qualification
in various Specialities.
Since Medical Technology is fast
developing the Specialists have to be hope-up with recent
Technologies and Skills.
Hence, they have to be trained
in their respective Specialities once in 5 years at selected
Institutions in India and Abroad for a period of one month
x
VII..
Non-Technical Group - 'R' Officers like Lay Secretaries/
Gazetted Assistants:The L'ay Secretaries/Gazetted Assistants are working in
District Hospitals/District Health and F.w.Offices/Taluk Health
Offices, other Offices of the Departments.
They are assisting
the Officers in Administration and Hospital Management including
They
Programme Management;have to be trained in the above matters for
a period of 4 weeks at Health and F.w.Training Centres once in
5 years.
There are about 150 Group 'R' Officers’ and they are to be
trained in any one of the Health and F.W.Training Centres
preferably at
Bangalore in 5 batches over a period of 5 years
The cost per batch will be Rs. 2,17,500,
and for 5 batches
will be Is. 10,87, 500 .
6
•/III. Training to Technical Supervisory Officers like District
Health Education Officers/District Nursing Officers/
Dy.Health Education Officers/Asst.Statistical Officers/
A.L.O and Health Supervisors etc., in I.E.C Strategy
and Programme Supervision'for 2 weeks at State institute
of Health and F.W., Bangalore:There are about 250 Technical Supervisory Officers
- to
attached to District Health and F.W.Offictt and:'some Programme
Officers. Since, I.E.C Component has become very important tool
for effective and quality Implementation of the Programmes
these Officers are to bn trained in I.E.C.
Strategy and
Programme Supervision . They will be trained at State Institute
of Health and F.W.
for a period of 2 weeks once in 5 years.
So these Officer have to be trained in 9 batches over a period
of 5 years.
The cost per batch will be 1.1,16,250 and for 9
batches total cost will be b. 10,46,250.
IX.
Orientation Training to Jr.Health Asst.(F & M) for 3
weeks at District Training Centres:-
These Hale and Female Health workers are working at gross
root level of the Department and are actually responsible for
effective Implementation of the various Health Programmers.
To make the Programmes gualitativ ly Superior and also accept
able to Community, these gross root level 'Workers are to be
re-oriented once in 5 years for a period of 3 weeks at Dist.
Training Centres.
There are about 10,000 Jr.Health Assts(F) and 6,000 Jr.Health
Assts(M) in the Department.
They have to be trained once in 5
years in 19 District Training Centres.
These 16,000 Officials
are to be trained in 533 batches of 30 participant each and 19
District Training Centres have to train 6 batches every year.
The cost per batch will be b. 1,04,250 and for total 533 batches
cost will be ib. 5,55,65,250.
X.
^e-orient.a t ion Training to Supervisory Staff like
Sr.Health Assts(M a
f)/B.H.E1s/N.MS.
etc.,
for period
of 2 weeks at District Training Centres:-
7
There are about 4,000 Supervisory Staff of above
are
Categories. They:involved in guiding, Supervising and
Monitoring of various Programmes Implemented by Jr.Health
Assts(M & F) .
Hence, their Supervisory Skills have to be improved
: and they have to be
:trained at District Training Centres for a period of 2 weeks
Once in every five years.
They will have to be trained in
133 batches over a period of 5 y°ars in 19 District Training
Centres.
The cost per batch will be
74,250
and 133
batches total cost will be Is. 98,75,250.
XI(A)
A.
LABORATORY TECHNICIANS:-
Induction Training to Newly Appointed Lab Technicians:-
It is expected that about 1,000 Jr.Lab.Technicians are going
to be recruited/appoirited in the corning years.
Most of these
Technicians are trained in Private Institutions,
they have to
be inducted to manage the Laboratory work of Hospitals
including Special Skills of examining Smears for Malaria,
T.S. and Leprosy etc.,
These Technicians are to be trained in Medical Colleges
and Public Health Institute, Bangalore for a period of 4 weeks
The total cost will be around .b. 43,12,500.
XI (
bJ
Inservice Re-orientation Training to Lab Technicians: -
There are about 1,500 Inservice Lab. Technicians in the
Department aril they n-^ed Orientation in improving their Labora
tory testing skills once in 5 years.
They have to be trained
in District L^boratory/Dist-. Training Centres for a period of
.
X
2 weeks in batches 10 participants each.
Total batches will
be 150 in 5 years.
The cost per batch will be 3s.28,750,
and for 150 batches will be Is. 43,12,500.
—: 8 : —
XII.
Orientation Training to Pharmacists ah District Training
Centres and Hospital based for 2 weeks:-
The Pharmacists are working in the various Health Insti
tutions like Primary Health Units/Primary Health Centres/
Community Health Centres/Taluk Hospitals and District Hospitals
They are responsible for maintainance of stores and stocks.
They are also responsible for maintaining disease statistics
and dispensing of drugs.
As these are very vital functions
these Pharmacists are to be given re-orientation for 2 weeks.
This Training should involve Clinical Pharmacy, maintainance
of Disease Statistics etc.,'
There are about 2,660 Pharmacists(Junior and Senior)
working in the Department.
They should be trained at District
Training Centres along with Hospital based Training.
The
Assistant Drug Controller ofDistricts should be involved while,
getting this Training, Duration of this Training should be 2
weeks, once in every five years.
These 2,660 Pharmacists will be trained in 266 batches of
10 participants each over a period of 5 years and yach District
Training Centre has to conduct 3 batches every year.
cost for one batch will be
. 28, 750
The total
and for 266 batches for
5 years will be >is. 76,47, 500.
XIII.
REPRACTIONISTS:Orientation Training to Refractionist for a- period of 02
weeks at Minto Hospital, Bangalore.
There is need of enhancing the knowledge'and skills of
Refractionists working in various Hospitals.
in vital National Blindness Control Programme.
'They are involved
They have
be
trained for 2 weeks at Minto Hospital, Bangalore, once in
5 years.
There are 515 Refractionists working in the Department.
Tney will be Trained
.in 52 batches of 10 participants each
over a period of 5 years.
The cost per batch will be Rs.38,750
and for 52 batches will be .to.20, 15, 000.
. .
. 9
9 :-
ORIENTATION TRAINING TO STAFF NURSES:-
A) General Training to all Staff Nurses is required for one
week once in a 5
years^
So that their Knowledge and Skills
in maintaining wards and patients care is enhanced.
Hence, it is proposed to train about 5,317 Staff Nurses
(Junior and Senior) at District Hospitals for one week, in
batch size of 10 participants.
The total batches will be
532 over a period of 5 years in 27 District Hospitals.
iTer,
each District Hospital has to train about 4 batches per year
The total cost per batch will be its. 13,000
and for 532
batches will be .is. 69,16,000.
Orientation Training to X - Ray Technicians for one
week at Medical Colleges and District Hospitals
attached to Medical Colleges:-
There are 375 X - Ray Technicians working in the
Department and they will be trained for one week at 10
selected Medical Colleges/District Hospitals.
They will be
trained in 190 batches of 2 participants each in 10 centres for
one week over a period of 5 years i.e., 4 batches per centre/
year.
The cost per batch will be Rs.
5,000
and total cost
for 190 batches will be Rs. 9,50,000.
Training to First Division Assts and Second Division
Assts. in record keeping at District Training Centres
for one week:There are 3,746 First Division Assts.and Second Division
Assts. in the Department.
They will be trained in record
keeping for one week at 19 District Training Centres, over a
period of 5 years.
They will be trained in 125 batches of
30 persons each and each District Training Centres will be
Training 1-2 batches per year for a period of 5 years.
The cost per batch will be Rs.
33,000
and total cost
will be Rs. 41,25,000.
10
10 : Information-Technology Skill Training to Faculty of State
Institute of Health and F.'J./Health and F.W.Training Centres:-
Karnataka is pioneer State in Information Technology in
India.
The use of Computer in Monitoring the various Training
Programmes in the State is very exxrantial.
Hence, the Faculty
of State Institute of Health and F.W./Health and F.W.Training
A
Centres have to be trained in Information Technology.
There
is need to develop Computer Centre at State Institute of Health-
and F.W./Health and F.W.Training Centres.
Computer Training to different Category of Health Staff:There is need to train various Category of Staff in basic
Computer Training at District Level to copy up with Information
Technology Advance.
F.D.As/S.D.As/Gazetted Assistants/A.S.Os/
Medical Officers/Taluk Health Officers/Distriot Health and F.w,
Officers and State Level Programme Managers have to be trained
for minimum of 2 weeks.
PLANNED VARIOUS
STATEMENT
IN_ the state' (KARNATAKA)
•
S,1
NO.
. ....NING PROGRAMSMES TO THE CATEGORY OF HEALTH PERSONNELS
i.
Name of the Training Programme
Category of
Personnel
Duration
No. of
Pers
ons
Venue of
Training
Batch
size
PER BATCH EXPENDITURE
Total
(Calculate as per IPP-IX(K) Expenditure Norms)Batche s
Total
Funds
required
Remarks
15
T.A.
D.A.
Honorarium
to Guest
Faculty
Contingency
Total
7
8
9
10
11
12
13
14'
3
4
5
6
01. Foundation Training to Medical
Officers(Newly Recruited)
Medical
Officer
06
months
300
SIHFW &
Periperal
Institute
02. Inservice Training for Medical
Officers of less than 6 years
of Service.
1!
30
days
2,000
HFWTC's
30
15,000
1,80,000
30,000
45,000
2,70,000
70
1,89,00,000
03^ a)Hospital Management and
Programme Management Training
to Specialist.
n
02
weeks
1,500
I)
30
15,000
90,000
12,000
18,000
1,35,000
50
67,50,000
03^ b) Hospital Manag .ent and
Programme Management Training
to Sr.Specialist
ii
1,500
SIHFW
30
30,000
90,000
12,000
18,000
1,50,000
50
75,00z 000
04. Orientation Training in Admini
stration and Management to Dist.
Health and F.W.Officers/Dist.
Surgeons/Dy.Director,
D:st./
Sc ate
Level
Officers
100
SIHFW
20
40,000
84,000
21,000
21,000
1f 66,000
05
8,30,000
1
2
* 0&i> a)T.O.T.for Faculty of SIHFW/
HFWTC
Faculty
05(P?b)T.O.T.for Faculty of DTC/
ANMTC/LHVTC
"
* 06. Specialised Skill Based Training
in Specialities like Cardiology,
Endoscopy, Truma Care, I.C.C.U
21
days
Specialists
150 ' SIHFW
600
30
30,000
30,000
5,000
7,500
72,500
05
Il
■300 Specialis
have to be
trained every
year.
one batch in
a year.
Budget not
calculated
26
They should be trained in any of the Institute in India or Abroad.
(4 from each
HFWTC, 10
from SIHFW)
05
days
400 M.Ob have
be trained ei
*
year.
3,62,500
They should be trained in their Speciality wise in 5 ye ars, in any of the
recognised Institute in India or Abroad.
All of them ha
to be trained
in a year
Budget not
calculated
G.A/Lay
Secretary
30
days
150
HFWTC
30
30,000
1,12,500
30,000
45,000
2,17,500
05
10,87,500
30 persons havt
to be trained i
a year.
08. P'r-tgtrawne Supe-rv^silKSn Train'd ng
DHEO/DNO/
Dy.HEO/ASO/
al®/k. s.
02
weeks
250
SIHFW
30
30,000
56,250
12,000
18,000
1,16,250
09
10,46,250
60 persons have
to be trained i
a year.
09. Orientation Training
Jr.H,A.Cm)
and(F)
03
weeks
16,000
DTC
30
3,000
78,750
9,000
13,500
1,04,250 533
5,55,65,250
06 batches havto be conducte
in each DTC,
each year.
07. Programme Management
2
1
4
3
2
5
6
7
8
9
10
11
J2
13
1,500
D.T.C.
■ 30
3, 000
56,250
6,000
9,000
74,250
133
98,75,250
■
■
14
10. Re-orientation to SupervisoryStaff .
Sr.H.A.(M)
02
and(F)/BHE/ weeks
Etc.,
Ila) Induction Training to Newly
Appointed Lab.Technicians
Lab-Technicians
”
1,500
"
10
1,000
18,750
6,000
3,000
28,750
150
43,12,5000 300 persons hav
to be trained i:
each year.
ll.b) Re-orientation Training to
Inservice Lab.Technicians
1!
II
1,500
"
.10
1,000
18,750
6,000
3,000
28,750
150
43,12,500
n
12. Orientation Training
Pharmasist
"
2,660
"
10
1,000
18,750
6,000
3,000
28,750
266
76,47,500
500 persons
to be traind^Qeach year.
13.
Refractionist
"
515
Minto
Hosp.
10
5,000
18,750
12,000
3,000
38,750
52
20,15,000
100 persons hav>
to be trained ii
each year.
14.
Staff Nurse
06
days
5, 317
15.
X - ray
Technicians
”
375
"
FDA/SDA
"
3,746
DTC
16 •
"
&
DTC/
10
Dist.Hosp.
1,000
7, 500
3,000
1,500
13,000
532
69,16,0G0
1000 persons hato be trained i
each year.
,02
200
1,500
3,000
300
5, 000
190
9,50,000
80 persons have
to be trained ii
each year.
30
3, 000
22,500
3,000
4,500
33,000
125
41,25,000
750 persons hav
to be trained i
each year.
Total
12,61,95,250
a) Salary and allowance to the Doctor s of Sl.No.l, 12,000 Pay x 6 months x 300
x 5 years)
b
b) Amount required for■ the component of T.A of Sl.No.l
c) Amount required for■ the component of D.A . of Sl.No.l
10,80,00,000
7,50,000
54,00,000
24,03,45,250
*
Budget could be calculate .f°r SI .No. 5 (A) & 6 Training Programmes as and when
the Training started.
02 batches to t
conducted in ea
DTC, in a year.
RESPONSE FOR THE DISCUSSIONS HELD ON JULY 5TH, 2000
IM CONNECTION WITH HEALTH, NUTRITION AND POPULATION FOR KARNATAKA
A PROJECT TO BE INITIATED WITH WORLD BANK ASSISTANCE.
1.
What Is the Rationale of the Project ?
To bridge the gap between the existing situation and the expected outcomes
2.
How do you initiate to identify the gaps?
By considering the data from :
JUh
* NFHS- 1992-93 - 1st round
* NFHS- 1999 -llnd round
* Disaggregated data - RCH survey -10 Districts-1998
RCH Survey- 20 Districts -1999
3.
What supplement is required to complete the picture of "gaps" ?
* Mortality and Morbidity data of communicable and Non communicable diseases
across the districts.
4.
What are Medico - Social Problems apart from poverty and illiteracy ?
* Low age at Marriage
* Anaemia
* High unmet need interms of spacing
5.
What are Priority problems of the State ?
* High perinatal mortality - High IMR
* High Child Mortality
* High Maternal Mortality
* Epidemics of Malaria, Japanese Encephalitis, Kasanur Forest disease, Dengue,
* Low immunization coverage levels
* Low levels of Institutional Deliveries
6.
Would you like to keep a uniform package of project interventions for the
entire state ?
Cluster District Approach needs to be adopted to take care of Regional Imbalance
as determined by baseline data of the district.
7.
Any thing about subcentre functioning ?
’ ANMs are overloaded with mui’ifarious activities
* Allocation of population should be reduced or activities restricted to no.of house
holds
-2-
* A trial should be given to upgrade the functioning of subcentre for “ Institutional
Services” instead of routine "outreach services"
* Jobs and responsibilities should be redefined to be more accountable
Does the project incorporate the issues contained in the National Nutrition Policy.
National Health Policy and National Population Policy ?
TO BE ADDRESSED ..
What is the crucial issue in setting right Regional imbalance ?
A separate organizational a structure of personnel with Non Medical Public Health
Z’zC’5
Managers who will closely work with the Health System should be considered.
Any thing to say about Primary Health Centres ?
The Needs of the people for PHC services should be assessed
Demand for Drugs should be assessed
* Higher inputs for atleast 50% of the Institutions to make them to provide round the
clock services.,
Mobility of the staff and Physical facilities should be supported
Which are priority training programmes ?
* Dai training
* IUD training
* Training for PRI's
* Public Health Training for all Doctors
12.
What is the answer to improve the Health in the Urban slums ?
.
* Contractual services
rfe. e.g.: Immunization by private sector on payment basis
13.
What others need strengthening ?
* Non communicable diseases - Mental Health, Diabetics and Disability Cancer
Heart diseases etc.,
14.
How do you rationalise curative care in PHCs ?
* Treatment protocol for each sickness I diseases eg. : Malaria , Pneumonia,
Diarrohoea, TB, Respiratory infection, Gl diseases, General weakness.
The treatment protocol should be uniform and documented and be made available
to all Doctors.
15.
What is lacking
at PHCs for creating
awareness through
Inter Personal
Communication ?
■ xX
16.
* Counselling centres with good counselling techniques and personnel
How do you create demand for services ?
* We must take each priority issue as a campaign approach through vigorous IEC
activities on the lines of Pulse Polio Immunization Programme,
* Lar9e no.of Health Educational Materials both for the staff and community
17
How can we ensure better and fast results ?
Quality assurance
v * Indicators of quality
* Who will measure ? How often ?
* Instrument for measurement
18.
Is there any better strategy to bring down Maternal death rates ?
* Focussed attention to the "Safe Motherhood"
* Separate "preventive care" structure of Doctors to take care of ANC registration,
identification of High risk pregnancy, referral, follow up etc.,
19.
Is there any scope for better utilization of work force?
Yes, redefining the roles and responsibilities of BHEs, Pharmacisits, Projectionists,
will result in optimal utilization
20.
Which areas NGO could support ?
a.
Area approach
b.
Gap filling e.g.: Immunization
c.
Awareness building
d.
Training of community volunteers
ox>>/e- Referral Services
V f. Contractual Services.
Director
Health & FW Serivices
AR. Circle, Bangalore
Identification of Specific Essential Public Health Functions
The Round 2 Questionnaire focused on reaching consensus on a list of Essential
Public Health Functions. The respondent group was presented with a generic list of 46
public health functions, which were categorized under the following main headings:
• Monitoring the Health Situation
• Protecting the Environment
• Health Promotion
• Prevention, Surveillance, and Control of Communicable and Non-communicable
Diseases
• Occupational Health
• Specific Public Health Services
• Public Health Legislation and Regulations
♦ Personal Health Care to Vulnerable/High Risk Groups_______________________________
Essential Public Health Function
Prevention, surveillance, and control of communicable and noncommunicable diseases
• Ensuring immunization coverage
• Ensunng disease outbreak control
— • Ensunng disease surveillance
• Ensunng the prevention of injury_________________________________
Momtonng the health situation
• Ensunng the monitonng of morbidity and mortality
• Ensuring the monitonng of the determinants of health
• Ensunng the evaluation of the effectiveness of promotion, prevention and service programmes
• Ensunng the assessment of the effectiveness of Public Health Functions
• Ensunng the assessment of population needs and nsks to determine which subgroups require
services_________________________________________________
Health Promotion
• Ensunng the promotion of community involvement in public health
• Ensunng the provision of information and education for health and life skill enhancement in school.
home, work and community settings including the use of mass media
• Ensunng the maintenance of linkages with politicians, other sectors and the community in support
of Health Promotion and public health adwcacy
Protecting the environment
• Ensunng the production and protection of, and access to, safe water
• Ensuring the control of food quality and safety
A- Ensunng the provision of adequate drainage, sewerage and solid waste disposal services
. , ' Ensunng hazardous substances and wastes are adequately controlled
" .'•■ • Ensunng the provision of adequate vector control measures
* Ensuring the prevention and control of atmospheric pollution
Public health legislation and regulations
——
• Ensuring the review, formulation and enactment of health legislation, regulations and
administrative procedures
• Ensunng health inspection and licensing
• Ensuring the enforcement of health legislation, regulations and administrative procedures
~
Occupational health
• Ensunng the setting of occupational health and safety standards
Specific public health services
• Ensuring school health services
• Ensuring public health laboratory services
• Ensuring emergency disaster services
___________
Personal health care to vuinerabie/high risk populations
• Ensuring maternal and reproductive health care and family planning
• Ensuring infant and child care
WHO DELIVERS THE
_____CARE?_________
PRIMARY HEALTH CARE
SATISFACTORY?
UNSATISFACTORY?
WHY
UNSATISFACTORY?
• Accessibility problems
• Ignorance
• Poverty
• Poor Reception
• Lack of trust
SOLUTIONS
PATIENTS
• Education as to their
rights
• Improved accessibility
• Health care at the door
• Better interaction
• Health education
• Primary health care
teams
oOn govt, medical service
oOn voluntary organizations
o On private medical
practice
0OCTORS
e No personal stake
o Corruption
□ Arrogance
o Poor training
□ Lack of commitment
o Lack of motivation
SOLUTIONS
DOCTORS
• General medical practice a
separate specialty
• Promotional opportunities for
PG GPS [NBE,MD In F.M]
• Instilling a sense of pride
o Eradication of corruption???
• Patient is a person with dignity
Education
doctorsjcontd.]
Education
Doctors [Contd.]
,\ Should have a stake in running the
unit
• General practice. Speciality?
x This could be personal/financial
o Depts, of General Practice in Medical
Colleges
x Unit can be run by groups of local
and trained GPs
x Involvement of peoples
representatives in the management
x Doctor as a public health person and
a team leader.
PEOPLES
INVOLVEMENT
• Incentives to the post graduation in GP
• Grades of service same as other
specialists
« Additional incentives
o Encourage Gonoral Medical Practice as a
career.
PRBVATE ME05CAL
PRACTICE
, ~-—T
x Monitoring the activity of the health
team
o Satisfactory?
x Right to demand and access to
records
o Unsatisfactory?
x Stake in running the institutions
x How not to corrupt officials
x leam to treat doctors as their friends
x Self management of illnesses
From whose point ot
view?
o Mine
a General public’s
MY VIEW
a Very Unsatisfactory.
WHY
. NOT COMPREHENSIVE
PEOPLE’S VIEW
. SATISFACTORY??
. NOT ROUND THE CLOCK
o INEFFICIENT
• OVERMEDICATION
. SYMPTOMATIC TREATMENT
• UNEDUCATED.
Peopie’s view contd.
o APPROACHABLE
> KIND
O PRODUCES RESULTS
« COMES TO THE HOMES
. KNOWS THE FAMILY
» LIVES IN THE COMMUNITY
WHAT THEY DONOT
KNOW
O HE PRACTICES OUTDATED
MEDICINE
o HE OVERTREATS
» UNDERDIAGNOSES
O HIDES HIS IGNORANCE
EFFECTIVELY
» TAKES CUTS FROM OTHERS
WHY THEY DONOT
KNOW?
• LACK OF EDUCATION
• INABILITY TO DEMAND
QUALITY SERVICE
. APATHY
■ DOCTORS HAVE KEPT THEM
THAT WAY?
3
WHY?
WHAT IS THE SOLUTION
x Knowledge that they are not true to
their professional ethics
x BE COMPETENT AND UPTODATE
x PROVIDE COMPREHENSIVE SERVICE
x Working in professional isolation
x START CROUP PRACTICES
x No avenues of professional
advancement
x PURPOSE BUILT PREMISES
x Insufficient financial returns
x 24 HOURS COVERAGE
x DONOT EARN UNETHICAL MONEY
x Loss of paying and educated
patients to other doctors
THANES YOU
FOR A PATIENT HEARING
4
A pro osa! for CHC to work with the Department of Health and Family
Weh’aie (DHi-W) to develop strategic approaches towards a comprehensive
health care system for the State, that will be pari of a project proposal to the
World Bank for the next phase of funding.
A discussion note for the EC meeting on 19th June 2000.
1.
Background
1.1
The Commissioner of Health & Family Welfare, Mr. Sanjay Kaul, in a first meeting
on 1st June 2000, and in a subsequent meeting with the CHC team and
consultants, on 5th June, requested CHC to become a partner with the DHFW and
STEM (a consultancy group) in developing the above project proposal.
1.2
.
Karnataka currently has a relatively small number of projects (all sectors) with
World Bank funding. Those pertaining to health are :
a&b)
India Population Project (IPP) VII and IX (primarily geared to infrastructure
support for population/ family planning/ MCH/ work in urban and rural
areas respectively).
c)
The Karnataka Health Systems Development Project (KHSDP) for
strengthening of secondary level health care institutions (taluk and district
general hospitals).
d)
RCH (Reproductive & Child Health
)
e)
HIV/AIDS - through NACO
) as part of the National
f)
Blindness control
) Programme
g)
RNTCP - State proposal currently under preparation and negotiation.
These projects cover specific components of the State Health Systems and have
functioned in relative isolation with duplication of efforts. Several of the bigger
projects (IPP VIII, IX, KHSDP) are nearing the end of the project cycle. They have
performed reasonably well mainly in the area of brick and mortar infrastructure
building and to some extent in training, development of manuals and HMIS system
for secondary care institutions. Health Directorate staff express having not felt
involved as a whole. The vision in terms of health gains, in decision making and
planning health agendas and activities have not been clear and have got further
lost in the process of implementation. Utilization of funds has been low e.g., 33 %
in IPP IX and 50 % in KHSDP indicating a low implementation capacity and
unrealistic planning.
1.3
There are fiscal constraints in the Government of Karnataka with only Rs 15-20
crores being available for services per annum in the DHFW, for the entire State,
after payment of salaries etc. Government of Karnataka is therefore planning to
approach the World Bank for another project in Health & Family Welfare going up
to Rs 750 crores, over a 5 to 7 year period, commencing probably from 2001-2.
1.4
The present government has proactively approached the World Bank for funding to
several sectors and being one of the ‘reforming" states is likely to receive
preferential attention.
1.5
The DHFW, Government of Karnataka will use the recommendations of the
Karnataka Task Force on Health and Family Welfare (KTFH) in the project
proposal. It has already used the Interim Report to prepare a base paper for the
last visit of the World Bank team. It states that it is interested in evolving a
comprehensive, integrated health policy and approach. The World Bank is also
moving in this direction with its Health, Nutrition and Population (HNP) department.
:2:
2.
Proposal to CHC
2.1
This has been through discussion so far. If CHC is agreeable, we have to write
our own Terms of Reference (TOR) very soon.
2.2
The specific request is for CHC to help the State Government, DHFW, to develop
and write up operational strategies by which a comprehensive health, nutrition
and population policy can become implementable through existing public,
voluntary and private health service providers.
2.3
This will require analytical working that derives from documentation and studies of
the existing system, an identification of needs and gaps, and adequate justification
or rationale for whatever strategies are proposed.
2.4
Time frame:
The final project document should be ready by July to September
2001 (possibly by March 2001). More immediately there is need for an initial
concept paper for a first round of discussion, around 17lh July, between World
Bank staff (Dr. Nawaz/ Dr. Peter Heywood) and the government.
The process of evolving a World Bank proposal involves frequent Mission visits,
many revisions, pre-appraisal, appraisal and finalization.
The actual project
period is for 5 to 7 years.
2.5
There could be 3-4 people taken on to work full time on this project. It was
suggested that we calculate person-months required and work around it for CHC
to put up a TOR covering objectives and specific tasks required to develop a
strategy document for Health, Nutrition and Population.
A project proposal could be developed covering person time, infrastructure
support, field work, number of short studies necessary, travel, computer time,
office staff time, stationery, etc.
2.6
Linkages:
A Project Preparation Committee of 10-15 members will be set
up with senior government Directorate staff and others. It was also suggested that
we could link up with a strategic group of researchers through Strategic
Management Board, as was done in U.P.
STEM Consultancy will be a partner and will develop unit costs, actual positions,
etc. the relationship with these structures will need clarity.
The Strategic Planning Cell of KHSDP and the planning body in the Directorate,
will need to be involved and strengthened through this process.
2.7
Dialogues and communications with the Task Force and Task Force Studies will
need to be close. This project proposal will in fact be operationalising the
recommendations of the Task Force.
2.S
Mechanisms will need to be set up for regular discussions/ communications
between the CHC group working on the proposal, with the concerned Secretariat &
Directorate Staff, with a larger group of researchers/ institutions who will be
contributing to this process.
2.9
A process of consultation/ discussion with the CHC team and the EC will be
undertaken before responding to this request. If we do take on this responsibility,
it will impact greatly on existing and ongoing CHC work. This will need discussion.
Our other major partners will also need to be kept informed.
TRAINING IN HEALTH MANAGEMENT
GOAL:
•
To develop managerial skill and technical competency among government
health functionaries in Karnataka through problem based, Task Oriented and
Participatory Learning Techniques.
(“A shift in emphasis from form filling to the actual utility of the health activity1')
PROBLEM STATEMENT:
*
The curriculum for basic MBBS degree does not adequately prepare a
person to handle managerial responsibilities of the Primary Health
Centre.
•
Training in medical colleges is often inadequate in the actual field level
management of National Health Programs and implementation of National
and State level policies.
■
Introduction of Medical Ethics as a compulsory subject in medical
colleges is a recent directive of the Health Sciences University.
■
Forensic Medicine and handling of Medico-legal cases is very often dealt
with only theoretically, with little or no actual practical experience in the
medical colleges.
*
Medical Officers in position often have inadequate technical support and
no definite contact person or contact Institute for help in management of
day to day problems or issues that arise at the primary Health Centre.
■
The change in position from PHC medical officer to higher administrative
levels is not always accompanied by adequate training in additional
administrative competency.
*
Continuing Public Health Education programs are very often not available
and if available are not adequately utilised by the medical officers.
□
Promotion from ANM to Lady Health Visitor is not always accompanied by
any formal additional training in administrative skills.
1
OBJECTIVES:
♦ To train doctors who have just been recruited to government primary health
centres/urban health centres in administrative skills to manage staff and
.activities at the given centre through problem based and participatory
learning techniques.
♦ To train these doctors in grass root level implementation of National Health
Programs and the National and State level Health Policy through guided
discussions, simulation exercises and exposure to field level activities.
❖ To sensitise doctors in the government health system to ethical and legal
issues relevant to their practice.
♦ To make the medical officers aware of the continuing public health education
facilities available and incentives offered for successfully completing the
same.
♦
To train doctors in additional administrative skills when they have been
promoted to higher administrative levels.
□
To train the LHVs in additional administrative skills when they have been
promoted from the post of ANM.
‘TYPES’ OF TRAINING:
♦> Continuing Public Health Education:
Continuing Public Health Education is a necessity and medical officers attending
these programs must be given incentives in the form of additional increments.
Continuing Public Health Education may be through:
♦ IGNOU (Indira Gandhi National Open University) and distance learning
modules or programs.
♦ Short-term training programs at Rural Institutes such as Gandhigram
Institute of Rural Health or Rural Unit for Health and Social Awareness
(RUHSA), Christian Medical College
♦ Refresher Courses in clinical practice as applicable in a primary health
care setting for Primary Health Centre Medical Officers at St. John’s
Medical College.
♦ Attending Training programs on specific National program updates or
revised strategies in a specific program conducted by apex institutes
responsible for the same. Eg. Training program on the RNTCP (Revised
National Tuberculosis Control Program) at NTI (National Tuberculosis
Institute)
2
❖ INDUCTION TRAINING:
TARGET GROUPS FOR INDUCTION TRAINING:
1.
•
•
2.
Medical Officers at Primary Health Centre & Taluk Level:
□ New Appointments
□ Change of postings to different department/higher administrative level.
□ Contract postings.
The training should be compulsory before joining duty.
There may be a pilot phase to assess if this pre-employment training is
workable. If it is not it must be made mandatory that every person of the
above target category successfully completes the training within six months
of joining. This may be made a mandatory criteria for confirmation of a
probationary post to permanent or for continuation of a contract appointment.
Auxiliary Nurse Midwives who have been promoted to take on additional
responsibilities as an LHV and junior health assistants male who have been
promoted to Health Assistant (male) must also attend a training program for
development of managerial skills related to health.
VENUE for Induction Training:
•
The venue for the Induction Training Programs will be the Regional Health
Training Institutes.
FACULTY for Induction Training:
•
This could include:
1. Faculty of the Regional Institutes
2. Co-opted faculty from Medical Colleges and NGOs, preferable with a
background of Community Health and with experience of working with
government health centres and government programs.
•
The Regional Institutes may need to have “Training of Trainers” (TOT)
program to equip these faculty to effectively use Participatory Learning
Techniques. Trainers who are co-opted from Medical Colleges will also have
to undergo this (TOT) training program, before they are recruited as faculty.
•
The TOT training’s may be conducted by faculty from medical colleges or
NGOs, who have been trained and are experienced in using these
participatory learning techniques. (St. John's Medical College, Department of
Community Health has been using participatory learning techniques in most
of its training programs)
3
ADMINISTRATIVE CONTROL:
•
A “Public Health Education Council” to be formed under Rajiv Gandhi
University and the Government, to guide and supervise the Regional
-Institutes. This council may consist of experts in Community Health, Medical
Ethics, Legal Medicine, Clinical faculty such as Obstetrics, Paediatrics or
General Medicine, Health Education, Sociology & Anthropology and Personal
and Financial Management.
DURATION OF TRAINING:
•
•
The duration of Induction Training will be of at least two weeks for new
appointments.
One week is considered sufficient when there is a change of posting with
promotion.
CONTENT OF TRAINING:
The content of the induction-training program will include:
I. Training to develop Administrative skills
II. Training to develop Technical skills.
I. Administrative skills:
1.1: Communication Skills.
1.2: Skills for effective supervision of staff and activities.
1.3: Skills for effective monitoring and evaluation.
1.4: Skills for optimum use of resources.
1.5: Skills to liaison with other governmental or non-governmental agencies.
II. Technical Skills include:
11.1: Skills in curative health care
11.2: Skills for preventive and promotive health care
II.3: Skills for training and facilitation of staff and their activities.
4
1.1: Communication skills:
❖
❖
❖
❖
Communicating with staff of the PHC
Communicating with higher level administrative staff
Communicating with other governmental agencies
Communicating with the community and community members.
I.2: Skills for effective supervision of staff and activities:-
❖
❖
❖
❖
❖
Supervision skills
Personnel Policies
Performance Appraisal
Resolving Conflict
Building team work
1.3: Skills for effective monitoring and evaluation:
❖ Skills to develop or identify indicators for monitoring, control and
evaluation of inputs, outputs and outcomes.
❖ Skills for register maintenance and documentation.
1.4: Skills for optimum use of resources.
❖ Skills for better time management
❖ Skills for optimum use of moneys (budget) allocated.
❖ Skills for effective indenting and control of drugs, vaccines and equipment
or vehicles.
l.5:Skills to liaison with other governmental or non-governmental agencies.
Skills to effectively communicate with:
❖ Block development Officer.
❖ Village Panchayat
❖ Non-Governmental Organisations
❖ Village level Health Committee
II. Technical Skills:
11.1: Curative skills for:
❖
❖
❖
❖
Effective running of the OPD (Out Patient Department) & (In-patient).
Emergency care and referral.
Appropriate Management of medico legal cases.
Effective and efficient use of laboratory services.
II.2: Preventive and Promotive Skills:
❖ Reproductive and Child Health program implementation, including family
planning.
❖ Epidemic Containment measures.
<♦ School Health Services.
❖ Anganawadi worker training and supervision.
❖ Sanitation.
5
11.3: Training Skills to:
❖ Conduct or facilitate inservice training of PHC staff in program activities
and register maintenance.
❖ Identify staff training needs.
.❖ Identify appropriate resources to depute staff for development and
training.
METHODOLOGY OF TRAINING:
The training methodology must include techniques, which encourage
participation of the trainees. Problems must be based on field level realities.
Suggested methods that may be used in the process of training include:
o
o
•
•
•
•
Case studies.
Epidemiological exercises.
Role-play.
Group discussion.
Simulation exercises at individual and group level.
Simulation games
In addition to Lecture discussions and Panel discussions.
Follow up and Evaluation:
It is an accepted fact that follow up and evaluation of any training program is an
integral part to its success in achieving desired objectives. It is therefore
suggested that:
There be at least one follow up meeting of the participants about 3-6 months
after the training program. During this alumni meet, issues that are relevant but
were not dealt with during the training program may be identified through a
participatory process. These may be addressed to the extent possible during the
alumni meet. However, suggestions, which arise during this meet, must also be
incorporated into future courses.
In addition, it will be useful some of the training programs are evaluated by
external faculty, who are appointed for the purpose. The evaluation must include
both process and content of training.
An annual evaluation of the training programs may also be carried out by
experts, internal and external, to determine to what extent objectives of the
training have been achieved and the impact of the training program.
Constructive suggestions arising from the evaluation must be incorporated into
future training programs.
6
Suggested reference materials:
1.
2.
3.
4.
Management Training Modules for the Medical Officer, Primary Health
Centre, NIHFW, New Delhi.
On being in charge: A guide for middle level management in Primary Health
Care, McMahon (Rose Mary) et al, WHO 1980.
On being in charge: A guide for middle level management in Primary Health
Care, McMahon (Rose Mary) et al, WHO 1992.
Epidemiology and Management for Health Care for All : P.V. Sathe and A.P.
Sathe, Popular Publications, 1990
7
8
Proposec Schedule, Methodology and Duration (in Italics)
Date/Day/
Theme
Day:1
Monday:
Introduction to
participants and
course
Registration
Inauguration.
Self Introduction
(Ice-breakers)
(Duration: 60 minutes)
Day:2
Tuesday
Organisation of
Health
Care
Services:
Organisation of Health
Care Services - a brief
review:
Lecture discussion
(Duration: 60 minutes)
Day:3
Wednesday:
Ethics & RCH
Day:4
Thursday
Monitoring,
Control
&
Evaluation,
Supervision
Day:5
Friday:
Supervision &
Team work
Day:S
Saturday:
Leadership,
motivation,
Session 1
Session 2
&
Session 3
Session 4
Introduction to the course: overall
objectives, Expectations:
Lecture discussion, verbal &
written expectations from course
linking expectations with course
content.
(Duration 60 minutes)
Primary Health care revisited,
National Health Policy in the
context of 2000 and beyond:
Lecture discussion
(Duration: 60 minutes)
Roles & responsibilities
trainers and participants:
Exercise & discussion
(Duration: 30 minutes)
Medical Ethics in PHC
settings:
Lecture & Exercises
(60 minutes)
Essential Obstetric care during
pregnancy, delivery & postnatal
period.
(Handout + Lecture discussion
with exercises: 90 minutes)
Handling
Medico-legal
cases in a PHC:
Lecture discussion
&
case study (60 minutes
Monitoring, Control, EvaluationTerms & Definitions:
Lecture discussion
Duration:30 minutes
Essential
Care
for
the
Newborn & Infants
(Lecture
discussion
with
demonstration on model of
baby)
Duration: 90 minutes)
Development of indicators for Supervision: its role in the PHC
monitoring and evaluation at Lecture discussion
PHC:
Format, content and use of
group exercise
supervisory checklist:
(Duration: 90 minutes)
Group exercise
(Duration: 90 minutes)
Discussion & finalisation of Characteristics of a team and
supervisory checklist
importance of team work:
(Duration: 45 minutes)
Group exercise & role play- 45
minutes)
Evaluation of the week’s
learning:
(Formal & Informal feedbackwritten & verbal- 45 minutes
Field Exercise on testing the supervisory Checklist
Duration: 180 minutes
Styles of leadership:
Lecture discussion,
Individual Exercise
Duration: 45 minutes)
Motivation :
Exercise & handout
(Duration: 60 minutes)
9
of
Introduction to Management in
the context of PHC MOH:
Reading, discussion individual
& group exercises.
(Duration: 90 minutes)
Overview of National Health
programs:
Panel discussion
(Duration: 75 minutes)
Membership
roles
and
responsibilities of health teams
at PHC, subcentre and village
levels:
Group exercise
(Duration: 45 minutes)
Open Session on RCH &
related programs
(Question answer)
Duration: 30 minutes)
Date/Day/
Theme
Day:7:
Monday:
Effective
Communication
&
Community
participation
Day:8:
Tuesday
Personnel
management &
Vehicle
management
Day:9:
Wednesday
Management
analysis
and
cold chain
Day:10:
Thursday:
Material
&
financial
management
Training skills
Day:11:
Friday
Patient referral
system & Action
Plans
Day:12:
Saturday:
Evaluation
Session 1
Session 2
Session 3
Session 4
Definition
of types
of
communication & barriers to
communication:
lecture
discussion
Duration: 60 minutes
Exercises
on
effective
communication, conduct of
staff meeting.
Duration: 90 minutes
Community,
community
organisation,
community
participation in Health:
Lecture discussion
Duration: 45 minutes
Indicators
for
assessing
community participation: Group
exercise based on case studies
(video based) -45 minutes
Performance appraisal:
Lecture discussion
(30 minutes)
Vehicle management- priorities,
policies and procedures:
Exercise, discussion & reading
(60 minutes)
Personnel
policies
for Staff conflict: group exercise
government
health (45 minutes)
personnel:
grades/salaries/benefits/allo
wances/
promotion/recruitment/
disciplinary
measures
/
transfer/retirement:
Lecture discussion
Duration: 90 minutes
Management analysis of the PHC system:
Field visit
Improving management systems:
Field visit followed by discussion
(Duration: 180 minutes)
Materials management
Financial
procedures,
policies and process:
budgetting, imprest, TA/DA,
Lecture
discussion
& festival advance,:
Exercises
Lecture discussion
Duration: 90 minutes
Duration: 90 minutes
Patient
Referral
system:T riageConcept
Policies, procedures and
referral slips:
Lecture
discussion
&
Exercise - 45 minutes
Formal Evaluation of the
course
and
informal
feedback
Types of data and methods of
data collection at PHC:
Lecture discussion
Duration: 45 minutes)
Valedictory
function
distribution of certificates
10
&
Confidential report:
Role play and exercise.
(45 minutes)
Cold chain system and vaccine storage requirements:
Demonstration, Lecture discussion & exercise
(Duration: 180 minutes, includes visit)
Training for staff of PHC:
methods and evaluation:
Lecture discussion
(Duration: 45 minutes)
Drawing up a lesson plan for
training program & micro
teaching
session
group
exercise
Duration: 90 minutes
Action Plans & Gantt Charts:
Group exercise
(Duration: 90 minutes)
Implementation & coordination
of PHC health Services:
Group Exercise
(60 minutes)
fjf
OFFICE OF THE COMMISSIONER HEALTH AND FAMILY WELFARE SERVICES, IPP
BUILDING, ANAND RAO CIRCLE, BANGALORE.
URGENT/TOP PRIORITY
FAX MESSAGE
To
All DHOs in the State.
Sub: State level meeting of DHOs on 24lh and 25°" January 2001
Agenda: Integrated Health, Nutrition and Family Welfare Services Project with World
Bank assistance
PLEASE COME WITH THE FOLLOWING INFORMATION TO THE MEEETING ON
24th AND 25 JANUARY 2001 WITHOUT FAIL.
LIST, WITH FULL NAMES, OF ALL PHCS SANCTIONED TO YOUR DISTRICT
UNDER THE FOLLOWING HEADINGS:
LIST, WITH FULL NAMES, OF ALL PHCS HAVING THEIR OWN BUILDINGS.
OUT OF A) ABOVE LIST OF PHCS HAVING i) MO QUARTERS, AND ii)
ANM/STAFF NURSE QUARTERS.
i) AND ii) SHOULD BE BROUGHT
SEPARATELY.
C) LIST OF PHCS WHERE i)MO QUARTERS AND ii) ANM QUARTERS ARE
URGENTLY REQUIRED. PRIORITY TO BE GIVEN WHERE RENTED
ACCOMODATION IS NOT AVAILABLE.
D) LIST OF PHCS, WITH FULL NAMES, OF PHCS PRESENTLY FUNCTIONING
FROM i) RENTED BUILDINGS AND ii) PHU BUILDINGS, i) AND ii) SHOULD BE
BROUGHT SEPARATELY.
E) OUT OF ) ABOVE, LIST OF PHCS WHERE BUILDINGS ARE REQUIRED
URGENTLY. SELECTION SHOULD BE BASED ON AVAILABILITY OF SITE,
AND POPULATION BEING SERVED.
F) LIST OF PHCS SANCTIONED BUT NOT OPERATIONALISED OR FUNCTIONING
AT PRESENT BECAUSE OF ABSENCE OF BUILDING, AND NON-SANCTION OF
STAFF. ,
G) LIST OF PHCS UPGRADED TO CHCS BY GOVERNMENT ORDER BUT NO CHC
BUILDING HAS BEEN SANCTIONED.
H) LIST OF PHCS REQUIRING MAJOR REPAIRS OR IN A VERY DELAPI-—DATED
STATE.
A)
B)
THE ABOVE INFORMATION SHOULD BE PROPERLY VERIFIED PERSONALLY BY
FINALISE THE INFORMATION. PLEASE EN
WITH COMPLETE INFORMATION.
TO THE MEETING
Oi
Il'jW
DRAFF
V ’
Review of Project Proposal:
Karnataka Integrated Health, Nutrition and Family Welfare Syprices Development Project
1.
A World Bank team of Christopher Lovelace (HNP Sector Director), Ta wind Nawaz (team
leader), David Peters, and I Inin Hnin Pyne met with the Karnataka I leal th, Nutrition, and Family
Welfare team, led by A. Sengupta (Principal Secretary, Department of Health and Family
Welfare), S. Kaul, Commissioner, HFW, and consultants from the Community Health Cell to
review the draft project proposal for a Karnataka Integrated Health, Nutrition, and Family
Welfare Services Development Project. The team also met with the Karnataka Health Task
Force to discuss key sectoral concerning health financing and roles of the public and private
sector in Karnataka, that would need to be addressed in the context of a proposed project. This
note summarizes the proposed next steps.
2^ The Karnataka team was congratulated on the quality of the initial project proposal. The
dWrt outlines some of the main goals, health outcomes, values and principles for a proposed
project, including a large set of activities that would be planned in the HNP sector. It provides a
good basis for further development of health sector plans and a potential project. The
preparation team intends to reformulatea Project Implementation Plan fora discrete project,
which would support a comprehensive HNP policy and program.
3.
The Karnataka team outlined their early thinking on what types of project goals and
components would be included. The Karnataka team discussed the relative merits of different
project and program approaches, and concluded that a discrete project would be proposed, based
in a comprehensive health policy and strategy. The main goals would be to... The main
components proposed include: .... The Bank team supported these general directions, and also
discussed some of the critical aspects of the health system that have been under-developed in the
past. These include developing a vision and first steps to address the long-term health financing
distortions; taking steps to capture the energies of the private sector while counteracting its
market failures; taking meaningful steps to take demand-side interventions in addition to making
th^ealth system more responsive to people.
4.
Some of the key next steps planned are:
a. Approval from Union Ministries ofFinance and Health and Family Welfare. The Karnataka
DOHFW would seek endorsement of a proposedT-INP project from the Union Ministries to
proceed with a project proposal to submit for potential IDA funding.
b. Development of a Project Implementation Plan (PIP). The key components of a PIP are
discussed below (para 5).
c. Health Policy Framework. The preparation team would prepare a comprehensive state HNP
policy. Some of the proposed features of a health policy framework are outlined in para 6.
d. Financial and Economic Analysis. As part of the preparation, the resource Hows into the
health sector in Karnataka should be assessed. This should fit within the medium term
expenditure framework of the state. The analysis should not only assess the state’s ability to
finance incremental recurrent costs of the proposed project, but map all the main sources and
uses of resources available to the health sector in Karnataka.
e. Institutional Analysis. The preparation team should review the organizational mandates,
management systems, organizational structures, and relationships of the health sector, including
the public sector and key actors of the private sector. Some questions to be addressed include:
What types of responsibilities, authorities, resources, and accountabilities are held at central,
state (and local) levels for HNP responsibilities? What types of decisions are actually being
made at the different levels? How should responsibilities, authorities, resources, and
accountabilities change?
f. Social Analysis. An assessment of the potential impact of the project and health policy on
different stakeholders of the state should be conducted. A special focus should be on the poor,
scheduled tribes, and other vulnerable groups.
Project Implementation Plan
5.
The following are the key components of the Project Implementation Plan:
a.
A summary situation analysis of the health sector in Karnataka, including health status,
epidemiology, organization of the health care system (public and private), service utilization
rates, financing, institutional, management, technical and quality issues in the sector, linkages of
the proposed state health project with other donor assisted and government programs in health,
nutrition and population.
b.
A clear articulation of the rationale for the overall project approach (i.e. why components
are included and why they are phased as proposed), including the risks and benefits from the
proposed interventions. The PIP should include a description of the long term vision for the
health sector, and what is expected to be achieved over the life of the project.
c.
A description of the project objectives, measurable indicators, means of monitoring, and
critical assumptions. Baseline and target levels should be determined.
d.
A description of the project management arrangements with respect to who will manage
and implement the project at the State, district and local levels. This should outline the decision
making processes, responsibilities and accountabilities, and structure. In particular, financial
management and procurement arrangements should be described. Financial management should
be in accordance with the Loan.Administration Change Initiative.
f.
A description of the major project components and activities. The implementation
schedule should be detailed for the first two years of the project, and outlined for the remainder
of the project. This should cover all components, benchmarks for major inputs, achievements
and monitoring and evaluation
g.
A detailed breakdown of project costs by components and sub-components.
2
h.
A detailed procurement plan for the first year of the project. Bidding documents requiring
prior clearance with the Bank would be developed as part of the preparation process.
i.
An outline of an environmental action plan addressing health care waste management.
Health Policy Framework
6.
The state plans to develop a comprehensive state health, nutrition and population policy,
which would also provide a basis for the proposed project. The mission discussed some of the
key issues to be addressed by the policy, which would include identifying:
•
•
•
•
•
•
•
•
•
•
♦
•
HNP outcomes as goals
how to protect interests of vulnerable groups
the long term health financing system toward which the state will work
criteria for resource allocation of public funds, and how private funding of health will be
influenced
how to monitor and improve targeting of public resources on the poor
the role the public will play in keeping the health system accountable
how to bring convergence between health, family welfare, women and child development
programs
how centrally sponsored schemes will be managed at state, district, and local levels
how the state will work with the private sector, including formal and informal for-profit
providers, and non-profit NGOs
the roles of water and sanitation programs in health, and how to coordinate with HNP
how performance of the health sector will be monitored
key innovations and pilot tests to be conducted
3
s..
NO
_
Coinmumcoucn
S"=togy
target group
Nature of
Mossage
Media
Timing
Actlc' initiated under
KHSDP
When to Do 7
inc.vtcua s
awareness of {J
services orcvic.
by •’•rst referral
nosotais
carucuiany on
disaovantageo
grouts such as
trio a is ano tneir
increased
utilisation of me
v*c:v »'
Sc.ncci tesener
Manna S^astha
Sa.-gnas
Mu;
Agrcun
assists;
Grams;
nos;
rnaya
:es
(he renovations
ana (he new
equioments.
new facilities
created at (he
hcsoitals. Bring
awareness
about me
referral system.
Distribute a
cony of tne
hosodal layout
with the Do s
and Don ts.
Hand bills to
| hospital scecific
be given to
me mcivicuais ■ area linxed activity
to be taken co as
' and wnen the
{ physical ecuioment
and man oewer
! facilities imerove.
| It sneuid net be
initiated before
* cnnging in me
I .-mcrovemer.ts.
Mei
• he .*• “SCP has
ccmcieted. the civil
werx ; no equioment
install;non m sixty
hcso»(3:s. it has been
recenmv possible for
me K>SDP (o take ’
care :* me mis-ma ten
in (he resting of the technical personnel to
a great extent. In these
ceveiczea hcsoitals
and in he health care
establishments m the
surrcurcing area
referrs. .inkages are
being estaolisnec.
Printed materials have
been suooiied/is being
suoofie-c to
Scnoc^’Anganwadis/M
•uftTOurrbse nearr.
worxe^ Gramoanchay
ats. New onwards
ncscica. .mx IEC
activities would be
given greater
emonazis. It's time for
KHSCP to begin its
IEC accvities in these
six nea m facilities.
Grcu-ds
C.tizens
SC/ST
Peculation
Inform about
the renovations
and the new
equicments.
new facilities
created at the
hosoitais Bring
awareness
aoout me
referral system.
Bring
awareness
aoout Yellow
Card
Programme
Posters Video
Street Plays
Organise
tours for me
Media
Personnel
Start oreoanng the
□esters and video
presentations
acout Yellow Cares
before me
programme is
launched.
Commence the
street piavs arter
imorcvmg the first
referral unrt.
Posters nave been
prepared on Yellow
Caro scheme. They
have been cisoiayed in
all hosc.iais or me
state, -urtner through
'ne taiuxa medical
officer me same nas
been sent to me suo
centre aiso. At me
Gistrxx -evei tr.e cistncc
heaitn commir.ee is
000(100100 dismeuting
details df the Yellow
Caro programme for
the member s of the
SC/ST community.
Tours nave been
•organized fcr me
media oerscnnel.
A video presentation
has been prepared on
Yellcw Card scheme.
Steps nave been
initiated to organize
street z ay on mis.
Major facility 'mxed lEC
activity nas been
initiated n the name of
(he ncscital raising day
celeorat.ons. Detailed
guidelines are aisc
issued.
31
35
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List of Furnitures Equipments proposed to be supplied to PHO
I [Furniture - Office /HosviraL
i ! Executive revolving Chair
I
6
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____ _
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2
‘
,
2
•
:
7 f? 7
2
I
■ - • ... . j
• j
2 Foot suction apparatus
3 Instrument .sterilizer
%• “~v.•••.D. ; rm
4 B.P Apparatus
j
-5 Weighing machine - Adult.. u.’.• .. . •---- ; . .
6 Weighing machine - Baby
—
v
;
-7- Oxygen cylinder - IOL j------------ .: -z.-z.zz.__ _____
Oxygen
cylinder
trolley
-IOL
.._'A
_..
_.
.Frj
8 .
-9 Kidney tray O + 10" .10 jDressing / Instrument tray with lid . .
.____
11 iNebuHzer—-------'-'_2 —___ ....____ .-.••• ■
------ r------- ------------------------------------------------- "--- ----- 1
12 lAnbuBags ------------ ------ 1 .l.™_....... _ |
13 |Ambu Bags 200 CC, 500 CC & Adult
... ...___
_
-
2_] Autoclave with burners - 2 bin (4)B -
*
-
j
.
18
.
U Equipments
1
M' W M
MA--
?------
1
2 1 ’S" Type Continuous arm chair
—-—I
3 1 Office Table - Steel
4 Steel cup board/ Almirah
X I 1
Revolving Stool with stainless steel top
-U Attendant stool
7 Wooden Stool
Q
-2_1 Rack Slotted Angle with 5 compartments
________________
9 Operation table ■
10 Examination Lable
U Delivery table
12 Foot Steps
22 Bed side screen
14 Bed side lockers Fibre/Stainless steel
----22 Iron Cot Adult
16 Mattress
____
17 Pillows
18 Saline stand
'
19 Dressing trolley
20 Instrument Cabinet
21 Wash basin with stand
22 Dressing table
23 Stretcher ............
.....
24 Wheel Chair ■
.
------ -..
List of Furnitures Equipments proposed to be supplied to PHCs
-------- _-------- —
TZ ~------------------------- - ----------------------.Enema can, set •• ■ ' " . •.•■..■
1__ lb Urine pot ■>•.«•••••• ■>■' C
17 Bed Pans .'>•■•■•■(■
•
J£ [PM Kit Box ■•
— -.
m •SMT^zcoZAriy
i
2
■■
Delivery kits
Episitomy kits
YriO' a:?’-i^rrtn ,
--A
.
•
-
. 2
2
■
• .
2
■
’
’« ' . ’ty;
'
■
2- •
: ■■■.-,■. ■
...; •
.
■ ‘ . ••
"r, ’
;• '
.
.......... . ..
.
.
2
r .
IV [Surgical Instruments
.
•
~
1 ■ Curette uterine sharp/blunt
2 Dilator uterine double ended Heggars
3 Forceps'- tissue holding young 170mm soft rubber jaws - ss
2/2
2 sets .
6.!
4
5
Forceps - uterine velselum - straight jacombs 250 mm
—
--- :----- y----- :—:--------- —-------------------------------Knife handle for major surgery —’
6
Knife blade for .major surgery
7
Speculum vaginal bivalve cusso's graves, small, medium
8
9
Retractor viginal SIMS medium blade 31 X 80 mm - ss
'
■■
6+6+6
~
3 do 3+3D+3F
Large 3 Small 2
Speculum vaginal double handed SIMS 165mm long ss
10 Sound uterine simpon 300 nun graduated in 20 mm
11 Speculum nasal SS
Large 3 Small 2 ,
2
2
12- Forceps Kellys ST 140mm S.S
-
13 Forceps Sponge holding St 228 mm SS
14 Allis forceps tissue with teeth 150 nun SS (3 sizes)
15 Forceps sterilizer (utility) 280 mm vaughen SS
6
12+6
2
17 Scissors curved 140 mm/ Sharp/ blunt
18 Scissors - surgical straight 140 mm sharp SS
6
___ 5
6
19 Scissors - surgical straight 140 nun blunt SS
20 Needle holder straight narrow jaw mayo heggar'180 mm
<
-6 _______
3", 4" & 6" -6 each
2
. 21 ■thermometer (Clinical) Digital
22 Toungcc Depressor
2
Farming Equipments
1 Crow Bar 51/2" X 1/4" Dia
2 'TATA )
3 Pick Axe
4 Iron Blading
5 Mumti
_________ 1_________
1
_________ 2_________
1
jV.v^o.^
"j^jXc. •
.
■
________________ _u________ I_______ y
Vk«\.\M
QyT«U
Ihcxttu l/«P,K5^
•-£)•,-, o
01 C.
.
List of Furnitures Equipments proposed to be supplied to PHCs
I 'furniture - Office /Hospital
1
Executive revolving Chair
"S" Type Continuous arm chair
1
18
Office
Table
Steel
__________________________________
3
6
4 Steel cup board/ Almirah
I
I?
—
-r
------------------------5 Revolving Stool with stainless steel top
6
6 Attendant stool
A
H--------------—--------------7 Wooden Stool____________
1
8 Rack Slotted Angle with 5 compartments______________ J_________ 8
9 Operation table ■__________________________
2
10 Examination table
J________ 2
11 Delivery table
2
- --------------- ---------------12 Foot Steps_______________________ .
1
8
13 Bed side screen
4
14 Bed side lockers Fibre/Stainless steel
lJ2j Iron Cot Adult
I
6
16 Mattress
!
6
17 Pillows
18 Saline stand
19 Dressing trolley_______
2
20 Instrument Cabinet
21 Wash basin with stand __________
4
22 Dressing table
1
23 Stretcher
1
24 Wheel Chair
. x
•
1
1
2
—-
T
CO
CD
n Equipments ■
■------ ---------- —
IF
CN C9
- 1 Autoclave with burners - 2 bin (4)B ■
2
. ’
2 Foot suction apparatus
- ' —
2
3 Instrument sterilizer • • 1< ; r..-.
4 B.P Apparatus
■
• ..
■5 Weighing machine - Adult. '.
2
6 Weighing machine - Baby
1
-7- Oxygen cylinder - IOL — _ .... .n -pst—___ _ - ____ _ —■------- 3
8 Oxygen cylinder trolley - IOL . ................... ______ ..
- '■ *
. 3 .
........ _____ _______
A Kidney tray 6" + 10" -.7.
----- 6 + 6 .
10 Dressing / Instrument tray with lid
___ ______
■
...3
'
11 Nebulizer -----------______ _ __________ :___
i-... .
2
~
12 AnbuBags .............. ........________ ____ r___
■ •
•* .
13 Ambu Bags 200 CC, 500 CC & Adult
__ __
2+1+1
~
14 Lamgoscope with blades (Infant, Child and Adult)________ 1
1 Each
.
List of Furnitures Equipments proposed to be supplied to PHCs
15 Enema can set
J64 Urine pot y17 BedPans
PM Kit Box ■
—-—
Zffi Surgical Kits •.?
11 Delivery kits
2 I Episitomy kits
__ _4
. 2
■ ••
2
-y.:--
2
2
.b • •
r.:
' •'
.
- ■ ■:■■■ ---■ ■ •
. •.
..
. 2
2
IV Surgical Instruments
11
Curette uterine sharp/blunt
2 Dilator uterine double ended Hcggars
3 1 Forceps - tissue holding young 170mm soft rubber jaws - ss
4 Forceps - uterine velselum - straight jacombs 250 mm
5 Knife handle for major surgery 6 1 Knife blade for major surgery
" '
7 Speculum vaginal bivalve cusso's graves, small, medium
—4
8 Retractor viginal SIMS medium blade 31X80 mm - ss
9 Speculum vaginal double handed SIMS 165mm long ss
212
2 sets .
6
2
6+6+6
3 do 3+3D+3F
___________________
Large 3 Small 2
Large 3 Small 2 .
Sound uterine simpon 300 mm graduated in 20 mm
11 Speculum nasal SS.
2
2
12- Forceps Kellys ST 140mm S.S
13 Forceps Sponge holding St 228 mm SS
AL Allis forceps tissue with teeth 150 nun SS (3 sizes)
15 Forceps sterilizer (utility) 280 mmvaughen SS
17 Scissors curved 140 mm/ Sharp/ blunt
18 Scissors - surgical straight 140 mm sharp SS
6
12+6
I
2
_________ __________
i
6
I
6
19 Scissors - surgical straight 140 nun blunt SS
20 Needle holder straight narrow jaw mayo heggar 180 mm
I_________ ®_________
21 Thermometer (Clinical) Digital
22 Toungcc Depressor
I
2
|
i
I
.2_________
I
J
1
1
I
2
I
I
1
I
Farming Equipments
1 Crow Bar 51/2" X 1/4" Dia
2 kTATA )
3 Pick Axe
4 Eon Blading
5 Mumti
| 3", 4" & 6" -6 each
'
Required Serviceabl Required
i As per
e
Augmen
SI.No.
Item | norms
stock
tation
ipp alloted
RNITURE FOR OFFICE/HOSPITAL
1
Executive Revolving Chair
2
S-Type Continuous Arm Chair
3
Office Table
4
Steel Cupboard
5
Revolving Stool with Stainlesssteel top
6
Attendant stool
7
Wooden Stool
8
Rack Sloted Angle with 5 compartments
9
Operation Table
10
Examination Table
11
Delivery Table
12
Footsteps
13
Bed side Screen
14
Bed side Lockers
15
Iron Cot - Adult
16
Matress
17
Pillows
18
Saline Stand
19
Dressing Trolley
20
Instrument Cabinet
21
Wash Basin with Stand
22
Dressing table
II
UiPMENTS
1
Auto clave with burners-Two bins
2
Foot Suction Apparatus
3
Instrument Steriliser
4
B.P. Apparatus
5
Weighing Machine Adult
6
Weighing Machine Baby
7
Oxygen Cylinder
8
Oxygen Cylinder Trolley
9
Kidney Tray
10
Dressing/lnstrument Tray with Lid
SURGICAL KITS
1
Delivery Kit
2
Episiotomy Kit
SURGICAL INSTRUMENTS
1
Currette Uterine sharp /Blunt
2
Dilator Uterine double ended heggars
Forceps
tissue
holding
young
170mm
Soft
rubber
3
jaws-ss
I
TRAINING PROGRAMMES CONDUCTED AND PROPOSED TO DE? CONDUCTED BY
STATE INSTITUTE OF HEALTH AND FAMILY WELFARE.
The State Institute of Health and F.W. ,
BANGALORE - 23.
Bangalore has
conducted the following Training Programmes for various
Categories of Personnel working in the Department of Health
and F.w.Services, during the years 1997-98,
1998-99,
99-2000 ■
and 2000-2001.
INDUCTION TRAINING PROGRAMME:-
I.
(UNDER KHSDP)
y
Induction Training Programme is being conducted to the
Newly Appointed Doctors of the Department with a view to make
them familiar with the day-to-day functioning of the PHCs/PHUs
and to introduce them to the different National Health 1’rogramrnes
being Implemented in the State.
During 1998-99,
Training Programme was for a period of six days.
the Induction
As the parti
cipants felt it was inadequate and in their suggestions to
include more Programmes,
it was increased
to 12 days.
During
these 12 days both Programme and Hospital Management Topics
were covered and the participants were given practical Training
by taking them to a PHC and Sub-Centre.
A total of nine batches in which 205 Doctors were
trained
.
during 1998-99 and two batch?s'of 45
Doctors were trained-duri.no 1999-2000.
incurred is shown in the Annexure-I.
The Expenditure
Total batches 11,
persons
; trained ^250.
II.
HOSPITAL ADMINISTRATION AID MAN AGEHE1-’T TRAINING PROGRAMME:-
(UNDER KHSDP)
This Training Programme is being conducted to the Medical
Officers of Community Health -Centros/Taluk Medical Officers for
a period of six days.
This Training is conduote1 with a view
to update and improve the Administrative and M:inagem~nt Skills
of Medical Officers of Community Health Centres and Taluk Hosp.
2
2
One batch of 14 Doctors was trained In 1907-98,
five
batches totalling 109 Doctors were trained during 1993-99
and 04 batches totalling 96 Doctors were trained during
99-2000.
The Expenditure incurred is shown-in the Annexure-II.
Total batches 10,
persons trained 219.
•
Both these Training Programmes were funded by the
Karnataka Health System Development Project,
III.
Bangalore.
TRAINING OF TRAINERS(T.O.T) IN INTEGRATED SKIM, BASEDTRAINING IN RCH UNDER I.P.P. - IX(K):-
Training of Trainers Programme; under RCH jn SI. 1.1 I
Based
Training for District Level Trainers for 12 days is being
conducted with a view to equip the trainers to give Training
1. Medical Officer -2.ANMs,
to the 6 Categories of Staff i.e.,
LHVs,
3.
4.Sr.H.A.(M),
5.Jr.H.A.(M),
6. Staff Nurses.
A total of four batches with 91 persons have been
trained during 2000-01, between July 2000 and October 2000.
The Expenditure Statement is shown in the Annexure-III.
This
Integrated Skill Based Training is funded by IPP-IX(K) Project
both for T.O.T, and District Level Training.
IV.
ORIENTATION TRAINING PROGRAMME TO FACULTY OF ANMTC/
LHVTC AND DNOs IN R.C.H.:Orientation Training to the Faculty of ANM Training
Contres/LHV Training Centres and District Nursing Officers
in RCH was conducted for three batches during 1999-2000.
A
total of 78 persons was trained for 12 days eaci) rand this
Training was funded by the Family 'Welfare Training,
Institute, Mufobai.
Research
The Expenditure incurred for this Training
is shown in the Annexuro-IV.
TRAINING Of TRAIMERS(T.O.t)
UNDER
INDIA
for
POPULATION
DISTRICT LEVEL OFFICERS
PROJECT
-
IX(K):-
IK TRAJ.I'irt’G TECHNOLOGY
3
3
Training of Trainers Programme for District Level
Trainers (Paediatricians and Obstetricians) and Faculty
of ANMTC/i 1 FWTG/LI IVTC for 5 days was conducted during the
years 1997-98. and 1998-99.
During 1997-98, a total of
8 batches totalling 210 was trained and during 1998-99,
batches totalling 107 persons were trained.
The Expenditure
Statement for this is given in the Annexure-V.
Total batches
5
13,
persons trained 317.
TRAINING IN HEALTH ADMINISTRATION AND MANAGEMENT;The .State Institute of Hoiltl
and Family Welfare,
proposes to conduct Training in Health Administration and
Management to District Health and F.w,officers,
District
Programme Officers and Taluk Health Officers.
This is for
a period of 12 days .
The State Institute of Health and Family Welfare,
proposes to conduct Training to D.H.E.Os and Dy.H.E.Os for
a period of three days during November 2000 in operationa
lising joint .RCH and IPP,
IEC activities.
AFNEXURE - I
-------- =~
-z. ~---------------------------------------------------------- ---------------------
——
.---- ------ - --
—
' STATEMENT SHOWING THE EXPENDITURE OF INDUCTION TRAINING FOR NEWLY APPOINTED DOCTORS UNDER KARNATAKAH HEALTH SYSTEM
DEVELOPMENT PROJECT, HELD AT STATE INSTITUTE OF HEALTH AND FAMILY WELFARE, RANGALORE- 560 023.
.
. -
Batch
Period
Attended
Target
Amount
drawn
Expenditure ;
Balance remitted
to R.B.I.
■
FOR THE YEAR 1998-99
30
'
I
13-07-98 to 18-07-98
II
27-08-98 to 02-09-98
30
III
14-09-98 to 19-09-93
30
1 IV
12-10-98 to 17-10-98
30
V
16-11-98 to 21-11-98
30
25
16
67,000
37,372
29,628
27
73,600
48,768
24,832
21
71,200
41,832
29,365
21
78,200
43,615
34,585
78,200
50,772
27,428
VI
14-12-98 to 19-12-98
30
25
78,200
48,604
29,596■
VII
01-02-99 to 06-02-99
30
21
85,400
46,494
38,906
VIII
15-02-99 to 20-02-99
30
27
85,400
47,989
37,411
IX
01-03-99 to 06-03-99
30
22
85,400
47,249
38,151
270
205
7,02,600
4,12,698
2,89,902
Total
*
X
19-07-99 to 31-07-99
30
XI
16-08-99 to 28-08-99
Total
.
FOR THE YEAR 99-2000
19
1,45,100
66,001
79,099
’30
26
1,45,100
84,775
60,325
60 ’
45
2,90,200
1,50,776
‘ 1,39,424
■
-
Remarks
ANNEXURc
-STATEMENT SHOWING THE 'EXPENDITURE’O?' HOSPITAL ADMINISTRATION ANO MANAGEMENT TRAINING FOR CHC/TALUK LEVEL. MS) ICAL
OFFICERS UNDER KARNATAKA” HEALTH-SYSTEM DEVELOPMENT PROJECT, HELD AT STATE INSTITUTE OF HEALTH AND FAMILY WELFARE,
----- -------------------- — ----------- Batch
• . .. -
............— —------- —--------------- -
Attended
Target
Period
BANGALORE-550 023.
Expenditure
Amount
drawn
15-12-97 to 20-12-97'
- ' Total '
--
—
Balance remitted ’
____ to g.B.I.
s
30
14
1,12,000
62,292
49,708
30
14
1,12,000
62,292
49,708
' v-
20-07-98 to 25-07-98
5
30
24
88r000
III • ’
21-09-98 to 26-09-98
-
30
13
88,000
52,421
IV
26-10-98 to 31-10-93
30
20
95,000
56,644
V
23-11-98 to.28-11-93 ' \
VI
22-02-99 to 27-02-99
— --- m
~
Total
' -
——-__ __ . _
30 ’
- 3Q ..
-
•
150
- 109
;
95,000
21
. 2S ...
•-
.
35,579
57,132
95,000 - - - 59,674 -
.. . -
38,356
...
37,818
- ----- 35,326
- .... 4,61,000■
„- - -
12-07-99. to. 17-07-99 r.--.
' 30
22
VIII
02-08-99- to. 07-08-99..
30
-. 25
27
IX—■X—- - — 20 09 99 to 25 0Q 99 - -
30
__
x\;;._ .. 25-10-99 to-30-10-99' .’ - 30 Total
120
22
'
96
1,11,900
1,11,900 ’
*.
' Remarks
25,966
61,034
FOR THE YEAR 99-2000
VT I-.
-
•
FOR THE YEAR 1998-99
•
------------------------------------- '■
.. ---
FOR THE YEAR 1997-98
I
•—
57,345
55,927
ri 54,555
~ 55,973
/' ’7
’~
61 448
' ' '
18 552
80,000 m- • - ' 53,750
. 1 -•
26,250
80 000
3,83,800 ■
2,25,726
1,58,074-
- .. .
.
.
ANNEXURE - III
/
STA-TETiENT SHOWING THE DETAILS OR TRAINING 0? TRAINERS .■'TRAINING PROGRAMME UNDER RCH ±N INTE>--RATED.~Sx1l,L
■
I/)
Batch
TRAINING. AT STATE INSTITUTE Op HEALTH AND P.AMILY WELFARE, SANGALCRE~-‘55C 023.
period
\ "
Target
attended
...Amount Draw
Expenditure
Balance
Remitted
’“64,057---- ----- --
5’, 943 ’
T
17-07-2000""to" 29"—07^2000
30"
’ 16
’ “’70,000
TT
17-08-2000 to 30-03-2000
30
26
1,00,000
95,330
4,670
VVT
11-09-2000 to 23-09-2000
30
24
1,05,000
1,03,500
1,500 r
09-10-2000 to 21-10-2000 30
25
1,05,000
1,05,000
-
91
3,80,COO
3,67,337
12,113
rv.
Total
120
Remarks
------- -
• -
?.
Batch
period
Target
attended
Amount Draw
Expenditure
Balance
Remitted
I .
21-10-1999 to 4-11-1999
27
26
1,83,150
1,59,379
23,771
II
25-11-1999 to 8-12-1999
26
25
1,83,150
1,16,820
65,330
III
27-12-1999 to 8-01-2000
27
27
1,76,900
1,29,160
47,740
1
80
78
5,43,200
4,05,359
1,37,841
Director,
State Institute of Health and
Family Welfare, Bangalore -23.
Remarks
ANNS'KURE - V
STATEN ENT SHOWING THE EXPENDITURE OF TRAINING t3F TRAINERS PROGRAMME HELD AT STATE INSTITUTE OF HEALTH AND F.W.,
BANGALORE UNDER IPP-IX(K)
...
T.O.T.
Batch
Period
1?arget
Budget
Alloted
Attended
•
Drawn
IN TRAINING TS QHNOLOGY
08-09-97 to 10-09-97'
30
II
25-09-97 to 27-09-97
30
III
05-11-97 to 07-11-97
30
IV
13-11-97 to 15-11-97
30
19-11-97 to 21-11-97
•
Guest ■
Lecturers
• • V
FOR THE YEAR 1997-98
I
Remittance
Expenditure
25
51,900
33,694
28,466
5,228
1,600
23
51,900
38,000
33,392
4,608
2,000
30
51,900
40,000
38,487
1, 513
1,000
30
51,900
38,000
35,921
2,079
1,600
30
28
51,900
36,000
31,754
4,246
2,000
VI-
22-12-97 to 24-12-97 ' 30
25
51,900 ■
39,000
33,032
5,968
1,800
VII '
22-01-98 to 24-01-93
30
22
51,900
30,000
28^153
1,847
2,400
VIII
05-02-98 to 07-02-93
30
27
51,900
37,000
33,021
3,979
2,600
240
210
4,15,200
2,91,694
• 2,62,224
29,468
15,000
Total
'•
FOR THE YEAR 1998-99
1
27-07-98 to 31-07-98
30
II
10-08-98 to 14-08-98
30
III
07-09-98 to 11-09-98
30
21 .
IV
05-10-98 to 09-10-98
30
22
V
03-11-98 to 07-11-98
30
•23
Total
... . _
• 150
22
'
' 107 '
'
67;000
57,000
43,934
13,066
3,600
67,000 v.
55,000
43,974 .
11,026
3,600
67,000
50,000
37,337
12,663
2,800
67-, 000
67,000
43,769
23,231
3,000
67,000
50,000
42,632
7,318
3,000
3,35,000
2,79,000
2,11,696
67,304
1
16,000
.
FOR THE YEAR 99-2000
NIL ■
-•
DEVELOPMENT OF CURRICULUM / SYLLABUS
The Stale Inslilulc of Health and Family Welfare has developed / prepared
Curriculum / Syllabus for lhe following category of Health Personnel in the year
1997-1999 for Training Programmes tinder 1PP-1X(K). viz.,
SI.
No.
Personnels
Duration
01.
Medical officers of PI ICs/PI lUs
06 Days
02.
Sr. 1 Icallh Assistant Male
09 Days
03.
Sr. Health Assistant Female
12 Days
04.
Jr. Health Assistant Male
08 Days
05.
Jr. Health Assistant Female
12 Days
06.
Block Health Educators
08 Days
This was followed by all lhe Tiaining Cenlies in the Tiaining of above
mentioned Category of Health Staff during 1998-1999.
DEVELOPMENT OF TRAINING MODULES
The Inslilulc has developed / picparcd the Training Modules with the
involvement of Faculty of Stale Institute of
Health and Family Welfare and other
Training Centres for (lie following category of staff. Via.,
01. T.O.T. Modules
- Both in English & Kannada
02. Medical Officers of PIICs
- in English
03. Sr. Health Assts. (M & FJ
- in Kannada
04. Jr. I Icallh Assts. (M & F)
- in Kannada
7
infriendcircle] Universal Access
Subject: Imfricndcirclcj Universal Access
Date: Sat. 23 Dec 2000 02:49:32 +0530
From: "Amar Jesani" <laral984@bom5.vsnl.net.in>
Reply -io: nitriendcircle d egroups.com
Fo: LrrC-eGroup" <mlriendcircle@egroiips.com>
Dear All,
For
they hXelSanc? intemet
3 Campaign f°r UniVSrSal 3CCeSS t0 hea'th Care in the US of A-
Amar
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Name: First They Came for the Uninsured.htm i
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Hu Competition in Health Care Poses Grave Dangers.htm:
Name: Competition in Health Care Poses
Grave Dangers.htm
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1/30/01 12:01 PM
First They Caine for the Uninsured
■
First They Come For the Uninsured
by Bob Griss,
Director of the Center on Disability & Health in Washington, DC
and a board member of UHCAN!
This piece was inspired by Martin Niemoller, a German Protestant minister and a leader of the
church's opposition to Hitler who was interned by the Nazis and who wrote:
"bi Germany they first came for the Communists, and I didn't speak up because I wasn't a
Communist. Then they came for the Jews, and I didn't speak up because I wasn't a Jew. Then
they came for the trade unionists, and I didn't speak up because I wasn't a trade unionist. Then
they came for the Catholics, and I didn't speak up because I was a Protestant. Then they came
for me, and by that time no one was left to speak up."
First they came for the uninsured (by passing an unenforceable health insurance portability bill that
prohibits private health insurers from imposing preexisting condition exclusions beyond twelve months, but
not guaranteeing access to the same benefits or limiting the premiums that can be charged).
Dut my family and I have health insurance, so I wasn't concerned.
Then they came for Medicaid recipients (by allowing states greater flexibility to get around federal
standards designed to ensure that low income persons had access to a comprehensive benefit package). Now
states can force Medicaid recipients into low cost Medicaid-only managed care plans with minimal federal
oversight. One Medicaid program has resorted to an exclusive list of durable medical equipment without
exceptions to restrict this benefit regardless of the type of equipment that can improve function and is
medically necessary according to the doctor. The Second Circuit Court of Appeals initial ruling in the
Desario case is to judge the adequacy of Medicaid benefits by whether they meet the needs of the "average
patient" not the needs of persons with rare, unusual or costly treatment needs, even if it imposes a "death
sentence" on some Medicaid recipients).
But I have private insurance, so I wasn't concerned.
Then they came for Medicare beneficiaries (by capping total reimbursement to Medicare providers based
on previous utilization levels that create incentives for Medicare providers, like home health agencies, to
withhold care from persons with the greatest needs who are less profitable to serve; health}' Medicare
beneficiaries will be encouraged to set up Medical Savings Accounts to ensure control over the health care
services they think they need, and to seek services from physicians who are not satisfied with the Medicare
payment fee schedules by using a private fee for sendee contract, even though this undermines public
leverage over provider reimbursement in the Medicare program).
But they told me I would have more "choices" so I wasn't concerned.
Then they came for persons with private insurance (when my employer told me that I could only choose
between two policies in a low cost health plan selected by my employer).
But I thought 1 was generally healthy so I wasn't concerned.
1 of 2
1/30/01 12:01 pm
Then I developed a chronic illness which led to a disability that required some durable medical equipment.
But my health plan decided that it was not part of the benefit package even though my doctor thinks it is
medically necessary.
Unfortunately, there is no one left to speak up for me.
LUCAN - Tel: 216/241-8422 or 800/634-4442 - www.uhcan.org
2 of 2
Competition in Health Care Poses Grave Dangers
September 2000
am
(Cshc© Posss Gir&!.vc Owffigsirs
by Donald W. Light, PhD
(abridged)
Editor's Note: Under pressure to come up with a specific policy proposal for prescription covet age undet
Medicare, Republican Presidential candidate George W. Bush recently resurrected the Breaux-Frist
Medicare managed competition model. The annual exodus of managed care companies ft om Medicat e
raises doubts about the practicality of this proposal. In addition, there are grave theoretical concerns about
making competition a central part ofa health care system.
Economic competition has transformed the modem world and spurred unparalleled economic growth. While
it rewards efficiency in the short run within a given sector or industry, its main effect is to provide rich
rewards for the invention of new products, the discovery of new markets, and the creation of new demands.
Adam Smith and other distinguished economists became acutely aware of the shortcomings of economic
competition. It creates a society that rewards people for seeking their own best advantage, rather than
looking out for one another, and will only be beneficial if there are conditions that prevent people from
taking advantage of one another.
Beneficial competition requires there to be many independent buyers and sellers who can enter and exit
the market easily, good cheap or free information about the qualities and prices of w hat is being
bought, and full use of this information. If these and related requirements are not met, then competition
can be damaging to individuals or to the community. This happens because the easy ways to win are not by
coming up with something new and better, but by colluding, fixing prices, skimping on services or quality,
deceiving customers, and other tricks of sharp sellers.
Competition seems so foreign to health care. Lt commercial life, the law of tire land is caveat emptor, let the
buyer beware. In health care, the law of the land is confidat emptor, let the buyer trust. Patients go to
doctors because when they are hurting, scared or anxious they want an expert they can trust to put their
interests first. Markets here are a paradigm misfit. No other nation with an advanced health care system has
embraced competition, and no other nation has turned its services over to investors seeking profits.
Nevertheless, American business executives and politicians have aggressively promoted the transformation
of health care into commercial competitive markets. Furthermore, up until 1999, they declared that this
transformation was completely successful in halting years of escalating costs. In fact, about a third of the
slowdown in health care costs was due to the general slowdown in overall inflation rates. Another third was
due to cutbacks in services offered by health insurance. And the final third was due to shifting costs back to
employees. None of this can be attributed to competitive health care.
Against these mythical or very modest gains, competition in health care poses grave dangers because it
can:
1. Undermine professional trust, the foundation of health care - distrust drives out trust;
.... 2. Fragment health care into "products," organizational complexity and sub-budgets - opportunistic
1/30/01 12:0° P‘VI
Competition in Health Care Poses Grave Dangers
products and markets feed on themselves;
3. Encourage cost shifting as different parts of the whole attempt to minimize their costs and maximize
gains;
4. Encourage gaming in the highly imperfect markets in a wide variety of ways;
5. Increase transactional costs, to market, contract, monitor, and coordinate;
6. Emphasize short-term "show-and-tell" gains, to the detriment of mid-term and long term projects;
7. Create "managerialism," the proliferation and elevation of managers to the detriment of clinical
service;
8. Privatize vital information on the performance and costs of different providers and facilities;
9. Fragment and undermine public health programs and their funding; and,
10. Fail to fund education and research, on which the system depends.
Donald Light is on the graduate faculty in sociology at Rutgers University and is a professor at the
University ofMedicine and Dentistry ofNew Jersey. In 1999, he won the William Foote Whyte
Distinguished Career Awardfor contributions to sociological practice in his work on health care reform.
UHCAN - Tel: 216/241-8422 or 800/634-4442 - www.uhcan.org
Annexure - II
(Rs. In Lakhs)
SI. No
Name of the District
No. of Sub
Centre
Buildings to
be
constructed
2
3
1
1
Amount
required
No ofPHC
Buildings to
be
constructed
4
5
Amount
required
No. ofCHC
Buildings to
be
constructed
Amount
required
Total
amount
required Total of Col.
No 4 + 6 +
8
6
7
8
9
Bangalore Urban
2
Bangalore Rural
88
396.00
31
558.00
4
300.00
1,254 00
3
Chitradurga
54
243.00
25
450.00
4
300.00
993.00
4
Davangere
38
171 00
30
540.00
3
225.00
936 00
5
Kolar
74
333.00
15
270.00
0
-
603 00
6
Tumkur
190
855.00
28
504 00
5
375.00
1,734.00
7
Shimoga
105
472 50
26
468.00
3
225.00
1,165.50
8
Belgaum
160
720.00
31
558.00
3
225.00
1,503.00
9
Bijapur
105
472.50
16
288.00
1
75.00
835.50
10
Bagalkote
63
283 50
10
180.00
4
300 00
763 50
11
Dharwad
50
225.50
4
72.00
1
75.00
372.50
12
Gadag
90
405.00
10
180.00
1
75.00
660.00
13
Haveri
98
441.00
17
306 00
4
300.00
1,047 00
14
Uttara Kannada
223
1,003.00
10
180 00
4
300.00
1,483.00
15
Gulbarga
265
1,192.50
59
1,062.00
3
225.00
2,479.50
16
Bellary
107
481.50
13
234.00
2
150.00
865 50
17
Bidar
103
463 50
3
54 00
1
75.00
592.50
18
Raichur
170
765 00
9
162.00
5
375.00
1,302.00
234.00
2
150.00
843.00
2,236.50
949 50
19
Koppal
102
459.00
13
20
Mysore
203
913.50
61
3
225.00
21
Chamarajnagar
161
724.50
0
-
3
225.00
22
Kodagu
66
297.00
0
-
4
300.00
597.00
23
Mandya
170
765.00
18
324.00
5
375.00
1,464.00
1,098.00
24
Hassan
259
1,165.50
33
594.00
5
375.00
2,134.50
25
Chickmagalur
220
990.00
22
396.00
2
150.00
1,536.00
26
Dakshina Kannada
0
-
2
36.00
3
225.00
261.00
27
Udupi
Total
289
1,300.50
23
414.00
1
75.00
1,789.50
3453
15,538.50
509
9,162.00
76
5,700 00
30.400.50
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Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
LINGSUGUR
LINGSUGUR
LINGSUGUR
LINGSUGUR
MANVI
RAICHUR
RAICHUR
RAICHUR
RAICHUR
SINDHNUR
SINDHNUR
SINDHNUR
Primary Health Centre, Anwari
Primary Health Centre, Mudgal
Primary Health Centre, Nagaral
Primary Health Centre, Mask!
Primary Health Centre, Sirwar
Primary Health Centre, Matmari
Primary Health Centre, Idapnuru
Primary Health Centre, Kalmala
Primary Health Centre, J.Mallapura
Primary Health Centre, Ragalaparvi
Primary Health Centre, Balagnooru
Primary Health Centre, Jawalgera
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
RAICHUR
LINGSUGUR
LINGSUGUR
LINGSUGUR
LINGSUGUR
MANVI
RAICHUR
RAICHUR
RAICHUR
RAICHUR
SINDHNUR
SINDHNUR
SINDHNUR
Primary Health Centre, Anwari
Primary Health Centre, Mudgal
Primary Health Centre, Nagaral
Primary Health Centre, Maski
Primary Health Centre, Sirwar
Primary Health Centre, Matmari
Primary Health Centre, Idapnuru
Primary Health Centre, Kalmala
Primary Health Centre, J.Mallapura
Primary Health Centre, Ragalaparvi
Primary Health Centre, Balagnooru
Primary Health Centre, Jawalgera
DIVISION
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
DISTRICT
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
TALUK
BELLARY
BELLARY
BELLARY
HADAGALLI
HAGARIBOMMANAHALI
HOSPET
HOSPET
HOSPET
HOSPET
KUDLIGI
SIRUGUPPA
SIRUGUPPA
AURAD
AU RAD
BASAVAKALYAN
BASAVAKALYAN
BASAVAKALYAN
BHALKI
BHALKI
BHALKI
BIDAR
BIDAR
BIDAR
HOMNABAD
HOMNABAD
HOMNABAD
HOMNABAD
ALAND
ALAND
ALAND
CH1NCHOLI
CHINCHOLI
CHINCHOLI
NAME of PHC requiring upgradation to CHC
Primary Health Centre, Orubayei
Primary Health Centre, Moka
Primary Health Centre, Emmiganuru
Primary Health Centre, Holalur
Primary Health Centre, Hampasagara
Primary Health Centre, Kaamalapura
Primary Health Centre, Kampli
Primary Health Centre, M.M.Halil
Primary Health Centre, Gadhiganuru
Primary Health Centre, Kottur
Primary Health Centre, Sirigere
Primary Health Centre, Siraguppa
Primary Health Centre, T.Kushanur
Primary Health Centre, Santapura
Primary Health Centre, Hunasura
Primary Health Centre, Rajeshwara
Primary Health Centre, Muchalamba
Primary Health Centre, Bhatambra
Primary Health Centre, Chincholi
Primary Health Centre, Mehakara
Primary Health Centre, Aanadura
Primary Health Centre, Mannalli
Primary Health Centre, Janawada
Primary Health Centre, Ghataborala
Primary Health Centre, Hallikeda(B)
Primary Health Centre, Hallikheda(K)
Primary Health Centre, Dubalagundi
Primary Health Centre, Kadaganji
Primary Health Centre, Jidaga
Primary Health Centre, V.K.Salagara
Primary Health Centre, Sulepet
Primary Health Centre, Chimmanchodh
Primary Health Centre, Chandanakera
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
RAICHUR
RAICHUR
RAICHUR
RAICHUR
CHINCHOLI
CHITAPUR
GULBARGA
JEVARGI
JEVARGI
JEVARGI
SEDAM
SEDAM
SEDAM
SHAHPUR
SHAHPUR
SHAHPUR
SHAHPUR
SHORAPUR
SHORAPUR
SHORAPUR
YADGIR
YADGIR
GANGAWATI
GANGAWATI
KOPPAL
KOPPAL
KOPPAL
KUSHTAGI
KUSHTAGI
KUSHTAGI
YELBARGA
YELBARGA
YELBARGA
YELBARGA
DEVADURGA
DEVADURGA
LINGSUGUR
LINGSUGUR
Primary Health Centre, Inapura
Primary Health Centre, Hebbal
Primary Health centre, Mahagao
Primary Health Centre, Aralagundagi
Primary Health Centre, Yadrami
Primary Health Centre, Nelogi
Primary Health Centre, Kolakunda
Primary Health Centre, Mudhol
Primary Health Centre, Malakhed
Primary Health Centre, Sagara
Primary Health Centre, Hayyal(B)
Primary Health Centre, Gogi
Primary Health Centre, Doranahalli
Primary Health Centre, Huniseegi
Primary Health Centre, Kembhavi
Primary Health Centre, Kodekal
Primary Health Centre, Honagera
Primary Health Centre, Gajarkot
Primary Health Centre, Sriramanagara
Primary Health Centre, Kanakagiri
Primary Health Centre, Batageri
Primary Health Centre, Kinnala
Primary Health Centre, Hiresindhogi
Primary Health Centre, Hanumasagara
Primary Health Centre, Hanumanala
Primary Health Centre, Dotihala
Primary Health Centre, Bannikoppa
Primary Health Centre, Mudhola
Primary Health Centre, Bevoora
Primary Health Centre, Mangalura
Primary Health Centre, Arkera
Primary Health Centre, Gabbur
Primary Health Centre, Gurugunta
Primary Health Centre, .Haiti
Annexure -1
SI.
No.
Name of the District
2
1
No. of
existing
Sub
Centre
3
No. of
existing
PHCs
No. of
existing
CHCs
4
5
1
Bangalore Urban
140
31
3
2
Bangalore Rural
286
73
11
3
Chitradurga
57
12
4
Davangere
70
7
5
Kolar
375
82
13
6
Tumkur
418
97
10
7
Shimoga
380
55
9
8
Belgaum
598
135
15
9
Bijapur
65
8
10 Bagalkote
46
10
Dharwad
28
3
29
6
50
11
11
458
456
596
12 Gadag
13 Haven
14 Uttara Kannada
316
61
12
15 Gulbarga
512
105
19
16 Bellary
264
54
9
17 Bidar
231
41
6
47
5
43
9
96
15
52
4
18 Raichur
378
19 Koppal
20 Mysore
21
690
Chamarajnagar
22 Kodagu
163
29
7
23 Mandya
376
71
9
24 Hassan
463
81
15
25 Chickmagalur
335
51
8
64
7
63
6
1676
249
26 Dakshina Kannada
708
27 Udupi
Total
8143
Annexure - II
(Rs. In Lakhs)
SI. No.
Name of the District
No. of Sub
Centre
Buildings to
be
constructed
1
2
3
Amount
required
No. of PHC
Buildings to
be
constructed
4
5
Amount
required
No ofCHC
Buildings to
be
constructed
Amount
required
Total
amount
required Total of Col
No. 4 + 6 +
8
6
7
8
9
1,254.00
1
Bangalore Urban
2
Bangalore Rural
88
396.00
31
558.00
4
300.00
3
Chitradurga
54
243.00
25
450.00
4
300 00
993 00
4
Davangere
38
171.00
30
540.00
3
225.00
936.00
5
Kolar
74
333.00
15
270.00
0
-
603.00
6
Tumkur
190
855.00
28
504.00
5
375.00
1,734.00
7
Shimoga
105
472.50
26
468 00
3
225.00
1,165.50
8
Belgaum
160
720.00
31
558.00
3
225.00
1,503.00
9
Bijapur
105
472.50
16
288.00
1
75.00
835 50
10
Bagalkote
63
283.50
10
180.00
4
300.00
763.50
11
Dharwad
50
225 50
4
72.00
1
75.00
372.50
12
Gadag
90
405.00
10
180 00
1
75 00
660.00
13
Haver!
98
441.00
17
306.00
4
300.00
1,047.00
14
Uttara Kannada
223
1,003 00
10
180.00
4
300.00
1,483.00
15
Gulbarga
265
1,192.50
59
1,062.00
3
225.00
2,479 50
16
Bellary
107
481.50
13
234.00
2
150.00
865.50
17
Bidar
103
463.50
3
54 00
1
75.00
592.50
18
Raichur
170
765.00
9
162.00
5
375.00
1,302.00
19
Koppal
102
459.00
13
234.00
2
150.00
843 00
20
Mysore
203
913.50
61
1,098.00
3
225.00
2,236.50
21
Chamarajnagar
161
724.50
0
-
3
225.00
949.50
22
Kodagu
66
297.00
0
-
4
300.00
597.00
23
Mandya
170
765.00
18
324 00
5
375.00
1,464.00
24
Hassan
259
1,165.50
33
594.00
5
375.00
2,134 50
25
Chickmagalur
220
990.00
22
396.00
2
150.00
1,536.00
26
Dakshina Kannada
0
-
2
36.00
3
225.00
261.00
27
Udupi
Total
28?
1,300.50
23
414.00
1
75 00
1,789.50
3453
15,538.50
509
9,162.00
76
5,700.00
30,400.50
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
KOPPALA
RAICHUR
RAICHUR
RAICHUR
RAICHUR
CHINCHOLI
CHITAPUR
GULBARGA
JEVARGI
JEVARGI
JEVARGI
SEDAM
SEDAM
SEDAM
SHAHPUR
SHAHPUR
SHAHPUR
SHAHPUR
SHORAPUR
SHORAPUR
SHORAPUR
YADGIR
YADGIR
GANGAWATI
GANGAWATI
KOPPAL
KOPPAL
KOPPAL
KUSHTAGI
KUSHTAGI
KUSHTAGI
YELBARGA
YELBARGA
YELBARGA
YELBARGA
DEVADURGA
DEVADURGA
LINGSUGUR
LINGSUGUR
Primary Health Centre, Inapura
Primary Health Centre, Hebbal
Primary Health centre, Mahagao
Primary Health Centre, Aralagundagi
Primary Health Centre, Yadrami
Primary Health Centre, Nelogi
Primary Health Centre, Kolakunda
Primary Health Centre, Mudhol
Primary Health Centre, Malakhed
Primary Health Centre, Sagara
Primary Health Centre, Hayyal(B)
Primary Health Centre, Gogi
Primary Health Centre, Doranahalli
Primary Health Centre, Huniseegi
Primary Health Centre, Kembhavi
Primary Health Centre, Kodekal
Primary Health Centre, Honagera
Primary Health Centre, Gajarkot
Primary Health Centre, Sriramanagara
Primary Health Centre, Kanakagiri
Primary Health Centre, Batageri
Primary Health Centre, Kinnala
Primary Health Centre, Hiresindhogi
Primary Health Centre, Hanumasagara
Primary Health Centre, Hanumanala
Primary Health Centre, Dotihala
Primary Health Centre, Bannikoppa
Primary Health Centre, Mudhola
Primary Health Centre, Bevoora
Primary Health Centre, Mangalura
Primary Health Centre, Arkera
Primary Health Centre, Gabbur
Primary Health Centre, Gurugunta
Primary Health Centre, .Hatti
DIVISION
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
Gulbarga Division
DISTRICT;:
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BELLARY
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
BIDAR
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
GULBARGA
.
'
TALUK ,
BELLARY
BELLARY
BELLARY
HADAGALLI
HAGARIBOMMANAHALI
HOSPET
HOSPET
HOSPET
HOSPET
KUDLIGI
SIRUGUPPA
SIRUGUPPA
AURAD
AURAD
BASAVAKALYAN
BASAVAKALYAN
BASAVAKALYAN
BHALKI
BHALKI
BHALKI
BIDAR
BIDAR
BIDAR
HOMNABAD
HOMNABAD
HOMNABAD
HOMNABAD
ALAND
ALAND
ALAND
CHINCHOLI
CHINCHOLI
CHINCHOLI
NAME of PHC requiring upgradatlon to CHC
Primary Health Centre, Orubayei
Primary Health Centre, Moka
Primary Health Centre, Emmiganuru
Primary Health Centre, Holalur
Primary Health Centre, Hampasagara
Primary Health Centre, Kaamalapura
Primary Health Centre, Kampli
Primary Health Centre, M.M.Halli
Primary Health Centre, Gadhiganuru
Primary Health Centre, Kottur
Primary Health Centre, Sirigere
Primary Health Centre, Siraguppa
Primary Health Centre, T.Kushanur
Primary Health Centre, Santapura
Primary Health Centre, Hunasura
Primary Health Centre, Rajeshwara
Primary Health Centre, Muchalamba
Primary Health Centre, Bhatambra
Primary Health Centre, Chincholi
Primary Health Centre, Mehakara
Primary Health Centre, Aanadura
Primary Health Centre, Mannalli
Primary Health Centre, Janawada
Primary Health Centre, Ghataborala
Primary Health Centre, Hallikeda(B)
Primary Health Centre, Hallikheda(K)
Primary Health Centre, Dubalagundi
Primary Health Centre, Kadaganji
Primary Health Centre, Jidaga
Primary Health Centre, V.K.Salagara
Primary Health Centre, Sulepet
Primary Health Centre, Chimmanchodh
Primary Health Centre, Chandanakera
ROTARY IN KARNATAKA
Contact persons for any inforniation/assistancc in polio eradication activities:
1.
Dr. P. Narayana.
Vice - Chairman, National Polio Plus Committee
Sharavathi Nursing Home. B.H.Road.
SHIMOGA577 201
Tel: 08182 23560(0] 78693 [R] 73737[Fax]
E-mail dr p naryana@vahoo.coni
2. Rtn. M.K.Panduranga Setty.
Vice- chairman, South Asia Regional Polio plus Committee.
14, Bull Temple Road,
BANGALORE 560 004
Tel: 080 3317653[O] 6610695[R] 3317665[Fax]
try
I 5"S=^ 2.oo\.
R.I.District 3160
Covering revenue Districts of Bidar, Gulbarga, Raichur, Koppal, Bellary and
Davangere. [4 Districts of Andhra also included]
POLIO PLUS CHAIRMAN
DISTRICT GOVERNOR:
Rtn. Dilip A Gadgil
Rtn. Dr.K.G.Kulakarni.
C/0 Comtech. D.No. 212
Dr. Simpi Linganna Road
IV Ward. Station Road.
KOPPAL 583 231
HOSPET583 201
Tel: 08539 20464(0] 20868[R]
TEL: 08394 28794(0] 27193 24108[R]
E-mail: kulkarnikg @yahoo.com
SURVEILLANCE CHAIRMAN
Rtn. Anil Mansubdar.
Shree Electricals, 10-6/15, N.V.Complex
Tel: 08472 27626 [S] 22030 [R] 29658 {Fax]
GULBARGA 585103
R.I.District 3170
Covering revenue Districts of Belgaum, Dharwad, Bijapur, Bagalkot, Gadag,
Haveri and Uttara Kannada. [4 Districts of Southern Maharashtra and Goa also
included]
POLIO PLUS CHAIRMAN
DISTRICT GOVERNOR:
Rtn. Dr.Mohan Biradar
Rtn. Pratap Puranik
Dr.Biradar’s maternity & nursing Home
D-18, MIDC. Shiroli
KOLHAPUR 416 122
MUDHOL 587 313
TEL:0231 656281(0]651566[R]
Tel 08350 20244(0] 20167[R]
653734[FAX]
E-mail: pratappuranik@vsnl.com
SURVELLANCE CHAIRMAN:
Rtn. Dr.Ashok Chougule
Trimurthy Building, Dr. Chougule complex A/P Peth Vadgaon Tai. Hatkangale.
Kolhapur Dist. Tel: 0230 471456(0] 471044[R]
R.I.District 3180
Covering revenue districts of Shiinoga, Chikmagalur, Hassan, Mysore, Kodagu,
Chamarajanagara, Dakshina Kannada and Udupi.
POLIO PLUS CHAIRMAN
DISTRICT GOVERNOR:
R. Krishna.
Rtn.K.Balakrishna Rao.
‘Sindhoora’ Eashwara Nagara II Cross
Vasu Agarbathies.
New Sayyaji Rao Road.
Opp. Manipal Dairy Road.
MANIPAL 576 119
MYSORE 570 021
TEL:08252 71121/36[O] 70568[R]
Tel: 0821 490693 490694 491653[O]
71141 [Fax]
543754[R] 497804[Fax]
email: kbrao@mpl.icdsltd.com
email: rkgov@ctli.net
SURVEILLANCE CHAIRMAN
DR.A.Basavannaiah.
Vijaya clinic
CHANNAGIRI 577213
TEL: 08189 28416[O] 28145[R]
R.I.District 3190
Covering revenue districts of Bangalore [urban & rural], Kolar, Tumkur and Mandya.
[Chittur District of Andhra pradesh also included]
POLIOPLUS CHAIRMAN
DISTRICT GOVERNOR.
Rtn. Prasad Sundaram
Rtn. Srivatsan.C.
#33, 3rd Cross, I Main.
Sampathkumaran&co
Vinayaka Layout. RMV II Stage
Chartered Accountants
BANGALORE 560 094
28/29. Shringar Shopping Centre.
TEL: 080 3412535
M.G.Road. BANGALORE. 560 001
Email: prasad sundaram@vahoo.coni
TEL: 080 5587172/5587479/5586035[O]
5243846/5243847[R]5587177[FAX]
Email: srivatsan@mantraonline.coin
SURVEILLANCE CHAIRMAN:
Dr.S.T.Kantharaj,
Kanaka Nursing Home
J.C.Extension.
KANAKAPURA 562 117
TEL: 08117 22326[O]22330[R]
GULBARGA DISTRICT CONTACT
Rtn. Nitin Thuse.
Pragathi Agencies.
96. Super Market.
GULBARGA 585 101
Tel:08472 27753 / 27536[O] 33717[R]
RA1CHUR DISTRICT CONTACT
Rtn. Shabbir Broachwala
City Talkies Circle.
RAICHUR. 584 102
Tel: 08532 43528/23281
BELLARY DISTRICT CONTACT
Rtn.B.L.Ananda Rao
3rd Road Gandhi Nagar
BELLARY 583 101
Tel: 08392 70452[O]55052[R]
KOPPAL DISTRICT CONTACT
Rtn.P.Mallikarjuna.
Asst.Manager, Safal House. KOF.
Agadi Complex, Jawahar Road.
KOPPAL 583 231
Tel: 08539 21548[O] 20471 [R]
DAVANGERE DISTRICT CONTACT
Rtn. Roop Kumar M.K.
139. Sri Dham. 2nd Main.
P.TExtension.
DAVANGERE 577 002
Tel: 08192 31464[O] 31518[R]
BIJAPUR AND BAGALKOT DISTRICTS
Dr. Yamal Shrikanth
A-7, Shantinikethan Colony
Bagalkot Road.
BIJAPUR 586 101
Tel: 08352 77878[O] 50186[R]
GADAG AND HAVERI DISTRICTS
Dr.S.B.Javai.
Sangam Nursing Home.
LAXMESHWAR. 582 116
Tel:08487 72326
5
F:\SKK\Lisls.doc
11.
Diuretics
1.
2.
Furosemide
Furosemide
Tab 40mg
Injection lOmg/ml in 2ml ampoules
12.
Gastrointestinal drugs
12.1
Antacids and other antiulcer drugs
I.
Aluminum hydroxide
2.
Magnesium Trisilicate
3.
Ranitidine
Tablet. 500 mg
Tablet. 500 mg
Tablet, 150 mg
Antiemtic drugs
1
Metaclopromide
Tablet, 10 mg (Hydrochloride)
A ntispasmodics
1.
Dicyclomine
Tablet, 10 mg
Laxatives
1.
Bisacodyl
Tablet, 5 mg (enteric coated)
12.2
12.3
12.4
12.5
12.6
Drugs used in diarrhoea
Oral rehydration salts (for glucose electrolyte solution powder 27.9 g/1
Components
Sodium chloride
Trisodium citrate dihydrate
Potassium Chloride
Glucose
g/1
3.5
2.9
1.5
20.0
Stomatological Preparation
1.
Chlorhexidine
Mouthwash, 0.2% (digluconate)
13
Hormones, other endocrine drugs and contraceptives
13.1
Adrenal hormones and synthetic substitutes
I.
Dexamethasone
Injection. 4mg dexamethasone phosphate (as
disodimn salt) in 1 ml ampoule.
2.
Hydrocortisone
Powder for injection, 100 mg (as sodium succinate in
vial)
3.
Prednisolone
Tablet. 5 mg
13.2
Contraceptives
13.2.1
Hormonal contraceptives
1.
Ethinylestradiol + Levonorgestrel Tablet, 30 mg + 50 mg
2.
Ethinylestradiol + Norethisterone Tablet, 35 mg + 1.0 nig
13.2.2
Intrauterine devices
1.
Copper containing device
13.2.3
Barrier methods
1.
Condoms
13.3
Estrogens
I.
Ethinylestradiol
Tablet. 50 mg
Cost per
unit
Centrifuge (Kemi)
2400=00
| Water bath (small) - Kemi
3300=00
12,690=00
CONSUMABLES/ EXPENDABLES
i Sulphosalicylic acid (100 gm)
125=00
| Benedicts Reagent quanitative (5 litre)
275=00
Sulphur powder (500 gms)
60=00
Fouchets reagent (125 ml)
70=00
N/10 HCl (500 ml)
42=00
WBC fluid (500 ml)
60=00
Leishman stain (500 ml)
237=00
3.8% Sodium citrate (500 ml)
42=00
| 5 mm Test tubes (12 x 75) per piece
4=50
JSB stain 1 (125 ml)
43=00
| JSB Stain 2 (125 ml)
43=00
ZN Stain (Strong) (125 Ml)
53=00
| VDRL Kit (For 50 tests)
285=00
| Widal Kit (4x5 ml for 35 tests)
387=00
| Blood grouping kit (3 x 5 ml for 35 tests)
320=00
, Distilled water (1000 ml)
40=00
I Test tube holder (each )
10=00
' Lancet (each)
2=00
Filter paper (9cm x 100)
28=00
Cover slip (superior quality - Blue star)
52=00
Spirit (400ml)
28=00
Sodium hypochlorite solution (1000 ml)
90=00
Glass slides (72s)
48=00
Anti-septic Solution (1000 ml)
90=00
Test tubes (each 20 ml 18 x 150 mm)
8=50
Depression slides
4=00
Xylene for cleaning (500 ml)
92=00
Liquor ammonia (50 ml)
55=00
Sodium Nitroprusside (100 gm)
230=00
Hydrogenperoxide (400 ml)
22=00
Ammonium sulphate (powder (500 gm)
60=00
Acetic acid Glacial (500 ml)
80=00
Liquid paraffin (400 ml)
90=00
Pipette (10 ml) each
60=00
Requirements
Per month
requirement
200gm
1000 ml
500 gm
125 ml
500 ml
500 ml
1500 ml
500 ml
1000
625 ml
625 ml
625 ml
50 tests
35 tests
35 tests
51itrres
5 nos
100
400
400
20 litre
2 litre
500
1 litre
500
100
500 ml
500 ml
25 gm
1 litre
200 gm
500 ml
1000 ml
5
Costs
250=00
275=00
60=00
70=00
42=00
60=00
711=00
42=00
450=00
215=00
215=00
265=00
285=00
387=00
960=00
200=00
50=00
200=00
112=00
208=00
560=00
180=00
300=00
90=00
4250=00
400=00
92=00
55=00
230=00
65=00
60=00
80=00
235=00
300=00
11954=00
One time purchase
12,690=00
Consumables / Expendables
11,954=00
TOTAL
24,644=00
(rupees twenty four thousand six hundred and forty four only)
It may be noted that the cost of Autoclave, hotair oven, electricity, running water, Laboratory furniture; fuel
source for the steriliser; costs for the gloves and other per sonal protective measures have not been included.
_____________ Requirements_____
______ Model
cost
Qnty/year
remarks
ONE TIME PURCHASE
II
I f ,.
2
Sahlis Haemoglobinomeler (imported)
S'CMc —
Including -Textra lubes
—
Neubauer Chamber (imported)
Z ■> 0 -o-c
WBC Pipette
/■?Z/ -On
ESR Stand with Tubes
/xa-av
Monocular Microscope (Indian Body;
Imported lens)______
Steriliser (Rectangular)
Reagent stand_________________________ —
Spirit Lamp___________________________
Waste containers (for Slides; cotton;
others)______________
X
Wire loop
Centrifu go________
0 0 - JO
Waler bath (small)
C
BP knife/scalpel
r\>
CONSUMABLES/ EXI’ENDABI _ES
■ P ',
Sulphosalicylic acid
I-00
Benedicts Reagent quanilative
—
Sulphur powder
<Tpe 'rs/
I Fouchels reagent
7 n— zn
N/10HC1
ANT) - C'O —
—
WBC fluid
/,? c m
Leishman slain
h cn u/
3.8% Sodium citrate
------- . — _...
—
5 mm Test tubes / per piece
r-T- 0
JSB slain 1
Z 7- Z v>
JSB Stain 2
ZN Siai
/, 7- nA
_______ //
vz 4
VDRL Kit
3 /■>
Widal Kit
__ ,3k? IS.a
Blood grouping kit
__ 375?-g~c
Distilled waler
-nr;
Test lube holder
zr
//■> - o r>
Lancet
___
—
Filter paper
---- <?Lw,Cm
Cover slip
/o
—rn
Spirit
---—
Sodium hypochlorite solution
7 A77.9
Glass slide
A
Anti-septic Solution
______ —
Test lubes
Depression slides
C'.~O
Xylene for cleaning _______________
/T OCA!/
Liquor ammonia
ff CO P\f
Sodium Nitroprusside
I_r>
too
Hydrogenperoxide
/ Kr'
~7o - (D-0
f v4«k
Government of Karnataka
TASKFORCE ON HEALTH AND FAMILY WELFARE
Ground Floor, Public Health Institute Building Annexe,
Sheshadri Road, Bangalore - 560 001
«
/V'
Ph: 2271021: Fax: 2277389; email: khs<lp@«nl.com
The Chief Minister has constituted the Task Force on Health and Family
Welfare under the chairmanship of Dr. H Sudarshan. The Task Force submitted
its Interim Report. A major component is strengthening of the Primary Health
Centres particularly with respect to making available good quality Basic
Laboratory services.
The following tests to be carried out at the PHC:
Albumin, Sugar, Bile Salts, Bile Pigments,
a) Urine analysis:
Ketone bodies, Microscopy
Ova and Cysts ( Normal and Saline preparation)
b) Stool analysis:
Test for occult blood
- Hb% by Sahlis Heamoglobinometer
c) Haemotology:
- TC / DC / ESR
- Bleeding time and Clotting time
- Smear Microscopy for Malaria, Tuberculosis,
Leprosy, Microfilaria
- Serology - VDRL, Widal, Blood grouping
and cross matching
Cholera, Trichomonas
d) Hanging drop
e) Other smear study
Gonococci, Paps Test
The following are the requirements:
Requirements
Cost per
unit
ONE TIME PURCHASE
Sahlis Haemoglobinometer (imported)
Including 4 extra tubes @ Rs 60 per tube
Neubauer Chamber (imported)
WBC Pipette (4 nos)
ESR Stand with Tubes (6 nos + 6 spare)
Monocular Microscope (Indian Body;
Imported lens)
Steriliser (Rectangular)
Reagent stand (local purchase)
Spirit Lamp (3 nos)
Waste containers (for Slides; cotton;
others)
__
'/o
1000=00
750=00
120=00
420=00
13,500=00
pLN
850=00
200=00
120=00
150=00
Remarks
Cost per
unit
2400=00
Centrifuge (Kemi)
3300=00
Water bath (small) - Kemi
12,690=00
CONSUMABLES / EXPENDABLES
125=00
Sulphosalicylic acid (100 gm)
275=00
Benedicts Reagent quanilative (5 litre)
60=00
Sulphur powder (500 gms)
Fouchets reagent (125 ml)
70=00
42=00
N/10 HC1 (500 ml)
60=00
WBC fluid (500 ml)
Leishman stain (500 ml)
237=00
3.8% Sodium citrate (500 ml)
42=00
5 mm Test lubes (12 x 75) per piece
4=50
JSB slain 1 (125 ml)
43=00
JSB Slain 2 (125 ml)
43=00
ZN Stain (Strong) (125 Ml)
53=00
285=00
VDRL Kit (For 50 tests) X MWidal Kit (4 x 5 ml for 35 tests) A "L
387=00
Blood grouping kit (3 x 5 ml for 35 tests)
320=00
Distilled water (1000 ml)
40=00
Test tube holder (each )
10=00
Lancet (each)
2=00
Filler paper (9cm x 100 )
28=00
Cover slip (superior quality - Blue star)
52=00
Spirit (400ml)
28=00
Sodium hypochlorite solution (1000 ml)
90=00
Glass slides (72s)
48=00
Anti-septic Solution (1000 ml)
90=00
Test tubes (each 20 ml 18 x 150 mm)
8=50
Xylene for cleaning (500 ml)
92=00
Liquor ammonia (50 ml)
55=00
Sodium Nitroprusside (100 gm)
230=00
Hydrogenperoxide (400 ml)
22=00
Ammonium sulphate (powder (500 gm)
60=00
Acetic acid Glacial (500 ml)
80=00
Liquid paraffin (400 ml)
90=00
Pipette (10 ml) each
60=00
Requirements
Per month
requirement
200gm
1000 ml
500 gm
125 ml
500 ml
500 ml
1500 ml
500 ml
1000
625 ml
625 ml
625 ml
50 tests
35 tests
35 tests
51ilrres
5 nos
100
400
400
20 litre
2 litre
500
1 litre
500
500 ml
500 ml
25 gm
1 litre
200 gm
500 ml
1000 ml
5
Costs
250=00
275=00
60=00
70=00
42=00
60=00
711=00
42=00
450=00
215=00
215=00
265=00
285=00
387=00
960=00
200=00
50=00
200=00
112=00
208=00
560=00
180=00
300=00
90=00
4250=00
92=00
55=00
230=00
65=00
60=00
80=00
235=00
300=00
11554=00
One time purchase
<22,690=00
Consumables / Expendables
11,554=00
TOTAL
24,244=00
(rupees twenty four thousand one hundred and forty four only)
It may be noted that the cost of Autoclave, hotair oven, electricity, running water, Laboratory
furniture; fuel source for the steriliser, costs for the gloves and other personal protective measures has
not been included.
•
rjffi nortosooo s^e.o(o>), t’dJTier^ *
03^
dorttfuTiOj , ’Gi^co'^z.} < $ ,^cc>a
•IhKj :— 500—1000 oa^rpuS
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The test which are normally conducted at Primary Health Centre
Labors tories
1) Under National Health Programmes
Malaria
- Examination of Blood smear //Lfcvi .<>. —
o-c^ &.'■ ri
Tuberculosis
Examination of sputum
Leprosy
- Examination of skin smear
RCH
- Urine analysis
Clinical haematology (TC DC EStlT Hb%) BT CT
Diagnostic
test
- Test for typhoid
VDRL
Jaundice
Stool examination
0//\f>
:
fane coze,' ,
50C0.00 ( Approx.)
1) Sodium Citrate
500gms
130.00
24 Hydrochloric acid
500ml
150.00 v--'
3) Sulfosalycilic acid
lOOcms
120.00
4) Leishman stain
500 x 5 hottie
600.00
5) Benedicts' reagent
500 x 15
750.00
6)
130.00
Fouchefr’a reagent
7) Sulphur powder
50.00 /
8) VDRL Test kit
300.00
9) h'idal test kit
200.00 '
10) Urine strips for ketone body
- 300.00
11) Glass slides
5 cox
2 00.00
12) Test tubes
200
300.00
•
13) ESR Tubes
10
150.00
-■
14) Cover slips
>5
100.00 ■
15) Haemoglobino meter
1
250.00 ✓
16) Test tube stand
2
- 100.00 '
17) Spirit lamp
1
25.00
18) Hb Pipette
3
•' 100.00 ✓
500
•700.00 -
19) Lancets
Approx, cost 5000/Z.N. stain and Sulfaric acid are not included in this
list as they may be obtained from concerned department.
Microscopesare also not included because the cost of one
Microscope
exceeds cost of all the chemicals and glasswa.-e
which are routinely done at Primary Health Centre Level
chemicals & glassware
to conduct the same.
1. U
Albumin
: Sulfosalycilic acid
Sugar
: Benedicts reagent
Bilesalt
: Sulfur powder
Bilepicment: Fouchets' reagent
Microscopy : Glass slide
coverslip
2. Stool exam
: Glass slide
covers lip
Routine Haematology:
Hb
: Haemoglobin meter
Hydrochloric acid
N/10
Neubaur chamber
WBC Pipet
s
Leishman stain
ESR
Bleeding
time
WBC F lu id
Sodium
ci trate
3.8%
: Lancet, Filter paper
Clotting
time
Test tube
Malaria
: JSB stain
5mm
I & II
: Ziel Neils. 5ns stain
Spirit lamp
Leprosy
: Z.N.
.Serology
: ^DRL Kit, Widal kit. Blood grouping
Kit
Microscop': Binocular
Test tube stand, ESR stand, sterliser/ shelf for keeping reagent.
bin with, Hypochlorite solu tion/powder.
antiSeptic lotion,
spirit
Revenue:Divisons
Bangalore,
Mysore
Belgaum
Gulbarga
Karnataka State
Total
29034
Particulars
SI.No
1
Total No. of Villages as per 1991 Census
12103
7852
5068
4011
2
No. of Uninhabnated Villages
1231
622
94
276
2223
3
No. of inhabitated Villages (1-2)
10872
7230
4974
3735
26811
4
No. of hamlets identified as per Survey
10140
12097
5507
2211
29955
5
Total No. of habitations (3^4)
21012
19327
10431
5946
56766
6
No of habitations included in externally aided projects'
1019
652
457
567
2695
7
No. of habitations in Greater than 55 LPCD Category
6172
4114
2079
761
8
No. of habitations Chemically affected
1637
498
85
1 1517
9
No. of habitations considered for Master Plan (5-6-7-S)
12184
14063
7860
3101
37208
2047
151
3386
;
13126
3737
10
No. of habitations in Less than 10 LPCD Category
619
569
11
No. of habitations in 10 - 20 LPCD Category
1167
2020
971
538
4696
12
No. of habitations in 20 - 40 LPCD Category
4719
5694
2580
1366
14359
13
No. of habitations in 40 - 55 LPCD Category
3060
3315
1331
696
8452
14
No. of habitations >55 LPCD for 2001 Population but < 55 LPCD for
2021 Population
2619
2465
831
350
6315
Total of 10 to 14
12184
14063
7860
3101
37208
KARNATAKA RURAL WATER SUPPLY PROJECT (MASTER PLAN)
— .''-'’’a
— ~"■
"
’ "
i.
—— ——,
*——**'*■"••
— - - —- - ' **- —
-w . .
■.-
«.> >
,
-
ZPE DIVISONS
Revenue Division : BANGALORE
Particulars
Sl.N
0
--
Habitations Considered for Master Plan
-----—■
Z
Z
<0-
✓
Bangalore ( R )
Z
z
District
*
ut
v\cV
CV
Kolar
District
1
Total No. of Villages as per 1991 Census
720
1039
818
1857
1802
1519
3321
2
No. of Uninhabitated Villages
49
111
69
180
232
206
438
No. of inhabitated Villages (1-2)
671
928
749
1677
1570
1313
2883
4
No. of hamlets identified as per Survey
461
,328
1423
1751
377
513
890
5
Total No. of habitations (3+4)
1132
1256
2172
3428
1947
1826
3773
6
No. of habitations included in externally aided projects:
0
32
46
78
306
28
334
7
No. of habitations in Greater than 55 LPCD Category
169
361
933
1294
703
■' 473
1176
8
No. of habitations Chemically affected
26
88
586
674
67
364
431
9
No. of habitations considered for Master Plan (5-6-7-S)
937
775
607
1382
871
961
1832
41
10 No. of habitations in Less than 10 LPCD Category
22
12
48
60
5
36
11 No. of habitations in 10 - 20 LPCD Category
110
27
42
69
48
67
115
12 No. of habitations in 20 - 40 LPCD Category
432
281
226
507
232
326
558
231
263
165
428
263
239
502
142
192
126
318
323
293
616
937
775
607
1382
871
961
1832
13 No. of habitations in 40 - 55 LPCD Category
,
14 No. of habitations >55 LPCD for 2001 Population but < 55 LPCD
for 2021 Population
Total of 10 to 14
KARNATAKA RURAL WATER SUPPLY PROJECT (MASTER PLAN)
Habitations Considered for Master Plan
Revenue Division : BANGALORE
ZPE DIVISONS
/
Tumkur
Particulars
SEN
0
X
District
c"
Davanagere
/
z“
-
0"
District
y
1
Total No. of Villages as per 1991 Census
1519
1199
2718
1048
673
245
2
No. of Uninhabitated Villages
91
88
179
124
96
37
133
3
No. of inhabitated Villages (1-2)
1428
1111
2539
924
577
208
785
4
No. of hamlets identified as per Survey
1596
10J8
2684
647
182
194
376
5
Total No. of habitations (3-4)
3024
2199
5223
1571
759
402
1161
6
No. of habitations included, in externally aided projects:
49
95
144
245
42
11
53
7
No. of habitations in Greater than 55 LPCD Category
603
643
1246
401
188
79
267
24
4
28
813
918
8
No. of habitations Chemically affected
74
345
419
30
9
No. of habitations considered for Master Plan (5-6-7-S)
2298
1116
3414
895
505
308
10 No. of habitations in Less than 10 LPCD Category
125
6
131
3
6
9
15
11 No. of habitations in 10-20 LPCD Category
332
96
428
54
12
44
56
1056
436
1492
393
175
150
325
486
281
767
272
172
72
244
299
297
596
173
140
33
173
2298
1116
3414
895
505
308
813
12 No. of habitations in 20 - 40 LPCD Category
13 No. of habitations in 40 - 55 LPCD Category
,
14 No. of habitations >55 LPCD for 2001 Population but < 55 LPCD
for 2021 Population
Total of 10 to 14
’
KARNATAKA RURAL WATER SUPPLY PROJECT (MASTER PLAN)
Habitations Considered for Master Plan
ZPE DIVISONS
Revenue Division : BANGALORE
Bangalore
Shimoga
Particulars
SI.N
0
District
Revenue Divison
1
Total No. of Villages as per 1991 Census
600
921
1521
12103
2
No. of Uninhabitatcd Villages
33
95
128
1231
3
No. of inhabitated Villages (1-2)
567
826
1393
10872
4
No. of hamlets identified as per Survey
1537
1794
3331
10140
5
Total No. of habitations (3+4)
2104
2620
4724
21012
6
No. of habitations included tn externally aided projects:
78
87
165
1019
7
No. of habitations in Greater than 55 LPCD Category
1209
410
1619
6171
8
No. of habitations Chemically affected
22
7
29
9
No. of habitations considered for Master Plan (5-6-7-8J
795
2116
2911
10 No. of habitations in Less than 10 LPCD Category
13
334
347
619
11
No. of habitations in 10 - 20 LPCD Category
31
304
335
1167
12 No. of habitations in 20 - 40 LPCD Category
209
803
1012
4719
13 No. of habitations in 40 - 55 LPCD Category
244
372
616
3060
14 No. of habitations >55 LPCD for 2001 Population but < 55 LPCD
for 2021 Population
298
303
601
2619
795
2116
2911
12184
Total of 10 to 14
1637
'
12184
KARNATAKARURAL WATER SUPPLY PROJECT (MASTER PLAN)
Habitations Considered for Master Plan
Revenue Divison : MYSORE
ZPE DIVISONS
Mysore
Particulars
Sl.N
0
'District
c/’z" /
Z
Hassan
District
1
Total No. of Villages as per 1991 Census
464
868
1332
511
1462
1548
985
2533
2
No. of Uninhabnated Villages
37
93
130
108
104
103
80
183
J
No. of inhabitated Villages (1-2)
427
775
1202
403
1358
1445
905
2350
4
No. of hamlets identified as per Survey
253
505 .
758
415
589
1425
443
1868
5
Total No. of habitations (3+4)
680
1280
1960
818
1947
2870
1348
4218
6
No. of habitations included in externally aided projects:
37
38
75
28
110
64
38
102
7
No. of habitations in Greater than 55 LPCD Category
124
212
336
186
472
571 j
273
844
No. of habitations Chemically affected
58
141
199
1
221
0
77
77
No. of habitations considered for Master Plan (5-6-7-S)
461
889
1350
603
1144
2235
960
3195
10 No. of habitations in Less than 10 LPCD Category
16
43
59
3
20
17
8
25
11 No. of habitations in 10-20 LPCD Category
29
97
126
16
88
126
120
246
12 No. of habitations in 20 - 40 LPCD Category
149
404
553
237
381
992
447
1439 ’
13 No. of habitations in 40 - 55 LPCD Category
14 No. of habitations >55 LPCD for 2001 Population but < 55
LPCD for 2021 Population
162
200
362
226
337
612
223
835
105
145
250
121
318
488
162
650
461
889
1350
603
1144
2235
960
3195
' 8
9
Total of 10 to 14
KARNATAKA RURAL WATER SUPPLY PROJECT (MASTER PLAN)
Habitations Considered for Master Plan
Revenue Divison : MYSORE
ZPE DIVISONS
MYSORE
z
z
Particulars
Sl.N
0
/
z
Revenue Divisor.
9-
c"
1
2
Total No. of Villages as per 1991 Census
1110
358
250
No. of Uninhabitated Villages
92
0
0
5
622
3
No of inhabitated Villages (1-2)
1018
358
250
291
7230
4
No. of hamlets identified as per Survey
. 2267
2787
3161
252
12097
5
Total No. of habitations (3+4)
3285
3145
3411
543
6
No. of habitations included in externally aided projects:
0
55
282
0
7
No. of habitations in Greater than 55 LPCD Category'
847
748
638
43
8
No. of habitations Chemically affected
9
No. of habitations considered for Master Plan (5-6-7-S)
296
0
0
0
0
2438
2342
2491
500
10 No. of habitations in Less than 10 LPCD Category
275
1
11 No. of habitations in 10-20 LPCD Category
444
575
—
7852
19327
i
652
4114
498
...
14063-4S
81
105
569
400
125
2020
12 No. of habitations in 20 - 40 LPCD Category
957
884
1069
174
5694
13 No. of habitations in 40 - 55 LPCD Category
443
519
537
56 .
3315
14 No. of habitations >55 LPCD for 2001 Population but <55
LPCD for 2021 Population
319
363
404
40
2465
2438
2342
2491
500
14063
Total of 10 to 14
KARNATAKA RURAL WATER SUPPLY PROJECT
Habitations Considered for Master Plan
ZPE DIV1SONS
Revenue Divison : BELGAUM
SI.
Particulars
No
/
Belgaum
c*
District
/
1 Total No. of Villages as per 1991 Census
694
475
1169
349
299
682
2 No. of Uninhabitated Villages
13
10
23
4
1
7
4
3 No. of inhabitated Villages (1-2)
681
465
1146
345
298
675
639
4 No. of hamlets identified as per Survey
229
201
430
23
43
70
457
5 Total No. of habitations (?~4)
910
666
1576
368
341
745
1096
6 No. of habitations included in externally aided projects
67
68
135
38
30
62
59
7 No. of habitations tn Greater than 55 LPCD Category
44
20
64
36
100
185
149
8 No. of habitations Chemically affected
0
0
0
12
62
9 No. of habitations considered for Master Plan (5-6-7-S)
799
578
1377
282
149
10 No. of habitations in Less than 10 LPCD Category
1
38
39
12
0
.
i
643
0
0
498
888
6
109
11 No. of habitations in 10 - 20 LPCD Category
49
151
200
44
12
32
163
12 No. of habitations in 20 - 40 LPCD Category
412
281 •
693
141
42
206
13 No. of habitations in 40 - 55 LPCD Category
14 No. of habitations >55 LPCD for 2001 Population but
LPCD for 2021 Population
278
88
366
55
42
146
358
162 '
59
20
79
30
53
108
96
799
578
1377
282
149
498
888
Total of 10 to 14
KARNATAKA RURAL WATER SUPPLY PROJECT
<
.
'
,
I..
.
Habitations Considered for Master Plan
Revenue Divison : BELGAL'M
SI.
Particulars
No
ZPE DIVISONS
----------------
BELGAUM
<5
9V
District
Revenue Divison
5068
U. Kannada
/
1 Total No. of Villages as per 1991 Census
600
539
787
1326
2 No. of Uninhabitated Villages
2
20
33
53
94
3 No. of inhabitated Villages (1-2)
598
519
754
1273
4974
4 No. of hamlets identified as per Survey
135
2100
2249
4349
5507
5 Total No. of habitations (3-4)
733
2619
3003
5622
10481
6 No. of habitations Included in externally aided projects
133
0
0
0
457
7 No. ofhabitations in Greater than 55 LPCD Category
111
449
985
1434
2079
8 No. ofhabitations Chemically affected
10
0
1
1
9 No. ofhabitations considered for Master Plan (5-6-7-S)
479
2170
2017
4187
85
; 7860 VyJSV.
10 No. ofhabitations in Less than 10 LPCD Category
68
521
1292
1813
11 No. ofhabitations in 10 - 20 LPCD Category
69
418
33
451
971
12 No. ofhabitations in 20 - 40 LPCD Category
196
696
248
944
2580
13 No. ofhabitations in 40 - 55 LPCD Category
123
288
199
487
1381
14 No. of habitations >55 LPCD for 2001 Population but <55
LPCD for 2021 Population
23
247
245
492
881
479
2170.
2017
4187-
7860
Total of 10 to 14
2047
'
Revenue Divison : GULBARGA
SI.
ZPE DIVISONS
Gulbarga
z
Particulars
X
/
District
No
1 Total No. of Villages as per 1991 Census
2 No. of L'ninhabitated Villages
626
747'
1373
602
878
628
40
54
94
22
83
40
3 No. of inhabitated Villages (1-2)
586
693
1279
580
795
588
4 No. of hamlets identified as per Survey
363
300
663
280
606
156
5 Total No. of habitations (3-4)
949
993
1942
860
1401
744
111
60
65
125
175
51
101
183
284
28
236
96
8 No. of habitations Chemically affected
63
193
256
341
410
226
9 No. of habitations considered for Master Plan (5-G-7-8)
725
552
1277
316
704
311
6 No. of habitations included in externally aided projects:
7 No. of habitations in Greater than 55 LPCD Category
■
26
24
50
49
41
3
11 No. of habitations in 10-20 LPCD Category
• 191
58
249
56
152
24
12 No. of habitations in 20 - 40 LPCD Category
343
248
591
133
271
148
13 No. ofhabitations in 40 - 55 LPCD Category
14 No. of habitations >55 LPCD for 2001 populanon but <55
LPCD for 2021 Population
102
172
274
48
145
93
63
50
113
30
95
43
725
552
1277
316
704
311
10 No. ofhabitations in Less than 10 LPCD Category
Total of 10 to 14
Habitations Con^sjdere^o£M3SterJP^ri?53^TS5Sr^T:
A
ZPE DB1SONS
Revenue Divison : GULBARGA'
SI.
Particulars
District
Revenue Divison
1 Total No. of Villages as per 199) Census
337
193
530
4011
2 No. nf I Jninhanitated Villages
28 •
9
37
276
3 No. of inhabitzted Villages (1-2)
309
184
493
4 No. of hamlets identified as per Survey
252
254
506
5 Total No. of habitations (3+4)
56!
438
999
6 No. of habitations included in externally aided projects:
. '72
33
105
3735
2211
5946
567
7 No. of habitations in Greater than 55 LPCD Category
75
42
117
761
, 1517
8 No. ofbabitanons Chemically affected
159
125
284
9 No. of habitations considered for Master Plan (5-6-7-S)
255
238
493
o
V.-< a
/
10 No. of habitations in Less than 10 LPCD Category
3
5
8
151
11 No. of habitations in 10 - 20 LPCD Category
26
31
57
538
12 No. of habitations in 20 - 40 LPCD Category
116
107
223
1366
13 No. of habitations in 40 - 55 LPCD Category
64
1L
136
696
14 No. of habitations >55 LPCD for 2001 Population but <55
LPCD for 2021 Population
46
23
69
350
255
238
493
Total of 10 to 14
&5>.l
■
./
cn
* >11.1 k l.'i 11 -Xm ii wI U X k
No
GULBARGA
BelIary
'' 3101v^g-7g-
Karnataka Integrated tt.M' sen ices uev.i-yuiun
Project Concept Document
South Asia Regional Office
Country Department
Date:
Country’ Manager/Director: Edward Lim
Project ID:
Lending Instrument: Specific Investment Loan
Project Financing Data
[X] Loan
[] Credit
For Loans/Credits/Others:
Total Project Cost (USSm)
Total Bank Financing (USSm)
[] Grant
Team Leader: Tawhid Nawaz
Sector Manager/Director: Richard Lee Skolnik
Sector: HY - Other Population, Health & Nutrition
Theme(s): Health/Nutrition/Population
Poverty Targeted Intervention:
[X] Yes
[]
[] Guarantee
Cofinancing:
Borrower Government of Karnataka
Guarantor Government of India
Responsible agency: Department of Health and Family Welfare Services
^aect implementation period:
Wiplementing Agency:
Contact person:
Address:
Tel:
Fax:
E-mail:
OCS PCD Form: October 15, 1998
[] Other [Specify]
No
■'
A: Project Development Objective
1.
Project development objective: (see Annex 1)
The objectives of the proposed project are:
♦
to improve efficiency in the allocation of health resources through policy and institutional
development
♦
to enhance performance of the health systems^ the primary' levef)
t
2.
Key performance indicators: (see Annex 1)
♦
_________ ____________
-t-
Increased public resources to health sector, with increased share ^primary and secondary levels
of care
""
Increased referral between levels of care, between health, family welfare, and nutrition programs,
and between private and public sectors
Increased utilization of primary health services, especially by the poor
Increased patient and community satisfaction with primary health services
B: Strategic Context
1. Sector-related Country Assistance Strategy (CAS) goal supported by the project: (see Annex 1)
Document number:
Date of latest CAS discussion:
The objectives of this proposed project reflect the goals and priorities identified by the CAS and India's
Ninth Five-Year Plan and National Population Policy, 2000. The CAS recommends focusing Bank-Group
financed investments on states that are undertaking economic restructuring programs and supporting
sectoral policy reform. Karnataka is one of the states that have initiated important fiscal, sectoral, and
governance reforms. Furthermore, it supports the CAS objectives by strengthening institutional capacity,
improving governance, engaging the private sector, expanding access to services, upgrading effectiveness
and quality of services and enhancing community participation and empowerment. Furthermore, the
project’s objective to meet the health needs of under-served populations, such as the poor, scheduled
*
castes and tribes (SC-'STs), women, and children, is at the core of poverty' reduction strategies in India.
2. Main sector issues and Government strategy:
HNP Sector Issues in India
India has made considerable progress in improving the health status of its population over the past fifty
years. The State of Karnataka reflects some of this gain, standing slightly above average in improvements
in life expectancy and declines in fertility, infant mortality', maternal mortality', and severe and moderate
malnutrition. Despite these broad favorable trends in both the country' and the state, a significantly high
proportion of the population, particularly those living in poverty, continue to suffer and die from
preventable infections, pregnancy- and childbirth-related complications, and under-nutrition. An
epidemiological transition is also taking place in which there are simultaneously high rates of
communicable and non-communicable diseases and where rapid urbanization is resulting in new health
problems. Furthermore, disparities between regions, men and women, and the poor and non-poor
r
uunluiue to widen.
Experience with pioject implementation and findings of the sector work indicate that the principal
constraints in the health, nutrition, and population (HNP) sector in India include: (i) inadequate
institutional arrangements and weak program management; (ii) limited financial resources; (iii) poor
governance; (iv) low quality of HNP services in both the public and private sectors; (v) limited access to
health services for the poor; and (vi) inadequate framework for engaging the private sector.
Inadequate institutional arrangement and weak program management. The existing fiscal and
administrative set up is complex, thereby hindering effective financing and accountability for
decentralized management of health facilities and deterring effective coordination across the health,
population, and nutrition sectors. More field level integration of the various health programs and
coordination of HNP services at the primary level are critical to improving health outcomes. In addition,
management skills at all levels are poor.
Limitedfinancial resources. Overall spending on HNP services in India is sizeable, albeit lower than in
comparable countries, and far less than the amount recommended to provide basic services. Spending on
preventive and promotive primary care services has not kept up with the growing need for services,
particularly for people below the poverty line. In addition to overall revenue constraints, weak
mechanisms for reallocating resources according to priorities, particularly operating and maintenance
expenditures, impede the delivery of effective public HNP services.
A major problem related to governance, which affects the performance of Karnataka's
public sector in HNP is a lack of accountability and transparency in areas such as management of human i
resources, particularly with respect to staff recruitment, appointment and transfer.
Poor governance.
Low quality of health services. Most Indians expect little, and receive little, from their health services.
Health facilities are often in disrepair, poorly equipped, and under-supplied, reflecting the low levels of
health spending. They are further constrained by staffing limitations, particularly in poor and remote
areas, by inappropriate skill-mix as well as by shortages of drugs and supplies and lack of attention to
supervision and maintenance. In both the public and private sectors, there are few standards and quality
improvement systems in place. Quality private health services are inaccessible for the poorest and most
vulnerable sections of society, and they do not address public health issues of national significance. As a
result substantial gaps remain in the effective delivery of health care services that are provided to the
population, especially for the poor and vulnerable populations.
Limited access for the poor. Those comprising the most vulnerable sections of society suffer the deepest
from the inadequacies of the public health system, ffiural populations', women, children, the disabled, and
people belonging to the scheduled tribes and scheduled castes have the worst health outcomes, are
allocated the least resources, and receive the fewest services to compensate for their increased risks. The
poor also pay relatively more for health care and receive worse care.
Inadequate framework for engaging the private sector. The private sector in India accounts for about 80
percent of overall health expenditures, one of the highest proportions of private expenditure on health in
the world. Services provided by the private sector are highest for primary health care, such as visits to
formal and informal health providers, and are financed almost entirely by out-of-pocket sources, placing a
disproportionate burden on the poor. The private sector, however, remains largely neglected in the
government’s policy formulation and program implementation. Appropriate policies to engage the
private sector, particularly with respect to providing information,(licensing) and regulations to protect and
empower consumers, especially poor consumers, need to be clearly articulated and implemented.
Government of India
India has made substantial progress in improving the health status efits population over the past two
decades. GOI has determined that public investments in health are critical for the sustainability of
development and poverty alleviation in India. Health is one of the six priority areas identified in the
Ninth Plan (1997-2002) which emphasizes successful preventive and promotive activities, better control
of communicable and non-communicable diseases, strengthened community and beneficiary
participation, and improved surveillance and systemic efficiency. The Central Council of Health and
Family Welfare has noted the importance of linking preventive and promotive care with selective aspects
of curative care as well as highlighted the importance of a well functioning referral system. Since the
states are largely responsible for the financing and implementation of health programs, these issues need
to be addressed at the state level.
Government of Karnataka
A
The Government of Karnataka (GOK) has had a long standing commitment to human development and
public health. In 1999 the GOK, prepared its first Human Development Report outlining developmental
disparities based on gender, income and region, as well as bringing to the fore issues of access and equity.
Building on the report, in early 2000 the Chief Minister of Karnataka commissioned a review of the
health system to ensure “Health for All”, with an emphasis on equity’ and quality. In order to ensure a
participatory process, a Task Force on Health consisting of key stakeholders in the government and civil
society’ was formed. The Task Force has developed a proposal outlining priorities for the health sector.
The priorities include developing an integrated health, nutrition and population project for the State
building on the gains of the existing Health System Development project, improving the existing primary
health care system with a special emphasis on equity' and quality’, increasing the health sector’s
responsiveness to the needs of populations with special needs, strengthening management, and developing
a comprehensive health management information system.
3.
Sector issues to be addressed by the project and strategic choices:
Achieving health and nutritional goals set by the Government of Karnataka —reduced infant and maternal
mortality’, reduced malnutrition, control of communicable disease;—will require concerted action from
the health sector, as well as from other sectors such as education, v-ater, sanitation, and rural and social
development. Important determinants of poor health and nutritional status include extreme poverty', low
educational status of women, lack of access to clean water and sanitation, and gender and caste-based
inequities; these factors cannot be adequately or directly addressed by interventions in the health sector.
To assist the GOK in reaching the state’s desired health and nutritional outcomes for its people, the Bank
has adopted a systemic and broad based approach to addressing the health system and has financed
projects and programs which include centrally sponsored disease control, nutrition, and family welfare, as
well as state health system development that focuses on increasing efficiency of resources and enhancing
the performance, of health systems at the secondary level of health care.
The proposed project will establish an integrated and responsive primary health care system supported by
a well functioning referral. It will build upon and expand the investment operation financed by the Bank,
Karnataka State Health Systems Development Project (KHSDP). and integrate delivery of health services
with family welfare services and disease control at the primary lev el. Furthermore, it will complement
fiscal and governance reforms planned under the economic restructuring program, which is also supported
with the Bank assistance.
The project will address the key sector issues in the following way:
Strengthening institutional arrangement and program management. The project will address institutional
problems through improving overall planning and management, manpower development, procurement of
Page 5
•
*f
drugs and equipment, referral, HMIS, surveillance, and training. Furthermore, the project will strengthen /
institutions to enable integration and coordination between health, nutrition, and family welfare services,/y'
as well as to work with the private sector at the primary care level.
!
Increasingfinancial resources. The project will supplement ongoing efforts by the Bank-financed
investment KHSDP, to (i) ensure adequate budgetary allocations to the health sector, (ii) increase the
share of health sector resources provided to the primary and secondary levels; and (iii) allocate adequate
resources for drugs, essential supplies, and operations and maintenance. In addition, under the fiscal
reforms supported by the Bank, Government of Karnataka (GOK) Medium Term Fiscal Plan envisages
increased spending on priority' social sector programs, of which health is one. The project will also
[address regional (intra-state) disparities in allocation of resources within the health sector, by intensifying
interventions in under-served areas.
Improving governance. GOK has initiated measures to improve governance, such as civil service reform
and human resource management, which will be expanded under the Bank’s structural adjustment
program. Within the health^sector^, KHSDP has already made considerable progress in increasing
transparency in the’trafisler'ofmedical personnel and contracting out non-clinical services at secondary'
level hospitals to private agencies. The proposed project will also adopt measures to improve governance
in the health sector, such as providing incentives for medical personnel to work in remote areas and with
vulnerable populations, mechanisms to establish merit-based selection and increase transparency in the
performance rating of personnel, and promoting the role of tire public in monitoring health services.
W
Enhancing quality’ of health services. The project will support policies and activities to improve the
quality of health services through supply-, as well as demand-side interventions. Supply' side
interventions include upgrading primary health care facilities, putting in place service norms, and
addressing manpower gaps and skills mismatches, and strengthening linkages between public and private
providers. Furthermore, this project will empower communities with information and mechanisms for
redress and quality improvement. The role of the community in increasing accountability of the health
systems will also be strengthened.
Expanding access for poor and vulnerable populations. The project will increase access by expanding
services in areas where poverty is concentrated, and health status poor. The project will intensify
j interventions with respect to physical infrastructure, staffing, IEC, and community' involvement in the
i northern districts of Karnataka, which have suffered from neglect and therefore, exhibit the lowest human
\development. Furthermore, NGOs and community based organizations (CBOs), in addition to local
private practitioners, will be engaged to deliver clinical and non-clinical services, such as IEC and
outreach, to communities difficult to access by the public health system.
g
Partnering with the private sector. The proposed project will promote private sector participation
through innovative schemes to involve traditional healers, NGOs, and other private practitioners in areas
such as referral, training, health financing, development of accountability' and transparency measures, and
monitoring and evaluation.
C: Project Description Summary
1.
Project components: (see Annex 1)
The project consists of three main components:
1. Management development and institutional strengthening component would consist of (i)
strengthening management and implementation capacity, in the areas of financial management,
procurement, technical management, and monitoring and evaluation; (ii) strengthening disease
surveillance and management information system; and (iii) improving institutional framework for policy'
Page 6
development The component would finance professional services, local training, vehicles, equipment,
including computers, furniture, studies, fellowships, workshops, operational expenses, and salaries of
incremental staff on a declining basis. This component
, h2. Improving access and service quality and effectiveness component would consist of (i) upgrading
primary health care facilities; (ii) improving human resource development and management, and curative,
preventive and support services; (iii) strengthening referral system between levels of care, between HNP
programs, and between public and private sectors; and (iv) expansion of health services in underserved
areas. The component would finance civil works, professional services, furniture, medical and other
equipment, local training, workshops, vehicles (purchase, hire, and maintenance), EEC, operational
expenses, and salaries of incremental staff on a declining basis.
3. Innovations to enhance partnership with communities and private sector component would
consist of (i) strengthening community capacity to identify' health needs and solutions and to monitor and
evaluate health services; (ii) piloting community driven schemes in the areas of healtb-fmancing and
health promotion; and (iii) piloting public-private partnership schemes. It would finance professional
services, NGOs, local training, IE(Wworkshops, studies, vehicles (purchase, hire, and maintenance),
operational expenses, and salaries of incremental staff on a declining basis.
^Bahkjg
.^Indicatives?
5^) Sector^: :c?.^cStS^^ ,^%'of^ jfin^nciri-y pi^Bank'ri;
gTotate
-financing
§(US$MK
1. Management development and
Institutional strengthening
2. Improving access and service
quality and effectiveness at the
primary care level
•
3. Innovations to enhancing
partnership with communities
Total
Total Project Costs
Interest during construction
Front-end fee
Total Financing Required
2.
0
0
0
0
Key policy and institutional reforms to be sought:
Many of the following key policy and institutional reforms have been initiated by GOK with the support
of KHSDP. The Task Force on Health and Family Welfare has also commissioned studies, financed by
KHSDP, to help inform these policy decisions and reforms. In addition to increasing support for current
efforts, the proposed project would expand particularly in the areas affecting primary care and
involvement of communities to improve health services and financing.
•
Increasing financing and improving resource allocation to the health sector, in particular primary and
secondary levels
Page 7
I
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■
■
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*
Developing policy and strategy to promote public-private partnerships, including traditional health
care providers
Improving manpower policy and procedures within the health sector by improving recruitment,
deployment, transfer, training, performance appraisal, sanctions, and incentives
improving technical efficiency by developing and strengthening management systems in tire areas of
planning and budgeting, finance, information, manpower, equipment procurement, and maintenance
Strengthening institutions to better manage and deliver integrated health, family welfare, and nutrition
services at the primary level
Improving financial protection for the poor T/1
■
Enhancing role of community based organizations (CBOs) in health promotion, service delivery, and
monitoring and evaluation
>
Enhancing public involvement and accountability of health sen ices and financing
3.
Benefits and target population:
■
Add
-I. institutional and implementation arrangements:
Institutional arrangements are currently under preparation. Our experience from implementing health
systems development projects indicates the following arrangements. The top of the proposed structure
would be composed of Project Governing Board, chaired by the Chief Secretary and including other
Principal Secretaries from other concerned departments of GOK—Health and Family Welfare, Women
and Child Development, Indigenous Medicine, Education, Sanitation (and possibly representatives from
the private sector, consumer groups, and NGOs). which would have responsibility for overall project
coordination and policy. A Project Steering Committee (PSC), led by the Secretary, Health and Family
Welfare Services, and composed of high level managers from the Stale Health and Family Welfare
Directorates, would be the second tier. The PSC would supervise and guide the implementation of the
project, in addition to coordinating with other health sector projects. The next tier would be the Project
Management Unit (PMU) to be headed by the Project Director. The Unit would consist of Financial
Management Wing, Equipment Procurement and Maintenance, Engineering and Architectural Wing,
Quality Improvement Cell, HMIS Cell, Community Empowerment Cell, and Training Cell, all composed
of professionals. The PMU situated at the Department of Health and Family Welfare Services, would
work with Directorates of Health, Medical Education, and Family Welfare and would be responsible for
day-to-day project implementation.
D: Project Rationale
1. Project alternatives considered and reasons for rejection:
The major alternatives considered include:
(a) Focus on selected parts of the State. Implementing exclusively in selected parts of the state would
be politically infeasible, and would miss the opportunity' to address key state-wide policy issues such as
increasing financing and improving resource allocation in the health sector, allocating adequate resources
for drugs, essential supplies and operations and maintenance, and institutional strengthening such as
rationalized service norms, referral mechanism, health care waste management system, equipment
management system, HMIS and surveillance of major diseases, procurement and financial management
arrangements. By addressing needs in only parts of the state, this alternative would not address the health
needs in a coherent and effective manner. Experience in the six states where State Health Systems
Development projects are currently being implemented indicates that the broad-based approach is the
appropriate mechanism to address systemic health sector issues.
(b) Leave the provision of basic services entirely to the private sector. There are several rationale for
undertaking this operation through the public sector (i) the private sector provides mainly curative care,
and does not provide the most appropriate services to those in greatest need; (ii) both sector work and
beneficiary assessment studies in several states in India indicate that more than 60% of tire beneficiaries
belong to the poorest sections of society and much of the remaining 40% are marginally above the
poverty line. They are unable to afford the costly fees for private services, which are paid almost entirely
from out-of-pocket sources. Since this project wishes to address the needs of the poor leaving the
provision of services to the private sector will fail to In addition, public health measures and essential
interventions is an important priority for government financing.
(c) Use an Adaptable Program Loan (APL). The advantage of the APL is that it encourages progress
against defined benchmarks, adds flexibility', cuts down on subsequent preparation time by focusing on
implementation and monitoring, signals a long-term commitment to assisting on long-term problems,
while keeping the whole problem under consideration in a phased manner. Due to limits on program
loans in the overall lending program, Regional Management prefers to use flexible lending instruments
such as the APL for sectors which are more conducive to phased reform monitoring, such as the power
sector (?).
(d) Use a Sector-Wide Approach (SWAp) was considered but rejected as a feasible alternative due to
the GOK’s weak institutional capacity to implement disparate elements of health sector operations under
one umbrella program. The GOK has clearly outlined as its' main priority in the health sector to build its’
own technical and managerial capacity and strengthen the existing health system. The government has
opted for a systems development approach within the framework of a broad based sector dialogue.
2. Major related projects financed by the Bank and/or other development agencies (completed,
ongoing and planned):
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"4?Latest Supervision'(Form 590) ;
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Implementation
Development
Progress (IP)
Objective (DO)
Bank-financed
Population VIII
Population IX
Reproductive and Child Health
Immunization Strengthening
State Health Systems II
Andhra Pradesh First Referral Health System
Orissa Health Systems Development
Maharashtra Health Systems Development
aUtter Pradesh Health Systems Development
National HIV/AIDS Prevention and Control
’’Cataract Blindness Control
Malaria Control
Tuberclosis Control
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Other development
agencies
Secondary Health Development (Gulbarga)
1P/DO Ratings: HS (Highly Satisfactory), S (Satisfactory), U (Unsatisfactory), HU (Highly Unsatisfactory)
KM
S
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3.
Lessons learned and reflected in proposed project design:
The project design takes into account key lessons learned from implementation of social sector projects in
India, and specifically four State Health Systems Development Projects currently under implementation
in six states, findings from sector work, and evaluations from Operations Evaluation Department (OED) .
Lessons from implementation of State Health Systems Development Projects', (i) maintain continuity in
project management and key project actors; (ii) empower Project Management Unit and Project manager
appropriately to ensure timely and adequate flow of funds, especially when the project is implemented by
a government line department; (iii) strengthen project management by providing greater autonomy with
respect to management and supervision, adequate staffing of key project management personnel and
improving management procedures; (iv) pay attention to qualivy aspects of tire project through
development of staffing and technical norms, referral mechanism, clinical and management training
programs, incentives for medical personnel, staff selection based on merit, and addressing skill-mix
during preparation; (v) emphasize software aspects, such as EEC. quality, and referral, to be implemented
in conjunction with hardware; (vi) improve HM1S to facilitate policy and institutional strengthening and
ensure information collected through M & E be used for management decision-making; (vii) use
independent agency in areas ofM & E and EEC; and (viii) undertake early preparation of procedures and
mechanisms to select and monitor NGOs and other private agencies contracted by the project.
Findings from sector work:
Keys lessons from implementation of social sector and other HKP projects in India: (i) ensure timely
and adequate flow of funds to the project entity; (ii) undertake advanced preparation of hardware and
software aspects of the project prior to approval; and (iii) speed up implementation and increase
supervision by strengthening implementation capacity' of the line agency to resolve problems in
procurement and disbursement early in the project cycle, and develop detailed implementation plans prior
to appraisal.
Key recommendations front OED: (i) place greater emphasis on institutional development and
governance issues in order to make a greater impact on development; (ii) engage in policy development
and debate; (iii) tackle the personnel problems and incentives structures in the sector; (iv) support
integration of referral system; (v) engage the private sector; and (v i) introduce performance-based
budgeting.
4.
Indications of borrower commitment and ownership:
Political commitment and ownership for the project are high. The commitment of GOK to health sectorw
reform is reflected in the constitution of the Task Force on Health and Family Welfare, which is
composed of prominent persons in the field of medicine and public health from academia, and the private
and NGO sectors. The principal responsibility of the Task Force is to provide strategic vision and
formulate recommendations for improving the health care system in the State. Furthermore, Karnataka is
one of the states partnering with the Bank to undertake broad reform measures, mainly fiscal, sectoral,
and governance changes to strengthen the enabling environment for poverty reduction.
5.
Value added of Bank support in this project:
IDA is best suited to provide funds to complement the medium and long-term policy initiatives of the
government. IDA'S approach to policy dialogue, which includes up front, and long-term engagement, are
useful in supporting the types of changes envisaged. The project would help consolidate the investment
made by a number of other IDA and donor-supported projects in the health, nutrition, and population
Page 10
sector, and provide a critical link to these investments. The project would also strengthen IDA'S strategy
of poverty reduction in India through its focus on the poor and under-served populations.
E: Issues Requiring Special Attention
1. Economic
[ ] Summarize issues below (e.g., fiscal impact, pricing distortions)
[ ] To be defined (indicate how issues will be identified)
[ ] None
• Economic evaluation methodology:
[ ] Cost benefit
[X] Cost effectiveness
[X] Other [specify]
The following economic analysis will be completed by appraisal and will contribute to project desicn (i) a
public expenditure review in the health sector addressing financial sustainability and the ability to
increase resources and protecting non-salary recurrent items, (ii) an analysis of private sector provision
. and financing to assure that public investments are not simply trying to substitute for private services, and
to examine who is benefiting from the proposed investments.
2.
Financial
[X] Summarize issues below (e.g., cost recovery, tariff policies, financial controls and accountability)
[ ] To be defined (indicate how issues will be identified) [ ] None
Project preparation will pay special attention to the fiscal impact of the proposed project as it relates to the
medium term expenditure framework and to issues relating to financial controls, accountability, and
sustainability', including (i) recurrent cost implications of the project, w ith the understanding that the
project would finance recurrent costs on a sliding scale (ii) an assessment of the resource flows into the
health sector. This analysis will examine issues of sustainability and the ability of the state to finance
incremental recurrent costs of the proposed project as well as the sustainability of IPP VIII, 1PP IX and
the Karnataka Health System Development Project.;(iii) mechanisms to ensure adequate flow of funds;
an
(iv)
assessment of financial control mechanisms to identify capacity, to collect and analyze financial
information, handle cash flow/disbursement issues, procure goods, and contract services. The assessment
will examine staffing and systems development and the need to develop financial management capacity to
better understand and manage public budgets, and improve financial accountability and controls. There
will also be an analysis conducted to outline feasible alternatives for health financing that will be piloted
during the project.
3.
Technical
[X] Summarize issues below (e.g., appropriate technology, costing)
[ ] To be defined (indicate how issues will be identified) [ ] None
Technical issues to be analyzed by project preparation include (i) integration of the health, family welfare
and nutrition services at the primary health care level, supported by a well functioning referral system, (ii)
the development of a comprehensive management information system (iii) human resource management
particularly in the area of skill mismatch, disruptive staff vacancies, performance based rewards and
incentives. A series of workshops and consultations will be held to clarify these issues. These workshops
will build on the workshops on staffing and service norms conducted under the State Health Systems
Development Project 11
Page 11
4.
Institutional
[X] Summarize issues below (e.g., project management, M&E capacity, administrative regulations)
[ ] To be defined (indicate how issues will be identified) [ ] None
An institutional assessment is being planned to provide guidance on how to implement the proposed
institutional reforms for the project. An analysis of the existing relationship between the public and
private sectors will be conducted to better identify and plan how the government can work with the
private sector in the area of referral, quality improvement and disease surveillance. As well, a study will
be conducted to examine the institutional arrangements needed to increase community involvement and
increase the community’s capacity to provide feedback and monitor and evaluate the health system.
Executing agencies:
The project will build on existing arrangements developed through the Karnataka Health Systems
Development Project
Project Management
The project will build on existing arrangements developed through die Karnataka Health Systems
Development Project
Procurement Issues
As a result of the existing KHSDP project, the GOK is well versed in the Bank procurement guidelines
thus there are no foreseen problems in this area.
Financial management issues
As a result of the existing KHSDP project, the GOK is well versed in the Bank procurement guidelines
thus there are no foreseen problems in this area.
5. Social
[ ] Summarize issues below (e.g., significant social risks, ability to target low income and other
vulnerable groups)
[ ] To be defined (indicate how issues will be identified) [ ] None
One of the key issues to be addressed in this project is how to overcome socio-economic and cultural
barriers, as well as gender discrimination and thereby increase access for vulnerable populations.
Additionally, an assessment of the potential impact of the project and any changes in health policy on the
various stakeholders will be conducted. A special focus will be on the poor, SC/ST, women, disabled
groups and under-served districts in North-East Karnataka. A mapping exercise, will also be conducted in
these under-served areas. The project preparation will also review the evaluation of the Yellow-Card
Scheme implemented under KHSDP to expand access to the scheduled tribes.
6.
Environmental
a. Environmental issues:
[ ] Summarize issues below (distinguish between major issues and less important ones)
[ ] To be defined (indicate how issues will be identified) [ ] None
Other:
b.
Environmental category:
c.
Justification/Rationale for category rating:
[]
A
[j
B
[X]
C
Page 12
The project is expected to have no adverse environmental impact given that the project only involves
upgrading of existing facilities. With regards to waste management, the project will ensure that it
complies with WHO standards
d.
e.
Status of Category A assessment:
EA start-up date:
Date of first EA draft
Current status:
t
Proposed Actions:
f. Status of any other environmental studies: Government has conducted audits of each secondary level
' facility.
g.
Local groups and NGOs consulted (list names): Not Applicable
h.
Resettlement Not Applicable
[ ] Summarize issues below (e.g., resettlement planning, compensation)
[ ] To be defined (indicate how issues will be identified) [ ] None
i.
Borrower permission to release EA:
j.
Other remarks:
7.
Participatory Approach:
[
]Yes
[
] No
[
] N/A
a. Primary beneficiaries and other affected groups:
[X] Name and describe groups (how involved, and what they have influenced or may influence.)
[ ] Not applicable (describe why participatory approach not applicable with these groups)
End beneficiaries, community groups, NGOs, private providers and local government officials, will
participate in the preparation phase through consultation workshops, exit interviews at health facilities,
and focus group discussions to define performance indicators and plans for monitoring and evaluation
during the course of the project, to identify’ needs and barriers to obtaining quality care and expanding
access. Monitoring of use by end beneficiaries, and of patient and community’ satisfaction with the health
services will be incorporated into the HM1S and will be used for local planning and management and
performance assessment of the project.
MOH will prepare the Project Implementation Plan (PIP)
b. Other key stakeholders:
[X] Name and describe groups (how involved, and what they have influenced.)
[ ]Not applicable (describe why participatory approach not applicable with these groups)
Local academic groups will be involved in the design and preparatory studies and in advising technical
elements of the drafting of the PIP. NGOs, and other technical agencies, WHO and KfW will be
consulted in the design phase and their inputs will be coordinated and shared.
Page 13
8.
Checklist of Bank Policies
a.
Safeguard Policies (check applicable items):
s§2.Ris kfo fiNjonlGldm p 1 i a tt.c el( ft M %if)
Environmental Assessment (OP 4,01)
Natural Habitats (OP/BP/GP 4,04)
Forestry (OP 4.36)
Pest Management (OP 4.09)
Cultural Property (OPN 11.03)
Indigenous Peoples (OP 4,20)
Involuntary Resettlement (OP 4.30)
Safety of Dams (OP 4.37)
Projects on International Waterways (OP 7.50)
Projects in Disputed Areas (OP 7.60)
Business Policies (check applicable items):
Financing of recurrent costs (QMS 10.02)
____ Cost sharing above country 3-yr average (OP/BP/GP 6.30)
____ Retroactive financing above normal limit (OP/GP/BP 12.10)
>1 Financial management (OP/BP 10.02)
•J Involvement of NGO’s (GP 14,70)
Other (provide necessary details)
b.
■J
c.
Describe issue(s) involved, not already discussed above:
F: Sustainability and Risks
1. Sustainability:
Financial, social, technical, and managerial sustainability is being addressed in the design and preparation
of the project. The economic analysis and monitoring of expenditures will determine whether the
incremental costs of tire project are affordable, and whether they will remain so as the program develops.
Institutionalizing a process to justify major capital investments is intended to maintain a sustainable
program. Social sustainability is addressed by instituting mechanisms to increase the involvement and
voice of consumers in the design of the project, and in routine provision of health services in both public
and private sectors. Updating the technical paradigms, streamlining services and integrating the referral
chain, working with the private sector, and focusing on management training and systems are steps taken
to ensure that the system is more technically and managerial!)’ sustainable than before the project.
2. Critical Risks: (reflecting assumptions in the foui
From Outputs to Objective
Institutional arrangements are not effective in
integrating centrally sponsored health and
family welfare and state health concerns (M)
t
Productive institutional linkages with the
private sector are not established (G,M)
Competent staff and managers are not placed
in project management units and health
facilities (M)
Provider behavior cannot be changed (S,O)
Strategic approach to behavior change
communication will not increase demand for
and accountability of health services (S)
From Components to Outputs
Flow of funds from GO1 to State project are
inadequate
Staff and consultants are not assigned in a
timely manner
Key staff and managers are not retained for
sufficient time
Procurement is not managed in a timely
manner
Funds are not made available for non-wage •
recurrent expenditures, especially drugs and
mobility
olumn of Annex 1)
’ 't ’
Institutional strengthening will be
emphasized in the proposed project
Financing would be linked to
performance
> ••
Information sharing, pilot studies, and
self-regulation will be encouraged.
Financing would be linked to
performance.
Address through Letter of Health Sector
Development Program, appoint key
personnel prior to negotiations
Emphasize consumer feedback and
provider incentives as part of the project
design
Use research-based communications anc
monitor results carefully
Address through Letter of Health Sector
Development Program, and financial
monitoring
Appoint key staff prior to negotiations
Include provision at negotiations to retair
well-performing staff
Develop robust procurement plans and
appoint key staff prior to negotiations
Address through Letter of Health Sector
Development Program, and continued
monitoring of health expenditures.
Link financing to performance
Overall Risk Rating:
Risk Rating - H (High Risk). S (Substantial Risk). M (Modes
usk). N (Negligible or Low Risk)
G: Project Preparation and Processing
1. Has a project preparation plan been agreed with 1: . borrower: (see Annex 2 to this form)
[X] Yes, date submitted: MM/DD/YY [ ] No, date ex: . cted: MM/DD/YY
2.
Advice/consultation outside country department:
[V] Within the Bank:
i
] Other development agencies:
3.
Composition of Task Team: (see Annex 2)
Tawhid Nawaz (Team Leader-Task Manager)
David Peters (Sr. Public Health Specialist)
Sadia Chowdhury (Sr. Public Health Specialist)
Preeti Kudesia (Sr. Public Health Specialist)
Hnin Hnin Pyne (Public Health Specialist)
Maj-Lis Voss (Economist)
Abdo Yazbeck (Economist)
Tazirn Mawji (Health Specialist)
Rajat Narula (Financial Management Specialist)
Mam Chand (Procurement Specialist)
(Legal Officer)
Vijay Rewal (Architect)
Shrelata Rao (Social Scientist)
Pradeep Kakkar (IEC)
4.
'
Quality Assurance Arrangements: (see Annex 2)
External Peer Reviewers:
internal Peer Reviewers
5.
Management Decisions:
t$g8^^^lssue^3^^i^|?S^iggAc:tiori/Declsibh^g^|gg?%xixRespbnslblllty.
Total Preparation Budget: (US$000)
Cost to Date: (US$000)
[
] GO
[
Bank Budget: (L'SSOOO)
] NO GO
(signature)
Team Leader: Tawhid Nawaz
(signature)
Sector Manager/Director: Richard L. Skolnik
(signature)
Country Manager/Director: Edwin R. Lim
Trust Fund: (USS000)
Further Review [Expected Date]
Annex 1: Project Design Summary
^India: JKarnataka Integrated HNP Services Development
r^HierarcJiyiofip.BjectlvesSs <Ke yiRe rfpnn a n cell o'd i c a t o rsy ? M o n i t o r i nqTa n d > Ey a 1 u a t i on? JSilCriticallAssuInp.ti.ons
Sector-related CAS Goal:
Sector Indicators:
Health and nutritional status of
Karnataka’s population,
particularly the poor, women,
children, and schedule castes and
tribes, is improved.
Decline in infant mortality
Decline in maternal mortality
Decline in malnutrition
Decline in anemia
Increase in immunization coverage
Increase in TB case detection and
cure
Project Development Objective:
Improve efficiency in the
allocation of health resources
through policy and institutional
development
Performance of health system
strengthened through
improvements in quality,
^Activcncss. and coverage of
primary health care services
Outcome / Impact Indicators:
1. Increased public resources to
health sector, with increased share to
primary' and secondary levels of care
2. Increased utilization of primary
health facilities, esp. by the poor and
*
SC/STs
3. Increased patient and
community satisfaction with
primary health sen-ices
*
4.
Increased referral between
levels of care, programs, and prriate
and public providers)
Sector / Country Reports:
(from Goal to Bank Mission)
Focusing on reforming states ar
human development will
contribute to poverty reduction
India
Improving quality of life and
health and nutritional status wil
increase opportunities and
productivity
Project Reports:
(from Objective to Goal)
Political commitment continues
Continuing investment in other
sectors, such as water and
sanitation, and education, affect
health and nutritional StatusContinuing support for centrally
sponsored programs, current!)
assisted by the Centra!
Government the Bank, UN
agencies, and bilaterals
Continuing support for improvin
quality, effectiveness and covera
of secondary level care, current);
financed bv the Bank
—
Output from each component:
1. Access to primary health
services expanded, particularly in
under-served districts and tribal
areas.
Indicators need further input: QQT
Output Indicators:
1.1. Increased awareness'of primary
health services offered, particularly
among SC/STs, women, and poor
*
1.2. Increased number of primary
health care facilities (functioning
according to service and staff
norms) in underserved districts and
tribal areas’
1.3. Increased number of NGOs
contracted to conduct outreach and
deliver services in tribal and remote
*
areas
7, F.fTrrHvrnrwM mid qunlily of
primary health services improved
7.1, Nuiiihri nf pi h nmy hr nil h cmn
facilities rehabiliatcd, equipped
versus planned
2.2. Percentage of facilities meeting
staffing, equipment, and medicines
norms
2.3. Increased number of medical
staff trained (clinical, management,
patient-provider communication.
MIS. referral, waste management)
2.4. Use of disease surveillance and
HM1S
3. Well functioning referral
system (between levels of care and
between programs) in place
3.1. Increased referral between
levels of care
3.2. Increased referral between HNP
programs
3.3. Increased referral between
private and public providers
4. Human resource development
and management capacity at the
primary level strengthened
4.1. IT system developed
4.2. FM system in place
4.3. Manpower gaps filled, esp
vacancies in underserved areas
4.4. Transparency in transfer of
medical staff (% of counseling used
for transfer)
4.5. Incentives system in place
5. Communities involved and
empowered to demand belter
services and to identify health
needs and problems
5.1. Mcchanisms/channcls for
communities to voice complaint and
demand for better services ??
5.2. Involvement of CBOs in M&E
(rating of services, etc.)
5.3. Training of CBOs and
community leaders in identify ing
health problems/necds and barriers
to access
Inputs: (budget for each
component)
Project Components/Subcomponents:
I. Management development and
institutional strengthening
2. Improvements in access and
service quality and effectiveness
3. Innovations to enhance
partnership with communities and
private sector
Project Reports:
(from Outputs to Objective)
Competent staff and managers arc
placed project management units
and health facilities, particularly i
remote areas
Synchronization of project inputs:
flow of funds, provision of
training, development of norms
and contractual arrangements.
Timely start-up of civil works,
training programs, and other soft
ware components, such ns IRC nnc
1IMIS, and piocuicnicnl ul drugs
and equipment
•
•
Project Reports:
•
(from Components to Outputs)
Flow of funds from GOI lo State
project are inadequate
Staff and consultants are not
assigned in a timely manner
TERMS OF REFERENCE FOR THE HUMAN RESOURCE DEVELOPMENT
STUDY FOR THE KARNATAKA INTEGRATED HEALTH, NUTRITION AND
FAMILY WELFARE SERVICES PROJECT
1.0
Background
1.1. The Government of Karnataka has received a TA grant from the PHRD fund for
preparation of an integrated Health, Nutrition and Family Welfare Services
Development Project (Po71160). The proposed grant is primarily to finance key
studies required for the finalisation of the project.
1.2. The Government of Karnataka has built up a vast primary health care and first
referral network in the State comprising 8173 sub-centres, 1676 Primary Health
Centres, (including 9 urban Primary Health Centres), 582 Primary Health Units
and 359 Community Health Centres. Under the World Bank assisted Karnataka
Health Systems Development Project (KHSDP) there have been major
improvements made to the first referral infrastructure.
Despite these
improvements, the Task Force on Health set-up by the Government of
Karnataka has identified many lacunae in the functioning of the primary health
care and first referral institutions. The primary health care system is expected to
deliver a wide range of services including maternal and child health, and
nutrition services, general curative care, management of communicable
diseases, health education & promotion and promote community involvement. A
major gap in the system is the poor quality of manpower and low levels of
management capacity in the delivery of primary health care services. The levels
of motivation and morale of the work force has been a significant factor in the
low level of utilisation of the infrastructure already built up. Needs assessment
for training the work force to enhance their skills and improve the management
capacity is required to be carried out. There is also need to assess the needs
from the community perspective and identify HRD capacity-building required for
the elected representatives and NGOs in building a strong community-based
primary health care system. There is also need to assess the capacity of the
existing training infrastructure and identify the upgradation in manpower and
infrastructure needed to face the HRD challenges of the sector.
2.1 General objectives of the Study
9eneral objective of the Study is to make an objective appraisal of the
- eXjsting |eve|s of skills and awareness of the health care providers as well as the
^community representatives, appraisal of the training institutions, conduct a
training needs-assessment of all the stake-holders and finalise a comprehensive
HRD Plan. The Study is expected to feed into the planning process of the
Department of Health and Family Welfare of the Government of Karnataka,
most directly through the proposed Karnataka Integrated Health, Nutrition,
Family Welfare Services Project. In this context the Specific Objectives are spelt
out in the succeeding paragraphs.
-(
'
2.2
Specific objectives
Within the general objectives enumerated in 2.1 above, the specific objectives will be
1) Training needs-assessment of the front-line health workers and para-medical staff; 2)
Training needs-assessment of PHC medical officers and specialists working in first level
referral institutions; 3) Training-needs assessment of community representatives; 4)
Institutional analysis of training institutions and recommend an infrastructure and
manpower plan for these institutions; 5) Assessment of the management capacity of the
Health system and recommend improvements.
2.2.1
Training-needs assessment of frontline health workers
The following categories of workers are critical in Karnataka’s primary health care
system, viz., a) Junior health assistant (female), b) Junior health assistant (male), c) lab.
technicians, d) pharmacists^ej. lady and male health supervisors f) health educators, g)
anganwadi workers, anJTKHraSitfohal birth afefistents (Dais).
a) Junior health assistants (female) (ANMs) are the most valuable personnel amonst all
health workers. They undergo an 18 month training before entering the work-force.
There is need to assess the existing curriculum, training materials, training methods and
assessment procedures and incorporate modifications to ensure their pre-service
training is effective. ANMs also receive periodic in-service training at District Training
Centres with IPP and RCH funds. There is need to assess the suitability and adequacy
of this training and suggest additions/modifications, periodicity and duration of such
training programmes, especially in view of the recent CNA approach and the need to
focus on the nutritional status of women and children.
b) Junior health assistant (male) (male health workers)- Male health workers have not
been effectively used in the system, and their lack of effectiveness is a major weakness
in the system. There is need to re-orient the male health workers and ensure they
provide services expected of them. The pre-service training structures for male health
workers have virtually become defunct. There is need to have a complete re-look into
the training infrastructure required and finalise the curriculum, periodicity and duration of
both the pre-service and in-service training programmes for male health workers.
c) Lab. Technicians provide the crucial laboratory services in Primary Health Centres.
They require training at the time of their induction into service as well as periodic training
to hone their skills.
d) Pharmacists also need to update their knowledge on the new generic drugs entering
the market and require tra ining on rational drug use, inventory and stores management,
and related areas.
e) Lady and male health supervisors provide the first level management supervision
structure and their proper training and motivation is crucial for effective supervision.
f) Health educators - Health education is critical in a public health approach;
unfortunately this aspect has remained neglected; health educators continue to be
perceived as support only to the family welfare programme. There is need to train them
effectively in the new communication and community empowerment strategies and
provide proper communication skills.
g) Anganwadi workers provide critical services in the area of child nutrition and health
as in looking after the needs of pregnant women. Their training needs also need to be
assessed.
bfMl^J)f^\\
viV-^-T .
h) Traditonal birth attendants (Dais) attend to almost 30-40% of ail deliveries in most
districts and there is need to ensure that they are recognized and given skills to ensure
safe deliveries.
2.2.2 Training-needs assessment of Doctors - There is need to look at the training
needs of Doctors working at PHCs/PHUs as well as those working in the first level
referral system. There is also need to look at other categories such as Taluka health
officers, programme officers, DHOs etc. and assess af the existing training
programmes and the gaps. There is also a need to equip the system for providing
both short and long term programmes in public health as also in the area of
programme and hospital management.
2.2.3 Training needs-assessment of community representatives - Community
empowerment for health can take place only if the local community leaders such as
Grama Panchayat members are properly oriented and sensitized.
2.2.4 Training needs assessment for trainers - The Health department has so far not
conducted a review of the existing capacities of training faculty. This is a pre-condition
to the successful implementation of any meaningful HRD Plan.
2.2.5 Institutional analysis -There are currently the following categories of training
institutions - ANM training centres, District Training centres, Regional HFW Training
centres, and the State Institute for Health and Family Welfare (SIHFW). A SWOT
analysis of each of these institutions is required as well a recommended integrated
structure with the SIHFW the apex.
2.2.5 Assessment of management capacity - A major weakness of the existing Primary
Health Care System is the weak management capacity; consequently Programme
implementation falters. There is need to prepare a proper HRD Plan that focuses on
capacity building at all levels.
2.2.6 HRD Plan - An objective assessment of the above issues will provide the basis for
developing a comprehensive HRD Plan for the department that takes into account the
existing structures and budgets, identifies the gaps, and recommends a Plan with
detailed time-phasing, costs and supportive infrastructure required.
3. The Tasks
3.1
3.2
The selected agency will be expected to constitute a core full time Project
team comprising a Human Resource Development specialist and a Public
Health manager that will function until the Agency submits its Final
Report. This team will be responsible for the designing, and
implementation all the activities contemplated in the study.
The Agency will carry out a needs assessment study through
questionnaires, interviews and focus group discussions. The
questionnaire will be addressed to all categories of health care providers
as well as to elected representatives, including Gram Panchayat
members, members of self-help groups and members of Mahila
Swasthaya Sanghas. Interviews will be both structured as well as
unstructured.
3.3
3.4
3.5
3.6
4.0
The Agency will conduct 4-5 Workshops in various parts of the State to
discuss institutional strengthening, strengthening of management
capacities, improvements in the quality of services, and measures to
make the system more responsive. The participants could be “mixed” or
different Workshops could be held for health providers, local elected
representatives and NGOs.
The Agency will visit a sample of each category of training institutions,
viz. ANM training centre, District Training Centres, and Regional Training
Centres. The Agency will also make a detailed study visit of the State
Institute of Health and Family Welfare
The questionnaires, interviews, focus group discussions and the
Workshops and study visit will be properly tabulated and documented.
The data from the Study visits, questionnaires, interviews, focus group
discussions, and the Workshops will be collectively utilised for developing
a set of strategies for preparing a comprehensive HRD Plan.
DELIVERABLES
The Needs assessment and Workshops should result in the following reports,
which should be presented to s to the Review Committee at various stages of the Study.
4.1
4.2
4.3
4.4
5.0
Resource support and review
5.1
5.2
5.3
6.0
A Status Report containing an Institutional Analysis for each type of
training institution.
A Status Report containing a needs-assessment for each level and each
type of health care provider, Doctors, ANMs, male health worker, lab
technicians, health educators, pharmacists, etc.
A Report on the Quality of existing training programmes.
A Synthesis Report of the above individual reports, accompanied with a
set of Recommendations containing a comprehensive HRD Plan for the
department focusing on the primary health care system.
The consultants will receive assistance and support from a Working
Group of knowledgeable individuals drawn from the various functional
areas of the Karnataka Health, Nutrition & Family Welfare Services units.
A Review Committee of the Karnataka Health, Nutrition & Family Welfare
Services will be responsible for the review, supervision, and approval of
the Plans. This committee will be chaired by the Commissioner of Health
& Family Welfare and consist of senior government officials, and selected
Task Force members.
The consultants will be provided necessary assistance from the Health &
Family Welfare Department for smooth conduct of the Study.
Work Plan
A tentative schedule of the Work Plan is presented below. Once approved
by the Review Committee tire schedule will require to be adhered to
strictly.
Name of the
Activity
Appointment
of core
Project team
Identify
Tasks
Finalise
sampling
design
Prepare
Study
Document
a
Finalisation
of Workshop
design
Appointment
of Study
teams
Conduct
of
workshops
Conduct of
Survey of
identified
facilities
Conduct
of
training
needs
assessment
Finalisation
of
Recommend
ations
Description Of the Activity
Deliverables
Time
Frame
1 week
Core team to be
appointed and approved
by Review Committee.
Listing of all the tasks that Activity list
3 weeks
come under the purview of the
study.
The Core Project team will
Finalisation
of Study 2 weeks
design and time-phasing
finalise the sampling design,
structure of questionnaires,
interviews, focus group
discussions and workshops.
Prepare document that will list
MOU
3 weeks
the responsibilities,
deliverables and time frames;
in short an MOLL
Workshop formats and
3 weeks
This will be done in close
consultation with the
workshop time table
Department
Appointment of full time Study
Approved Study teams
3 weeks
teams comprising of two public
health specialists, including
one training specialist.
Workshops along with medical Workshop Reports
8 weeks
officers, NGOs, elected
representatives and health
staff
Appointment of a core Project
team
Analysis
16
weeks
Assessment
16
weeks
Final Report including
institutional Analysis,
Needs Assessment and
a comprehensive HRD
Plan with costs and time
-phasing
18
weeks
On site visits to randomly
selected institutions
Institutional
Reports
The assessment will be
conducted through
questionnaires, interviews,
focus group discussions, visits
and Workshops
An approved set of
recommendations and
strategies.
Needs
Reports
7.0
Review Committee:
The review committee will consist of
Chairman: Commissioner of Health &Family Welfare.
Members:
•
»
•
»
•
°
o
Project Director IPP IX
Director HFW
Director SIHFW
Additional Director PHC
Project Director RCH
Dr. C. M. Francis, Member Task Force
Dr. Thelma Narayan, Member Task Force
71. Selection criteria
Selection of the Agency will be through National Competitive bidding on the basis
of quality based selection, providing for negotiating with the highest ranked bidder.
Co
H '
STUDY FOR KARNATAKA HEALTH, NUTRITION & FAMILY WELFARE
SERVICES PROJECT
TERMS OF REFERENCES (Revised)
Review of Regulations concerning Civil Service employment and
transfers for health department
1. Background
The Government of Karnataka has received a TA grant in response to preparation of an
integrated Health, Nutrition and Family Welfare Services Development Project (Po71160).
The proposed PHRD fund is primarily to finance key studies required in the finalization of
the project.
To improve health outcomes of the Karnataka’s population, especially among the poor and
vulnerable groups, the State Government has requested the Bank to support and finance a
health sector operation that aims to strengthen primary health care and public health services.
Agreement was reached over a few key sector reform initiatives, which include the following:
Making infrastructure more cost effective and linking it more clearly to stated health
outcomes;
Exploring other forms of service delivery (outreach/NGO/private sector);
Improving GOK’s oversight over the whole health sector, including development of
new mechanisms to monitor and upgrade service quality;
Strengthening health financing through development of better information systems,
strengthening of insurance schemes, and improved financial management;
Increase accountability and enhancing the incentive system in the public system.
The Review of Regulations concerning Civil Service employment and transfers for health
study is meant to contribute to item number 5 above. Quality of health care (promotive,
preventive, curative, caring and rehabilitative) depends largely on the clinical, technical and
managerial skills, the ethical and social behaviour, motivation and commitment, and
knowledge of the health personnel. To improve the health services, there is a need to increase
accountability and change the incentive structure within the public system. Professional
merit, commitment to serve the community, and good practice should be adequately
rewarded, accountability levels should be enhanced and, particularly at the primary care
level, transparent and needs-based recruitment, transfer and promotion criteria should become
established. Primary care providers must be rooted and feel a responsibility towards the
communities they serve and this is impossible to achieve if they arte continuously transferred.
2. Objectives
Key Objective:
Strengthen Primary Care Services: Transform Human Resources Management
A. HR polices to increase accountability and improve services
B. HR polices to reduce bias in HR deployment
C. Enhance quality of human resources/training
D. Reduce corruption
7
Review the existing polices that guide decisions over new capital investments
E.
Increase the efficiency of the delivery systems at the primary level (PHC, PHU, CHC
level)
F. Incorrect utilization and duplication of services in referral chain
G. Reduce compartmentalization and segmentation of different programmes.
Specific objectives:
i.
Review the existing recruitment, transfer and promotion criteria to
develop transparent needs-based recruitment and promotion process
and to enhance accountability levels particularly at the primary care
level
ii.
Reward professional merit, commitment to serve the community, and
good practice
iii.
Analyzing the existing data on absenteeism to see if issues like levels
of vacancies, the state of the facilities, or the capacity of local
management affect the level of absenteeism experienced in a
particular District.
Conducting focus groups of health personnel to ascertain the what
motivates them and affects their performance. Whilst many of the
factors are in a sense well understanding the behaviours of health
personnel is an essential prerequisite to the introduction of any
incentive scheme.
v. Establishing the current state of supply and demand of health
personnel. It has been suggested for example that there is a surplus
of doctors.
vi. Decrease vacancies, decrease skill mismatch
vii. Engage and contract NGOs and private sector providers to serve
underserved arrears.
viii.
Strengthen DHOs’ management capacity
ix. Enhance knowledge of both public & providers on good practices
and clinical protocols
x. Strict enforcement of anti-corruption laws and regulations.
xi. Develop clear and realistic regulations for extra hour private practice
in public facilities
xii. Grievance mechanisms set up
xiii.
Implementation of the most cost effective strategy to achieve
planned health gains in underserved arrears.
xiv.
Central, state and externally funded programmes are to be
integrated
iv.
8
3.
Measurable Outputs
Increased efficiency and quality of services, measured by
Quality:
Better clinical results
Increase inpatients’ satisfaction
Decreased absenteeism
Decreased skill mismatch
Increase efficiency, reduce costs, reduce waste and duplication
Reduce costs. Improve health outcomes, reduce maternal mortality
Improvement in all priority health indicators
Independent evaluation should also improve quality of services
4,
Outputs /An outline of the task to be carried out
n)
Under take a detailed review of the existing recruitment, transfer and
promotion criteria in the Health & FW Department and suggest
transparent needs-based recruitment and promotion process to enhance
accountability levels particularly at the primary care level
o)
Collection of data and materials pertaining to the study from Heath
Department and Government.
p)
Consider the effect of existing transfer policy and suggest transfer polices
to be adopted to avoid frequent transfer of Officers and Officials in the
department
q)
Suggest measures to be taken to reward professional merit, commitment
to serve the community, and good practice
r)
Suggest HR polices to Transform Human Resources Management for
cadre development, health human power planning, identifying and
responding to current and future health personnel requirements.
s)
Share the key findings with the departmental Officers that will be used
t)
Suggest ways and means to contract NGOs and private sector providers to
serve under reserved arrears
u)
To find out the facilities available to the staff of Health department in rura
& urban areas
v)
To find out deficiencies in procedures in imposing penalties to inefficient
and erring Officials/Officers.
9
5.
w)
To indicate e-govemance for implementation of Regulations concerning
Civil Services.
x)
To carry out any other task assigned in pursuance of objectives and give feed
back.
y)
The consultant should provide periodical reports on all issues assigned to him.
Schedule for Completion of Tasks
Outputs
Amount of time for
task after signing of
contract
Identify Tasks'. Listing of all the tasks that come under the
purview of study
1 week
Make document: Preparing a document that will the
responsibilities deliverables time frames
2 weeks
Out line of work plan
2 weeks
Review of existing Systems: A study of the existing mechanisms
in the State and Collection of data and materials
4 weeks
Monthly progress reports.
First Draft Report
4 weeks
Revised & Final Report should include Final Summary
2 weeks
Total
15 weeks
The final report must include accessible summary on the principal conclusions, policy
implications and recommendations for wider implementation to the Govemment/department.
6.
Data Services and Facilities to be provided by the Client
The Department of Health and Family Welfare will provide consultancy with documents
available in a timely manner, including reports of studies that have been undertaken under
KHSDP. . The consultant would make efforts to collect the required data and information from the
concerned Directorate or the Secretariat as required by the Project Administrator.
Facilities to
undertake work would also be provided by issue of a circular from a competent authority.
10
7.
Payment Schedule
10% Signing of contract
15% Summary of desk review/Inception report and Out line of work plan
40% Draft reports
35% Final Reports
Total compensation includes all cost of work such as communication, travel, lodging, food,
materials, printing, etc.
8.
Composition of the Review Committee
Review Committee will consist of following members.
•
•
•
•
•
•
®
•
»
•
•
•
•
•
•
Commissioner of Health & FW Services.
Project Administrator, Karnataka Health Systems Development Project
Director of Health & FW Services.
Additional Director SPC, Karnataka Health Systems Development Project
Chief Administrative Officer, Directorate of Health & FW Services
Chief Administrative Officer, Directorate of Medical Education
Deputy Secretary to Government, Health & FW Department
Deputy Secretary to Government, Department of Personnel & Administrative Reforms
Deputy Secretary to Government, Finance Department
Deputy Secretary to Government, Planning Department
Joint Director, Health & Planning, Directorate of Health & FW Services.
Chief Administrative Officer, Karnataka Health Systems Development Project
Chief Finance Officer Karnataka Health Systems Development Project
Deputy Director (Training), Karnataka Health Systems Development Project
Special Invitees-, (a) President, IMA, Karnataka Branch (b) President, Red Cross
Society, Karnataka Branch
There will be a monthly meeting of the Review Committee with the consultants for
monitoring the progress of the studies per time schedule and directions. All final out puts
submitted by the Consultant including reports will be reviewed.
9.
Consultant’s Qualifications
The Consultancy will comprise of a team of experts well versed with:
a)
Civil services rules and regulation of Karnataka Government with regards to
recruitment, transfer and promotion of Karnataka State Government Officers/
Officials. The consultant should have minimum qualification of graduation and have
minimum 10-15 years of experience handling civil service regulations of Karnataka
Government employees.
b)
Manpower Management / Human Resource Management with specific reference to
Health Sector. He/She should be a postgraduate in Manpower Management / Fluman
Resource Management with specific reference to Health Sector or A Ph.D in
Demography and specialised in Human Resource Management. He / She should
have at least ten years of experience in Manpower Planning related to any department
at the National / State level. It is desirable that the Consultant has experience in.
working with the health sector.
11
Background Paper
tdr/bp/oo.i
UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases
(1997) “Prospects for elimination: Chagas’ disease, Leprosy, Lymphatic filariasis, Onchocercia
sis" (TDR/GEN/97.1),
UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases
(1998) “Tropical Disease Research: Progress 1997-98: Fourteenth Programme Report of the
UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases”,
World Health Organization, Geneva, Switzerland.
Wall J.F. (1970) Andrew Carnegie. University of Pittsburgh Press, Pittsburgh.
Wehrwein P. (1999) Pharmacophilanthropy. Harvard Public Health Review. 32-39 Summer
issue.
World Health Organization (1996) “Guidelines for drug donations”. Geneva: World Health
Organization.WHO/DAP/96.2.
W.H.O. (1998) Health For All in the Twenty-First Century World Health Organization Docu
ment AS 1/5 Geneva.
World Health Organization. (1999a) “Building Partnerships for Lymphatic Filariasis”:World
Health Organization, Geneva.
World Health Organization. (1999b) "Guidelines for Drug Donations". (Revised):WHO/
EDM/PAR/99.3; I-23 World Health Organization, Geneva.
Selected web sites
Organisation
Internet Address
Baby Milk Action
http://www.inbc.org/
Global Forum for Health Research
http://www.globalforumhealth.org/
International Trachoma Initiative
http:/www.trachoma.org/abouttrachoma.html
Malarone Donation Programme
http://www.malaronedonation.org/
Mectizan Donation Programme
http://www.taskf0rce.0rg/M DP/
Task Force for Child Survival & Development
http://www.taskforce.org/
UNDP/World Bank/WHO Special Programme
for Research and Training in Tropical Diseases
(TDR)
http://www.whoj nt/td r
World Health Organization
http://www.who.int/
WHO Control ofTropical Diseases (Filariasis)
http://www.who.int/
13
P2g2 1 of* 2
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2003
Ci ion pci 6U« i
SryMtal r>o-.fpif>rvmcsnT
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Dear Dr. Narayan.
rcound iaoie Consultation on Health
me Confederation of Indian industry (CH), has been invited by the Department for International
Development (DFiD) to organise a series of Rounci Tables to seeK private sector views on pro-poor
economic growth through public-orivate partnerships. The recommendations from these consultations will
help in developing DFID’s Country Assistance Plan (CAP) for poverty reduction in India
DriD is tne British government aepartment responsible for Britain's contribution towards international
efforts to eliminate poverty.
issues iu be duuicaacd i» cuuuaiiUii. Govci iPiniefils face a problem ifl delivering public services
even wnen it nas tne anility io aeiiver, oecause me nign constituency oemanas outstrips government
capacity in many cases. The private sector can play a proactive role and best practices_ln_ privatisation
and partnership strategies need to he worked out I am pleased to invite you for the Round Table on
health scheduled for
July 2003, Wednesday at CH institute of Quality, Near Dliarat Nagara, 2nd
wage, Magaai Main Road, vishwaneeoam Post, Bangalore.
The consultation io designed to solicit effective participation from experts in the field of health. It can give
DFID an understanding of how the private sector can be leveraged to achieve outcomes favorable for pro
poor economic growm.
Your enriching experience on the issue will add value to the consultation and go a long way in developing
a realistic’Country Assistance Plan for DFID's interventions in India. A brief background paper is attached
tor your reference.
~
1 look forward to your participation in the Round Table. Please confirm your participation at the earliest to
facilitate logistical arrangements.
■ ~
ire
~
■ --j >
Chanda Sinah
6/30/03
Pago 2 of 2
KX Please confirm your acceptance by mail to
Ms Navaiiiid ortaiiaciiarya at navanita.bhattacharyavS^ciionline.ory or
Mr S Raian at s rajan^ciionline org
S
^rMi’..........
horn Oor<ir\n_l<'arnofj5l<p
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*Fax 80-52^6709
smpil- s raianijfrciinnline nrn
Piease visii our wee sire ar:
www.c11-K3rn3taKa.Qrg
www ciionline org
6/30/03
1) Approximately 80% of healthcare in India is provided for by the private sector.
2% of me market); smaiier hospital services (which can constitute a iarge part of
care in some states such as AP); private formally qualified doctors practising
aiiopau.ic medicine; smaller practitioners in indigenous medicine; over the counter
(OTS) drugstores (providing unautnonzed diagnosis and prescription along with
medicine sales); and Rural Health Providers (or quacks) who provide by far the
largest element of care . The NGO sector by comparison appears very small and
marginal to the health of most people.
2) DFID’s work in India concentrates upon central and state level. It pursues
strategies to improve service delivery, reform and strengthen health system
operations and enhance the quantum and quality of health financing. The private
heaun sector is important in aii these aspects, most particularly as an additional
means of delivering services, as an issue for stewardship and regulation and as a
CiictuGPi^G iO mitigating GcitciotrOpuiC shock and poverty. In addition to the work or
many otner agencies, we nave undertaken a numoer of analytical studies to better
ur,dc5rstand
hpfi2vln”r
Hrtts npoviri^rg and cor^umers of private health care.
iiiese studies nave looked, amonysi other things, at motivating influences, quality
of care, access and affordability, the public private interface, the feasibility of reform
QPid institutiorid 3rrsngomGr«ts in ths privoto sector
3) There are a number of macro-level issues that it is worth exploring with the
private sector. These are described below:
a) The bulk (some 50-60%) of primary curative care that poor people access is
through less than fully qualified (LTFQ) practitioners. Globa! and Indian experience
would strongly suggest that this is uniikeiy to change even in the medium to long
term There appears to be a significant and troubling impasse on this subject: the
iMA and other professional bodies resisting dialogue with representatives for LTFQ
providers; State Governments and externa! agencies seeing LTFQ providers as
one of the means of reaching the poor.
i)
Question: How can this impasse be constructively resolved so that
poor people can access services?
b) The private sector offers the potential to address the health care needs of the
better off, this freeing up time and space for the public sector to provide services to
the pooi. This howevei requires conscious decisions lo be taken by poiicy makers,
as the market still needs to be carefully managed if distortions (such as large scale
movement of human resources into the private sector) arc the to be prevented.
i)
Question: what are the plans of large scale providers and insurers
r ■wr r
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see the medium-tenri future
jj> Questions whst mcchsnisms 2nd nrocsss2s need to he nut m
piace io manage a piurai neaitn system, so inai ine benefits are
shared eoually?
cj Systems of regulation and accreditation are curremiy quire weak in india. i he
nrimanz fnrm of reoulation of qualified allopathic doctors is self-regulation by State
aiiC <>ci'iuai ivicGiCai OOuHCii ii"i aCCOiOanCC With liiGiciii iviowivai ^OunCii Act, 'ic/OO.
However, the tunctioninq of the Council is hamoered bv not beino able to provide
*r^rrmorjeta+irvn
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fnr rtarponac nr nT^r'r2Ct!C0 10 p2tlSntS 2fld h2V!nCJ WS2k pOWGfS Of
deieneiiue aS lai as maiuiaciice Oi unethical practice is COucenieu.
i he iack Oi a
laroe-scale accreditation system undermines the ootential of both the Dublin and the
manter where india couid benefit.
ana
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be
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and
effectively
d) Private out of Docket expenditure tor health care in India is amongst the highest
*n ths world. This impsets most cstsstrophicsliy upon the poor and introduces
inflationary pressures into the health care market. The government and private
providers (for profit and not-for-profit) have instigated a number of measures to
facilitate the introduction of pre payment mechanisms. The potential from such
approaches may be significant, however in practice the schemes are limited in
coverage and evidence suggests that it is difficult to provide real cover to rural
populations.
i) Question! what options are there for pre-payment schemes that
Cail reach Gut ailu iiiCiiide the Ui'bail and i'ui'ai pOOf?
lnd’2 hss become 2 dominant force in the globs! Pharmaceutical market. WTO
ayieeiTien is have the puieniicii io have a mixed impact upon the domestic market.
At the same time market pressures are resulting in less research on drugs for
WWMM.U^MV
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Question: what expectations are there for the future of the industry
MI1.V.1 mv ■■■«.■
il) Question
*
w.
w iviuivm ik.vj■ wiMtuxzi■ .
Wh<?t role is there for public private partnerships to
explore ti'eatiTients for the diseases of the poor?
in me cnanging dynamics of globalisation, there is a convergence or interests of
government and business. In South Asia, governments have begun to look at the
private sector as engine of growth. Best practices in privatisation and partnership
strategies ( outright privatisation of facilities and service delivery, public ownership.
private management, micro-privatisation, and/or build own transfer modalities)
need io be woiked out.
i he consultation is designed to give DFID an understanding of how it can usefully
enable iiie private secioi's role in india io achieve outcomes favourable for pro pool
economic growth.
Karnataka Health ISSP
Ver.Ol
-NA.1V- ■H-r
TERMS OF REFERENCES
INFORMATION SYSTEMS STRATEGY PLANNING
(ISSP) STUDY FOR KARNATAKA HEALTH,
NUTRITION & FAMILY WELFARE SERVICES
/ PROJECT
Directorate Of Health & FW Services
Anand Rao Circle,
Bangalore-560034
Page 1 of 9
Karnataka Heal tit ISSP
i.o
Ver.Ol
Background
1.1
The Government of Karnataka has received a TA grant in response to
preparation of an integrated Health, Nutrition and Family Welfare
Services Development Project (Po71160). The proposed PHRD fund is
primarily to finance key studies required in the finalization of the project.
1.2
The rapid technological advances in connectivity, bandwidth availability
WEB based technologies, local area networks (LAN) and Client/Servercomputing environment creates a great opportunity for Karnataka Health,
Nutrition & Family Welfare Services to strategically plan its future
information technology (IT) investment for a great return in better Health
management information, increased staff productivity and enhanced
Health, Nutrition & Family Welfare services.
1.3
Currently, IT enabling in Karnataka Health, Nutrition & Family Welfare
Services program consists of limited computerization in fragmented
technology architecture. There is no integrated Management Information
Systems (MIS) that could facilitate in coordinated monitoring and
management decision-making across the entire Health, Nutrition and
Family Welfare Services program. If an uncoordinated information
technology deployment were to be put in place without the guidance of a
well-defined strategy plan, it could result in incompatible hardware and
software systems, which would, in the future, be costly to maintain and
implement. Other difficulties would involve staff training and fungibles
across the Health, Nutrition & Family Welfare Services.
1.4
As one of the first steps in IT enabling, the Karnataka Health, Nutrition &
Family Welfare Services Development Project develop a strategic
information systems plan (ISSP). This plan will define the long-term
information requirements of the program, recommend a technology
architecture, and prepare long-term system implementation, equipment
acquisition and staff training plans. The ISSP will be a foundation upon
which Karnataka Health, Nutrition and Family Welfare Services
information systems will develop in an integrated, orderly manner to
support key sectoral and institutional priorities.
1.5
The ISSP must be prepared in an abbreviated time frame (around 4
months) and format, and be particularly concrete in outputs. Since the
information systems strategy is expected to be cross-cutting across various
agencies, it will be sponsored through the Office of the Commissioner of
Health & Family Welfare, GOK with participation and inputs by all
related agencies and departments.
Directorate Of Health & FW Services
Anand Rao Circle,
Bangalore-560034
Page 2 of 9
Karnataka Health 1SSP
z 2.0
Objective of the Information Systems Strategy Plan
2.1
<4o
Ver:01
With above background, there is an imperative and immediate need for a
long term information technology (IT) strategy study for Karnataka
Health, Nutrition & Family Welfare Services program to identify the
medium term and long term information needs of that sector and to
establish a technical set of standards that all proposed solutions must
adhere to. The study should address the following areas for IT enabling of
the existing systems:
2.1.1
The pace of Telecom Industry developments in driving
development of more intelligent communication technologies as
well as bandwidth capability and ensure compatibility of various
electronic systems.
2.1.2
Examine the development and maintenance of links with other
agencies that deal with Health, Nutrition &. Family Welfare
Services issues.
2.1.3
To develop Integrated IT enabled Health Care Systems.
2.1.4
To review the IT enabling activities of Karnataka Health
Department and Modalities for strengthening it.
2.1.5
Work out strategies for data validation from Primary Health
Centers (PHCs) to District and District to State.
2.1.6
A system to monitor various information systems in the
department for coordinating with existing National Health
Programmes.
2.1.7
To incorporate Decision Support Systems for Recruitment,
transfer, and inventory management.
2.1.8
To incorporate information and document system using computer
networking facilities
Scope of the Information System Strategy Plan-ISSP
3.1
To study the existing computerization activities in Health Department
identify the gaps in information and bring out the extent of re-engineering
required for an overall Integrated ISSPfor the Department.
To study the present computerization activity in HR system to include
Personnel recruitment, Promotion, transfers and training, various
Governmental Policies on the subject and propose aj^IT enabled Decision
Support System for development of Human Resources for the long term
needs of the department.
Directorate Of Health & FW Services
Page 3 of 9
Anand Rao Circle,
Bangal ore-560034
3.2
Karnataka Health 1SSP
Ver-.Ol
3.3
To study the information systems in Institutional facilities that are
available in KHFWS for their functionalities, requirements and
performance monitoring and propose IT measures required which will
improve their efficiency, better management and enhanced health services.
3.4
To study the Disease Surveillance system, epidemic Surveillance and
reporting system, Reproductive Child Health Care (RCH) systems and
suggest an IT Structure for effective Speedy Information flow, close
monitoring and early warnings on outbreak of epidemics.
3.5
To study the progress of programmes, projects that are underway in
KHFWS under S&te, Central and International agencies and suggests
information requirements, data requirements necessary for speedy
implementation and integration.
3.6
To study the logistic system for supply of drugs, equipments, transport,
inventory management in KHFWS and suggests measures for automation
of inventory management for automatic invoice generation for supply of
drugs, equipments and management of transport.
3.7
To study the financial system, budgeting, forecasting and suggest an
automated Financial Management System.
3.8
To study the availability of raw data, data entry, input validation, updation
and suggest a suitable data base system which can provide smooth
information flow.
3.9
Study the availability of Hardware, Software, Network Connectivity and
suggests a system architecture for a responsive online server client
information system which can integrate the entire IT activities in KHFWS
and facilitate easy interaction from PHC to KHFWS.
3.10
To study the system requirement, accessibility, and ownership of systems
with responsibilities for updation and maintenance of data, System
administration, security standards bringing out clear-cut responsibilities at
all levels.
3.11
Assess the skill set requirements, availability of manpower, short and long
term training needs for technical staff and identify suitable agency to
implement the IT enabling in KHFWS.
3.12
To study the requirements of developing various application software,
identify suitable operating systems, case tools for implementing various IT
initiatives being proposed and identify standard set of Core Applications
for day-to-day functions.
Directorate Of Health & FW Services
Anand Rao Circle,
Bangalore-560034
Page 4 of 9
Karnataka Health ISSP
3.13
4.0
Ver:01
Propose long-term plan for technology acquisition, system development
and deployment and periodic updation and modernization.
DELIVERABLES
The study should result in following reports, which should be presented to review
committee of KHFWS for their approval.
4.1
Report on all available Information Systems in KHFWS, their
functionality, gaps in information and extent of re-engineering required for
integrating the same with the proposed Information System.
4.2
Report on the IT initiative in present HR practices in KHFWS and suggest
a Decision Support System for an Integrate4.HR system, which can cater to
the short and long term, needs of KHFWS.
4.3
Report on institutional facilities available, their monitoring systems
possible improvement and propose an IT system for better management,
increasing efficiency to enhance Health Services in KHFWS.
4.4
Report on Disease Surveillance ‘early warnings on outbreak of epidemics,
Reproductive Child Health Care’ System and IT measures to enhance their
responsiveness and for better Disease Management.
>
4.5
Propose an IT model for effective monitoring and implementation Report
of existing programmes, projects on health in KHFWS.
J
4.6
Report on existing logistics system to include supply of drugs,
equipments, transport and inventory management and suggest an
Inventory Management system for automatic invoice generation,
movement of drugs and equipments and level of inventory in all the
hospitals.
4.7
Specification for an IT package for automating the finance department.
4.8
Specification of data requirement, their availability, data entry methods,
sectoral, institutional and appropriate database system.
4.9
Specifications of Hardware, Software, Network connectivity for meeting
the online requirements of IT initiative being proposed.
4.10
Specifications of the proposed information systems
functionality, internal & external data sources, outputs.
4.11
Processing and storage volumes, data recovery, backup data, disaster
management, security standards, access rights, system administration.
Directorate OfHealth & FW Services
Anand Rao Circle,
Bangalore-560034
to
include
Page 5 of 9
Karnataka Health ISSP
5.0
6.0
Ver.Ol
4.12
Recommendation on procurement of proposed technology acquisition to
include software, application software, tentative cost and timetable for
acquisition.
4.13
Recommendation on training programmes to include types of training,
identification of personnel for training and tentative cost involved.
/
4.14
A plan of action for implementing the overall IT enabling strategy for
KHFWS after discussing with officials, World Bank regional informatics
team.
The proposed action should lay down priorities, project
management, various milestones, costing, testing and acceptance for
smooth completion of project in correct time frame.
V
Resources & Management Oversight
5.1
The consultants will prepare the ISSP Plan, with the assistance of a
Working Group of knowledgeable individuals drawn from the various
functional areas of the Karnataka Health, Nutrition & Family Welfare
Services agencies. Staff in the working group will be assigned to this task
for a maximum of four months on a part time basis.
5.2
A Review Committee of the Karnataka Health, Nutrition & Family
Welfare Services will be responsible for the sponsorship, supervision, and
approval of the ISSP. This committee will be chaired by the
Commissioner of Health & Family Welfare GOK and consist of senior
government officials to be determined by the GOK. It will also include
some senior technical staff from all user departments to provide requisite
input and in particular to sponsor and monitor the ISSP.
5.3
The consultants may be provided necessary help from Karnataka Health &
Family Welfare Department for smooth conduct of study. The consultants
must provide any specialized software ad hardware technology needed to
document the ISSP, as well as the necessary training to Karnataka Health,
Nutrition & Family Welfare Services support staff in the operation of this
technology.
WORK PLAN
The work plan is arrived at after noting that the proposed study should
encompass the study of the activities of all the functions that are involved
with the HMIS under the various programs right from the process of data
collection for the monitoring of the diseases to the drugs distribution and
equipment maintenance to the transfer of employees and the performance
monitoring of the hospitals. It is imperative that all the activities that are to
be undertaken be listed out, agreed upon with active user participation.
A tentative schedule is presented with a note that the time frames
mentioned hereunder are critical and must be adhered to with a high
degree of participation and co-operation from the concerned members.
Directorate Of Health & FWServices
~
Page 6 of 9
Anand Rao Circle,
Bangalore-560034
W
Karnataka Health ISSP
Name of the
Activity
Description Of the Activity
Appoint
Consultant
Appointment of a consultant with key
personnel having the expertise in the
concerned areas of IT, Public Health,
Epidemiology and who has familiarity
With the existing systems and
processes.
The team must comprise of members
from the Consultant company and also
members from the Health Department
with considerable experience on all
the functions, who will undertake to
impart correct information to the
information gatherers.
Listing of all the tasks that come under
the purview of the study.
Preparing a document that will list the
responsibilities deliverables time
frames commercial aspects in short an
MOU.
A study of the existing mechanism in
the state vis a vis the ones in
developed/developing countries to
improve the existing system.
t
This would include the study of the
various programs, Financial
Management Systems, HR Related
practices.
This would involve the in-depth study
of the performance parameters, the
facilities available, the reporting and
the monitoring systems.
Identify
Team
Identify Task
Make
Document
Review
Existing
System
Study
Institutions,
and their
performance
monitoring.
Study
logistics
On site visits
Travel
The method of distribution of the
drugs their inventory the method of
disbursing of the facilities to the
various agencies under the Health
Department
A travel plan that will comprise of
visits to four reprentative districts and
Taluks to study the functioning of the
institutions. (PHCs and SCs)
Directorate Of Health & FW Services
Anand Rao Circle,
Bangalore-560034
Ver.Ol
Delive
rabies
Time
Frame
Responsibility
Man
Mont
hs
4 weeks
Health
1
Health/Consultant.
0.5
Consul 2-3
tant
Days
Team
Health
Team
Nil
4 weeks
Consultant/Health
1
MOU
2 weeks
Consultant
0.5
4.1,
4.2,
4.3,
4.5,
4.6,4.7
30
weeks
Consultant/Health
7.5
28
weeks
Consultant/Health
4
28
weeks
Consultant/Health
4
28
weeks
Consultant/Health
4
Page 7 of 9
Ver.Ol
Karnataka Health 1SSP
Study
existing IT
infrastructure
To study the existing hardware and
Software (that will include an account
of the existing numbers) and
connectivity. (LAN, N1CNET) and
associated hardware.
4.8,
4.9,
4.11,
20
weeks
Consultant/Health
5
Propose an
IT plan
The proposal shall include the short
term and the long term plans,
recommendation for a technology
architecture with plans and estimates
for putting it in place, a plan for the
implementation of the above system, a
list of applications that could be
developed for decision support by the
Government.
Should include what all to be procured
equipment and software, connectivity,
faxes, applications, scanners, modems,
where to be installed, cost of the
activity, concerned vendors, models
cost comparisons so on...
Develop detailed information
schedules, proforma for the Disease
surveillance, National Health
programs and a monitoring system.
Who should be trained, on what they
have to be trained, duration of the
courses, tentative fees, who can be the
trainer etc
Include findings of the study, list
recommendations, plans which were
made etc.
Refine the above and give the final
copy.
4.14
12
weeks
Consultant
3
4.12
8 weeks
Consultant.
4.4,
12 weeks
Consultant/ Health
3
4.13
12 weeks
Consultant/ Health
3
Draft
Copy
8weeks.
Consultant.
2
Final
Copy
4 weeks.
Consultant.
1#
Total Man-Months
41.5
Action Plan
for
Procurement
of the above.
Plan inputs
for Disease
Surveillance.
Training
plan.
Make a draft
report.
Final report.
7.0
Review Committee:
HNP Pre project Studies review committee will consist of
Chairman: Commissioner Of Health &Family Welfare GOK.
Members:
•
•
•
•
Director Of Health &Family Welfare Services.
Demographer Of Health & FW services.
One member of the KTF on Health (Dr. C.M. Francis)
Joint Director Of Communicable Diseases, Director of Health & FW.
Directorate Of Health & FW Services
Anand Rao Circle,
Bangalore-560034
Page 8 of 9
•
Karnataka Health 1SSP
80
Ver.Ol
Inputs from the clients:
•
•
Existing HMIS proformas, protocols of the National Health Programs.
Details of the SCs, PHCs, Taluk Hospitals, District Hospitals, and Channel
of communication.
• HMIS inputs and Surveillance activities from the KHSDP.
9.0
Study Progress Monitoring
There will be a monthly meeting of all the key consultants with the commissioner
for monitoring the progress of the studies as per the time schedules.
10.0 Costing and Payment Schedule
Total INR-45.0 Lacs.
The breakup is as follows:
Man months estimated: 41.5
Industry' standard per man month: 1.2 Lac.
Travel and accommodation
: 2.0 Lacs.
Total Cost
: 51.8 Lacs.
The agency will be paid
40% of the contracted amount on signing the agreement
40% on submission of the draft final report.
20% upon acceptance of the final report.
Directorate Of Health & FW Services
Anand Raq Circle,
^angalpre-^60034
Page 9 of 9
BPL INNOVISION BUSINESS GROUP PROFILE
Bplinnovision Group, which is into Mobile and Convergent Network Service Provision, is part
of the well known BPL group. Bplinnovision has technical collaborations with leading
companies across the world, ensuring immediate access to the world's most advanced
technologies. Some of the Strategic Partners in Telecom are US West, France Telecom.
Through its group company, BPL Telecom it has 3 Decades of Telecom Experience.
Bplinnovision offers a wide and diverse range of services in four important areas, namely
Wireless, IT Services, Internet Services, Global Technology Solutions
WIRELESS - It has installed GSM Cellular Network and providing Services in Mumbai,
Maharashtra, Goa, Kerala, Tamilnadu and Pondichery. It is India’s largest Cellular Network
and Covers 41 District Head Quarters in addition to Mumbai. It covers a population of 182
million and has commissioned five Main Switching Centres, 35 Base Switching Centres,
390 Base Terminal Switch and 465 Microwave hops. It also has Microwave backbone
covering 6000 kms and is the second largest network.after Dept, of Telecommunication.
IT SERVICES - The group has been providing focussed IT Solutions, leveraging on its
domain expertise and software development skills. This portfolio has a large pool of skilled
and competent software professionals delivering development, support and maintenance
projects. Both on-site, at customer locations in Europe and USA and offshore at development
centers in Bangalore, India, bplinnovision's IT services is presently focused on the following
areas:
Internet Solutions
•
e-commerce end -to-end solutions
•
web enablement of legacy systems
•
web solutions
•
web content
Systems Integration & Network Solutions
•
LAN/WAN Planning and Implementation
•
E-mail and workflow solutions
•
Lotus Notes/Domino Based Intranets
•
Network Management Systems and Network Security
INTERNET SERVICES - Bplnet.com, the Internet Company, is a national Internet Service
Provider (ISP). As an end to end solutions and service provider, bplnet.com has built a wide
range of products and services portfolio. These include innovative access solutions through
Digital Subscriber Lines (DSL), leveraging the GSM backbone, Radio, Leased Lines. With a
strong focus on service excellence, the company has Account Managers for dedicated
relationship building, Solutions Architects for customized internet & connectivity solutions, and
Net Assist, a 24 hour customer care center. Bplnet.com is poised to provide every internet
solution that a corporate may require.
GLOBAL TECHNOLOGY SOLUTIONS bplinnovision provides leading edge solutions in Design & Development and Technical
Services. Signaling Protocols, Web Enabled Solutions and SS7 / ”IN”. Technical Services
provide project/product support on site in the sphere of Telecom, Datacom, and Internet.
These services can be extended or migrated to an offshore model. The group is presently
working on the following :
Telecom Business Solutions
•
Network Management System, Operating support System, Base Station System
•
Offshore Development Centre for Motorola
•
Geographical Information Systems (GIS)
•
e-govemance. Presently working on Karnataka Health & Management Information
System (KHMIS).
In pursuit of excellence, bplinnovision’s comerstone is quality, adopting the best practices in
Software Engineering. It has well defined and documented Project Management and
Software Development processes. Periodic reviews, audits and proactive measurements are
part of the critical Quality Assurance activities, supported with state-of-the-art tools. This
leads to better project tracking and management, resulting in a Quality Product that meets
critical time-cost requirements. Bpl Innovision focuses on training to continuously improve the
skill sets of its employees, which in turn results in core competency development.
Bplinnovision provides an environment where team members enjoy their work and where
learning is a continuous process that elicits proactive organizational support. A place where
targets and their delivery make for superior business performance. Over a period of time,
each individual experiences personal growth and prosperity. The people policies of
bplinnovision are firmly focused towards achieving
o A happy and open work atmosphere
o A continuing focus on learning, education and training for each team member
BPLinnovision, based in Bangalore, has established a ‘Ready-to-use’ Facility consisting of
requisite office space and infrastructure, including PCs on LAN, with e-mail, Fax and Internet,
allowing employees to work on off-site projects for specific customers. The facility enables
customer projects to be planned and initiated within a short span of time. In the near future,
Bpl Innovision will move to a 15 acre campus in Bangalore. Innovatively designed to provide
a stimulating environment to aid creative mind power in the fields of software and technology.
It will have excellent landscaping including smart buildings with more than 150000 sq. ft of
work area with world class work and recreational facilities.
Bplinnovision Business Group has got a separate division for IT Services headed by Ajay
Bhatkal, the Head of Information System for the group. In an earlier assignment, Ajay Bhatkal
assisted by five consultant has designed, tested, implemented the local and wide area
network for 38 C&FA's, 11 branches of BPL and the Central Marketing Office for the
implementation of oracle financials ERP. This included the local cabling at the C&FA’s
branches, forward infrastructuring hardware, training on ERP and wide area netowrk using a
combination of VSAT’s, leased (inks and dial-up modems. Besides the accounting system
being put in place through the ERP, this team also implemented the messaging system and
the intra net. Despite the project being live and running, regular periodic functional training is
conducted for various mode! and enhancements therein.
This also covered the application and commissioning, installation, implementation of links to
the net through which an E-commerce model was put in place for booking and buying white
goods of the company through the distribution channels like the dealers. The project was
designed with HP unix services at the centre (Bangalore) with built in redundancy through
mirroring and local NT servers at the locations which replicate incremental data with central
site using the VSAT links. The entire hardware and bandwidth sizing was done by this team
and the methodology was outsourcing to vendors for actual cabling, hardware/VSAT delivery
installation and commissioning after a detailed evaluation process wherein the vendors were
examined on their capabilities, technical competence spread across the country for support
and pricing.
Ajay Bhatkal's short profile is as follows
1.
1983 -1996
-
-
Brooke Bond India Limited
Design and development of SW applications
IT operations for the corporate office at Brookefields
Complete LAN cabling including VSAT network for the WAN
across the country
Computerising C&F agents across the geography including training on
messaging, intranets and Mfg-PRO
Voice and data communication networks
Application systems for Factories and Sales and Marketing divisions
2.
1996 - 1998
Praxair India Pvt Limited
Bring them up from one hired PC to a fully networked building of three floors
IPLC connectivity into their Singapore office
Implementation of JD Edwards and Lotus Notes for messaging and intranet
IT operations and IT enabling for business benefits, office automation
3.
1998 - 2000
BPL Telecom Limited
Local networks at Rockline and internets links and security
Complete local area networks and wide area connectivity using leased lines and
VSAT for 52 C&FAs of BPL
Design and architecting the IT infra for Oracle Financials ERP to be deployed
across the 52 locations
Messaging systems and internet applications like billing on the net, payment
gateways, etc
4.
2000 - 2001
Microland Limited
Joined as the group CIO reporting to Pradeep Kar
Put in place Radio Links and Leased Links/ISDN for the 7 group companies & their
offices
Bandwidth and hardware sizing, internet security, access and mail routing
MS Exchange functionality across the group
Implementation and enhancements on SAP as the ERP for the group
Customising requirements on SAP for functional areas like Finance, Distribution, HR
Conceptualizing and content management of the web sites on the net and the
info management therein
Spread of a groupwise intranet for use as a complete workflow automation and
groupware, conferencing, etc
5.
2001 - currently at BPL Innovision Business Group
Joined as the Head - IS for the group
On board since 15th Feb'2001
With the above profile, bplinnovision is eminently capable of undertaking system study for
Karnataka Government for its IT enabling initiative in Health and family welfare department It
has necessary expertise, infrastructure and manpower to undertake the study and capable of
completing the task in a stipulated time. The following team structure is proposed to
undertake the study.
a.
b.
c.
d.
Project Manager - One
System Analyst - Two
Chief Consultant IT - One
IT Consultants - Three
Draft outline
internal circulation only
jJkKfF—V-l
Cj?
Government of Karnataka
The Health, Nutrition & Population (MNP)
initiative for Karnataka
towards equity and quality
with focus on primary health care
May 2000
Office of the Commissioner, Health and Family Welfare Services
H" G
Draft outline
For internal circulation only
The Health, Nutrition & Population (HNP) initiative for Karnataka — towards equity and
quality with focus on primary health care________________________
The chief strengths of the health, nutrition and population sector (HNP)
A. SECTORAL
sector in Karnataka include:
DIAGNOSIS
Strengths of Sector
(i)
(ii)
a state policy, that has consciously fostered a large number of
privately owned and managed medical, nursing, dental and other
health educational institutions;
/? 0 (iv)
an overall improvement in the health status of the people as
evidenced by increased LEB from 26 years in 1947 to 66.3 years
for women and 65.1 years for men in 1997, decline in CBR from
41 per 1000 to 22 in 1998, and, decline in CDR from 22 per
1000 to 7.5 in 1998, complete eradication of small pox and
guinea worm infestation, control to a considerable extent of
vaccine preventable diseases such as polio, whooping cough and
measles, and, the effective couple protection rate has increased
from 23.8 in 1981 to 57.7% in 1997;
capacity to well utilize externally assisted projects; a case in
(v)
point is the satisfactory implementation of the World Bank
assisted health system project._____________________________
The main constraints in the health, nutrition and population (HNP) sector in
Karnataka include
high levels of poverty in some parts of the state, contributing to
and being aggravated by poor HNP outcomes (high fertility,
mortality and malnutrition);
gender inequities leading to overall poor health indicators;
(iii)
limited public information and capacity to make healthier
choices and demand better health services;
low quality and poor accountability of health services in public
(iv)
and private sectors;
poor infrastructure management;
(v)
overall neglect of public health principles with inadequate
(vi)
emphasis on preventive, promotional and rehabilitative care, and
even less on determinants of health including nutrition, water
supply and sanitation
inefficient and inequitable financing of health services;
(vii)
(viii) weak public sector management, and poor regulatory framework
for private sector participation;
(ix)
poor governance and low morale in health te
lack of focus on regional and inter-district disparities;
(x)
widespread and growing (Corruptions
(xi)
inadequate attention to human resource development;
(xii)
(xiii) inadequate integration of externally assisted projects into health
system planning._________________________________________
(>>i)
/^Z >
Problems with
sector
an overall health status above the national average;
a wide network of health care institutions at all the three levels primary, secondary and tertiary levels have been established,
B. GOALS
Objectives for sector
The broad objectives are to;
improve HNP outcomes, namely the reduction of population
growth, fertility, mortality and malnutrition levels, and reduce
the overall disease burden;
empower the public, particularly women, to make healthier
choices and demand better HNP services;
improve quality, effectiveness and coverage of services,
especially for the poor and underserved - focus on improving
quality of primary health care services;
improve efficiency and equity in the financing of HNP services
with focus on women, children, SC/ST, disabled, aged, and the
poor,
improve the organization and management of health services in
the public and private sector;
significantly improve accountability and transparency;
improve and strengthen urban health care, with focus on urban
slums
strengthen medical pluralism by promoting Indian systems of
medicine and homeopathy,
improve regulation of the private sector,
improve linkages and evolve meaningful partnerships with
NGOs, other sectors and departments which impact on health.
C. SHORT TERM
STRATEGIES
To achieve the above objectives the strategy will be translated, in the
short term, into “an agenda for action” for implementation in the next
one year as suggested in the Report of the Task Force.
C.l Primary Health care | This will include strengthening PHCs and sub-centres
(i)
through filling up vacancies,
(ii)
increasing allotment of medicines by Rs. 25000 per PHC,
(iii)
providing phones to each PHC, and
(iv)
providing minimum required equipment.
|C. 2 Secondary level
C.3 Reproductive and
child health
aJ
Action will also be taken to
A,
(v)
fully utilize RCH and IPP IX funds
/
‘S/
(vi)
make 200 PHCs fully functional and make them work
round the clock, and
(vii)
widen scope of urban family welfare centres as. providers
of comprehensive health care;
v
The strategy in the short term will be to
(i)
fully complete and make functional all secondary care
institutions under KHSDP and Kfw and work out
effective linkages with PHCs,
(ii)
strengthen blood banks and establish 8 banks in districts
lacking them,
(iii)
empower consumers using public information;
(iv)
improve the quality of health services, including
introduction of quality assurance systems.
The above will be achieved using the KHSDP and Kfw project
funds.
In the short term the strategy will be to
(i)
vigorously implement the RCH project
(ii)
speed up work under IPP VIII and IPP IX and,
(iii)
introduce the Anganwadi system as an effective support
institution at the village level.
C.4 Capacity building,
including health planning,
training, management and
administration__________
D. SUSTAINABILITY
Sustainability studies
| In the next one year the department will
accelerate capacity building to support progressive
(•)
decentralization to the district level including Zilla
Panchayats;
take concrete measures to further integrate health and
(ii)
family welfare programs;
build better partnerships with the private sector and
NGOs, and linkages with other sectors that affect
health;
focus on consolidation and impose a moratorium on
(iv)
new medical, dental, nursing, physiotherapy, ayurvedic,
homeopathic and unani institutions for the next three
years;
strengthen health human resource development by
(v)
introducing courses on public health and upgrade the
State Institute of Health Welfare into a premier A'AuAautonomous institution;
introduce transparent measures
for personnel
(vi)
deployment and significantly reduce mismatch, and,
put in place a comprehensive health monitoring system
(vii)
which will include (a) personnel MIS, (b) disease
surveillance, (c) GIS for all medical institutions (d)
infrastructure and facilities, and (e) RCH indicator
monitoring.
Three externally assisted projects, namely KHSDP, IPP VIII, and
IPP IX will come to a close in the next two years. Action is required
to
finalise a sutainability plan for these projects
(i)
identifying the activities which will need to be
continued, the posts required to be continued,
,
the annual funding required and
strategies required to integrate these project initiatives
into the main health system.______________________
sy- 1
E. MEDIUM TERM
STRATEGIES -THE
HNP PROJECT
INITIATIVE__________
El HNP goals and
objectives for the medium
term
While in the short term the above initiatives are expected to visibly
impact on HNP indicators there will be need to go in for a major
initiative to achieve the HNP goals. This initiative will require
enhanced funding for the health sector and will in addition require
another external financed project to supplement the state resources to
meet critical gaps in achieving the HNP objectives for the sector.
The following specific goals are proposed for achievment by 2007:
1. Crude birth rate
2. Crude death rate
3. Total fertility rate
4. Infant mortality rate
5. Immunisation coverage
6. Institutional deliveries
7. Maternal mortality rate
7.
8.
Couple protection rate
Anaemia among women
9. Anaemia among children
10. Nutrition status of children
11.
LEB
12.
Overall burden of disease
13. HIV/AIDS
14. Quality assurance
17 per 1000
7 per 1000
1.9
30 per 1000 births
100%
> 80%
< 100 per 10,000 live
Births
65%
< 20%
< 40%
25% more than current
Level
71 for women, 70 for
men.
reduce to East Asian level_ 2 [,
contain spread
“equal to” or “better’
than in private sector
iQ >
E2. Primary and
secondary health care
The medium term strategies will include:
making all PHCs and sub-centres fully functional by
(>)
provision of buildings, equipment, consumables, drugs,
addition to staff, filling up of posts and training inputs;
(■■)
a pro-active policy to reducing inter-district disparities in
7
health indicators, specially the Northern districts, and
within them the five districts of Gulbarga division;
integration in the working of urban health care services
with the regular health system;
(iv)
making all taluka and district level hospitals fully
functional to diagnose and manage all communicable
diseases and establish an integrated and effective
computerized disease surveillance and monitoring
system;
convergence and integration in the management of all
(v)
“vertical” disease control programmes,
strengthening facilities to tackle mental health and
(vi)
psychiatric disorders;
b.
introduce community based rehabilitation for persons /
(vii)
with disability;
i
support to traditional sytems of medicine and its
(viii)
introduction into the mainstream health structure;
(ix)
initiation of a rural cancer registry and linkage to all
cancer treatment centres;
use of Anganwadi workers as village levql community
(x)
health workers on a large scale;
(xi)
introduction of effective coordination among rural
development, water supply Boards, municipalities and
the health department for monitoring of water quality and
for improving sanitation and waste management,
specially in urban areas;;
introduction of a meaningful tribal health programme;
(xii)
(xiii) emphasis on health education that promotes a healthy life
style, and launch of a massive IEC campaign using
appropriate health education and communication
materials;
9^
(xiv) strengthen and introduce an effective school health
programme;
(xv)
review of the drug procurement and supplies system and
its reorganization on modem lines with full transparency
and backed by a fully computerized drug inventory
management system.______________________
E3. Nutrition
interventions
E 4. Population and social
development___________
Medium term strategies will include
(i)
making nutrition an important concern in the health care
system and making the health system fully accountable
for poor nutritional status of the population, as opposed
to the current practice of holding poverty responsible for i
this situation;
(ii)
giving nutrition education among all sections of the
' population, including school-age children, high priority;
(iii)
effectively tackling the high prevalence of mild and
moderate malnutrition through imaginative and need
based nutrition interventions with introduction of local
specific weaning__fgQdj for the < 2 year olds, regular
child growth monitoring, and introduction of micro
nutrients where required;
The principal strategy in the area of population and social
development is the recognition that the best strategy for population
stabilization is through improved health and nutrition status backed
by emphasis on female education. Specific strategies will include
(i)
vigorous implementation of the RCH initiative,
(ii)
meaningful community based interventions empowering
and enabling households to making informed choices;
(iii)
fully meeting all “unmet” needs for family welfare
services;
(iv)
improving service delivery at the village and sub-centre
levels;
(v)
making gender inequalities the comerstone of policy at
all levels
(vi)
improve services for RTI/STI and HIV/AIDS;
(vii)
empowering women for health and nutrition in close
collaboration with women and child development and
education departments;
(viii)
significantly increasing participation of men in planned
parenthood;
(ix)
close collaboration with NGOs and diverse health
providers;
(x)
providing for the older population and equipping
hospitals towards geriatic care
(xi)
launching and sustaining a massive holistic and
integrated IEC campaign that converges family welfare,
__________ AIDS control, health and nutrition education.______ -
E 5. Capacity building
E6. Evidence that
existing strategic
project interventions
are working.
The HNP project initiative will take note of the “risk” inherent in such
projects of non-integration and will from the beginning be fully “grounded”
in the main health system structure. The strategy will include
(i)
introduction of well defined health manpower planning policies
with focus on public health, and use of professional medical
colleges and Rajiv Gandhi Health University besides the State
Institute on a large scale for training;
(ii)
full support to the State Institute to become a premier world
class institution;
(iii)
restructuring of the strategic palnning cell and its integration
into health system planning;
(iv)
redeployment of personnel according to need and qualification
through a well functioning personnel information system;
(v)
restructuring of Directorate and injection of professional
managerial inputs as all levels, specially at state and district
levels;
(vi)
reviewing current procedures to make the system more
transparent and accocmtable,
(vii)
setting of performance standards and measurement of
“satisfaction” levels at all levels
(viii) introduction of an effective regulatory mechanism for private
health care institutions, with self-regulation and accreditation
wherever feasible;
(ix)
utilizing a well functioning, fully networked HMIS and GIS for
decision making at local, district and state levels.
Overall the strategy is working as shown by the following;
(i)
improved health outcomes;
(ii)
improved intra-sectoral allocation of public funds;
(iii)
increased utilization of public health facilities in the SHS
project hospitals;
(iv)
acceptance of technical paradigm shifts in disease control,
RCH and nutrition projects;
(v)
improved project implementation in the state and in some
centrally sponsored schemes;
(vi)
improvements in capacity in the area of civil works,
procurements, and training;
(vii)
increased awareness of the need for involving NGOs (as in
RCHand 1PP IX) and the private sector (as in the SHS project);
(viii)
increased quality of services and improved morale of staff
through implementing user charges and retaining and using
___________ such funds at the facility level._____________
F. NEXT STEPS
What work needs to be
done and when.
Immediate steps include
(i)
finalizing the strategic plan;
(ii)
commencing and completion of sustainability studies;
(iii)
implementation of all “short term” recommendations of
the Task Force and strategies agreed on; .
(iv) _ identification
of
a
committed
group
of
professionals/organisation(s) to refine strategy and
commence documentation;
(v)
holding work shops at various levels involving all clients
to obtain inputs;
(vi)
commencement of pilot studies/trialling where required;
(vii)
finalisation of a calendar of activities with time
schedules; and,
(viii) conducting a survey to obtain current health, nutrition
and demographic indicators on a district-specific basis;
(ix)
use of IT, including GIS in a big way for strategic
planning and decision making;
io
H",
<2c? r^y -H. ~ 6-^1
Draft Outline
For Internal Circulation Only
Department of Health & Family Welfare
Government of Karnataka
Integrated Health, Nutrition &
Family Welfare Services
Development
Initiative in Karnataka
Towards Equity & Quality
In Health Care Services
July 2000
CONTENTS
Title
'
Page
No.
1.
INTRODUCTION
1
2.
CONTEXTUAL BACKGROUND OF KARNATAKA STATE
2
3.
2.1
Historical Background
2.2
Current State Profile
3
2.3
Public and Private Health Services and Access to Care
4
2.4
Health Budgets and Expenditure
5
2.5
Externally Aided Projects
6
2
HEALTH SECTOR ANALYSIS
6
3.1
Strengths of the Health Sector in Karnataka
6
3.2
Problems and Constraints
9
4.
GOALS
10
5.
VALUES
10
6.
GUIDING PRINCIPLES
10
7.
OBJECTIVES
11
8.
9.
7.1
Public Health and Primary Health Care
11
7.2
Health Systems Issues - Training and Management
13
7.3
Partnerships
13
EXPECTED OUTCOMES
14
14
8.1
Quantitative Indicators of improved health and nutrition status
8.2
Qualitative Indicators
14
8.3
Health System Indicators
15
BROAD STRATEGIES
15
10.
SPECIFIC STRATEGIES
Public Health and Primary Health Care
16
10.1.1
Access, quality and effectiveness of Primary Health Care Services
16
10.1.2
Nutrition
16
10.1.3
Improving health for school age and children and adolescents
17
10.1.4
Health Promotion and Empowerment training
17
10.1.5
Reduction in Morbidity and Mortality
18
18
19
19
19
19
20
20
10.1.6 Increased Services to neglected and emerging health problems
10.1.7 Health Information System
10.1.8 Reduction in Regional disparities
10.1.9 Improve health of SC/ST and Others
10.1.10 Strengthening Urban Health Care Services
10.1.11 Improve Women’s Health
10.1.12 Fertility Decline
-------
10.2
Health System Issues
20
10.2.1
10.2.2
10.2.3
Human Resource Development
Management Development
Develop capacity for decentralised district level planning
20
21
21
10.3
Partnerships
21
10.3.1
10.3.2
Intersectoral co-ordination
Empowerment of members of Panchayati Raj Institutions and
Nagarpalikas for Health
Partnerships with the private (for profit) sector, with NGO's and health
professional bodies
Promote and support Indian Systems of Medicine and Homeopathy
(ISM & H)
21
10.3.4
10.3.5
11.
16
10.1
FINANCIAL IMPLICATIONS
21
22
23
25
INTRODUCTION
The Government and the people of Karnataka have aspirations for a
better quality of life and for' overall development. Improved health status and better
access to good quality health care services is integral to human development.
The Government of Karnataka through a series of policy measures has attempted,
over the years, to create an enabling environment through which this can be achieved. In
recent times there has been an acceleration of these efforts.
The health sector is to be addressed in its totality including public, voluntary and
private health care services. This would require an approach covering all systems of
medicine and local health care traditions.
The role of public health and related services is critical in addressing basic
determinants of health, in responding to public health problems and in protecting and
promoting the health of the poor and of marginalised sections of society. The state also
has a role in maintaining standards and in fostering the practice of ethical principles in
medical care and public health.
At the same time, along with the public sector, the private sector also plays an
important role in providing medical care to the people.
To improve the health care systems in the State, the Government of Karnataka set up
the Karnataka Task Force on Health & Family Welfare (KTFH) in December 1999. The
composition of the 14 member Task Force (13 outside experts and one senior officer)
indicates the commitment of the State Government to develop partnerships with different
sectors. The Task Force submitted its Interim Report in April 2000. Its final report is
expected in a few months time (end 2000, early 2001).
The Department of Health & Family Welfare, based on the recommendations in the
Interim Report, and its own experiences and planning processes, is developing a plan for
an integrated health care system. Vertical health programmes and ongoing externally
aided projects, such as the KHSDP and IPP VIII and IX, will be sustained and integrated
functionally into the health system.
This paper addresses the identified gaps in the health care systems,
public, private and voluntary and provides the conceptual framework for an integrated
health care system.
2.
CONTEXTUAL BACKGROUND OF KARNATAKA STATE:
2.1
Historical Background
Karnataka State (known till 1973 as Mysore State) was created during the reorganization of
States in 1956. It incorporated the erstwhile princely state of Mysore; the northern districts of
Bidar, Raichur and Gulbarga from Hyderabad State, previously under the Nizam’s rule;
Belgaum and Dharwad districts from Bombay Presidency; Dakshina Kannada and Bellary
from Madras Presidency; and the autonomous princely state of Kodagu. The Presidencies had
been part of British India, while the others were semi-autonomous. The political histories,
traditions and administrations of these regions of the new State were very different. These
continue to influence later development.
Health services had developed in the different regions in the pre-Independence era. Under the
Mysore Maharaja and his visionary Diwans, health services grew within a liberal, welfareoriented administration, evidenced by establishment of the Krishna Rajendra Hospital in 1876,
the College of Indian Medicine (Ayurveda and Unani) in 1908, a medical college (Allopathy)
in 1930 (all in Mysore city), besides hospitals in other cities and towns. The first primary
health units, serving rural populations in India, were pioneered in the State in the 1920s, the
first being established in Ramanagram. Thus, traditions of State runs health services had been
established early.
After 1956, the State Government expanded its health care infrastructure on the foundations
of the existing health units and hospitals. National health programmes, which were being
formulated during this period, were implemented in the State. Guidelines and financial
support from the Government of India strengthened the development of rural health services
based on population norms.
-2-
Current State Profile:
Table 1 below gives the current profile of the State.
Table 1: State Profile
Variable
Current Status
Comment
Area
191,79 Isq.km.
Population (2000 est.)
52 million
Rural-urban population
distribution (1991)
69% rural (27,066 revenue villages
inclusive of 48,000 habitations),
31% urban in 254 towns/urban
areas.
16.4%, Scheduled caste;
4.26%, Scheduled tribe.
Scheduled caste
population Scheduled
tribe population (1991)
Literacy rate (1996 est.)
Per capita income
(1995-96)
Average District Income
(1995-96) at 1993-94
prices.
f*ource: HDR-GOK, 1999.
Overall literacy rate - 63.4%.
females 52.6%, males 73.7%;
rural 47.7%, urban 74.2%.
Rs. 7,155 at 1993-94 prices
Rs. 58512 million in Bangalore and
Rs. 6416 million in Bidar.
5.38% of the area of the country, approx, equal
to Germanv
Current growth a little less than a million a year,
with the rate steadily decl i nine.
Urban population has increased by 10% over 50
years
This section constituting 20.7% of the population
are the most vulnerable economically and also
socially most backward.
Large inter-district differentials exist. Dakshina
Kannada has a literacy rate of 85%, while
Raichur is still at 40%. Total literacy drives
since 1990 have achieved major gains in a few
districts like Dakshina Kannada and modest
improvements in others.
Range is from Rs 20,120 in Kodagu to Rs 6,223
in Kolar District.
Inter-district variations affect human
development.
Table 2 gives the health status indicators of the State. As is seen Karnataka is ahead of the all
India targets for the year 2000.
Table 2: Health Status Indicators in Karnataka, 1998 - Rural Urban
Indicator
| Crude birth rate
______
J Crude death rate
| Infant mortality rate
(per 1 OOOJive bjrths)___
! Life expectancy at birth
Male
| Female
Karnataka
(1998-99)
22/1000
7.5/1000
52
58 (SRS)
65.1 years
6 6.3 years
• 25.9
8.7
63 '
India-Targets
for 2000
21.0
9.0
<60
62.4
63.4
64.0
64.0
India (1998)
s'ource7W8-99 Annual Report DII&FWS, GOK, 1998 SRS, NFHS II, I999
-3-
!
|
2.3 Public and Private Health Services and Access to Care:
Karnataka has developed a widespread network of services since 1951. The progress
achieved during the period between 1951-1987 is indicated in Table 3, while the number
or institutions existing at present is given in Table 4.
Table 3: Development of Public Sector Health Services in Karnataka, 1951 - 1987.
Health Institutions
Hospitals with above 30 beds
Teaching Hospitals
District and Major Hospitals
Hospital beds
Dispensaries + Primary Health Units
1951
1987
23
0
20
5481
282+125
134
23
30
26646
1310
Primary Health Centres
0 '
Primary Health Units with 6 beds
20
X-ray Plants
15
Nursing Schools
5
Health & Family Planning Training Centres
2
Auxiliary Nurse Midwife Training Schools
0
Laboratory Technician Training Units
0
X-ray Technician Training Units
0
Source: GOK 1998-99, Annual Report ofDH &FW, SRS, 1998.
465
106
126
9
5
4
4
;
10 1
Table 4: Public Sector Health Services in Karnataka, 1998
Type of Health Service
Hospitals - district, major (specialised, teaching), maternity *
Community Health Centres
Primary Health Centres
Urban Primary Health Centres
Primary Health Units
Subcentres
Public beds (1996)
Private beds (1996)
Source: GOK 1998-99, Annual Report of DH & FW, HDR 1999
Number
176
252
1676
9
583
• 8143
43868
40900
* There are additional specialised hospitals for TB, leprosy, infectious diseases, mental health under the
Directorate of Medical Education. Institutions run by municipal corporations in urban areas are not included, as
they come under the respective local bodies.
Studies show that over 45% of patients utilizing public sector services in Karnataka had
annual incomes below Rs 15,000/-, which is close to the official poverty line, while over
90% had incomes below Rs 50,000/- (World Bank, 1996).
-4-
Private sector medical services had a growth spurt during the 1980s. Located primarily
’n
yeaS (80%)’ they account for 33% of hospital beds (ibid). A 1995-96 summary
iQQQ'i * l'sted 1709 medical institutions (clinics to hospitals) in Karnataka (HDK
). The 1993 NCAER survey reports that 46% of out patients and 40% of inpatients
were treated by the private sector (ibid.)
A majority of patients using private clinics in Karnataka were found to belong to the
middle and upper socio-economic classes (World Bank, 1996). The quality of care in the
private sector varies greatly from village and mofussil towns to the big cities (Narayan
1998).
The public sector has the most evenly distributed widespread services, covering all
districts and rural areas, and is utilized to a larger extent by the poor. Accessibility and
affordability of health care services, particularly for the poor, is one of the cardinal
principles of primary health care.
2.4
Health Budgets & Expenditure
Nationally 80% of public spending on health is by the State, 20% being from the center.
In Karnataka, about 18% of the state health budget comes from the center. According to
an analysis by the Department of Health and Family Welfare (KHSDP, June 1999) the
expenditure on health related services (which includes medical care, public health, family
welfare, water supply& sanitation, housing and nutrition) has grown in real terms at the
rate of 7.2 per cent per annum during the period 1990-91 to 1999-2000. However, there
has been large variation in different components. The expenditure on nutrition declined in
real terms at the rate of 4.3 per cent per annum. In overall terms, government health and
family welfare expenditures continues to be low.
According to a study made by the World Bank (1996), the per capita expenditure on
Health and Family Welfare has increased in 1980-81 prices from around Rs. 19 to Rs. 30
during the period 1980-81 to 1993-94. The Health and Family Welfare budget as a
percentage of the State Budget is around 5%.
Table 5: Expenditures on Health and Family Welfare in Karnataka
Category
Expenditure on H & FW
as % of State Domestic
Product
Per Capita expenditure on
II & FW (in 1980/81 Rs)
Source: WB 1996
80/81
85/86
89/90
90/91
91/92
92/93
93/94
1.26
1.33
1.25
1.18
1.11
1.29
1.29
19.00
22.12
26.00
24.12
25.01
27.83
30.20
-5-
2.5 Externally Aided Projects:
Externally aided projects negotiated since 1994-95 include:
a) Rs 1508 million for India Population Project IX from World Bank, for
development of rural primary health care infrastructure, to strengthen family
welfare and MCH services.
b) Rs 5458 million from the World Bank for the Karnataka Health Systems
Development project, (KHSDP) for strengthening secondary care institutions at
CHC, Taluk and district levels.
c) Rs. 591 million from KfW (Germany), for secondary care at district, taluka and
CHC level hospitals in Gulbarga division.
d) Rs 830 million for IPP VIII from World Bank for strengthening Family Welfare
& MCH in Bangalore city and 11 other cities.
e) An OPEC grant of Rs. 292 million for a superspeciality hospital in Raichur.
3 HEALTH SECTOR ANALYSIS
3.1 Strengths of the Health Sector in Karnataka
Strengths of the health sector in the State are:
i.
Health gains made taking health status levels above national average. National
Health Policy goals of 1983 were met, e.g.
•
•
.
•
•
•
ii
Increased LEB from 26 years in 1947 to 66.3 years (women) and 65.1
years (men) in 1997.
CBR declined from 41/1000 from 1951 to 22/1000 (1998)
CDR declines from 22/1000 from 1951 to 7.5/1000 (1998)
Eradication of small pox & guinea worm infestation.
Control to a considerable extent of vaccine preventable diseases, polio,
whooping cough, tetanus, diphtheria, and progress is being made to
reduce measles disease.
Increased Couple Protection Rate from 23.8% in 1981 to 57.7% in 1997
with fairly rapid fertility decline.
Development by the state of a widespread network of health care institutions at all
three levels (primary, secondary, tertiary), even in excess of GDI norms.
-6-
iii.
Support to innovations through research institutions - N1P through .
,
community mental health programmes through NIMHANS, bio-environmen a
control of malaria through MRC.
iv.
State policy support to growth of voluntary and private sector in medical & h
care and in health professional education, with some initiatives towar s
regulation.
v.
Capacity to negotiate & utilize to a fair extent external assistance e.g. KHSD
IPP VIII and IPPIX.
vi.
Most recently the setting up of the Karnataka Task Force on Health & Family
Welfare.
vii. Fairly active civil society groups and organisations.
viii. Premier academic and research institutions providing a sound knowledge base.
ix.
Private and voluntary sector involved with a broad range of activities from
primary medical and health care, secondary and tertiary care, health professional
education, to research and medical informatics.
x.
A project planning policy matrix was developed and is being used. Table 6 on the
next page summarises the cunent position on the important issues identified and
the Table shows that action is being taken on the major issues identified.
-7-
^-3-------- 9 health sector development nolicv nronrammc in Karnataka
Issues
Proposed Changes and Action Taken
1. Adequate budget for Public
Allocations stepped up progressively. Increased from Rs. 535.49
Health. Earlier only 5% of State
crores (1996-97) to Rs. 1112.64 crores (2000-2001) Increased from
budget and 1.48% GDP spent
■ 5.9% to 6.1% of State budget.
on Public Health.
2. Imbalances in expenditure on
Increased allocation to primary care (43.96%) & secondary care
health with more emphasis on
(40.9%) as against only 15.2% to tertiary care.
tertiary care.
3. Regional imbalances with six Preferential health policy for these districts by increasing funding ,
districts
Gulbarga.
Bidar, from state, IPP IX, KfW, OPEC and RCI I.
Bijapur, Raichur, Dharwad and
Bellary having poor health
indicators._____________
4. Improving quality of hospital
• Upgradation in 181 hospitals under K.H.S.D.P.
I
services and accessibility by
• Skill development training for Doctors, nurses and
women and SC's/ST's.
paramedical staff.
Filling up of vacancies by recruitment or on contract basis.
Contracting out non-clinical services.
Yellow card scheme for SC's/ST's
Successful pilot project of Women's Health check-up at ,
Mysore to be replicated in other districts.
• No user charges for those below povertv line.
• Strategic planning cell established, published 9 bulletins and '
brought out booklets for improving health knowledge of
Doctors & paramedical staff.
• Improvement in hospital waste management
• Networking with private health service providers.
• Establishment of Task Force w.e.f. 10.11.99 studying all
sectors relating to Health & submitted draft Interim Report
to Govt, for approval and implementation.
• Bill for regulating nursing homes and private practitioners
introduced.
• Licensing of blood banks.
• Enlisted NGO's for participation in Task Force, HIV/AIDS
prevention and other Govt. Programmes.
• Post of Addl. Director (Communicable diseases) has been
filled up.
• State surveillance lab at Bangalore has started functioning.
• Improvement in district labs.
;
• Manual on case definition, lab techniques and reporting
formats (as per WI IO guidelines) issued.
• Disease surveillance system in advanced stages of
______ development.___________________ ____ _____ _______
•
•
•
•
5. Strategic planning to reduce
sub-optimal use of resources.
6. Private sector and NGO's
7. Prevention and control of
communicable diseases.
-8-
2 Problems & Constraints
i.
Continuing high levels of poverty with 40% of people below the poverty line.
This contributes to and is aggravated by undernutrition, high morbidity, mortality
& fertility. These health indicators are still unacceptably high.
ii.
Relative neglect of nutrition in the larger health strategy.
iii.
Inadequate attention tlirough multisectoral linkages to other basic determinants of
health namely sanitation, potable water, waste management, education.
iv.
Gender inequities leading to poor women’s health status indicators (MMR
4.5/1000, anemia in women, violence against women.)
v.
Other disparities - regional, caste, socio-economic groups, persons with
disabilities.
vi.
Neglect of public health principles & practice with inadequate emphasis on
promotive, preventive & rehabilitative care, with resultant high burden of TB,
malaria, I1IV/A1DS, gastrointestinal problems, tobacco related problems.
vii. Poor quality, unethical practices & poor accountability with corruption in public
and private services, leading to patient dissatisfaction & loss of public confidence
in services.
viii. Poor governance & management of public health services.
ix.
Inadequate regulation & facilitation of private sector
x.
Inequitable financing of health
infrastructure/asset management.
services
&
inefficient
financial
&
xi.
Inadequate human resource development
competencies, low morale & motivation.
and
management
with
poor
xii. Inadequate community involvement in planning, decision making and feedback at
local levels. Relationship with PRIs conflictual. Their potential in public health
& primary health care unutilized.
xiii. Weak strategic planning, inadequate research base;
xiv. Inadequate integration of externally assisted projects into health system planning
-9-
4 GOALS
To further improve health status and increase access to health care for people,
with an emphasis on the marginalised sectors of society, such as women,
children, SC/ST, disabled and the elderly in Karnataka.
To strengthen public health systems and primary health care with community
participation, NGO and private sector involvement.
To focus on equity, with quality of services, making explicit efforts to nurture
and increase motivation and capacity of health care providers.
To work within a time frame, with regular reviews and transparency in
functioning.
a)
)
c)
d)
5 VALUES
The underlying values will be equity, medical and public health ethics, accountability,
concern and respect for people, democratic functioning, respect for local health
knowledge and culture. These values will form the basis for project planning and
implementation. Reviews will
consider how much these have been internalized and
what difficulties are faced in these aspects.
6. GUIDING PRINCIPLES
The guiding principles for implementation will be:
•
•
•
■
.
Integration - moving from vertical disease/problem oriented programmes to
horizontal integration at primary care level (sub-centrc, I’HC, Taluka, general
hospital) and more specialized referral and support services at district and state
level.
Phased decentralization - moving towards district and local planning and
management using information from the HMIS. The elected representatives will
also need to be sensitized and local bodies made accountable for responding to
the health aspirations of the people.
Building partnerships-
a) by inter-sectoral linkages between and within departments;
b) with NGOs for participation in planning, implementation and evaluation; and,
c) with the private sector for participation in state health plans and in referral
services, and, provision of secondary and tertiary level care.
d) With peoples’ organizations by providing access to information and
encouraging feedback.
Social inclusiveness - particularly of socially excluded groups and their
involvement in all levels of care.
Community participation - leading to the empowerment of the local
community.
« Gender sensitivity across all levels of care.
- 10-
7.
OBJECTIVES
The general objectives for a six-year period (2001-2007) are outlined below. Indicators
will be developed regarding achievement of objectives. The Logical Framework Analysis
will be used for identifying means, resources, activities, persons responsible and time
frames.
Problems are deeply embedded in social structures, therefore the choice of objectives is
based on needs, feasibility of a health sector intervention, likelihood of making an impact
and cost effectiveness, given the resource availability.
The objectives are broadly grouped under three categories, namely,
1.
Public Health & Primary Health Care
2. Health System Issues - Management, Capacity Building, Finance, Institutional
strengthening.
3. Partnerships - with private sector, NGOs, PRIs, local community and other
sectors/dcpartmcnts.
7.1
Public Health & Primary Health Care
7.1.1
a) Improve quality, effectiveness and coverage of primary health care.
Ensure access to care at all levels for the poor and under-served.
b) Strengthen the referral linkages with Secondary Health Care
Services, and fill up gaps, especially in Gulbarga division.
7.1.2
7.1.3
7.1.4
Improve nutritional levels, particularly of children (focussing on under
two’s), adolescents and women, by reduction of undernutrition and
nutritional deficiencies, such as Vit. A, Iron and Iodine.
Improve health of school age going children and adolescents through a
mix of medical, health promotional and educational efforts.
Health Promotion & Empowerment, particularly of women and young
people through sharing of information and health promotion activities
enabling people to make healthier choices and to demand better health and
nutrition services.
7 1 5
Reduce Morbidity & Mortality resulting from priority public health
problems. A public health approach will be used to reduce unnecessary
- 11 -
suffering from TB, Malaria, HIV/Al DS, water borne diseases, disability
etc. Priority will also be on decreasing infant, under-five and maternal
mortality. Deaths due to accidents and violence (especially unnatural
deaths of women) will also need attention.
Measures for health
promotion, prevention, early detection and cure, and rehabilitation to
reduce the suffering and burden of diseases will be taken and encouraged
by all health sectors.
7.1.6
Increase services for neglected & emerging health problems, namely,
Mental health, care of the elderly, tobacco related problems, accidents,
violence, particularly against women, and non-communicable diseases
such as cancer, and, heart diseases.
7.1.7
Develop and sustain a comprehensive Health Information System
including health surveillance.
7.1.8
Redress Regional Imbalances & Disparities. Actively work to reduce
regional imbalances with specific attention to Gulbarga division.
7.1.9
Improve health of scheduled castes and tribes and those below the
poverty line.
7.1.10 Strengthen Urban Primary Health Care Services, especially in smaller
cities, towns and regions.
7.1.11 Improve women's health
7.1.12 Enhance further fertility decline by provision of reproductive health
care through well functioning and credible general health services and
by an educational approach. Focus on districts with continued high
fertility rates, with emphasis on child growth and child survival, on overall
women’s health and women’s empowerment. Avoid distortion of health
services by excessive emphasis on a programme like sterilization of
women.
- 12-
7.2
Health Systems Issues - M
Institutional Strengthening
lanaScment>
Capacity
Building,
Finance
and
stra* e3'e5 for human resource development that focus on
Pac’ y ui mg, continuing education, motivation and morale of health
™S a a exels. Encourage research and academic work.
Improve the planning, organization, management and administration of
t te public health systems, to cover management capacities, personnel
management, strategic planning and evaluation, asset management,
management of supply lines for equipment, drugs and other consumables,
as well as information and communication systems. Decentralised
mechanisms to be evolved/ reviewed. Introduce cadre development and
management systems.
7.2.3
Develop decentralised district level planning.
7.2.4
Improve equity and efficiency in health financing and financial
management maintaining a balance between primary, secondary and
tertiary care, and between urban and rural based institutions. Safeguard
and improve the health budget and ensure adequate utilization with
accountable and transparent systems.
7.2.5
Focus on implementation factors and processes by building competence
and morale of field stall, developing leadership abilities from PHC to
State level, and having regular public and social audits to safeguard
against non-action.
7.3
Partnerships - with private sector, NGOs, PRIs, local community and other
sectors/departments.
7 3 1
Develop specific functioning mechanisms at local district and state levels
for better intersectoral coordination.
77 7
Strengthen capacity of Panchayati Raj and Nagarpalika Institutions for
greater responsibilities and roles in health and health care.
„
7.3.3
r- i a mechanisms for involvement of the private sector at different
Evolve
/
7
nce Work actjvely with the NGO/voluntary
levels WIUl quam;
sector.
.import Indian and other systems of medicine and local
734 Promote ana supp
health traditions.
- 13-
8
EXPECTED OUTCOMES
Table 7: Specific
<o be whi*ed over,
1.
Life expectancy at birth in years
---------2.
Crude birth rate
—-------- ----------- ---------- 71 for women. 70 for men
3.
Crude death rate
--------------------- ---------- 17/1000
4.
Infant mortality rate
------------------ ------------ 7/1000
5.
Under - five mortality rate
-------’--------- ---------- 25/1000
<35/1000
6. ' Maternal mortality rate
---------------------< 199/100,000 live births
7.
Nutrition status of children
Progressive improvement Planned
Severe undemutrition
< 0.5%
Moderate undemutrition
10%
Mild undemutrition
60%
Normal
> 30%
8.
Anaemia among women
<20%
9.
Anaemia among children
<40%
10. Newborns with low birth weight < 2500 gms
10%
11. Immunisation coverage with maintenance of cold chain
> 95%
12. Safe deliverieswith access to Emergency Obstetric
> 85%
Care
75% and 85% respectively
13. Case detection and cure rates in TB
as
per programme guidelines,
14. Specific health programmes
accelerated.
(IHV/AIDS, malaria, blindness, etc.)________________
8.2 Qualitative Indicators'. External cum internal reviews will be conducted using qualitative
research methods. These reviews, among other things, will focus on:
1. Mechanisms for community involvement at local, district and State level.
Participation of all sections of society.
2
Linkages with Gram Panchayats and Zilla Parishads.
3
People’s feedback and perspectives on functioning of PHCs, CHCs, Taluk
. ’ General Hospitals, District Hospitals and other health services. This would
include staff attitudes, payment systems and quality of care. Feedback to be
inclusive - from women / SC/ST / poor / differently abled/ elder persons.
4
Gender perspectives - availability of privacy, toilets, harassment, recording of
5.
1
violence, gender disaggregated data.
Functioning of referral system.
i"f®tructural s“PP<’rt 10 ‘SMS/ °lh“ SyS‘"“'l heir i"VOlV'n’en'
in programme planning.
- 14-
8.
mid^c 118 Proc,esscs’ co°rdinatior _
coordination and communication mechanisms, reviews and
points
modif«=atir-ions in programmes, identification of learning
9. Reduction in regional disparities.
10. Feedbnctc°IeXPe^
* tU^e
l^ree 'eve's and urban- rural distribution.
°Z1 ^overnment health personnel from all levels regarding working
ns, jo satisfaction, continuing education, feeling of self worth.
8.3 Health System Indicators:
Staff positioning.
Condition of infrastructure through the GIS.
Supply systems for drugs, laboratory, reagents, and other consumables.
Transport - vehicles, drivers, POL.
Communication systems.
Utilisation of health services - outpatient and inpatient
Hospital Institutional morbidity, case fatality.
Management indicators.
8.4 Indicators for Equity & Quality:
Equity and quality indicators arc critical and will need to be developed through a
participatory method involving the stakeholders.
9
BROAD STRATEGIES
Develop a comprehensive Karnataka State Health Policy.
Update the Karnataka Public Health Act on the model of Public Health Act circulated
by the Government of India in 1987.
Put in place an Act for private sector accreditation to ensure quality, ethics and
standards of care among private sector health providers.
Use an evidence based and dialectical approach in the development and modifications
of policies and plans. This will allow for constant learning from difficulties faced.
Move towards decentralized planning, management and monitoring cum reviews at the
District level, within a framework and guidelines developed at the State level.
Allow for flexibility, creativity and local innovations/ initiatives in responding to
health problems at the local level, but also ensuring accountability and
responsibility.
Develop and nurture leadership and a critical mass of public health specialists and
managers at all levels.
Use private health care specialists and professionals in the Health care system.
The fundamental thrust will be on capacity building at all levels, in all sectors.
- 15 -
Planning processes, coordination and communication mechanisms, reviews and
mid-course changes/ modifications in programmes, identification of learning
points.
9. Reduction in regional disparities.
10. Analysis of expenditure by the three levels and urban- rural distribution.
11. Feedback from Government health personnel from all levels regarding working
conditions, job satisfaction, continuing education, feeling of self worth.
8.
8.3 Health System Indicators'.
Staff positioning.
Condition of infrastructure through the GIS.
Supply systems for drugs, laboratory, reagents, and other consumables.
Transport - vehicles, drivers, POL.
Communication systems.
Utilisation of health services - outpatient and inpatient
Hospital Institutional morbidity, case fatality.
Management indicators.
8.4 Indicators for Equity & Quality:
Equity and quality indicators are critical and will need to be developed through a
participatory method involving the stakeholders.
9
BROAD STRATEGIES
Develop a comprehensive Karnataka State Health Policy.
Update the Karnataka Public Health Act on the model of Public Health Act circulated
by the Government of India in 1987.
Put in place an Act for private sector accreditation to ensure quality, ethics and
standards of care among private sector health providers.
Use an evidence based and dialectical approach in the development and modifications
of policies and plans. This will allow for constant learning from difficulties faced.
Move towards decentralized planning, management and monitoring cum reviews at the
District level, within a framework and guidelines developed at the State level.
Allow for flexibility, creativity and local innovations/ initiatives in responding to
health problems at the local level, but also ensuring accountability and
responsibility.
Develop and nurture leadership and a critical mass of public health specialists and
managers at all levels.
Use private health care specialists and professionals in the Health care system.
The fundamental thrust will be on capacity building at all levels, in all sectors.
- 15-
10. SPECIFIC STRATEGIES
These will be developed further using a consultative, participatory and evidence based
approach.
10.1
Public Health and Primary Health Care
10.1.1 Access, quality & effectiveness of Primary Health Care Services will be improved by,
a) Filling in gaps in physical infrastructure for primary health centre and subcentres,
including construction of quarters and undertaking renovation and maintenance where
required. This would include provision of water supply, electricity and basic equipment
and consumables required for diagnostic and therapeutic work. Findings of the facility
survey being undertaken will be validated and used for cost estimation of requirements.
b) Filling up of gaps in health manpower by sanctioning / creating of required / additional
posts in the existing / newly created health centers as per norms.
c) Selective upgrading of PHCs into FRUs and CHCs according to current norms, in
Gulbarga division and other backward pockets of the State.
d) A well planned referral system that functions both ways to be implemented in a district
and then expanded. Gaps in the existing secondary health care services to be filled up.
e) Steps to improve quality of services provided by the private sector through
accreditations/ guidelines will be implemented.
f) Put in place a system for outcome and financial audit of primary health care institutions.
g) Ethics training.
10.1.2 Nutrition:
Good nutrition is an entitlement (Amartya Sen), with the need for adequate income or
purchasing power. Nutrition is a basic determinant of health, has been grossly neglected
by the health sector in Karnataka so far. Recent data from NFHS II and NNMB provides
evidence of a high level of under nutrition in Karnataka. Therefore nutrition is taken up
as a priority with specific interventions by the health sector, and with intersectoral
linkages with the Departments of Women and Child Development, Food & Civil
Supplies, Agriculture, Rural Development & Panchayati Raj & Education. The health
system needs to be accountable for the poor nutritional status of the population.
Child Nutrition-, particularly of under-twos, from the period of conception, will be given
the highest priority. Strategic action points include: ■
a. Closer collaborative mechanisms between health, WCD (Women and Child
Department) and Panchayats particularly at the local level in the functioning of
Anganwadis (AWs).
b. Universalize AW centres for every 1000 population in rural areas and 1500 in
urban areas. Priority will be given to Gulbarga division. Valuable lessons learnt
- 16-
from the T1NP programme of Tamilnadu will be studied and used where
appropriate.
c. Vacancies of Anganwadi Supervisors to be filled urgently (currently there are
approx. 660 in position out of 2000 posts to cover the existing 40,000
Anganwadis) and these supervisors will be provided refresher training.
d. As far as possible women to be appointed as CDPOs. Gender sensitization at all
levels.
e. Persons with nutrition training and experience to be positioned at senior levels at
state and district levels both in the Health & FW and W&CD departments.
f. Gram Panchayats to be involved more closely and decentralization monitored to
ensure that the poor have access and benefit optimally.
g. The strategies for under two children include mothers’ education and
supplementary feeding in areas of need, especially in Gulbarga division.
h. Micronutrients iron supplementation for children, adolescent girls, women and
men when required, regular deworming, Vit. A supplementation and Iodine where
required.
i. Education regarding nutrition at all levels of the health, WCD and education
systems. Nutrition education to be seen as part of health promotion.
10.1.3 Improving health for school age children and adolescents
A blue print for a programme for improving health for school age children that includes
out of school children. (The existing programme does not cover school dropouts. This
will include:
♦ Physical(health - health cards for children, including medical checkups and
•follow-up treatmenu"
♦ Health preventive and promotive education and activities. This would involve:
•
teacher training - in teacher training schools and through in-service
programmes,
•
development of modules, manuals for teachers development
educational material for children, building on what already exists.
•
use of child to child methods to reach out of school children
•
adolescent health education
of
This shift in emphasis will require close collaboration between the departments of Health
and Education. This effort will be tested and phased in different districts.
10.1.4 Health Promotion & Empowerment
a)
b)
c)
This will include training of leaders of women's groups, from Mahila Samakhya,
agricultural women's Sanghas, DWCRA, NGO women's groups, self-help groups, etc.
Training of youth groups, opinion leaders, etc.
Reaching out to the marginalized and unreached sections of the population using
different methods of communication from interpersonal modes, and mass
communication modes.
- 17-
Launching of a comprehensive and coordinated 1EC campaign covering all sectors
and levels of the Health System. To the extent possible, the campaign will focus on
local area specific problems and issues.
d)
10.1.5 Reduction in Morbidity and Mortality
The system will be strengthened for control of public health problems (TB, Malaria,
HIV/A1DS etc.) through integration at primary care level, with specialized referral and
technical support at secondary/tertiary levels. Provisions will be made to fill in gaps in
the existing system and for response to sudden needs, including outbreaks.
10.1.6 Increased servicesfor neglected and emerging health problems.
a)
Mental Health Care - This is an orphan subject with very limited resource
provisions in Karnataka. Research studies in the State show that at least 2% of the
population suffer from severe mental morbidity, and at least 10% from neurotic
conditions, alcohol & drug addition & personality problems. While mental health
care needs to be provided at PHC level in the long term, during the next 5 years it is
necessary to
i. Improve training in psychiatry & psychology in the MBBS course & in general
nursing training.
ii. Strengthen psychiatric and counseling services at district hospital level and
subsequently at Taluk Hospital.
iii. Organize training programmes for PHC - MO’s and staff using manuals
prepared by NIMHANS. Ensure provision of psychiatric and epileptic drugs.
iv. Encouragc/make provision for care/ facilities for chronically mentally ill
persons, as in the present context family members are unable to do so.
v. Develop working links with NGOs, traditional healers, religious organisations,
etc.
b) Care of the elderly - Developing geriatric services/units in secondary and tertiary
care institutions; developing training programmes for health personnel with the
Health University; providing support to developing long term, home based
programmes.
c) Tobacco and substance abuse programmes - support to public education and
advocacy programmes and to tobacco quitting.
d) Accidents - support to research, legal measures, trauma centres and rehabilitation.
Intersectoral coordination with dealing in transport, industry, roads and highways.
e) Violence - training programmes for health professionals for recognition of the
problem, introducing recording and reporting systems, support to care homes and
rehabilitation centres. Violence against women to be specially addressed.
j) Other non-communicable diseases - Non-communicable diseases such as cancer,
diabetes and heart diseases, etc. will be addressed.
- 18-
10.1.7 Health Information System:
Processes are already under way to rationalize recording and reporting systems from
primary care levels upward, to develop comprehensive HM1S and GIS and a disease
surveillance system. Support for development, maintenance, technical manpower and
upgrading of the system will be required.
10.1.8 Reduction in Regional disparities
Specific efforts will be made to reduce Regional disparities by strengthening
infrastructure, personnel and educational inputs. This will cut across most strategies.
10.1.9 Improve health of SC/ST and others below the poverty line
The initiative taken under KHSDP with the Yellow Card scheme needs to be sustained
and deepened to include follow up, health promotion and full curative services. This
programme will be expanded to cover all families below the poverty line as it has been an
acknowledged effort at providing health care interventions for certain vulnerable sections
of the society. Special effort will be made for improving health care for tribal families,
especially with the help of NGOs.
10.1.10 Strengthening Urban Health Care Services
Due to historical reasons, urban health care services are administratively under the
respective local municipal bodies. This is also mandated by the 74lh Amendment of
the Constitution. The large number of teaching, tertiary & specialist hospitals in
urban areas come under the administrative purview of the Dept, of Medical
Education. The private sector too has a large presence (80%) in urban areas with a
range of services from corporate super-specialty hospitals and diagnostic centres to
individual private practitioners. Most of the above institutions are providers of
curative care.
There is an urgent need to strengthen public health interventions and provide primary
health care services, particularly for the urban poor. The following steps are
envisageda) Support to Public health measures for provision of safe water, sanitation;
solid waste disposal, and hospital waste disposal. This will include
support to testing of water quality.
b) Existing municipal corporation dispensaries and IPP VIII centres to
expand the scope of their work to cover primary health care. Add new
urban primary health centres where necessary, especially in small towns.
c) Involvement of local communities through link workers, health
committees, boards of visitors.
d) Involvement of NGOs in primary care, community mobilization,
rehabilitation and in areas of their- expertise evolving methods of
financing, using their knowledge base, professional and managerial skills.
- 19-
Developing referral links with private sector institutions evolving
methods of financing, using their knowledge base, professional and
managerial skills.
e)
10.1.11 Improve Women’s Health
Women s health status will be improved by:
a) gender and social sensitivity training for all staff
b) positioning of women medical officers at PHC's where possible
b) empowerment training for women leaders and communities
d) increased access to care and improved reporting of women's health problems
10.1.12Fertility Decline:
It is recognized that the best strategy for population stabilization is through
improved health and nutrition status.
a)
b)
c)
d)
e)
10.2
The burden of contraception so far has been on women. Participation of
men will be increased through community education and provision of
facilities and expertise for men’s sterilization.
In districts with high TFR, especially in Gulbarga Division, women’s
literacy rates, utilization of antenatal care and childhood immunization rates
are poor. Additional inputs and efforts will redress these disparities by
improving service delivery to meet unmet needs.
Quality of contraceptive services will be ensured to minimize side effects.
Systems to monitor complication and adverse reactions will be initiated.
Only safe contraceptive technology will be used.
Increase in the age at marriage and postponement of the first pregnancy
will be a key strategy.
Compulsory registration of births and marriages will be attempted.
Health System Issues - Management, Capacity Building, Finance and Institutional
Strengthening
10.2.1 Human Resource Development
This forms the core thrust of this project, and is critical coming as it does along a period
of infrastructure development. Orientation courses, in-service training, continuing
education and skill development will be part of the efforts to make the DH & FW a
learning organisation. Steps to be taken will include:
a)
b)
Developing working links with the Rajiv Gandhi University of Health Sciences
with medical colleges, nursing schools and other allied health science
educational instructions for training. Medical colleges to take charge of 3
PHCs and associated sub-centres.
Full support to the State Institute of Health & Family Welfare to become a
premier training institution in public health, health management &
administration, medical and public health ethics.
-20-
c)
d)
Orientation and in-service training for PI1C Medical officers ANMs, Junior
ea th Assistants Females, and male, laboratory technicians, lady health
visitors & nurses. PHC team training could be considered and undertaken at
taluk I district level.
Private sector professionals and institutions to be involved in training, and
skills development.,
Management Development
10.2.2
Strengthen management capacity at all levels through training
Introduce non medical health managers and hospital administrators
Health cadre planning & management to be systematically undertaken
Drug equipment procurement and supplies systems to be modernized
and made transparent with development of district stores.
e) Critical issues of morale and motivation of government health
personnel to be addressed, using a research based approach to see what
works. Decentralized small working units with independent decision
making powers to be tried.
f) Strategic planning & evaluation cell to be given high priority and
adequate infrastructure
a)
b)
c)
d)
10.2.3
Develop capacityfor decentralised district level planning by
a) Developing district epidemiological units, of which the surveillance
and HM1S units are a part.
b) Microplanning exercises at T.Narsipur Taluk to be studied and further
developed / expanded.
10.3
Partnerships
10.3.1 Intersectoral co-ordination
This will be actively attempted with Dept, of Women & Child Development,
Education, Rural Development and Panchayat Raj, Water Supply & Sewerage Boards,
PDS agriculture, Social Welfare Board etc at the state, district and primary care level.
These are required for
a)
b)
Monitoring water quality, improving sanitation and waste management
Nutrition, school health, rehabilitation, links with PRIs etc.
10.3.2 Empowerment of members of Panchayati Raj Institutions and Nagarpalikasfor Health
Panchayati Raj institutions (PRIs) are mandated constitutionally to form part of
governance structures for primary health care and public health. To enable and equip
members to play an effective role, empowerment training of newly elected
representatives of PRIs for health, will be conducted by the DHFW in collaboration
with others.
-21 -
Current numbers of elected representatives are as follows:
Table 8: Elected representatives in Karnataka (July 2000)
Male
Female
Elected Body
%
No.
%
Gram Panchayat Members
35,187
44.85
43,273
55.15
Taluk Panchayat Members
601
15.25
3,340
84.75
Zilla Parishad Members
339
26.94
919
73.06
36,127
43.14
47,532
56.86
Total
No.
These 78,460 elected gram Panchayat members commenced their five-year term in April
2000 and the 5,199 Taluk Panchayat & Zilla Parishat members assumed office on la July
2000. Training programmes on health conducted by the DH&FW will be refined and
undertaken with the cooperation ofNGO’s, health science training institutions and other
academic bodies. Women Panchayat members, especially at Gram Panchayat level, have
a greater interest in health and will be selected first for training.
Training programme content will cover priority health problems, existing government
health services and programmes and how to access them, health promotion messages,
utilisation of local health traditions, when to refer etc. Kannada manuals have already
been developed for the Women’s Health Empowerment Training Programme at two levels
for Training of Trainers and for Community Leaders. Other existing material in Kannada
developed for the RCH, IPP VIII and other programmes could also be used. Training
could be at two levels, namely, ‘Training of Trainers’ for district level teams, followed by
training of GP members at sub-district level. The entire state could be covered over a
period of 1 year.
10.3.4 Partnerships with the private sector, with NGO's and health professional bodies.
This important strategy aims to increase access to health care to involve all sectors in
state health plans and programmes; to bring in specialists and academics from the private
sector to support implementation training, and research; and to increase quality of care.
Strategies include:
a)
b)
Working links will be established or furthered with representative bodies such
as the Indian Medical Association, Indian Association of General Practitioners
(IAGP) Confederation of Indian Industries, FICCI, Federation of Obstetric &
Gynecologic Societies of India (FOGSI), Associations of Surgeons,
Pediatricians, Physicians, Ophthalmologists etc, with the Voluntary Health
Association of Karnataka, FTVORD-K, AIDS Forum Karnataka, CHAIKA,
and other bodies This should provide additional professional and financial
support to programmes.
A deeper study /cluster of studies of the private sector to understand its
distribution, the type of work done, the strengths and weaknesses.
-22-
Quality assurance through the Accreditation Act, and the Consumer Protection
Act.
d) Provision of referral services at FRUs for emergency and other obstetric &
gynecological care through FOGSI members, to be introduced first in Bellary
district and then in a phased manner.
e) Involvement of the private sector in non-clinical services such as transport,
cleaning, equipment and asset maintenance, etc.
f) Pilot trialling of health insurance system for the poor in selected areas, with
involvement of private health institutions.
g) Involvement of medical colleges through the ROME scheme (Reorientation of
Medical Education) to run 3 PHCs & associated subcentres, with
administrative control & freedom in staff appointment. This will require
upgradation of buildings, equipment, transport, communication & HMIS
systems to promote best practices as part of teaching/ academic institutions. Of
the 23 medical colleges in Karnataka, 19 are private. Totally 69 PHCs would
get covered in the state under this programme. This will assist colleges in
meeting Medical Council of India & University requirements. It will also help
develop / strengthen links between universities and health services. This
strategy could potentially allow for involvement of state health service
personnel in the training of medical undergraduates, which will have mutual
benefits.
h) A body of experts drawn from relevant areas in the private/NGO sector to be
considered for supporting the department’s public health efforts.
c)
10.3.5 Promote and support Indian Systems of Medicine and Homeopathy (ISM & H) by the
following measures:
a. Progressive increase of budgetary allocation from the present level, which is
less than 1 % of the State health budget.
b. Involvement in planning processes and in service delivery by posting
ayurvedic/ homeopathic physicians as Medical Officers in ISM & H units that
will be established at District Hospitals and subsequently at taluk Hospital
levels.
c. Support to education & research institutions for ISM & H.
10.4
Project Management
10.4.1 Project Monitoring Information System
To ensure all the project objectives are achieved project input as well as outcome indicators will
be developed before the commencement of the project and woven into a comprehensive PMIS.
This will include financial monitoring as well monitoring of physical benchmarks.
-23-
10.4.2 Project Implementation and Steering Committees
Structures designed in the context of the KHSDP have been found effective. Similar structures
with appropriate modifications, as well as additional review structures at the Directorate and
district levels will be set up.
10.4.3 Supervision and inspections
To ensure quality as well as speed of implementation, supervision and inspection mechanisms
involving external agencies, consultants as well as the Health administration will be put in place.
10.4.4 Consultancies, studies, fellowships and workshops
Project implementation and capacity building will be supported throughout the project with
consultancies, research studies, workshops and fellowships.
-24-
Tentative Costing for (he Integraled
Development Initiative in Karnataka : 2001-2006
SI. No.
Project Strategies
1.
Public Health and Primary Health
Care
1.1
Access, quality & effectiveness of
primary health care services.
Improving nutrition levels.
Improving health for school age going
children and adolescents.______
Health promotion and empowerment.
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
Reduction in morbidity and mortality.
Increased services for neglected and
emerging health problems.
Health information system.
Reduction in regional disparities.
Improve health of SC/ST and the poor.
Strengthening urban health care
services.
Improving women’s health.
Fertility decline.
Nutrition and Family Welfare Services
(by Strategies)(figs. in rs. crore)
Investment
costs
Recurrent
costs
Total
costs
200.00
50.00
250.00
30.00
10.00
40.00
10.00
70.00
20.00
10.00
10.00
10.00
10.00
30.00
10.00
20.00
40.00
20.00
10.00
10.00
20.00
30.00
10.00
30.00
10.00
20.00
20.00
40.00
30.00
50.00
0.00
10.00
10.00
10.00
10.00
20.00
2.
Health system issues, training and
management
2.1
Human resource development.
10.00
30.00
50.00
2.2
2.3
Management development.
Decentralised planning
10.00
10.00
10.00
0.00
20.00
10.00
3.
Partnerships
3.1
3.2
Intersectoral collaboration.
Empowerment of members of PRIs and
Nagarpalikas.
------------------Partnerships with private and NGO
sector.___________________________
Promoting and supporting Indian
cvstems of medicine and homeopathy.
10.00
10.00
0.00
0.00
10.00
10.00
10.00
0.00
10.00
10.00
10.00
20.00
10.00
20.00
0.00
0.00
10.00
10.00
450.00
290.00
740.00
30.00
20.00
0.00
10.00
30.00
30.00
500.00
300.00
800.00
3.3
3.4
4.
Pmiert monitoring and supervision
4.1
4.2
COnsuiidiicy,
5.
r>_- „ nnd nhvsical contingencies
rrice anu
g------------------
5.1
5.2
---------.-------------- *----------
Physical comingeilu!rr----------------- - —
rrojen
_____ ———
-25-
Tentative Costing for the Integrated Health, Nutrition and Family Welfare Services
Development Initiative in Kmmataka : 2001-2036 (by Components)
SI. No.
1.
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
------- ----------;______ _______________
Project Components
Base costs
Investment Costs
Civil Works (Renovation)
Civil Works (Extension)
Professional services
Furniture
MIS materials
IEC and health promotion materials
Local training
Local consultants
Fellowships
Workshops
150.00
80.00
20.00
50.00
20.00
10.00
40.00
20.00
10.00
10.00
10.00
10.00
10.00
10.00
Total investment costs
450.00
Equipment
Vehicles
Medicines
Other supplies
2.
Recurrent Costs
2.1
2.2
2.3
2.4
Salaries of additional staff
Operational expenses
Building maintenance
Equipment maintenance
160.00
60.00
40.00
30.00
Total recurrent costs
Total BASELINE COSTS
290.00
Physical contingencies
Price contingencies
30.00
30.00
Total PROJECT COSTS
800.00
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