KARNATAKA TOWARDS EQUITY, QUALITY AND INTEGRITY IN HEALTH
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KARNATAKA TOWARDS EQUITY, QUALITY AND INTEGRITY IN HEALTH
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KARNATAKA
TOWARDS
EQUITY QUALITY AND INTEGRITY IN HEALTH
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FINAL REPORT
of
THE TASK FORCE ON MEAS.™ & FAMILY WELFARE
GOVERNMENT OF KARNATAKA
APRIL 2001
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Sowards Equity, Quality
and
Integrity in Health
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Finfil Report of the
Task Force on Health and Family Welfare
ABRIDGED VERSION
TASK FORCE ON HEALTH AND FAMILY WELFARE
Government of Karnataka
PHI Building, Sheshadri Road,
Bangalore - 560 001
Ph : 2271021, 2274883 E-mail : khsdp@vsnl.com
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REPORT OF THE TASK FORCE
PREFACE
The Task Force on Health and Family Welfare is happy to present this Final Report. It would be recalled that
the Task Force had presented an Interim Report in April 2000. It made recommendations therein which, the
Government of Karnataka, we are pleased to record, received with appreciation, and more importantly, acted
upon. The issues of concern and key messages of that Report have been considered and studied further in greater
detail, against the backdrop of a vision for better health in the State. The conclusions of the deliberations on these
issues are presented in this Final Report.
At first sight, the recommendations may seem rather detailed, extensive and wide ranging. However, in view of
the importance of health as probably the most important element in the effort to achieve an acceptable standard
of quality of life for all, the consideration of issues had to cover all aspects of the health services and closely
inter-related sectors of development. It is rarely that such an opportunity arises, which permits examination of
issues in full of the health services and in conjunction with the sectors that lend these services strength and
support. A holistic view of health services as an integral part of the entitlement of the people to basic services
has, therefore, been taken. Consequently, this Report has considered the content, quality and reach of health
services, and administrative and management issues in the social and economic context of the State.
In the course of examination of the issues relating to health services it has repeatedly become apparent that the
key factor that influences the efficiency of these services and ensures the social accountability of the system is
the issue of governance. It is apparent that professional skills, financial allocations and departmental infrastructure,
important as they doubtless are, can contribute to performance only up to a point. The core issue, however,
remains the motivation and commitment of the staff. There is need to nurture the young health professional and
other allied health workers, supervising and facilitating them. There is also the need to institutionalise discipline
tempered with morale building, peak performance and accountability to the public, together with the involvement
of the people in attaining and maintaining their own health. The recommendations on restructuring of the health
services have been made keeping these essential parameters in view. It is appreciated that the recommendations
call for basic structural changes. They have been made in the full confidence mat such changes are not merely
desirable, but essential, and would be viewed by those in the system in this light.
It is recognised that the examination and implementation of many of these recommendations by Government
would take some time. Others can be implemented without delay, as had been done for the short term
recommendations. It is hoped, and indeed urged, that the same sense of urgency and concern on matters relating
to health, that induced the constitution of this Task Force, would continue to prevail, and that no time would be
lost in establishing mechanisms for implementation of the recommendations. Such a mechanism has been
suggested in the Report. Priority in setting up these mechanisms is urged. As responsible and responsive persons,
the members of the Task Force would be happy to contribute their expertise in this effort. As an effective
measure for implementation of these recommendations and for monitoring implementation and generally to further
the objectives of rapid improvement of the health services, the early constitution of the Commission on Health
recommended herein is urged.
The Task Force has attempted to cover as much ground as possible. However, it need hardly be emphasised
that many aspects would still need consideration. At best, what has been presented is a detailed blueprint. This
iv
REPORT OF THE TASK FORCE
acceptance of the need for change, and change at a quick pace.
The recommendations made therein have been welcomed enthusiastically and many of them have been
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G0Vernmel’t in a sh?rt s?an of time- Th^ response evokes confidence in the Task Force
the recommendations made in this Final Report would be implemented in the' same spirit in which they have
been made, namely of concern for the health of the people of the State and their welfare Once these
r^ommendations are implemented, the health services in the State will achieve both professional competence and
1
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IV-SU—-
Sri Arvincl G Risbud
Member Cowtven^r^
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Dr. H. Sudarshan
Chaisrman
Members:
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Dr. ^andrashekar Shetty. 8
Dr. C. M. Francis
4
Dr. T. Jacob John
Dr.
. Kamini Rao
Dr. M. Maiya
Sri Padmanabha. P
Swami Japananda
Dr. Jayaprakash Narayan
4
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Dr. Latha Jagannathan
Dr. Ramesh S.
agga
Dr. Thelma Narayan
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REPORT OF THE TASK FORCE
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ISSUES OF CONCERN AND AN AGENDA FOR ACTION
Over 14 months, the Task Force on Health and Family Welfare, Karnataka has had the benefit of a very wide
range of interactions and discussions with a large number of health care providers, decision makers, policy
makers, representative of professional associations, voluntary and private sector health care organizations,
elected representatives of the people, representative of citizens groups and the community. These discussions
were open and frank, in a sprit of dialogue and very constructive. Concerns were shared and suggestions and
ideas to improve the health care system in Karnataka were freely given. Many of these have been included in
the different’chapters included in the final report.
There are some major concerns and cross cutting themes that affected all aspects and sectors of health care.
These need to be tackled on an urgent and sustained manner through what we have suggested as an Agenda
for Action. Many of these factors are not specific to the health care system itself. They are also problems of
the larger society within which our efforts in health care are located. Therefore they impinge and distort our efforts
to evolve a health care system that is committed to equity, quality and integrity with a special focus on
primary health care and public health. We need to tackle them seriously.
1.
Corruption
Throughout the discussions, the task force was informed through a wide variety of sources of the widespread
and growing ‘corruption’ at various levels of the system and in all aspects and sectors of health care. This took
many forms.
Monetary considerations for appointments, promotion and transfer.
(Every level had a price and a hierarchy of amounts depending on importance of job.)
•
Corruption at the time of selection of candidates for educational institutions / programmes and
at the level of examinations.
(The process had become so vitiated that students are now paying not to pass but to prevent being failed.
Even awards and distinctions had a price.)
•
Monetary factors distorting access and utilization of health care services at different levels.
(Whether it is a charge for a sputum cup for a tuberculosis patient, or to get facilities in an urban or rural
health centre; or taluka hospital for an emergency surgery; or even just to see a newborn baby in a
corporation hospital with rates for male babies exceeding that for female babies! Monetary demands for
routine services that are supposed to be free are rampant).
While such widespread corruption is nowadays often passed off as a worldwide phenomena; or as being linked
to our political system and its funding mechanism, and so on, it is essential that the leadership of the state at all
levels be committed to tackling this problem and move actively towards a zero-tolerance level. We have
particularly been encouraged at steps including counselling during recent appointments made after the Interim
report, during which monetary transactions did not play a role.
•
Agenda for Action
We suggest a ‘vigilance system’ in the directorate and health ministry that will monitor and help
a.
REPORT OF THE TASK FORCE
RE
proactively counter this widespread problem. (See section on Administration) We believe there is
already political and bureaucratic will, as demonstrated by decisions taken on our interim
recommendations and by the recommendations of the Administrative Reforms Committee.
b.
We also suggest that senior leadership of the health care system should discuss and monitor this
issue so that a new climate against corruption is built up proactively at all levels.
2.
Neglect of Public Health
b.
There is an overall neglect of public health principles and practice in planning, organisation and management of
health care services, and this has shown worsening trend. The neglect is symbolized by
•
Inadequate emphasis on tackling the determinants of ill health particularly nutrition, water supply and
sanitation, housing, literacy and poverty alleviation, which are crucial to public health and were even
identified as early as in 1?46 in the Bhore committee blue print that was accepted by independent India
as a framework for health service development. Further by compartmentalization of the ongoing efforts
in these directions by different departments and ministries, the intersectoralilty of all these with basic health
has been lost.
•
The key to good public health is a robust health information system which monitors both the health
status indicating problems and health care inputs and outcomes, supported by an efficient epidemiological,
microbiological and entomological surveillance system. Inspite of so many projects and programmes, the
quality, reliability and scientific validity of all the data that is being routinely collected and published leave
much to be desired, it is another aspect of this overall neglect.
•
The overall lack of emphasis on preventive, promotive and rehabilitative care, except perhaps for
some focus on immunization and family welfare and some relatively inefficient nutritional supplementation
is another key factor. Curative care and the increasing privatization and commercialization has resulted in
over 65% of health care being in the private sector today, mostly unregulated and unrepresented in the
State’s-health monitoring’ or health planning systems.
•
In addition, health education has been neglected at all levels and rational drug management policies not
adequately addressed.
|
•
Inspite of the presence of good public health resource persons in the state, public health cadres have
neither been nurtured nor strengthened. Also at different levels of health care, decision makers with no skill
or capacity in public health policy making have been allowed to make decisions that have therefore
supported individualized curative care or the market economy of medicine, rather than sound public health.
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Agenda for Action
a.
There is urgent needfor strengthening public health competence and skill at all levels of the system
to improve health for all without distinction or discrimination. This must include a two pronged
approach.
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All decision makers at all levels beginning from the medical officer of a primary health centre
to the leadership both technocratic and bureaucratic at the state directorate level, need to be
given short public health orientation and skill development as a ongoing continuing
education process for capacity development.
Public health competence through relevant training for Diploma, MD, Masters and Doctoral
programmes should be built up and a cadre ofpublic health consultants / specialists should
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be built up who will take over health planning decisions making in the state over a period
of time. These must have the competence to make a broad social - economic - cultural political situation analysis of the health and health care situation, and be skilled in the
challenges both technological and managerial, to address the problem through good team
work and empowered community participation.
As a complementary action, the agenda will focus on:
•
determinants of health;
•
comprehensive health information system and surveillance; and
•
preventive^ promotive and rehabilitative aspects of every priority problem must become
the sheet anchor for health planning and service development in the state.
This will again mean a proactive reorientation effort at all levels of health care administration and in all
the training programmes geared to producing health human power for the health care system.
3.
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ive
Distortions in Primary Health Care
Though the state has promoted primary health care, this has not been well defined at policy level and has been,
additionally distorted by various factors which include:
•
Inadequate efforts to involve the people in the health planning and management process so that
community participation if at all has been very passive and adhoc.
•
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Increased verticalisation and selectivisation of programmes at the cost of more integrated and
comprehensive approaches and at the cost of greater flexibility and local planning effort. Externally aided
projects have contributed particularly to this verticalisation and selectivisation.
•
Inadequate preparation to empower the evolving Panchayatraj system to participate and be actively,
involved in health decision making at community level.
lot
•
Lack of adequate involvement of general practitioners; local healers and healing systems; voluntary
agencies; NGO’s and civic society and the private sector in complementing and supplementing the
governments primary health care system.
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Lack of development of appropriate technology and very slow up-gradation of the technological
competence of the health care system at the primary care level.
Increased compartmentalisation of health care from intersectoral action that is so crucial to address
the deeper determinants of health, and lack of integral linkages with nutrition programmes including the
ICDS scheme; the school system; the cooperative movement; poverty alleviation and development
programmes; water supply and sanitation programmes; and women’s credit cooperatives.
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Not surprisingly the comprehensive concept of primary health care including focus on equity;
appropriate technology; intersectoral action; and community participation has been diluted or nearly
forgotten.
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Agenda for Action
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Id
a.
There is urgent need to reiterate the commitment to primary health care as a core principle of health
care service development in the state at all levels and sectors within the directorate and the ministry
and its associated institutions.
■
report of the task force
Al'///
b.
There is need to improve orientation and capacity for the promotion of primary health care by
improving quality of primary health services by strengthening human power resources', maintenance, logistics and supplies and supportive referral systems.
c.
Simultaneously the strengthening of the community partnership in the ownership and management
of the programme should be undertaken orienting and involving Panchayatraj institutions actively
in the process.
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d.
A complementary strategy.to involve and enhance the participation of local community organisations,
voluntary agencies and NGO’s; local practitioners of all systems of health care including folk
healing traditions, must be actively promoted.
e.
Finally the crucial intersectoral linkages required to address the determinants of health - income,
gender, literacy, housing, water supply and sanitation and environmental pollution and make the
primary health care system more integrated and comprehensive, must be urgently promoted
Making primary health care work must be a renewed commitment.
4.
Lack of Focus on Equity
There is growing evidence that inequalities in health between regions and districts of Karnataka and between
groups within our society / community are widening and despite some efforts the present health care system and
programmes do not address these inequities adequately.
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The inequities identified are
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The northern districts of Karnataka especially the seven districts (category C) have the lowest figures for
most health, development and social indicators. Certain talukas in some of the southern districts also show
poor development indicators.
Rural - urban differentials continue to exist and are also widening.
iGTd!r djscrimination is seen in
continuing neglect of the girl child, the increase in female foeticide (sex
linked selective abortion); continuing disparity between male and female malnutrition; violence against
women; and lower access to care. i|
I
The gaps between the scheduled ca^te and tribes (SC / ST) sections of the population, and the rest
casteteftdc inequity
035168 <'0BC’S) continue t0 exist’in sPite of programmes trying to address this
Other neglected groups in our society include growing numbers of the elderly; continuing numbers of
working children including increasing numbers of street children; people with disabilities and a large group
of people socio-economically or socially marginalised through a variety of factors in our society.
Inadequate responses to tackle these continuing or growing inequities is an important concern. The lack of focus
on equity and disparities is further complicated by inadequate monitoring of these inequities and the continuing
lack of disaggregated data to help understand the situation and mount more focussed responses.
Agenda for Action
a.
There is urgent need to address the equity issue by establishing a health monitoring system that
focusses on regional disparities, gander inequalities; class and caste / ethnic inequalities; the
geographical (rural / urban) divide and collects disaggregated data.
Ag
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REPORT OF THE TASK FORCE
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■
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b.
Equity as a policy imperative must be built into the situation analysis; the goals of the health policy
and health care system, and the monitoring of inputs and outcomes. When equity becomes a crucial
indicator of health care process then suitable responses will emerge in the health planning and
implementation process. Special packages for the seven category C districts; scheduled castes and
tribes; women; and other vulnerable groups are required, besides an overall focus on improving
rural health care. The best administrative and management expertise must be utilised to work on
these areas.
5.
Implementation Gap
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,••■■■■
Over the last few decades the state has invested in public health, primary health care as well as secondary and
tertiary health care. In the last two decades external aid has also been substantially increased to meet new
challenges and widen the focus and outreach of existing programmes. A lot of efforts have been put into planning
programmes and strategies, and implementation guidelines and manuals of every sort have been evolved.
However at all levels and sectors of public health and primary health care, one sees a widening gap between
policy intent and implementation; between what is professed and what is practiced. This implementation gap
is a major area of concern and a major obstacle to improving the health status of our people.
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The ‘gap’ is contributed to by multidimensional factors
•
There is lack of political will in that health is not high on the agenda of governance. Health budgets are
stagnant and often underutilised. The commitment and capacity to get plans off the ground and reach those
who need to be reached is lacking.
; for
•
There is overall lack of vision and mission, and perspectives of health are neither comprehensive nor
integrated, with increasing programmatic compartmentalisation that ‘misses the forests for the trees’.
•
The planning, administration, supervision and evaluation of the health system are poor, often adhoc
and not always evidence based or quality conscious. This is true particularly at programme, district and
subdistrict levels. The work of good people get neutralised with resulting frustration and demoralisation.
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Leadership of the department has lacked a problem solving orientation, team building and team
motivating capacities. Lobbies and interest groups work to further their own narrow, short term interests,
at the cost of the greater common good.
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Individual agendas based oh caste or local politics have often predominated over collective good.
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The continuation of key and critical vacancies not being promptly filled up has also greatly contributeu
to a vacuum affecting implementation. In addition, frequent transfers affecting continuity and lack of
younger people at district level also affects the implementation process.
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Surprisingly even in departments and programmes when many of the above factors are not at play there
is a phenomenal apathy further affected by bureaucratic red tape and delays, or the burden of
not taking responsibility that has contributed to this growing mismatch between plan and implemen
tation.
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Agenda for Action
a.
There is urgent need for a comprehensively articulated State Health Policy which provides the vision
/ mission / goals and framework for an integrated health plan that has long term perspectives built
into the system.
■■
xix
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REPORT OF THE TASK FORCE_______________________________________ _ __________________________
C.
d.
e.
There is urgent need to raise the status of health on the political agenda and to ensure that adequate
financial and budgetary^ resources are provided to reach health for all goals, in keeping with
constitutional and health policy obligations.
REl
There is urgent need to monitor and improve the quality of health services by increasing competence
of health staff; improving logistic support and ensuring supplies; preventing duplication and
compartmentalisation; strengthening monitoring of quality care and setting realistic and achievable
quality of care standards.
There is urgent need to increase accountability and transparency to prevent distortions due to
extraneous influences of the market economy; of lobbies; social and political agendas; and money
power.
There is urgent need to nurture competent, committed and capable leadership at all levels to
maintain, motivation, morale and ethical commitment of health personnel at all levels.
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There is an urgent need to introduce a supportive and problem solving, decentralised, supervisory
system so that implementation gaps are constantly monitored and their causes addressed proactively
and effectively.
6.
The Ethical Imperative
7.
Th
Over the years there has been a gradual decline in the commitments to ethical values at the professional level
which has allowed the market forces and economic gain to distort professional values and commitments. In
addition there are an increasing number of social developments and new technologies that have now been
included under various legal acts / provisions to ensure that they benefit human development and not cause harm
by misuse, abuse, overuse or exploitation. The increasing connivance of the medical profession in sex-selective
abortion by misuse of prenatal diagnosis; and the unethical practices, recently exposed in getting donors for organ
transplantations are significant examples of these trends.
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Ethics and law which are complementary are crucial for the evolution of a comprehensive health policy and health
care system - the former providing the spirit and inspiration, the latter the safeguard and framework. If both these
are ignored the health care structure will weaken and the framework will no longer respond to the needs and
aspirations of the people. The loss of the ethical imperative and the disregarding of legal framework and law
determined responsibilities is another contemporary phenomenon which needs an immediate response.
b.
b.
c.
d.
A
a.
c,
d
Agenda for Action
a.
Qi
The state must evolves charter of citizens rights and rights ofpatients and participants of health
programmes. These should be distributed widely and people made aware of them through formal
and informal programmes. Provisions under the Right to Information Bill should be published and
utilised.
Ethics and law as they relate to medicine and health must be taught as an integral part of training
of all health care professionals at all levels.
All health professionals must be made fully aware of all the legal provisions that relate to the health
care system and be conversant with the legal framework, guidelines and implications.
Finally some form of monitoring of ethical and legal issues must be professionally determined and
organised and government should support all such endeavours in this regard. Citizens groups must
be part of this.
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REPORT OF THE TASK FORCE
7.
'ence
and
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xx i
Human Resources Development Neglected
There has been an overall neglect of planning and policy for human resource development and deployment inspite
of the training of an army of health functionaries of all types and at all levels, through a wide network of
institutions including governmental, non-governmental and private institutions.
This neglect is symbolised by
te to
oney
•
A lack of clarity of the capacities and skills required by each member of the team;
•
An inadequate estimate of the numbers required to be deployed to enhance the efficiency and effectiveness
of the system;
The absence of any clarity in policies of nurture, career development or career advancement, inability to
maintain morale and motivation of the health teams;
Is to
•
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ively
•
Little or no efforts at continuing education excepting some adhoc and sporadic efforts for the doctors,
•
Lack of clarity in promotion policies; and
•
The absence of social accountability,
level
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In recent years the commercialisation and the unplanned and unregulated growth of health human power training
institutions - medical, dental, nursing, pharmacy, other systems of medicine etc - has led to fall in standards, poor
quality of training, and infiltration of market values into these mushrooming network of institutions.
jalth
b.
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law
c.
Agenda for Action
a.
d.
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There is need to urgently develop a state policy on health human power development that is an
integrated part of a comprehensive health policy.
There should be well planned estimates of quantum or number of personnel required currently for
every category along with predictions for the next 5-10 years and the norms for recruitment and
deployment including promotion.
There should be sound programmes for nurture, career development, skill / capacity training and
continuing education for all categories at all levels. Plans for retraining may also be required.
The trend towards commercialisation and unregulated mushrooming and growth must be
countered by an imaginative HHRD policy which stresses quality over quantity; is competence
based; accountable and transparent and which develops in response to the needs and
aspirations of the people, and not the changing demands of market forces — local, national or
international.
8. Cultural Gap and Medical Pluralism
As identified in the National Health Policy of 1982 there is a major cultural gap between the aspirations and
needs of the people and the culture, personal aspirations, attitudes and work ethic of the health care system and
health professionals who work in it. This is symbolised by:
•
Continuing lack of awareness or sensitivity of the health teams to:
local health traditions and health centre;
herbal and folk medicine; and
the work of the local health practitioners and traditional birth attendants.
xxii REPORT OF THE TASK FORCE
-------------------------------- - -------- --------------------------
This is further complicated by the dominance of one system over others in our training programmes. This cultural
a renation between the health system and the people becomes an obstacle to work.
*
Lack of a positive attitude towards medical pluralism that affords to all systems and traditions both respect
and an open-minded evidence based scientific approach, promoting dialogue, debate, sharing of ideas and
resources.
Lack of fruitful dialogue between the organised systems of medicine, inspite of state support to educational
institutions and research of other systems.
Lack of a cogent, congruent state policy that considers this rich diversity
as an important resource for
health planning and is keen to evolve a framework for integration.
®
•
Agenda for Action
a.
Theje is urgent need to strengthen the functioning and development of Indian Systems of Medicine
and Homeopathy and to build up better, working linkages, with potential for dialogue between the
systems moving gradually towards a more integrated and comprehensive health policy utilising the
nubUrh
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Parti^ly primary health care and
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At the community level ther\ is urgent need to bridge this cultural gap by making health teams more
b.
sensitive to peoples needs, life situations, belief systems and aspirations and building primary
health care systems and the new public health systems with the full and enthusiastic involvement
of the members of the community as empowered participants not passive beneficiaries This
P^adiSm shift in the dialogue between professional medical culture and peoples health culture is
ur^cniiy required.
9.
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From Exclusivism to Partnership
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‘ "T1?™8 eff0rtS Of 1116 d^ate focused only on government health care. Ibis view
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swot, .nd the large mission senior in health care as well. This isolationist and oompmmenialised attitude
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Agenda for Action
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needf°r a Cofnprehensive PartnershlP Policy that must enable the health secretariat
and health directorate to continue to play the key leadership role in health care along with
proactively designing and operationalisingfunctional partnerships with all these sectors and groups.
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a.
These partnerships should be well planned, well regulated, well supported and committed to
predetermined primary health care and public health goals.
•
The policy should ensure accountability and transparency of the partners and their supportive
supervision, public health orientation and commitment to quality.
b.
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REPORT OF THE TASK FORCE
Like the government programmes these new partnerships should also move towards
community empowerment and increase the ownership and participation of the
community.
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x.xiii
10. Ignoring the Political Economy of Health
Over the last decade neo-liberal economic policies have been promoted at both international and national levels.
New international trade related agreements like WTO, TRIPS and others ate affecting the economies and
development strategies of many developing countries. Structural adjustment programmes and conditionalities
linked to international development assistance are geared towards reducing social sector spending, removal of
subsidies, greater privatisation and contracting out of services. Within the country, new economic policies that
favour globalisation, liberalisation and privatisation are also affecting the marginalised sections of society
inequitously with widening disparities between classes, between districts and within regions. All these new
economic trends adversely affect various aspects of health care delivery systems, with reduction or stagnation
of public sector and public health budgets; rise in prices of drugs and diagnostics; contraction of the public sector;
the potential impact of WTO and change in patent laws on pharmaceuticals and health care options; increasing
corruption and scams; and the impact of all these factors on public health and access by poor to health services
and medical care.
An important concern is that there seemed to be no group at the state level which was monitoring or studying
the political, economic, social, institutional dimensions of these new trends and their impact on health. This is
an urgent imperative.
Agenda for Action
a.
There is urgent need for a multidisciplinary, intersectoral resource group to study the impact of all
these new economic trends on the health of the poor and the public health and primary health care
goals of the state. This group should not only monitor these trends but also suggest counter
strategies and policy responses as well.
11. Research
Finally one of our greatest concerns was that ‘research’ of any type — basic or applied; biomedical or socioepidemiological; field research or action research and operational research was totally neglected in the health
sector. In spite of large numbers of ongoing programmes including over ten externally aided projects the focus,
the commitment, the outlay, or the importance given to research was surprisingly poor. Research seems to have
become a very neglected, under funded activity reflected in the overall poor quality, efficiency or effectivity of
health care programmes and initiatives. A radical and renewed commitment is urgently required, since it is
through ‘research’ and objective enquiry that the strengths and weaknesses of our existing system can be
identified, and only through research can evidence based solutions emerge.
Agenda for Action
There is urgent need for a multidisciplinary research programme to be initiated so that the study,
a.
monitoring, evaluation and problem solving approaches to health care development can be greatly
strengthened. This programme should be very strong on behavioural and the social sciences and
not just be biomedically oriented.
Research by the Rajiv Gandhi University, the medical and other professional colleges; the
b.
department of social work, sociology, psychology of the University and NGO’s and health policy
REPORT OF THE TASK FORCE
REi
resource groups and consumer groups and civic society should be encouraged, and supported.
Greater linkages between the health care system and these research projects would help to generate
more evidence-based support to change and improve health services.
12. Countering the Growing Apathy in the System
While all the above factors seem more tangible with definitive agendas for action, the greatest area of concern
is a growing apathy and cynicism in the health care system. Many enthusiastic members of the health team at
different levels have become more passive and even cynical, due to unfortunate experiences of corruption,
political interference, lack of accountability and transparency; routinisation of effort and loss of meaning and a
growing cynicism in the larger society. This seems to have reached very substantial proportions. The task force
process because of its interactive discussions and its wide range of dialogue has helped to address this apathy
and cynicism (which had developed over ye^rs) and may have created a short term breakthrough, by providing
a large number of people in the system with
•
•
•
a stake in a change of the system;
a hope in a more concerted effort to tackle problems;
a vision for a more people responsive health care.
5.1
Per
Per
Pen
haA
5.1
Ma
for
vec
*caf
dev
esti
the
However unless this inspirational prpeess is maintained and the process of dialogue and involvement enhanced
and sustained, all the cross cutting concerns may never get adequately addressed.
Agenda for Action
6.
a.
Therefore the most important agenda for action is the nurture and sustained support to the top
health sector leadership. Vision, capacity and enthusiasm must over ride the seniority factor or the
caste politics linkages.
Fev
sigi
the
b.
There is need to nurture visionary leadership at other levels that can improve the morale and
motivation of the health teams and move them from cynicism and apathy, to enthusiastic team
work, so as to reach primary health care, and public health goals and to meet the aspirations of the
people.
This is both a challenge and an urgent imperative.
Inter Sectoral Co-oridnation 407
REPORT OF THE TASK FORCE
>rted.
erate
icem
im at
lion,
Hid a
force
•athy
ding
5.11 Poverty and health
Poverty has been defined by UNDP as “ the denial of opportunities and choices basic to human development”.
Poverty has economic, social and political dimensions. It produces helplessness, insecurity and powerlessness.
Poverty breeds ill health and ill health leads to poverty. Any attempt at alleviation or eradication of poverty will
have its impact on health. So also, improving the health of the people is one sure way of reducing poverty.
5.12 Development and Health
Many developmental activities directly or indirectly affect health. An example would be digging canals to provide
for irrigation. The water may partly be used for drinking purposes and thus improve health. But it may also breed
vectors (like mosquitoes) and lead to vector - borne diseases (like malaria). Health Sector must develop the
-capacity to undertake studies and collect data to measure and estimate the possible health impacts of
developmental activities. The death and disease burden of development activities should be measured with an
estimation of the contribution that the social and environmental factors are making to the health problems, as also
the health opportunities presented by developmental programmes.
“ Human beings are at the centre of concerns for sustaiinable development.
They are entitled to a healthy and productive life in harmony with nature”
- U. N. Agenda 21. Programme of Action for Sustainable Development,
Rio declaration on Environment and Development, Rio de Janeiro Brazil, 1992.
iced
6.
top
the
and
tam
the
Critical pre-requisites for intersectoral action for health
Few or no mechanisms are available to enable health professionals and health policy makers to have any
significant role in the process of developmental policy making, which needs intersectoral collaboration. Among
the critical pre-requisites are:
o
conviction among health professional that a key strategy for improving health is to work together with other
sectors;
0
governments, State and local, should make health central to the development policies;
©
a general recognition by all that better health is an integral part of community development; and
9
developing the technical capacity to advise other sectors about modifications to their activities that would
improve health of the people and actively listening to suggestions of other sectors and acting upon them.
Recommendations
O
The State must establish administrative machinery and Co-ordination committees at the State,
district and local levels for intersectoral action for health. These groups must be involved in the
preparation of the State plan.
Have a High Power Core Committee (intersectoral) headed by the Chief Secretary at the state level
and committees at the district level with participation by D.Cs and C.E.Os. The Committees should
have representations from Health, Education Women and Social Welfare, Agriculture,
Horticulture, Animal Husbandry. Irrigation, Housing , Industry, Pollution Board and Environment.
Subcommittees can be formed to reflect and take action on specific matters.
All developmental programmes must have inputs from the health sector to make use of the
opportunity to improve health and prevent problems.
Health personnel (Public Health) should be trained to anticipate and find solutions to possible
health hazards of developmental programmes. They should continue their association during
implementation, monitoring and evaluation of the programme.
408 REPORT OF THE TASK FORCE
Karnataka State Health Policy
RE.
1.
LI
22. THE KARNATAKA STATE INTEGRATED HEALTH POLICY 2001
(Draft)
CONTENTS
1.
2.
3.
4.
5.
6.
7
8
Introduction
1.1
Health Gains
1.2
Health gaps
1.3
Health policy approach
Karnataka: Vision for better health and health care
Karnataka: Mission statement on health and health care
Karnataka health policy perspectives and goals
Karnataka health policy components
5.1
Scope of policy-comprehensiveness and integration
5.2
Public health approach and primary health care strategies
5.3
Equity in health and health care
5.4
Quality of care
5.5
Multisectorality and intersectoral coordination
5.6
Private, public and voluntary sector partnerships
5.7
Health Financing
!
5.8
Health Planning
5.9
Health Management and Administration
5.10
Environmental health
5.11 Nutrition
5.12 Population Stabilisation |
5.13 Education for health personnel
5.14 Rational drug policy
5.15 Medical Industry (Diagnostics, bio-medical equipment, health accessories)
5.16 Medical and health research
5.17 Indian systems of medicine and homeopathy
5.18 Health promotion
Policy components on priority health problems and issues
6.1
Communicable / infectious diseases
6.2
Women’s Health
6.3
Children’s Health
6.4
Mental Health
6.5
Prevention and control on non-communicable diseases
6.6
Disability
6.7
Occupational health and safety
6.8
Dental health / Oral health
6.9
Emergency Health Services and Trauma Care
Cross-cutting Policy
" :y Issues
7.1
Medical and Public Healt|i Ethics
72
Policy Process and Implementation factors
‘ isions
Conclusions
L2
1.3
r
olicy
REPORT OF THE TASK FORCE
Karnataka State Health Policy 409
1.
Introduction
1.1
Health gains
During the past century and particularly after Independence in 1947, several gains have been made in
health and health care in Karnataka. Life expectancy at birth (LEB) has increased from 26 years in 1947
to 66.3 years for women and 65.1 years for men in 1998. The Infant Mortality Rate (IMR) declined from
120 in 1951-60, to 81 in 1981, and further to 58/1000 live births ih the late 1990s (SRS, 1998).
Smallpox has been eradicated. The state has become free of plague and more recently of guinea worm
infection. The incidence of polio has been reduced to just 6 cases in 2000. A widespread infrastructure
of health and medical institutions has been developed through government policy measures. A large pool
of trained health personnel has also been created through support to training institutions in the public and
private sector.
1.2
Health gaps
However, gaps remain. Large rural-urban differences remain, exemplified by IMR estimates of 70 for rural
areas and 25 for urban areas (SRS, 1998). Despite overall improvements in health indicators, inter district
and regional disparities continue. The five districts of Gulbarga Division (Bidar, Koppal, Gulbarga,
Raichur, Bellary) and Bijapur & Bagalkot districts of Belgaum division continue to lag behind. Under
nutrition in under five children and anaemia in women continue to remain unacceptably high. Women’s
health, mental health and disability care are still relatively neglected. Certain preventable health problems
remain more prevalent in geographical regions or among particular population groups. Decision making
and financial powers are insufficiently decentralized or exercised, to develop swift and effective local
responses to health problems.
DI
The public lack confidence in public sector health services, particularly at primary health centres. Lack
of credibility of services, adversely affects the functioning of all programmes. Underlying reasons for
implementation gaps need to be understood and addressed.
1.3
Health policy approach
The State has so far followed policy guidelines through the framework of successive Five Year Plans
developed by the Planning Commission, decisions of the Central Council of Health and Family Welfare,
central health legislation and national health programmes developed by the Central Government.
Over time, separate policies at national level have developed for health (1983), education for health'
sciences (1989), nutrition (1993), drug policy (1988 and 1994), Medical Council of India (MCI)
guidelines (1997), blood banking (1997), the elderly (1998), and population (2000). All these have
served the State well in developing its health system, and will continue to be used as a standard for further
growth.
Health however is constitutionally a state subject. Health needs, defined socio-epidemiologically,
vary between states and even districts, requiring more specific planning. Health expenditure is met largely
by the State budget, with 82% of public sector expenditure on health from the State Government of
Karnataka and 18% from Central Government. A comprehensive Karnataka state policy for the
integrated development and functioning of the health sector is therefore being articulated explicitly,
for the first time in 2000-2001, at the turn of the millennium. The policy with a strong emphasis on
process and implementation will be an instrument for optimal, people oriented, development of health
services.
410 REPORT OF THE TASK FORCE
Karnataka State Health Policy
•
•
It will build on the existing institutional capacities of the public, voluntary and private health sectors.
It will pay particular attention to filling up gaps and will move towards greater equity in health and
health care, within a reasonable time frame.
•
It will use a public health approach focussing on determinants of health such as food and nutrition,
safe water, sanitation, housing and education.
It will expand beyond an excessive focus on curative care and further strengthen the primary health
care strategy.
•
•
•
•
It will encourage the development of Indian and other systems of medicines and healing.
It views health as the right of every citizen and will work within a framework of social justice and
decentralization as envisaged in the 73rd and 74th Constitutional Amendments.
Most importantly it is intended to be a guiding document that needs to evolve and be changed in
response to changing situations.
This policy evolution derives from intense, interactive discussions organized at all levels through the Karnataka
Task Force for Health, throughout 2000 and early 2001.
2.
The Karnataka vision statement for better health and health care
2.1. Karnataka State recognizes the immeasurable value of enhancing the health and well being of its people.
The State’s developmental efforts in the social, economic, cultural and political spheres have, as their
overarching goals, improved well being and standards of living, better health, reduced suffering and ill
health, and increased productivity of its citizens. It is recognized that health and education are central to
development. Health is a basic human right, an entitlement, and an individual and collective responsibility.
The constitutional mandate, role and responsibility of the state (government) in giving direction, in creating
a policy framework, in health care provision and related endeavours including maintenance of standards
of health care, is of critical importance in meeting these social development objectives.
The understanding of health was articulated by the World Health Organisation (WHO), 1948 as “a state
of complete physical, mental and social* well-being and not merely the absence of disease or
infirmity” creating the ability to lead a ((socially and economically productive life” (WHO 1978). This
is the ideal towards which individuals and institutions in society strive. While India and Karnataka accepted
the goal of the World Health Assembly of 1978, of Health for All by 2000, it is acknowledged that this
has not been achieved. The State will work with a sense of greater urgency and commitment to a renewed
goal of Better Health for Al|, Now, particularly for the underprivileged.
Karnataka reaffirms the relevance of the strategy of Primary Health Care, and the importance of practising
the principles of Public Health in order to reach this goal.
The state is supported in its health and health related efforts by the Constitution of India, which states in
its Directive Principles that,
aThe enjoyment of the highest attainable standard of health is one of the fundamental rights of every
human being, without distinction of race, religion, political belief economic or social condition. ”
*
Addition of the word ‘spiritual1 was suggested by India, but was not accepted by others, who argued that it wasincluded in social.
RE
Th
po
nu.
du.
gn
Th
(tE
ant
2.2
Policy
jctors.
and
rition,
lealth
e and
ed in
REPORT OF THE TASK FORCE
Karnataka State Health Policy 411
The 1983 National Health Policy recollected the aim of the Constitution of India for ,(the elimination of
poverty, ignorance and ill health”, and its direction to the State, t(to regard the raising of the level of
nutrition, the standard of living of its people and the improvement of public health as among its primary
duties, securing the health and strength of workers, men and women, especially ensuring that children are
given opportunities and facilities to develop in a healthy manner”.
The United Nations Universal Declaration of Human Rights, 1948, of which India is a signatory, states that
“Everyone has the right to a standard of living adequate for the health and well-being of himself (herself)
and his (her) family” (words in brackets have been introduced).
2.2. The State and her people are proud of the several achievements made in terms of improved health and
better access to health care. However, the State also a recognizes that some goals have not been met.
The State expresses certain current concerns and commitments.
9
ataka
It is concerned about the current inequalities and inequities in health status by region, urban / rural
location, gender, social and economic groupings.
It is also concerned that good quality health care services are unevenly distributed and are
inaccessible and unaffordable to a significant proportion of its citizens.
ople.
their
id ill
al to
•ility.
iting
Sards
state
z or
This
pted
this
wed
sing
;s in
MOS'
It is aware of the escalating prices of diagnostics, medical therapeutic technologies and pharmaceu
tical products that are occurring as a result of globalization.
©
It also recognizes the health impact and consequences of broader policies that affect employment,
income, purchasing capacity, food security, education and pollution.
The State accepts that public sector expenditure for health, while growing, does not meet
recommended norms and is inadequate to support health services to respond to basic health needs.
Out of pocket expenditure by people, largely in the private sector, while fairly substantial, has not
produced requisite health gains and also results in adverse economic consequences to families,
especially the poor. Judicious investment in health brings major gains in terms of human well being,
development and economic productivity.
It acknowledges the growing recognition, that access to comprehensive health care has a poverty
alleviating effect.
It also recognizes the urgent need to address poverty and inequality, and the social forces that
underpin them, as poverty and ill-health linkages are strong, having been adequately researched and
documented.
It is committed to pursuing social development policies and increasing intersectoral coordination to
accelerate improvement of health of all sectors of society in an equitable manner.
It recognizes the critical role of the state to initiate and steer policies;
to ensure equity and quality of care;
to promote the sustainable development of public health services;
to promote community/ peoples’ participation in the governance of health service;
to facilitate private and voluntary health sector growth as augmenting health care while
maintaining professional and ethical s:andards and keeping in mind distributive justice;
to provide adequate resources to different levels of health care and to maintain accountability
and transparency in functioning.
410 REPORT OF THE TASK FORCE
•
•
•
•
•
•
•
Karnataka State Health Policy
It will build on the existing institutional capacities of the public, voluntary and private health sectors.
It will pay particular attention to filling up gaps and will move towards greater equity in health and
health care, within a reasonable time frame.
It will use a public health approach focussing on determinants of health such as food and nutrition,
safe water, sanitation, housing and education.
It will expand beyond an excessive focus on curative care and further strengthen the primary health
care strategy.
It will encourage the 'development of Indian and other systems of medicines and healing.
It views health as the right of every citizen and will work within a framework of social justice and
decentralization as envisaged in the 73rd and 74th Constitutional Amendments.
Most importantly it is intended to be a guiding document that needs to evolve and be changed in
response to changing situations.
This policy evolution derives from intense, interactive discussions organized at all levels through the Karnataka
Task Force for Health, throughout 2000 and early 2001.
2.
The Karnataka vision statement for better health and health care
2.1. Karnataka State recognizes the immeasurable value of enhancing the health and well being of its people.
The State’s developmental efforts in the social, economic, cultural and political spheres have, as their
overarching goals, improved well being and standards of living, better health, reduced suffering and ill
health, and increased productivity of its citizens. It is recognized that health and education are central to
development. Health is a basic human right, an entitlement, and an individual and collective responsibility.
The constitutional mandate, role and responsibility of the state (government) in giving direction, in creating
a policy framework, in health care provision and related endeavours including maintenance of standards
of health care, is of critical importance in meeting these social development objectives.
The understanding of health was articulated by the World Health Organisation (WHO), 1948 as ,(a state
of complete physical, mental and social* well-being and not merely the absence of disease or
infirmity” creating the ability to lead a “socially and economically productive life” (WHO 1978). This
is the ideal towards which individuals and institutions in society strive. While India and Karnataka accepted
the goal of the World Healt^i Assembly of 1978, of Health for All by 2000, it is acknowledged that this
has not been achieved. The State will work with a sense of greater urgency and commitment to a renewed
goal of Better Health for All, Now, particularly for the underprivileged.
Karnataka reaffirms the relevance of the strategy of Primary Health Care, and the importance of practising
the principles of Public Health in order to reach this goal.
The state is supported in its health and health related efforts by the Constitution of India, which states in
its Directive Principles that,
t(The enjoyment of the highest attainable standard of health is one of the fundamental rights of every
human being, without distinction of race, religion, political belief, economic or social condition. ”
*
Addition of the word ‘spiritual’ was suggested by India, but was not accepted by others, who argued that it wasincluded in social.
RE
Th
po
nu.
du.
8^
Th
UE
aru
2.2
1___ L
Policy
xtors.
th and
rition.
lealth
e and
ed in
REPORT OF THE TASK FORCE
The 1983 National Health Policy recollected the aim of the Constitution of India for t{the elimination of
poverty, ignorance and ill health”, and its direction to the State, '"to regard the raising of the level of
nutrition, the standard of living of its people and the improvement of public health as among its primary
duties, securing the health and strength of workers, men and women, especially ensuring that children are
given opportunities and facilities to develop in a healthy manner”.
The United Nations Universal Declaration of Human Rights, 1948, of which India is a signatory, states that
“Everyone has the right to a standard of living adequate for the health and well-being of himself (herself)
and his (her) family” (words in brackets have been introduced).
2.2. The State and her people are proud of the several achievements made ih terms of improved health and
better access to health care. However, the State also a recognizes that some goals have not been met.
The State expresses certain current concerns and commitments.
•
ataka
•
ople.
their
id ill
al to
•ility.
iting
lards
state
? or
This
pted
this
wed
sing
;s in
’ery
was-
Karnataka State Health Policy 411
It is concerned about the current inequalities and inequities in health status by region, urban / rural
location, gender, social and economic groupings.
It is also concerned that good quality health care services are unevenly distributed and are
inaccessible and unaffordable to a significant proportion of its citizens.
It is aware of the escalating prices of diagnostics, medical therapeutic technologies and pharmaceu
tical products that are occurring as a result of globalization.
It also recognizes the health impact and consequences of broader policies that affect employment,
income, purchasing capacity, food security, education and pollution.
The State accepts that public sector expenditure for health, while growing, does not meet
recommended norms and is inadequate to support health services to respond to basic health needs.
Out of pocket expenditure by people, largely in the private sector, while fairly substantial, has not
produced requisite health gains and also results in adverse economic consequences to families,
especially the poor. Judicious investment in health brings major gains in terms of human well being,
development and economic productivity.
It acknowledges the growing recognition, that access to comprehensive health care has a poverty
alleviating effect.
It also recognizes the urgent need to address poverty and inequality, and the social forces that
underpin them, as poverty and ill-health linkages are strong, having been adequately researched and
documented.
It is committed to pursuing social development policies and increasing intersectoral coordination to
accelerate improvement of health of all sectors of society in an equitable manner.
It recognizes the critical role of the state to initiate and steer policies;
to ensure equity and quality of care;
to promote the sustainable development of public health services;
to promote community/ peoples’ participation in the governance of health service;
to facilitate private and voluntary health sector growth as augmenting health care while
maintaining professional and ethical s:andards and keeping in mind distributive justice;
to provide adequate resources to different levels of health care and to maintain accountability
and transparency in functioning.
412 REPORT OF THE TASK FORCE
Karnataka State Health Policy
3.
Karnataka - Mission Statement on Health and Health Care
3.1
Karnataka State, through a process of planned policies and strategies, and through ongoing reflection,
research and learning, aims to respond to the aspirations of its people for better health and for improved
access to good quality health care. It will do this by using policy mechanisms and instruments to create
and support an enabling environment for further development of the entire health sector - public, private
and voluntary. It will foster active participation of people through decentralized systems to take part in
the governance and social control of the medical and health sector.
3.2
3.3
Karnataka state has rich spiritual, philosophical and cultural traditions. In keeping with these, the
development and functioning of the health sector will be guided by values of equity, ethics, accountability,
concern and respect for all people, participatory democratic functioning and respect for local health
knowledge and culture. Principles of integration, decentralized governance, working in partnership, social
inclusiveness, community participation, empowerment and gender sensitivity will be actively promoted
through all its health sector interventions.
The Karnataka State Government will foster the further development of living and working conditions that
improve the health status of all its people, particularly of the poor and marginalised. It will work, in the
next five years, towards ensuring that all citizens have access to the basic determinants of health. These
include nutrition, housing, employment, safe water, sanitation and education, recognizing that many of
these lie outside the healtji sector. It will provide an enabling environment for the equitable growth
and development of good quality health care services in the public, private and voluntary sectors,
based on humane moral and ethical values. It will actively encourage a spirit of collaboration and
cooperation between the different sectors and also with elected bodies and citizens’ initiatives. It will
put into practice the principles of public health and the primary health care approach, including the
education of health personnel. It will govern and nurture the vast number of personnel working in its
network of health services in the Directorate of Health and Family Welfare, in urban municipal and other
bodies.
4.
Karnataka health policy perspective and goals
4.1
Building on strengths of the system evolved over the years, specific will be undertaken at various levels
and within a reasonable time frame, to further improve health status and increase people’s access to health
care, particularly for women, children, disadvantaged communities and regions, the disabled and the elderly
in Karnataka.
4.2
A comprehensive integrated approach will be used to develop the health care sector, so that it is
responsive to the health needs of the community, defined socio-epidemiologically.
4.3
There will be a strengthening of public health systems, using the primary health care approach, with an
emphasis on community participation and inter sectoral coordination. Functioning referral systems will be
built with secondary and tertiary health care services. Health management and hospital administration
will be further developed. Building institutional capacity, including leadership, professional
competence, communication skills, managerial skills and teamwork will be encouraged and fostered at all
levels.
4.4
While efforts will be made to increase financial and human resources to the health sector, from public and
private sources, issues of sustainability, cost-effectiveness, self-reliance, accountability and transparency
will receive serious consideration.
Ri
4.
4.
4.
4.
4.'
4.
In<
ob
5.
5.j
5.2
....
Policy
action,
)roved
create
)rivate
^art in
e, the
bility,
lealth
social
noted
is that
in the
Chese
ny of
owth
:tors,
i and
twill
g the
in its
?ther
REPORT OF THE TASK FORCE
4.5
Human resource development will be ongoing, through appropriately designed basic and continuing
education and accreditation systems, which will be introduced in a phased manner for all grades of health
and allied professionals. Social and community orientation will be a major focus.
4.6
Partnerships will be built with institutions and practitioners from the private and voluntary health sectors,
also ensuring maintenance of acceptable professional and ethical standards.
4.7
Health promotion and empowerment will be a thrust area with active involvement of the education sector,
media and civic society.
4.8
Indian systems of medicine, homeopathy, local health traditions, Tibetan medicine and other systems of
healing will receive greater recognition, resources and support, to contribute to overall health goals.
4.9
Decentralized planning and functioning within the health system, and decentralized governance through the
Panchayat Raj system will be developed further with professionalism, accountability and fairness.
4.10 Values of equity, gender sensitivity, accountability, transparency, fairness, self-reliance, humaneness, respect
for local health knowledge and culture and participatory democratic functioning will form the guiding
principles, with explicit efforts made towards internalizing them.
Indicators and systems for monitoring and evaluation will review and assess progress towards achieving specific
objectives that derive from the goals.
Karnataka
5.7
Scope of policy - comprehensiveness and integration
To facilitate the balanced development of health systems and services, responsive to health needs and
aspirations of people, Karnataka State considers it necessary to have a comprehensive health policy
statement in which different elements are integrated together and viewed as a whole. Various units and
sub-sectors may evolve more detailed policy guidelines. However, this comprehensive statement will allow
each one to be placed in the context of others. A comprehensive approach is important, since at the point
of delivery of services or the point of contact between the public, the patient and the provider, there is
need for horizontal integration.
The need for development of comprehensive health care was first identified by the Bhore Committee in
1946. The importance of integrated health services was reiterated by the National TB Programme in 1962.
The damage caused by vertical programmes was recognized by the Kartar Singh Committee in 1973. It
recommended integration, as did the Srivastava Committee Report in 1975. The State will undertake
measures to operationalise a comprehensive, integrated health service, with promotive, preventive, curative
and rehabilitative health care services at primary, secondary and tertiary levels, linked together with good
referral systems.
it is
and
:Mcy
Health Policy Components
5.
jvels
salth
ierly
h an
11 be
tion
□nal
it all
Karnataka State Health Policy\ 413
5.2
Public health approach and primary health care strategies
The practice of public health principles was strong in the State till the sixties. These unfortunately declined
since the seventies. The state recognizes the value of practicing public health and primary health care, for
the common good of all citizens. It has committed itself to revitalizing these aspects. While the clinical
or curative approach to health is focused on individual persons and their disease problems, public health
tries to protect, promote, restore and improve the health of all people, through collective action.
yyH REPORT OF THE TASK FORCE
Karnataka State Health Policy
REF
Programmes, services and institution^ give priority attention to disease prevention and health promotion,
responding to the health needs of the population as a whole, particularly the deprived. Public health
addresses the basic determinants of health. Epidemiology is one of the basic sciences of public health,
studying the distribution and determinants or risk factors of disease and ill health in society. Public health
interventions address communicable disease transmission and attempt to reduce risk factors for other
diseases. An evidence basec^ approach using action research and other sources will help develop and fine
tune strategies. This will be supplemented by feedback from the public, from patients and from frontline
implementers or health personnel. This will enable the development of a problem solving approach that is
locally specific.
Public health and primary health care work in synergy, particularly emphasizing principles of,
•
•
•
•
intersectoral coordination at all levels, especially at the district and below;
community participation through panchayati raj institutions and other mechanisms and fora for
involvement in decisions making concerning their own health care;
equitable distribution of good quality care; and,
use of appropriate technology for health.
The primary health care strategy does not focus only on the primary level of care but also on the secondary
and tertiary levels.
The new public health recognizes and attempts to address the socio-cultural and political economy factors
that affect health status and implementation of health programmes.
5.3
Equity in health and health care
Equity will be a key pplicy thrust, encompassing four main parameters, namely, region,
disadvantaged groups (Scheduled Castes and Tribes), gender and vulnerable groups (street children,
elderly).
a)
Region
The state is deeply concerned by recent data analyses that reveal continuing regional disparities in
health status, in distribution of primary health care facilities and in their utilization. The districts of
Bidar, Gulbarga, Raichur, Koppal, Bellary, Bijapur and Bagalkot scored the lowest on all indicators.
These districts will receive priority attention through a special package of services inclusive of
infrastructure development, additional personnel, a good management structure and special efforts
at community empowerment for health, particularly with women, through women sanghas and
NGOs.
The districts of Belgaum, Gadag and Chamarajnagar have negative indices at a lower level, while
Dharwad and Bangalore Urban lack government primary health care services. These districts also
require attention.
The districts of Kodagu, Uttar Kannada, Chikmagalur, Udupi, Dakshin Kannada, Shimoga and
Bangalore Rural have better indices regarding health determinants, health status and utilization of
health facilities. Howeyer, specific pockets and population groups within them are more disadvan
taged and vulnerable. Services Here will be maintained with a focus on vulnerable groups and taluks
or areas.
5.4
i
5.5
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Policy
REPORT OF THE TASK FORCE
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Taluk level disparities have also been identified in all divisions of the State. These will be factored
into the planning process.
b)
Disadvantaged groups
Persons from Scheduled Castes and Scheduled Tribes will receive priority attention. Besides primary
care, access to complete treatment, follow up and referrals, to secondary and tertiary care services
at very subsidised costs, will be assured. The camp approach will be replaced by ensuring good
quality care for vulnerable groups within the health care system. For indigenous people a package
with nutrition communicable disease control, care for specific diseases such as sickle cell anaemia
and special norms for health services will be implemented.
c)
Gender
The poor status of women’s health, the declining gender ratio and poor coverage and quality of
mother and child health services are areas of concern. Measures to improve women’s health status
and access to care will be implemented and closely monitored. Efforts will be made to increase the
number of women doctors, senior health assistants (LHVs and ANMs) by providing adequate
residential facilities and personal security. This will be done, particularly at Primary Health Centres
and Community Health Centres. The districts with poor health indicators currently, namely Bidar,
Koppal, Gulbarga, Raichur, Bellary, Bijapur and Bagalkot will deceive high priority. Quality of
maternal health services will improve, in particular emergency obstetric care. Widely prevalent
conditions affecting women, such as anaemia, low backache, cancer of the cervix, uterine prolapse
and osteoporosis will be addressed. Services for psychosocial problems and emotional distress will
be developed. Empowerment of women for health will be encouraged and supported. Programmes
for the special needs of adolescent girls and boys will be developed in collaboration with the
department of education.
d)
Vulnerable groups
Innovative, flexible and collaborative approaches for meeting the health needs of street children, out
of school and working children, persons with disability and the elderly, will be used.
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5.4
Quality of care
Having developed an extensive statewide health care infrastructure over the past five decades, an
important policy thrust area in the next phase will be improvement in quality of care and patient satisfaction.
Standards of care for different levels of health institutions will be developed. Mechanisms will be
established to assure good quality medical and public health care in public institutions and to facilitate
and ensure similar standards in the private and voluntary sector. Mechanisms may include accreditation,
repeat registration, legal measures, mandatory continuing education for all health care personnel,
patients charters and grievance redressal systems. Provisions of good care to patients will be the primary
concern.
5.5
Multisectorality and intersectoral coordination
Intersectoral coordination has been inadequate even though its importance was recognized since the late
1970’s. Working links, joint programmes and regular communication will be institutionalised between the
Directorate of Health and Family Welfare and the Departments of Women and Child Development,
Education, Rural Development and Panchayati Raj, and the Public Distribution System in particular. Links
with the Water Supply and Sewarage Boards, Pollution Control Boards will be developed with clarity
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Karnataka State Health Policy 415
OF THE TASK FORCE
..3 REPORT
----------------------------------- ------------------------------1—--------------------------- -
Karnataka State Health Policy
REPO
regarding the roles of each department and areas of shared responsibility. Functional mechanisms at
village/ward level, taluk, district and state will be developed.
5.6
Public, private and voluntary sector partnerships
Though already existing in an adhoc and often informal manner, public private and voluntary partnerships
will be further developed in a planned, systematic manner in order to develop in spirit and practice a
collective, community ownership for better health care and also for optimal utilization of health resources.
District and Taluk health action networks and issue based networks will be encouraged with active
participation from the public sector in such voluntary sector initiatives.
5.7
Health Financing
Greater attention will be paid to equitable health financing systems in view of the rising costs of medical
care and the large out of pocket payments that often have adverse consequences on the poor. Social
insurance schemes, prepayment schemes, selection of cost effective strategies including use of generic
drugs and central purchasing will all be tried out.
State government spending on health will be brought up to acceptable norms, as investments in the social
sector are recognized to produce gains in human development. The present allocation is not adequate to
meet the needs; it is also much less than what has been suggested by various organisations, including the
World Health Organisation. The allocation much be increased in a phased manner. Equitable proportions
of spending will be in the primary, secondary and tertiary levels and between rural and urban areas.
Resource flows will help increase access to quahty health care in rural areas. Allocation and spending on
health promotion will be enhanced. The indigenous systems of medicine and homeopathy will receive a
higher share of resources.
5.9
A system for state health accounts with necessary data bases will be developed to monitor health revenue
and expenditure, including those from externally assisted projects and centrally sponsored schemes.
District wise health expenditures will be analyzed, reported in annual reports and made available to people
on request. A larger proportion of funds will be allocated to the Panchayati Raj Institutions, including some
untied funds to enable district authorities to respond to local needs. Districts with a lower ranking on
the Human Development Index need more funds for health, but may also a lower capacity to utilize it.
Besides increased resource flows, financial management and administrative capacity will also need to
be strengthened in these districts. Systems of transparency and accountability will be established.
Pilot studies will be undertaken and encouraged to experiment with innovative health financing schemes
such as community financing and social insurance, with particular focus on the rural and urban poor.
Since the Government of India has opened up the health insurance sector to private and foreign investment,
the state government will introduce mechanisms to ensure that they operate in an equitable manner seeing
that the interests of consumers/ patients, particularly the underprivileged are protected. Regulation of health
insurance through appropriate authorities will be undertaken. Public sector insurance companies will be
promoted.
5.8
Health Planning
Health planning will be undertaken at state level more and more, keeping in view national policy and
programme guidelines. The state will institutionalize a strategic planning monitoring and review unit, into the
Directorate/ Secretariat. The unit will use an evidence base whenever necessary and possible.
5.1C
Policy
REPORT OF THE TASK FORCE
sms at
Epidemiological units will be developed alongside the surveillance units, at district level and state level.
Descriptive and analytical work will be undertaken, by the epidemiological units, in priority diseases and
health problems. They will help to improve the quality of data collected through the surveillance systems
and HMIS.
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The Strategic Planning Cell (SPC) will have a multidisciplinary team including economists, sociologists and
anthropologists. Studies will be undertaken by them and also contracted out to other institutions, including
educational institutions. The SPC will need to be supported by adequate facilities, such as computers,
library and online information systems. Over time, a medical and health research body or council will be
established at the State level with links with the State Institute of Health and Family Welfare and the Rajiv
Gandhi University of Health Sciences. The council would undertake relevant research to support decision
making and planning by the Health Directorate. This will make planning more systematic, rational and
responsive to local needs and situations.
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Karnataka State Health Policy 417
Health financing and health personnel planning will be a critical and ongoing part of the state health
planning.
5.9
Health Management and Administration
Through a process of recruitment of trained personnel and in service training, skills in health management
and administration will be strengthened. Two streams of the health cadre are being envisaged for medical
care and public health respectively. The public health stream of the health cadre will have programme
management and implementation skills. In the medical care stream, hospital administration, especially for
hospitals above 50 beds, will be professionalised.
The Health Management Information System will be an important means for decision making and for
introducing correctives at institutional and higher levels.
Issues such as leadership, governance, strengthening institutional capacity, developing efficient communi
cation systems, within and between tiers and levels, will receive priority attention, with the help of experts
and institutions such as the Indian Institute of Management.
Sections for engineering, construction and infrastructure maintenance; equipment procurement and main
tenance; drug procurement and transport, will be strengthened in-house and developed further into
specialized units. These are critical support areas for health systems to function optimally.
The newly introduced systems, under the Karnataka Health Systems Development Project (KHSDP), for
contracting out non-clinical services such as cleaning, laundry, security, dietary department etc., will be
reviewed and the positive aspects internalized. Minimum wages and working conditions of staff under
these systems will be ensured.
5.10 Environmental Health
Environmental health is an important issue of concern with increasing pollution of air, water and soil due
to rapid and sometimes unplanned industrialization, inadequate compliance with pollution control regula
tions, poor monitoring and control systems. Motor vehicle fumes also add to the toxic chemicals in the
air. Excessive use of chemical pesticides including those, which are banned, are causing pollution of the
food chain. The State will introduce measures to control exposure to these sources of pollution in order
to protect its citizens from these health hazards. Environmental and health impact assessment studies will
be undertaken around industrial and power plants, dams, mines etc. and clearances will be required before
new plants are commissioned.
418 | REPORT OF THE TASK FORCE______________________________ _ _______________ Karnataka State Health Policy
The health sector will also take responsibility to ensure the improvement of drainage and sullage systems
and solid waste management in keeping with the guidelines of the committee set up by the Supreme Court
of India.
The government will ensure water quality through a monitoring and surveillance system according to
accepted norms and standards.
Health education and health promotion activities will promote personal hygienic practices and methods to
safeguard against environmental health hazards.
5.11 Nutrition
The magnitude of undemutrition and deficiencies in Karnataka revealed by recent data, place nutrition as
a major public health problem in the state.
The state policy reflects the National Nutrition Policy (NNP) adopted by the Govt, of India in 1993 and
the National Plan of Actiop in Nutrition (NPAN) developed in 1995 by the National Standing Committee
on Nutrition.
The goals to be achieved by 2007 are:
(a) Reduction of under nutrition (Gomez classification) among pre-school children as follows - severe
undemutrition to 3% frojn 6.2% (1996); moderate undernutrition to 30% from 45.4% (1996). (b)
Reduction in anemia among women from 42% (1998) to 30%. (c) Reduction in anemia among children
from 66% (1998) to 50%. (d) Reduction in new boms with low birth weight from 35% (1994) to 10%.
(e) Elimination of blindness due to Vit. A deficiency and elimination of iodine deficiency in goiter prevalent
districts, (f) Promotion of balanced, low cost diets using locally available foods for different age groups
including children, adolescents, pregnant and lactating mothers and the elderly, (g) Improving household
food security through poverty alleviation programme.
The short-term interventions envisage district wise goals and targets will be developed, nutrition
interventions for vulnerable groups, particularly:
(a) Focussing on under-twqs with supplementary foods, (b) Expanding the nutrition intervention net (ICDS,
UIP, ORT)* with wider coverage, regularity and better quality, with special attention to girls and
underprivileged social groups, (c) Empowering mothers and families with nutrition and health education,
with emphasis on caring for children and on low cost, locally available nutritious foods, (d) Control of iron
deficiency anemia, Vit. A deficiency and iodine deficiency.
To achieve the above, the state will enhance its investment in nutrition interventions, will fill up vacancies
and ensure full capacity of staff, strengthen supportive supervision and improve/ develop nutrition
monitoring systems.
The indirect, long term institutional and structural changes, as also recommended by the National
Nutrition Policy, 1993, are:
(a) improved food security; (b) increased production of nutritionally rich foods such as pulses, oilseeds
and ragi, and protective foods such as vegetables, fruits, milk, poultry, fish and meat; (c) improved
*
Integrated Child Development Services (1CDS), Universal Immunization Programme (UIP), Oral Rehydration
Therapy (ORT).
REPORT OF THE TASK FORCE
Karnataka State Health Policy 419
purchasing power by active implementation of poverty alleviation programmes; (d) strengthening the public
distribution system; (e) preventing food adulteration; (f) improving the status of women; (g) ensuring
community participation.
5.12 Population Stabilization
Population stabilization through fertility decline has long been a goal of the state government, in
consonance with national priorities. It is widely recognised that the public sector in particular has
generated awareness, demand for services and has also provided widespread access to contraceptive and
family welfare services, especially terminal methods, and to health care. There have been resultant gains
with declines in birth rates from 41.6 (1951-60) to 22.1 (1998-99), dekth rates from 22.2 (1951-50) to
7.9 (1998-99), and growth rates from 2.2 (1951) to 1.8 (2000 estimate). The Total Fertility Rate
(TFR) is 2.13 and the effective Couple Protection Rate (CPR) is 60%. Thus the State is fairly near
to reaching replacement levels of fertility. Data indicates declines in growth rates, particularly after
1981 in all districts except Gulbarga division (with slower or stagnant declines). This momentum of
decline is likely to continue. Expert analysis suggests that improvement in social development,
quality of life and gender development will hasten the process of demographic transition. This
will be an important component of the state strategy, with emphasis on districts in greater
need.
Drawing from the guidelines of the Rational Population Policy 2000 the State will follow certain basic
principles.
It will promote the spirit of voluntarism and will protect human rights. It will not adopt coercive
strategies in any form.
It will provide good quality contraceptive services, integrated with primary health care throughout the
state. Reproductive technologies that are safe and effective will be used. Quality of care will be
further improved with screening, follow-up services, managing and minimizing side effects. Spacing
methods will be made more available and more popularized. Male methods will be increasingly
used, reducing the burden from women only.
The government is committed to providing for informed choices and to seeking the consent of
citizens.
Responding to the specific situation in Karnataka the State will develop a special package for
districts with greatest unmet need in terms of health and family welfare services. It will endeavor
to increase the utilisation of these services by making them user friendly, being particularly sensitive
to the special needs of women.
The objectives of the state in terms of population stabilization are:
9
To provide good quality family welfare services integrated with general health care services to all sections
of the population, particularly in areas of greater need, though strengthened health care infrastructure and
health personnel and by developing partnerships and coordination within and between government
departments, with industries, the private sector and voluntary sector.
•
To bring the Total Fertility Rate to replacement levels in all districts at the earliest, by 2005.
•
To achieve a stable population by 2030.
420 REPORT OF THE TASK FORCE
Karnataka State Health Policy
Strategies and Steps to be taken will include:
•
Setting up a State Commission for Population and Social Development.
•
Making all efforts to ensure adequate,facilities for good quality mother and child health care.
•
The State will attempt to develop a good civil registration system, working towards 100% registration of
births, deaths and marriages. It will pilot this in a few districts and then expand. This will help provide
accurate information regarding population dynamics.
•
The State is concerned about increasing son preference that is adversely altering the gender ratio. It will
implement legal measures such as The Prenatal Diagnostic Techniques (Regulation and Prevention of
Misuse) Act 1994 to prevent female foeticide. It will also strengthen norms about the intrinsic value of
girl children.
•
Introducing life-skill and population education for adolescent girls and boys, using methods that capture
their interest and responding to their needs.
Promoting delayed marriages for girls in particular and boys, delaying of the first pregnancy and spacing
of the second child.
The equitable and sustainable social development dimensions of a people centered population policy,
including the education for all children; enhancing programme, implementation for basic amenities (and
rights) such as safe water supply, sanitation and health care; increasing employment; and empowerment of
women. Given the broad scope of interventions, implementation of the Population Policy would not be
the sole responsibility of the Department of Health and Family Welfare, but will involve considerable
intersectoral coordination for which working mechanisms will be established.
•
•
5.13 Education for Health Personnel
Learning and education in Indian tradition are accorded an almost sacred place and role. Karnataka has
many achievements in the realm of education for health personnel, including medical and all allied health
professionals. Institutions of high quality have developed. The private sector has been encouraged and
a vast network of educational institutions has been established. The relatively new Rajiv Gandhi University
for Health Sciences is workjng towards ensuring better academic and professional standards and norms.
Institutes and systems for education, training and continuing education play a critical role in the formation of
medical and allied professionals, and ip the maintenance ofthis human resource as a well-informed, up to date
and motivated force. This is particularly important in a profession on whose decision-making abilities and
practices depend the life, health and well being of people. The regulation of the profession including of its
educational systems and institutions and the role of the state therefore are issues of great importance.
A situation analysis reveals many ills in the health personnel educational system and institutions and in
professional practice and conduct. These include a rapid expansion in quantity, namely numbers of
educational institutions and seats, at the expense of quality. There is an overproduction and supply
particularly of medical graduates. In post-graduation, there is a mismatch between the specialties, with
certain specialties remaining underrepresented. Growing commercialisation and corruption in student
selection, during examinations, and ip the professional practices of teachers, cause double standards, with
dilution of professional standards and ethics. Student and patient interests are compromised with
inadequate numbers of teaching staff, inadequate and poor quality infrastructure and equipment. Profes
sional councils are often not playing strong roles to regulate their respective disciplines.
REPORT OF THE TASK FORCE
Karnataka State Health Policy 421
Keeping these and other factors in view, the health policy has evolved certain principles and strategies
for education for health personnel.
The focus will not be only on medical education of doctors but on all allied health professionals and
on Indian Systems of Medicine and Homeopathy. The functioning of a variety of health professionals
in teams makes for better health care services to respond to people’s needs. Conducting team
training will be encouraged.
9
Norms regarding number of institutions and number of seats will be respected. Issuing of essentiality
certificates and University affiliation for new medical, dental, nursing, pharmacy and physiotherapy
colleges will be stopped for the next 3 years, with an exception for nursing colleges in the under
served areas of Karnataka. The distribution of institutions will receive greater attention. The number
of students per college will be stipulated (e.g. maximum of 100 per batch in a medical college) in
order to maintain quality.
Similarly the moratorium on new Ayurvedic, Homeopathic and Unani Colleges will continue for two
more years.
9
Efforts will be made to improve the infrastructure and functioning of existing colleges (all systems,
all levels) bringing them up to acceptable norms laid down by professional councils. The State will
in particular initiate measures in this regard for govemmeht teaching institutions and hospitals. It will
allocate resources for repair, maintenance and where justified extensions of buildings. Similarly
systems for regular equipment repairs, and maintenance will be established. Staffing will be
according to norms in the teaching and non-teaching category. Essential Services will be maintained
round the clock especially emergency services, casualty, accidents, bums, X-ray, laboratory, blood
bank etc. Uninterrupted supply of drugs required for such institutions will be made available.
A study of financial and other resource requirements for these institutions will be made, with various
options for raising of resources and for ensuring sustainability of these institutions.
Closer working links will be encouraged between the University, educational institutions and health
services for mutual advantage and development. Health Service professionals can undertake some
teaching responsibilities, while a part of the teaching of undergraduates and postgraduates could be
based in district and taluk hospitals, with postings to CHC and PHC’s as well. Teaching staff also
will be exposed to the reality of situations in such institutions so their teaching and research could
be relevant. Teaching institutions, will work in collaboration with the Department of Health and
Family Welfare in service provision in a specified number of PHC’s / CHC’s / Wards etc.
Improvements will be made in the pedagogy of health science institutions. The University and Para
-Medical Board will organise Teacher Training Programmes on Teaching Methodology for health
sciences suited to adult learners. It will be mandatory for teachers to undertake these courses.
Learner centred, problem-solving approaches will be used, moving away from the banking system
of education. Each institution will be encouraged to initiate and run educational units with the specific
objective to improve teaching capacity. Systematic feedback from students'will help to modify
training programmes. Performance appraisal of teaching faculty will help to further develop their
competence.
State Councils, such as the Karnataka Medical Council, Dental Council, Nursing Council, Pharmacy
Council etc., need to be strengthened and professionalised. They should also to provide for
^22 REPORT OF THE TASK FORCE
r
Karnataka State Health Policy
community representation through consumer groups, NGOs and then professionals being nominated
or co-opted in order to reflect social and community concerns. The Councils could develop a good
information and knowledge base and also a database regarding their membership.
A Commission at State level will bring together representatives from different councils, including
Indian Systems of Medicine and Homeopathy along with government policy makers and University
/ board representatives to address issues raised by the National Education Policy for Health
Sciences. The Commission will need to be alert to trends in the sector including negative trends
mentioned earlier and make suggestions for regulations and correctives.
•
The State Institute of Health and Family Welfare will be developed into a high quality centre for
training and continuing education, especially in the fields of public health, management and ethics,
linked with the Rajiv Gandhi University of Health Sciences. It will provide orientation and in-service
training to personnel from the department of health. It will be linked with the district and
health worker training centres. Its infrastructure will be upgraded especially, library, teaching
halls with audiovisual equipment and computer facilities, as also personnel. It could offer certificate
and diploma courses. It will be encouraged to develop links with other educational and
specialized institutions, including the Indira Gandhi Open University. It will also undertake research
studies
|
5.14 Rational Drug Policy
The government is aware of the advances and developments made by the pharmaceutical industry in the
country and in the state, with good technological and production capacity, high turnovers and exports.
However it is concerned that essential drugs of good quality are not available in adequate quantities to
many, particularly in rural parts of the State. The rising cost of drugs especially in recent years, and
adulterated substandard drugs are also areas of concern.
The State has developed a public sector pharmaceutical concern, the Karnataka Antibiotics and
Pharmaceuticals Ltd (KAPL), which has been functioning well and at a profit over the years. There are
also several small scale producers and larger Indian companies, besides foreign and multinational
companies in the state. The public sector, organised Indian private sector and small scale sector are the
major producers of bulk drugs, while the others operate in formulations and in production of inessential
drugs which are more lucrative.
There are over 60,000 formulations of medicinal drugs in the market. The essential drug list of the World
Health Organisation (WHO) has listed about 300 drugs necessary for secondary care, while only about
25 - 30 drugs are required for primary care. However these drugs, are produced much below
requirements estimated according to epidemiological need and also below licensed capacities, resulting in
shortages. These are drugs required for common diseases such as tuberculosis, worms, filaria, typhoid,
anaemia etc. On the other hand there is abundant production of vitamins, tonics, health drinks, cough and
cold preparations, over the counter preparations (OTCs), tranquilizers, antacids etc. The production and
sale of irrational and hazardous drugs is another area of concern.
The State recognizes its responsibility as to ensure that all people are able to obtain the drugs they need
or required at a price that they and the state can afford; that these drugs are safe, effective and of good
quality. It will implement this responsibility through various measures, including better drug selection,
pooled procurement, quality assurance, management and transparency in procedures, using resources in
REPORT OF THE TASK FORCE
Karnataka State Health Policy 423
a socially productive way, and encouraging participation and discussion from the public and professionals
in this vital area concerning lives and health of citizens.
The Government supports the concept of essentiality based on criteria of therapeutic need, efficacy,
safety and value for money. Essential drugs only are selected for the Rate Contract lists. Essential
drug lists for different levels of institutions will be adopted.
Spreading of information concerning essentiality and essential drug lists to medical professionals,
pharmacists and to citizens will be promoted in consumer and patient interests. The patients / citizens
right to information will be protected by making available information about harmful, hazardous,
irrational and essential drugs.
o
The government supports the system of monitoring Adverse Drug Reactions (ADR) already
initiated by the Karnataka State Pharmacy Council. It will increasingly get all its institutions
linked to the system. Early detection of ADRs will allow for corrective actions to be
initiated.
The state through its technical bodies will keep abreast of latest developments regarding drugs and
therapeutics and will initiate suitable action to withdraw hazardous drugs from the market in
consumer interest e.g. baralgan (a hazardous antispasmodic), novalgin (a hazardous analgesic),
enteroquinol (a hazardous antidiarrhoeal). Outside experts, the pharmacy council and consumer
- activists will be inducted into technical bodies. The names and lists of banned drugs and their
formulations and trade names will be widely publicized.
©
!
Drug package labeling and package inserts will be made to carry unbiased drug information and
cautions to consumers of warnings for drugs not to be taken during pregnancy, drugs not
recommended for the elderly, for children, for people with liver or kidney impairment etc. This
should be made available in Kannada also and in print large enough to read. The state recognizes
its responsibility in protecting the health of its citizens against iatrogenic problems, since health is of
higher value than profits to companies.
In this it will also endeavor to enhance the knowledge of medical and allied professionals through
professional and other bodies. The ethical and legal aspects of the need for rational therapeutics
will also be highlighted.
e
It will strengthen the Drug Control System by providing for adequate staff with the required
qualifications. It will introduce inspection of good manufacturing practices as recommended by
WHO. Systems will be established wherein prescribers can send drugs they suspect to be
substandard for testing. Random samples of drugs will be sent for testing in recognised laboratories
in the state and in different parts of the country.
e
Key staff and doctors will be trained in rational drug policy issues and in how to identify and solve
problems relating to drug prescription, dispensing and consumption. Newsletters and updates on
drug categories, cautions, contradictions, side effects, dosage for different age groups etc., will be
made available to improve quality of service to consumers.
I
Monitoring and studies of prescription practices, pharmacy practices etc. will be encouraged to
provide regular feedback for continuous improvement in the area of rational therapeutics
I
I
424 REPORT OF THE TASK FORCE
Karnataka State Health Policy
•
Rational drug policies for the Indian Systems of Medicine and Homeopathy will also be introduced
following discussions with their Councils and experts.
•
Measures to increase effectiveness of drug procurement, warehousing and distribution are also being
undertaken.
•
Expert groups will look at drug pricing issues and issues relating to access to drug for persons with
HIV / AIDS with psychiatric illnesses and other diseases requiring new drugs which fall under the
new patent laws and are therefore out of the reach of the majority of people.
The State will stjudy the impact of the new patent regime on the pricing, production patterns and
availability of pharmaceuticals. Necessary measures will be taken to protect the interests of patients
and consumers. 1
•
•
The State will support strategies in collaboration with professional and consumer bodies to ensure
safe drugs and rational drug use for people. It will be alert to implementation of drug policies,
including bans. Problem drugs or unsafe drugs will not be allowed to be marketed or used e.g.
pediatric preparations of loperamide or diphenoxylate, unnecessary combinations of antibiotics with
antidiarrhoeals, analgesics, irrational over use of second line antimalarials (mefloquin) and antitubercular drugs, growth stimulants, harmful contraceptives, hormone replacement therapies and psycho
tropics.
A State drug formulary and therapeutic guidelines will be developed, adopted and regularly updated.
Use of generic prescribing will be promoted.
•
The Directorate of Health and Family Welfare will take responsibility for the drug policy and will not
leave it only to the Departments of Petrochemicals or Industry. Forums for intersectoral working
will be made functional.
•
Pharmaceutical Companies will need to follow nationally and internationally accepted codes of
marketing practices, registration and re-registration of drugs for production will also have to follow
acceptable norms especially with regard to advertisements, sponsorship, indirect promotional
methods, and availability of unbiased information.
•
Drug donation guidelines will be developed and implemented.
•
fforts will be continued to attain and retain self-reliance in the production of all essential drugs
and vaccines. The economy of scale will help these to be available at low cost. Modernization and
upgradation of public sector facilities including infrastructure and personnel will be undertaken
so that they can contribute to contain drug and vaccine prices and to maintain gold
standards.
5.15 Medical Industry (diagnostics, biomedical equipment, health accessories)
The production, procurement and marketing systems for diagnostics, medical equipment, health accesso
ries and educational material will be regulated, keeping in mind need, quality, cost effectiveness, safety and
ultimately patient and consumer interests.
There is need for a body to lay down standards and for production to be brought within the purview of
a legally binding act. Necessary action will be taken in order to safeguard consumer interest.
REPORT OF THE TASK FORCE
©
©
©
6.3
Karnataka State Health Policy I42?
Gender and age disaggregated data to improve the database and analysis of problems,
and the impact of interventions. Qualitative and quantitative indicators will be developed and
used.
Special attention will be given to developing counselling and mental health services for women at
district and taluk level with trained professionals and by short term training of health workers at
primary care levels to respond to needs at community level.
Facilities for diagnosis and treatment of STDs and RTIs will be made available at the primary care
level supported by a referral system.
Education regarding reproductive health will be given higher priority.
Children^ Health
Karnataka State has a special interest in and commitment to the health and well being of children during
their intrauterine period, infancy, toddler years, school age and adolescence. Its interventions reach out
through MCH programmes, through anganwadis of the ICDS scheme through schools and colleges. A
policy document, “The State Programme of Action for the Child” brought out in 1994, reiterated the
state’s commitments, in keeping with the spirit of the National Policy for Children in 1974, the World
Summit for Children in 1990, the four sets of Rights of Children (to survival, protection, development and
participation), and the National Plan of Action: A commitment to the Child, adopted in 1992. The State
will be guided by the principle underlying the national plan, namely “first call for children”, wherein the
essential needs of children will be given highest priority in allocation of resources at all times. This will
also be applied specifically to the spheres of health and nutrition, as recent data reveal unacceptably
widespread high levels of undernutrition and anaemia in Karnataka, which leads to illhealth and stunted
growth and development. Specific efforts will be made to reach children, especially from socially deprived
groups, who are still unreached by the IDCS system and who are out of school. A multisectoral approach
will be used to provide services for working and street children, and to address underlying issues that result
in their having to work.
The state will undertake all efforts to ensure child survival with no damage to the processes of
growth, maturation and development. Continuing efforts will be made to reduce infant and neonatal
mortality.
The coverage and quality of services of the Integrated Child Development Services (ICDS) with
regard to health, nutrition and care will be improved by providing adequate resources and training
of all levels of personnel. Supervisory and monitoring systems will be strengthened. Recognizing
the importance of the child care, responsibilities of anganwadi workers, who are volunteers on an
honorarium, caution will be exercised in adding additional responsibilities that may be detrimental to
their prime responsibility. Constructive partnerships with gram panchayats and parents will be
developed and linkages with Primary Health Centre staff will be made more functional and regular.
Quality of food given to children will be ensured and health promotion and nutrition education will
be undertaken more proactively and professionally. The most needy children, including scheduled
castes and scheduled tribes, will receive particular attention. Disaggregated data by age, sex, taluk,
and social grouping will be regularly validated and analysed.
School health programmes will be developed, being initiated by the public sector in partnership
with parents, voluntary organisations and the private sector. The goal is that a health promoting
school will provide a healthy environment, health and nutrition education, school health services,
430 REPORT OF THE TASK FORCE
Karnataka State Health Policy
physical education and recreation/ extra - curricular activities. Through health promotion, preventive
health, screening and early detection it helps prevent disease and disability.
School age children account for about 25% of the population. The school health programme will
help attain their full potential in physical, psychosocial, emotional and intellectual growth and
development. The two-fold purpose is improvement of health and health promotion. Key strategic
interventions include training of over 3.15 lakh teachers in the 58,000 schools through a training of
trainers; school curriculum review of health related topics; health promotion using activity based
learning principles; a focus on life skill education to prepare children for life; ensuring universal
coverage with good quality school health services including follow up treatment.
Schools will b? seen as community institutions and will be centres from where out of school
children will also be reached.
•
6.4
The adolescent age group has been relatively neglected and currently faces greater risk
during this phase of rapid social transition. Adolescent care and educational programmes will
be designed and implemented with sensitivity. These will include family life education, life skill
education, basic understanding of sexuality, interpersonal relationships, conflict resolution, coping
capacities for dealing with stresses of increasing responsibilities and expectations from others.
Mental Health
The burden of suffering due to mental illness is large. Research work done over the years by premier
institutions have helped to quantify this in Karnataka. At least 2% of the population suffer from severe
mental morbidity at any point of time and an additional 10% suffer from neurotic conditions, alcohol and
drug addictions and personality problems. A large proportion of outpatients (20-25%) in general health
services have somatoform disorders and come with multiple vague symptoms. Unsupported and untreated
mental illness has an impact on families as well. Mental ill health is thus an issue of public health
importance, requiring proactive, sensitive interventions, particularly since more effective and better
management is now a reality.
However, there continue to be shortages of trained personnel in Karnataka, compounded by maldistribution
of facilities and staff with a greater urban concentration in big cities.
The state will make systematic and sustained efforts to enhance mental health services by:
•
Improving training in psychiatry and psychology in the undergraduate medical and general nursing
courses.
•
Introducing district men: al health programmes in a phased manner by strengthening psychiatric teams
and services at district ■ ispital level and planning for counselling services at taluk hospital level.
•
Ensuring minimum stai dards of care for mentally ill patients.
•
Providing for mental I icalth care at primary care level by training primary health centre medical
officers and staff, using manuals already prepared by NIMHANS.
•
Encouraging and making provision for care facilities for persons with chronic mental illness, through
NGOs and other organizations.
•
Introducing the mental health component into school health services on a pilot basis in different
districts and later expanding it.
olicy
REPORT OF THE TASK FORCE
Supporting broader societal strategies that address violence, particularly against women; discrimina
tion in any form; substance abuse; poverty and destitution.
Establishing institutional mechanisms at the State level through which mental health care services can
be promoted.
Caring for and nurturing health care personnel, who are carers working under difficult
conditions.
o
itive
©
will
and
egic
ig of
ased
jrsal
1001
risk
will
skill
Ping
6.5
Karnataka State Health Policy 431
Prevention and control of non-communicable diseases
Karnataka and India, along with other developing countries, carry a double burden of communicable and
non-communicable diseases. The latter include, in particular cardiovascular diseases, including hyperten
sion cancers and diabetes. These have on the whole received less public sector and policy attention due
to the magnitude of other problems and issues. However with a future perspective, especially considering
rising life expectancies, growing urbanisation and industrialisation in the state, and rapidly changing i e
styles including diets, the state will provide greater support to the prevention and control of noncommunicable diseases.
It will use a public health approach by adopting strategies to reduce the risk factors for these
diseases and by using health education to promote healthier life styles.
It will initiate policies to stem the rapid increase in production, advertisement, aggressive marketing
and use of Tobacco and Alcohol products. Over 25 serious diseases are associated with the use
of tobacco and several diseases and social problems are linked to alcohol. These are described as
communicated diseases. They are both addictive substances and once hooked, their manufacturers
are assured of consumers for life, event though for shortened lives. Policies required for their control
are broad and include bans on sponsorship of sports and entertainment; bans on direct and indirect
advertising; higher taxation; sales to be permitted to only over-18s; sales barred within certain
distances from educational institutions; and public education, especially among children and youth as
part of life skills education; education of health personnel.
©
nier
vere
and
:alth
ated
alth
itter
In the case of tobacco, measures include banning smoking in public places to prevent passive
smoking and working towards alternative crops and alternative employment. Chewed tobacco in
particular is a growing problem with widespread use among women (40-60% in different groups)
and even among children as its addictive nature is not widely known. Comprehensive Tobacco
Control includes smoked and chewed tobacco.
tion
sing
In the case of alcohol there is a need for strategies to help women and children cope with men who
drink heavily. De-addiction strategies using group therapy such as alcoholic anonymous groups will
need to be supported, besides individual therapy and counselling.
ams
el.
Education regarding tobacco and alcohol will be included in school and college curricula.
ical
»
ugh
•
rent
Diagnosis and treatment for non-communicable diseases will be made available at primary health
care°level. This will require preparation of treatment guidelines and supply of diagnostic equipment
and drugs.
Recording and reporting of non-communicable diseases as per the International Classification of
Diseases will be introduced into the diseases surveillance system.
432 REPORT OF THE TASK FORCE
•
Karnataka State Health Policy
The cancer control programme will also be strengthened by tobacco control, health education,
early detection and provision of treatment. Facilities will be made available at regional level and later
in a phased manner in some districts where medical colleges exist. Grants provided by the national
programme will be fully utilised.
6.6 Disability
It is estimated that about 2-3% of the total population of Karnataka consists of disabled people with 76%
in rural areas and 58% men.' Disabilities include locomotor, visual and learning disabilities, hearing and
speech impairment, mental illness, mental retardation, multiple disabilities, etc.
An inclusive approach will be used for persons who are differently challenged or persons with disability,
with their full participation in decision making and implementation.
The Department of Health and Family Welfare will increase its role and responsibility in respect to
disability, which has been largely under the Directorate of Welfare of the Disabled, under the Department
of Women and Child Development.
The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation) Act of 1995
will be made more widely known and implemented. Interventions will need to include medical, social and
environmental components. The different steps would be:
•
Disability prevention — through universal immunization, good nutrition, MCH, accident prevention
through drink and not drive policies, helmets for two wheelers and car-seat belts etc.
•
Disability limitation - through prompt treatment, particularly at primary care levels.
•
Reducing the transition from disability to handicap - by rehabilitation. Establishing rehabilitation units
at district hospitals.
•
Actively supporting Community Based Rehabilitation.
•
Providing access to aids and appliances to those who cannot afford them.
•
Using apex and specialized institutions in the state for training of levels of health workers.
•
As per the Medical Council of India recommendations, starting Physical Medicine and Rehabilitation
departments in every medical college.
6.7
Occupational Health and Safety
Though services exist in some large public sector and private sector units, this specialty needs greater
support. The focus will be on the agricultural and unorganised sectors who comprise the largest proportion
of die work force and who are at risk because few safety devices and precautions are used. The services
of institutions like the Regional Occupational Health Centre and experts will be utilised to evolve a strategy.
6.8
Dental Health/ Oral Health
Oral health has so far received little policy attention. However, the state recognises that peridontal
diseases and dental caries are widespread in the population. These impact on general health as well.
Fluorisis is prevalent in certain taluks and districts (North Kammataka, Kolar, Pavagada). Oral cancers
are one of the commoner cancers. The state has the largest number of dental colleges in the country,
numbering 41, of which 40 are private. However, there are concerns regarding substandard quality and
the lack of impact on oral health in the state.
■*■1
i Policy
REPORT OF THE TASK FORCE
Karnataka State Health Policy 433\
Karnataka will integrate oral health within its health care services by providing equipment and trained
personnel at CHC level and services at PHC level through the medical officers and dental/oral hygienists.
School health programmes will have dental/oral health as an important component both for services and
ication,
nd later
lational
health promotion.
6.9
Emergency Health Services and Trauma Care
\
n
Initiatives to develop this area will be strengthened and expanded. Besides accidents and injuries this will
include emergency obstetrics care; snake/insect and dog bites and stings; and other medical emergencies.
Existing centres of excellence in the state will be utilised to train expand services statewide. Transport and
communication links will be established and 24 hour services provided in selected institutions. Training in
first aid and life support systems will be imparted to children, teachers, factory workers, drivers an
conductors and paramedics. Preventive measure such as helmets and seat belts will be encouraged, e
right of the citizen as determined by the Supreme Court to access emergency care in any hospital and to
received the first line of critical care will be publicised.
7.
Cross-cutting Policy Issues
7.1
Medical and Public Health Ethics
The state is aware of public dissatisfaction and loss of confidence in the health services, particu ar y o e
public sector. The state takes cognizance of expressions of dissatisfaction through the media, electe
representatives, people organizations and movements and through the issues of concern raised by the Task
Force on Health in its Interim Report. In keeping with its constitutionally mandated responsibility and m
collaboration with professionals and the people it represents and works for, it will initiate and make
functional institutional mechanisms to provide for checks and balances to protect public interest, an
human rights including the right to health and health care.
th 76%
ng and
ability,
?ect to
rtment
•f 1995
ial and
ention
□ units
•
The state will promote the principles and practice of medical ethics in all its institutions, in all
sectors and in all systems of medicine.
e
i
itation
7.2
reater
ortion
rvices
ategy.
i
lontal
well.
incers
untry,
y and
The state will ensure the practice of public health ethics in its decision making, resource allocation
and in implementation of policies and programmes.
Policy Process and Implementation Factors
The policy document is just one step in the overall ongoing policy process that makes explicit the current
concerns, intentions and priorities concerning health by government.
The competence and attitudes of implementers, especially at the point of contact with patients or people
is critical in giving life to policies and programmes. Human resource development to develop competencies
and capability and caring attitudes will be a priority with a focus on front line implementers and just not
on leadership. Energising the primary health centres and all health institutions is our goal Good
communication, supportive supervision, regular updates, small group work, decentralistion of decision
making and financial powers, participatory methods, better governance and accountability systems, along
with strategic planning at all levels will be the strategic approaches to better implementation.
Strong politico-economic and social forces also influence implementation in directions most often against
the interests of the poor and marginalized groups.
These include professional bodies and interests; industrial and business interests of pharmaceutical,
I
434 REPORT OF THE TASK FORCE
Karnataka State Health Policy
Ri
diagnostic and medical equipment manufacturers; the media; donor agencies; International agencies and
others. On the other hand, patients and people, particularly the poor, are relatively unorganized and most
often unheard in the policy process. The state recognises that it represents this public interest and it
commits itself to undertaking this responsibility to improving health and health care of its citizens.
8.
Conclusion
In conclusion, through this policy document Karnataka state is placing health high on its agenda. It reaffirms
the wisdom of the sages who said that health is wealth. It will translate this into action by allocating
adequate human and financial resources, by good governance and institutional capacity building. “Better
health for all now” can only be achieved if it is seen as a common endeavour of all sections of society.
The state will play a facilitating role in harnessing resources, energies and ideas from the private and
voluntary sector. It will stay committed to its mandate and will work towards equity, integrity and quality
in health and health care.
Recommendation
The draft Integrated Health Policy should be adopted after dialogue with Directoarte of Health
and Family Welfare Services, other Government Departments, Voluntary Organisations and the
Public.
T
v<
le
to
in
a-\
al
K
in
th
H
to
fc
1
T
Pi
ar
a\
w
re
m
in
ot
ec
ac
2<
T1
re
(b
in
• w-:
.■'a
Vision 2020 437
Vision 2020
REPORT OF THE TASK FORCE
1 care and
id primary
of patients, the citizen’s charter and the Right to Information Bill. Increasing emphasis on ethics and integrity in
the training programmes, better governance, supervision and creation of the vigilance cell will all help in reducing
corruption in health care services. The balancing role of civic society organisations will be encouraged by
involving people’s organisations, NGOs and elected representatives in various capacities.
^re will be
3 common
and of the
at the first
ho will be
taken will
Action taken with respect to recruitment, postings and transfers of doctors and others has reduced corruption.
These steps will be continued.
the Crude
:tion Rate
guarding
luction in
salth care
ities), and
he health
ssionally
grammes.
lie (class
There were many complaints of corruption by examiners in University examinations. Action by the University to
remove such examiners has produced the desired results.
8.
Community Participation
One of the requirements for improved primary health care is community involvement. There is greater degree of
participation of the people in all matters affecting health and health care. This has been helped by the institution
of health committees from the village level onwards.
9. Water Supply and Sanitation
By 2020, we envisage complete coverage of the entire population with safe potable water supply, and coverage
of 80% of the population with sanitation facilities, through an intersectoral effort.
There is improvement in water supply, an important determinant of health. The Bangalore Water Supply and
Sewerage Board and the Karnataka Water Supply and Drainage Board are working towards improved water
supply in cities and towns. The Department of Rural Development and Panchayati Raj is spearheading service
provision in rural areas, supported by a variety of externally assisted schemes. There is also improved supply
of drinking water, both in quantity and quality, through the activities of the panchayats and village committees.
There is better monitoring of drinking water supply by the Health Department, using simple devices and improved
chlorination and other measures to assure better quality. These will be carried out by the male health workers
who are trained for the purpose and the work will be supervised. The scarcity of water is tackled by better
harvesting of rainwater and better management of surface water, bore wells and hand pumps, Fluorosis and other
problems are also being tackled.
Sanitation receives greater attention in the cities, towns and villages. This includes disposal of garbage, sewage
and human and industrial waste. There are more latrines but not sufficient. People are encouraged to have
sanitary latrines attached to their dwelling places, instead of women having to wait until its is dark to relieve
themselves in the open.
Hospital wastes are receiving greater attention, with segregation of the waste and appropriate disposal.
□utcome
alth care
; gaining
ch were
nd other
le rights
10. Environment
Everyone has the right and responsibility to live and work in healthy environments. Many people, especially those
living in urban slums are compelled by circumstances to live in un-sanitary conditions. The situation becomes worse
in rainy seasons. The slum dwellings are often below the road level and filthy water flows into the houses. Work
environment particularly for the unorganised and small-scale sector is suboptimal. Housing, living and working
conditions have to improve, through the efforts of all sections of society enabled by the state. Bodies set up by the
state will also look at action required at state level to study and respond to broader environmental issues as depletion
of the ozone layer; global warming; air, water and soil pollution; and others; all of which impact on health.
438 REPORT OF THE TASK FORCE
Vision 2020
11. Nutrition
REPOR
The percentage and absolute numbers of severely and moderately undernourished children will be significantly
reduced, as a result of better nutrition awareness and action. Mid-term goals stated in the health policy document
will be improved by a further 50% by 2020.
of the i
with th
12. Immunisation
There are many achievements by 2020. There is better coverage of children under the Universal Immunisation
Programme. Paralytic polio has been eradicated. The number of vaccine preventable diseases is reduced.
However coverage is still incomplete, especially in backward districts. There are still problems of maintenance
of cold chain with frequent breakdown of electric supply. There is need for dependable refrigeration system. By
2020, this basic preventive health strategy will have universal coverage with good quality.
The nt
It is ur
(mostl;
has coi
error,
attenti
13. Transition Stage
18. :
Karnataka is still in the epidemiological transitional stage. It still has a large share of infectious diseases,
characteristic of the underdeveloped world, as well as the degenerative and other diseases of industrialised and
affluent societies. The old scourges of tuberculosis and malaria continue. It is envisaged that by 2020 the burden
of preventable infectious diseases will be contained keeping alert to newer and re-emerging diseases that continue
to remind us of the need to address deeper underlying socio-cultural, behavioral and political economy factors.
Health promotion regarding risk factors and healthier lifestyles will be actively undertaken with creativity,
professionalism and broad based participation.
Alcoh<
the bo‘
from t
Tobaa
diseas
HIV infection has been contained to some extent; anti-retroviral drug combinations are being used against HIV
infection.
14. Medical Services
Primary, Secondary and Tertiary Care Services are available through Public, Voluntary and Private Sectors. But
there are problems due to commercialistion of medical care. With a middle class mindset, policy and decision
makers do not see the needs of the poorest of the poor. With globalization of medical care, the cost of care
has gone up. The affluent can afford the care but the very poor continue to be outside the medical care in the
private sector. There is need for social security, ensuring that the poorest can get the needed medical and health
care.
15. The Non-Communicable Diseases
17. f
19.
Not er
of Me
Nature
Herba
Other
and m
20.
There
Institu
implei
impac
The non-communicable diseases are on the increase. Diabetes Mellitus continues to be a serious condition. A
very large number of people are affected in urban and rural areas. 8-10% of males and females of 20 to 80
years are affected. The disease leads to many complications. Management and control of blood sugar level are
absolutely essential.
21.
High blood pressure is also prevalent in a large proportion of the population. Cardio-vascular diseases are very
common. Primary, secondary and tertiary prevention are necessary; changing life styles have added to the
problem. The state has a large number of patients with asthma and chronic bronchitis.
22.
16. Cancer
There is not enough community-based data on the prevalence of cancer in the State. Cancer registry data may
not reflect the true cancer situation. Changes in life style, longevity and use of tobacco in various forms are some
Theu:
in the
incres
Kama
are fo
S
ion 2020
Vision 2020 439
REPORT OF THE TASK FORCE------------------ ------------------------------------------------------- ---------------- ----------------------
of the important causes leading to increase in cancer. The increase in treatment centers has not been able to cope
ificantly
Dcument
with the demands.
17. Sight for all
I
.
The number of the visually impaired continues to be high. The major cause (80%) is cataract. This is curable.
nisation
educed,
tenance
tern. By
attention paid to other.
18. Substance Abuse
iseases,
sed and
burden
ontinue
factors,
ativity,
ist HIV
Alcohol consumption continues to be high, resulting in various kinds of diseases, affecting almost.everyorgat o
the body. Not enough is being done to reduce the demand or supply of alcoholic drinks and the harmful
from their abuse.
Tobacco is another substance which has widespread harmful effects on the body, including cancer, cardiovascular
diseases and other problems.
19. Indian Systems of Medicine
Not enough is being done to improve the functioning of the health care institutions belonging to the IndiamSystems
of Medicine. The people continue to use the systems of Ayurveda, Unam, Siddha, Homoeopathy, Yoga
Naturopathy.
Herbal medicine is very popular.
Other healing practices such as Tibetan Medicine, acupuncture, acupressure, pranic healing, Reiki, magnetotherapy
-rs. But
xision
)f care
in the
health
and many others continue to be popular with the public.
20. Panchayat Raj
.
There is greater co-operation between the Panchayat Raj Institutions and Health Services The Panchayat Raj
Institution members are more aware of their responsibilities and powers. They are involved m the planning and
implementation of the development programmes including health at various levels. This is making a substantial
impact on the improvement of health services at the periphery.
ion. A
• to 80
/el are
21. Medicinal drugs
e very
to the
22. Informatics Technology
i may
some
The use of drugs has become more rational. Most of the essential drugs are available at the health care institutions
in the public sector. But some of the drugs, under the new patent laws are not easily available because of the
increased cost. The patent laws have affected the production of some of the drugs in the country.
Karnataka has made vast strides in Informatics Technology and this has made its impact on Health Care. There
are four main areas where informatics technology can be useful.
•
Patient care (diagnostic and therapeutic decisions)
©
Medical education, training and research
Public health
©
Health Systems management.
440 REPORT OF THE TASK FORCE
Vision 2020
Patient care, both diagnostic and therapeutic, has benefited from telemedicine in secondary and tertiaiy care with
cardiac monitoring and ECG evaluation via a telephone line. ECGs and sonograms are transmitted to experts
and their advice obtained. It can be expected that these facilities will be extended in due course to primary health
care in remote areas. Computerized ECGs, stress test equipment and scanners can be linked to computer
networks and opinions of experts (situated in the cities) can be obtained.
Medical education can benefit from computer assisted instruction. Visual information (images) can be very useful
Computer animation can be added to it. MEDLARS has been helpful in promoting education, training and
research in health.
Health Management Information System has been developed and has been in place for some time. It helps in
better management of health care systems. Hospital Information System has also been developed. Improving the
utilisation of the facilities available and bringing out lacunae and mismatches.
Public health can benefit enormously. Disease surveillance has been computerized. Early information leads to
early and effective interventions and containment of disease out breaks.
The vision is promising. The need is to have a mission to achieve that vision, where there is equity integrity and
quality in health and health care.
KARNATAKA VISION 2020
Indicators
2001 (Source / Year)
Infant Mortality Rate
2020
Under -5 Mortality Rate
Crude Birth Rate
Crude Death Rate
58 / 1000 live births
69 / 1000 live births
SRS 1999
NFHS - 2
25 / 1000 live births
35 / 1000 live births
22.3 / 1000 population
7.7 / 1000 population
SRS 1999
SRS 1999
Maternal Mortality Rate
13 / 1000 population
6.5 / 1000 population
195 / 1,00,000 live births
SRS 1998
90 7 1,00,000 live births
61.7 years
65.4 years
2.13
51.1
1996-2001
1996-2001
NFHS - 2
NFHS - 2
70.0 years
75.0 years
1.6
75
59.2
35%
NFHS - 2
1994
2000
>95
10%
100
70%
90
40.0%
Life Expectancy at Birth
Male
Female
Total Fertility Rate
Percentage of Institutional Deliveries
Percentage of safe deliveries
Newborns with Low Birth Weight
Percentage of mothers who received ANC
Percentage of eligible couples protected
Percentage of children fully immunised
Anaemia among children (6 - 35 months)
Nutritional Status of children
Severe under nutrition
Moderate under nutrition
Mild under nutrition
Normal
Sex (Gender) ratio
Sex (Gender) ratio, 0-6 years
86.3
59.7
60
70.6%
2000
NFHS-2
NFHS-2
6.2%
45.4%
39.0%
9.4%
964F/ 1000M
949F/ 1000M
Gomez, 1996
2001 census
2001 census
..
J..
2.0%
25.0%
43.0%
30%
975F/1000M
970F7 1000M
REPORT OF THE TASK FORCE
Implementation of the Report 441
24. IMPLEMENTATION OF THE REPORT
The Task force had the unique opportunity of considering the entire health system of the State. Consequently,
the recommendations of the Task Force are wide ranging and impact on almost all aspects of the health system.
At first sight the recommendations may seem too many and too detailed. However, it would be evident that in
the effort to cover all aspects of the health system, all issues had to be considered and inter-relationships both
within this system and the links with other social and development activities had to be included. Obviously, it
would be necessary while considering and implementing these recommendations to prioritize them by urgency for
change, feasibility within a set time frame and need to ensure a smooth transition. The recommendations could
be broadly said to consist of three types.
•
Those that relate to the changes in the basic structure of the health services and involve formulation of new
Cadre and Recruitment Rules and associated elements;
•
Those that relate to “governance” issues such as training, morale building, transparent transfer polices;
personal appraisal system, monitoring of finances, administrative and technical aspects of work; disciplinary
systems; relationship with the Panchayat institutions and other elements of management;
•
Those that relate to enhancement of equity, quality, integrity and coverage and building in emphasis on new
elements in the health services provided. These include the elements such as expansion and addition of
services, better surveillance, better access and reach of services, reduction of disparities and the like.
It must be emphasized that these are not exclusive. On the other hand, they are inter-connected since they
together seek to re-engineer the health system for higher efficiency and productivity and greater equity. However,
these three sets of recommendations would need special expertise appropriate to the character of the category
of recommendations. Such expertise would range from administrative, financial, legal and management experience
to knowledge of the professional content of both public health and medical (clinical) services. The structures for
examination of the recommendations would, therefore, have to be based on these special requirements.
A two-tier structure is suggested for this purpose. The first could be an Implementation Committee. The
second would be subject matter Sub Committees whose reports would be considered by the Implementation
Committee and, in due course, by the final decision making level in Government.lt is suggested that the
recommendations be considered by an official Implementation Committee (for Health Systems Reform) which
could include:
Principal Secretary for Health & FW, Secretary Medical Education, Commissioner for Health, Director,
KHSDP, who has been Member Secretary of the Task Force, Secretary Department of Personnel and
Administrative Reforms, Director, Health & FW representative of the Finance Department and a representative
of the Law Department.
442 REPORT OF THE TASK FORCE
Implementation of the Report
The Implementation of recommendations for change is essentially the responsibility, the prerogative and the
privilege of the Department of Health and Family Welfare. It is to be done in an atmosphere of freedom
innovation and creativity. The government need to provide the department with the best officers to lead and
steer this important and challenging process of change, ensuring them adequate time, space and support The
TiflquTred
detaihnS lmp,ementation plans but exPresses its willingness to be a sounding board
1
To initiate implementation of the recommendations at the earliest, a small core group of young energetic doctors
7oi
fCtl°n Undfr the Coramission for Health to study the recommendations and Ivolvf plans This
Division The c " & Ort’‘eml baS1S'1116 WOrk would be later continued by the Planning and Monitoring
the
d
Cv gr°UP 'nay f’rSt pr0CeSS the ^commendations for consideration of Government prioritiz!
by
DeXjSnr Th""',.
“
™plementation' Some the recommendations can be implemerted early
,he pr°““
The-tow. *. time tame
Other experts could be co-opted for specific issues by the Implementation Committee or the Sub Committees.
The Implementation Committee would need the assistance of a small but efficient secretariat by way of a Cell
to process the recommendations, prepare notes for the Committee and the Sub Committees and follow up all’
action points. It is recommended that this cell be constituted of full time officers drawn from within the
Department and other connected Departments. Expertise from outside could also be inducted with advantage.
The number of such officers and experts and the supporting staff may be determined and the positions filled by
selection of capable persons^ This cell may be placed under the Commissioner and will function till the Planning
and Monitoring Division is fully established.
°
TTie Implementation Committee could set up Sub Committees for specific aspects. Priority would have to be
given to the reorganization of the health services. This would include basic issues such as setting in place through
Government orders the suggested system, transition provisions, establishing the District Cadres and the
procedures for allocation of existing personnel and future recruitment procedures, preparation of the separate
semonty lists for the two Cadres of Public Health and Medical, determination of time scales for those who prefer
o remain as doctors at the PHC level, preparation of the new Cadre and Recruitment Rules, etc.lt would be
useful to list out all these issues and develop a calendar of operations, with specification of the Sub Committees
that would deal with each issue. It must be reiterated that the effort should be to implement the recommendations
the fi 7
aSpOSSlble'If these recommendations are implemented, there would be little doubt of
rfaS aHr
heaIthtS.erV1CeS °f
in terms of efficiency and professional excellence and, most important
of all, ability to serve the people of the State to their full expectations and satisfaction.
I
o
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in
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re:
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un
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the
The woods are lovely, dark and deep,
But I have promises to keep
And miles to go before I sleep.
And miles to go before I sleep.
- Robert Frost
The
Bui
“M
thoi
ther
Fx
report of the task force
25.
Major Recommendations 443
MAJOR RECOMMENDATIONS AND EXPECTED OUTCOMES
"
■...................................................................................... "
"Our main business in life is not to see
what lies dimly at a distance
but to do what clearly lies at hand"
- Dale Carnegie
The Task Force on Health and Family Welfare had made some short-term recommendations to improve health
Government and many of them have been implemented or, are in the process of implementation. The Final Report
tokes cognisance of the acceptance of the short term recommendations and builds on them with the medium and
ong term recommendations. Implementation of these recommendations would yield good dividends by wav of
improved health and human - centred development.
The overall thrust of the short term recommendations had been Equity With Quality. These continue to be the
major rusts, unng discussions with various groups and individuals, and observations in the field another
■mportant focus became clear: Integrity. It deals with corruption which is widespread and must be’tackled
relative's “abrite^°rr"ptIOn .lnThealth Serv.ices=if the newbo™ baby is to be seen by the mother or close
relatives, a bribe has to be paid. If an operation is to be done, a bribe is demanded. It is true that there are
many, many health professionals and health workers who do their work honestly. But there are others who are
unethical in their practice and hold the public to ransom.
The hallowed precincts of theUniversity and teaching institutions are not free of this lack of integrity. Bribes
are demanded if a pass is to be given. Even a good student has to pay to ensure that the he/she does not
ran.
But integrity goes beyond these. It deals with/uiZure to do one’s duty. Non-performance has come out as a
major issue.
There are a large number of recommendations given under each chapter or subchapter. These are all important,
“sr m
'0 h‘8hhgh,t, the more lmPOrtant recommendations, they have been brought together as
Major Recommendations We have also given the expected outcomes” against each recommendation, even
though in the majority of the recommendations, the outcomes are self-evident within the recommendations
themselves.
I
i
444 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendation
Major Recommendations
Outcome expected
1. EQUITY IN HEALTH CARE
1.1
All policies of the Government (State and local), likely to
have direct or indirect effect on health, should be gov
erned by the principle of equitable access to effective
care to meet the needs of the people; they should be
formulated such that disadvantaged are addressed to
reduce inequity. Monitor inequities in health based on
social, economic and health care services, disaggregated
with respect to age, gender, socio economic status, geo
graphical regions and others.
All people have equal opportunit}
to meet their health needs.
1.2
The Health System must improve availability and access
to quality health care (particularly primary health care
and public health) in the underserved talukas / districts
and for the poor and vulnerable population. Ensure
better utilization of the primary health care services by
making the facilities fully functional and people friendly
and through monitoring and supervision improve the
quality of service.
Quality health care is available to
the poor and the disadvantaged
and in underserved areas, consid
ering talukas and districts as the
base
The State Government and the local governments should
take special steps to bring up the health status in areas
where the health status is below the State average.
1.3
In the large and undivided districts like Gulbarga and
Belgaum the districts should be divided into two and a
post of Additional DHO / DM0 should be created with
additional team of Programme Officers.
O • ■
The quality of health care will im
prove with better supervision.
2. QUALITY OF HEALTH CARE
2.1
Have minimum acceptable standards worked out by
independent committees for health care institutions at
different levels and locations and for public health mea
sures.
Standards are worked out for health
care institutions at different levels
and locations and for public health
measures.
2.2
The Joint Directors, Medical and Public Health, will be
designated as the persons in charge of Quality Assur
ance. The Administrative Medical Officer in charge of
• each hospital will be responsible for ensuring quality of
care in each institution.
Nodal officers and administrative
medical officers assigned the re
sponsibility for quality assurance will
be held accountable.
» '• z.
c
rh’ 5'.
• h.5'I
...
\
_______
REPORT OF THE TASK FORCE
Sl.No.
3.1
Major Recommendations
Major Recommendations
3. PRIMARY HEALTH CARE
Have the philosophy of comprehensive primary health
care accepted through training and advocacy and imple
mented by all concerned: the people and the health
services.
Outcome expected
Priority is given to comprehensive
primary health care, as distinct from
selective primary health care and
in preference to secondary and
tertiary health care.
3.2
All existing vacancies of doctors, nurses, pharmacists,
laboratory technicians and ANMs in the primary health
centers and subcentres must be filled up immediately.
Appointments made on contract basis must be regular
ized. Have regular appointments made based on needs for
which there must be a continuous assessment and moni
toring of vacancies likely to occur in the PHCs&subcentres.
All posts at PHCs and subcentres
are filled up promptly with quali
fied personnel, appointed regularly,
improving service.
3.3
Appoint staff nurses at all PHCs, creating posts where
there are none at present.
Qualified staff nurses are available
regularly.
3.4
All essential staff, including doctors, pharmacists, nurses
and ANMs attached to the Primary Health Centres must
stay at headquarters.
All essential staff are available for
service at all times.
3.5
Have a construction and renovation programme such
that every PHC will have a suitable building within the
next 5 years and quartersfor the essential staff within the
next 10 years. In the interim period, take suitable
buildings on rent for PHCs and staff quarters.
Every PHC will have its own build
ing over a time frame. Buildings
will also be available for the stay of
all essential staff.
3.6
Consider the possibility of making available rural medi
cal practitioners / physician assistants / nurse practitio
ners/nurse obstetricians available for service in the rural
areas, where qualified MBBS doctors are not available.
Where MBBS doctors are not
available for service at PHCs, other
trained practitioners are available.
3.7
Have telephones at the PHCs installed without delay for
better communication. Make arrangements for the speedy
transport of patients to the referral centers by provision
of ambulance vans or funds to hire available transport, in
the case of the poor.
Communication and transport are
assured
3.8
There is need to have fully functional laboratory services,
with trained technicians.
Diagnostic services are assured
■)
\
J
446 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
____________ Major Recommendations
3.9
Have Village Health Committees at Gram Panchayat
level. Two representatives each of the committees will be
members of the PHC level co-ordination committees,
which will have representatives of voluntary organisations,
professional bodies and elected representatives. The De
partment of Health must stipulate the working hours of
PHCs and subcentres to suit the community needs.
3.10
PHCs must have round the clock service. Make avail
able the services of Lady Medical Officers. Progressively
increase the number of lady medical officers at PHCs
such that, in the course of the next 10 years, every PHC
will have one male and one female medical officer.
3.11
An appropriate referral system and linkages between
PHCs and Secondary Care Institutions must be put in
position to make primary health care more efficient and
effective.
3.12
Have Urban Primary Health Centres, one for 50,000
population in cities and towns, converting the existing
resources such as health centers, urban family welfare
centers and maternity homes. While these Urban Pri
mary Health Centres will be the responsibility of the local
body (Corporation or Municipality), technical guidance
will be provided by the Directorate of Health and Family
Welfare Services.
3.13
Every PHC will display prominently a Charter of Rights
of patients and citizen "s charter.
3.14
Distribute the male health worker, one for each Gram
Panchayat, redefining his job responsibilities. He will
belong to the District Cadre. The technical control will
be with a designated PHC medical officer.Or Male Health
Worker could be given the responsibilities of 2 Subcentres.
3.15
Reorganise and restructure the PHCs, PHUs and
subcentres (including staffing) considering the population
and area covered and accessibility.
Improved functioning of PHCs,
PHUs and subcentres.
3.16
Provide interest free loans for the purchase of two wheel
ers for the transport of Medical Officer and health workers at PHCs and subcentres.
Improved mobility and availability
of functionaries at the first contact
level.
Outcome expected
Community involvement is assured
at the village and PHC levels.
More convenient working hours
of PHCs.
PHCs must provide round the
clock service. The services of lady
medical officers are assured.
An efficient and effective referral
system is in place.
Comprehensive primary health care
in urban areas comes to function,
administratively under the local
bodies, with technical guidance
from the Department of Health and
Family Welfare Services
Greater transparency and better
appreciation of the rights of pa
tients are assured.
Better utilization of the services of
male health workers with defined
responsibilities.
"■1
REPORT OF THE TASK FORCE
Major Recommendations 447
Sl.No. _ ___________ Major Recommendations
Outcome expected
4. SECONDARY AND TERTIARY HEALTH CARE
4.1
4.1.1
_
SECONDARY AND TERTIARY HOSPITALS
Make the secondary and tertiary health care institutions
fully functional, with the required staff (avoiding mis
match) and equipment in good working condition. Ap
point an expert committee to examine the needs of the
State with respect to the specialities and their rational
distribution in the districts and talukas, together with
requirements of personnel, equipments, etc.
4.1.2
Make the hospitals under the Indian Systems of Medicine
and Homeopathy function well. Standards for these hos
pitals must be worked out and implemented.
4.1.3
Steps must be taken during training (in-service)
programmes to inculcate the feeling of ‘ownership’ of the
hospitals by the staff at every level, with good ‘supervision* and facilitation".
4.1.4
CHCs need the post of anaesthetists for the functioning
of the Departments of Surgery and Obstetrics &
Gynaecology
4.1.5
The equipments must be maintained in good working
condition; the downtime must be reduced to the absolute
minimum.
4.1.6
The Administrative Medical Officer must be trained in
Hospital Administration.
4.1.7
The Secondary Care Hospital must have a social worker
and a Dharmashala for the care of the patients and
attendants.
4.2
EMERGENCY HEALTH SERVICES
4.2.1
Develop Emergency Medicine and Trauma Care Centres to
provide comprehensive medical care, including medical,
surgical, obstetric, paediatric and trauma care. To start
with there will be 44 such centers developed by the
Karnataka Health Systems Development Project. This will
be expanded gradually to include more hospitals, spread
throughout the State. Each center will have 10 beds for
emergency medicine and trauma care. The Centres will have
trained personnel, all necessary equipment andfurniture.
The needs of the people for sec
ondary and tertiary care are better
met.
The hospitals under ISM&H pro
vide quality care.
Improved functioning of the hospi
tals.
Improved surgical, obstetric &
gynaecological procedures.
Better utilization of the equipments
Improved hospital administration;
better service to the patients.
Improved facilities for the patients
and better patient satisfaction.
’
Improved emergency care, reduc
ing death, disease and disability.
448 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
Major Recommendations
Outcome expected
4.2.2
A good and working communication system will be devel
oped. This will include telephone facilities and wireless
sets. Well-equipped ambulance services with trained per
sonnel will be provided. The help of the police will be
taken to ensure early and easy communications. A system
of community insurance will be developed.
All available delay is removed.
Patients get the best possible care
at the earliest.
4.2.3
Helmet wearing should be made compulsory for two
wheeler users (including pillion riders). Seat belts should
be worn while driving cars. First aid training should be
mandatory to drivers and conductors of buses, trucks
and other vehicles. These vehicles will carry functional
first aid boxes.
Improved safety on the roads.
4.2.4
The Additional Director, (Medical) will be the Chief Nodal
Officer for coordinating all work with respect to Emer
gency Medicine and Trauma Care.
A designated person is given the
responsibility for co-ordination.
4.3
DIAGNOSTIC SERVICES
4.3.1
The Public Health Institute must be redesigned and
strengthened to encompass Epidemiology and laboratory
components. This State Level Laboratory should have
expertise in Bacteriology, Virology, Mycology, Parasitol
ogy, Medical Entomology and Toxicology. Its functions
include Supervision, Training, Quality Management, Re
agent preparation and Standardisation.
A State level laboratory with nec
essary expertise and facilities is
available.
4.3.2
The District Hospital Laboratory and the District Health
Laboratory will be integrated; the District Laboratory
will fulfill both functions - diagnostic service for health
care, and for public health. The District Laboratory
should be supervised by one MD / DCP (Microbiology)
and MD / MSc (Biochemistry) and one MD / DCP (Pa
thology), and adequate respective staff, technical and
administrative. The Taluk Hospital Laboratory should be
supervised by one specialist of DCP qualification, sup
ported by other staff. CHC and PHC laboratories will be
managed by Trained Technicians.
District, Taluka and PHC level
laboratories are provided.
4.3.3
Imaging and miscellaneous investigative services will be
provided to meet the requirements for diagnostic tests at
various levels.
Imaging and other diagnostic ser
vices are available according to
needs and feasibility.
lai
—
REPORT OF THE TASK FORCE
Major Recommendations 449
Sl.No.
_________ Major^Recommendations
4.4
BLOOD BANKING AND TRANSFUSION SERVICES
4.4.1
All blood banks should have the required equipment, and
be supplied with adequate reagents and testing kits in a
timely manner. They should have adequate number of
trained staff. All blood banks should put in place a
quality assurance programme.
4.4.2
A comprehensive plan to motivate and mobilize voluntary
and relative blood donors to ensure adequate supply of
safe blood throughout the year and all over the state
should be developed with their help.
4.4.3
The medical community should be sensitized to make
optimal & rational use of blood. Every hospital should
have a blood transfusion committee to ensure this.
4.4.4
A pilot project to study the logistics, management and
monitoring of the centralized 3-tier system comprising Blood Component Center- blood collection -blood storage
& issue points should be initiated in Bangalore; and this
model replicated later inother major cities, iffoundfeasible.
4.4.5
An adequate number of well-equipped (Whole Blood)
blood banks will have to be set up, keeping the blood
needs and regional disparities in mind.
4.5
BIO-SAFETY
4.5.1
Radiation Protection programmes must be strictly fol
lowed by the X-ray equipment users.
4.5.2
Adequate consumables for barrier protection like aprons,
masks and gloves should be provided to staff.
All health care workers who are at potential risk for
infections which may be transmitted through blood and
body fluids should be immunized against Hepatitis B.
;.i
.i.i
Outcome expected
All blood banks are of the re
quired standards and quality.
Availability of safe blood is as
sured
Optimum use is made of the blood.
Information on management of the
blood banking system becomes
available.
A system is in place to provide for
the requirement of blood through
out the State.
Health professionals and patients
will be protected from radiation
hazards.
Health professionals and patients
will be protected from nosocomial
infections.
__________ 5. PUBLIC HEALTH__________
PUBLIC HEALTH AND PRIMARY HEALTH CARE- A
SYNERGY________
All the staffofthe Department ofHealth and Family Welfare
Services must appreciate the importance of Public Health
and the synergy between primary health care and public
health.
Public Health is given due impor
tance.
Jl
450 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations
Outcome expected
5.2
WATER AND SANITATION_______ ______________
While other departments are responsible for storage,
treatment and distribution of water, the department of
health, has specific responsibilities for monitoring quality.
5.2.1
Set standards for water quality and ensure regular testing
to ensure that they are maintained. This information
should be made available to the public.
Standards are set for quality of
water and periodically monitored.
5.2.2
Undertake, supervise and be responsible for water puri
fication treatment e.g. chlorination of wells in rural areas
by junior health assistants in collaboration with the
panchayats / local bodies. Undertake periodic testing for
microbial contamination. New water sources will need an
initial detailed testing for chemical contamination.
Junior health assistants carry out
periodical testing, chlorination and
other measures.
5.2.3
Undertake surveillance and notification of the concerned
authorities regarding early outbreaks of waterborne dis
eases, as part of the disease surveillance system.
Initiate rapid action in suspected outbreaks.
Waterborne diseases are controlled.
5.2.4
Integrate health promotion activities concerning water
and sanitation related problems at all levels - through
schools, panchayats, women's sanghas, the print and
audio visual mass media and folk culture groups. The
linkage between health status and water supply, sanita
tion and drainage needs to be highlighted. Positive mes
sages regarding personal hygiene practices, environmen
tal hygiene and how to utilise government schemes.
Health promotion activities with re
spect to water and sanitation.
5.2.5
Ensure availability of toilets in schools and public places
and in individual households.
Improved sanitation, with decrease
in water borne diseases.
5.3
POLLUTION AND WASTE MANAGEMENT
5.3.1
General Waste Management:
- Set up a working group to look at the recommendations
of the Supreme Court Committee for management of solid
waste in Class I cities and draw up an Action Plan for
implementation in Karnataka.
- Learn from experiences in Bangalore regarding primary
(door-to-door) collection of garbage and expand it to the
other cities and towns.
- Accelerate the process of identifying and utilising the
Landfill sites.
- Delineate the elements of an Integrated Waste Manage-
A policy for waste management
becomes available and action taken
to dispose off solid waste.
REPORT OF THE TASK FORCE
Major Recommendations 451
SLNo. _____ _______ Major Recommendations
Outcome expected
ment Policy at the State Level.
- Identify mechanisms for improving the functioning of the
local self-governments with regard to Solid Waste handling
(Financial and Technical expertise including).
The government should provide certain common facilities
like collection & transport, incineration, sanitary landfill
sites etc., for all Towns and Cities and support private
initiatives for common waste management facilities includ
ing recycling units.
5.3.2
>.3.3
.3.4
Hazardous Waste
Steps to be taken to publicise and bring in greater trans
parency in the functioning of the State Pollution Control
Board including the punitive measures taken against the
polluting industries.
Set up the working group to examine the existing provi
sions of the Environment related acts (Water Act, Air Act
and Environment Protection Act) and the impact of the
73rd and 74th Amendment to the Constitution of India
(Nagarapalika and Panchayath Raj Acts).
Regulate the use of Plastics including the implementation of
the ban on plastics less than 20 microns thick.
- Steps to be initiated to regulate the use of Mercury and
other heavy metals in industries.
Natural Resources depletion and Pollution abatement:
Study the recommendations of the Eco-committee report
under the chairmanship of Sri A N Yellapa Reddy and
draw up of an Action Plan for implementation.
Health Impact Assessment to be made mandatory along
with Environment Impact Assessment for developmental
projects.
Initiate steps to address the abatement of indoor air pollution
within households (efficient and effective use of firewood and
other fossil fuels; popularising the use of LPG).
Bio-Medical Waste
- The Andhra Pradesh experience (Task Force for indepen
dent monitoring and reporting), and Tamilnadu experience
(Development of Model centres in each district) towards
development of systems for safe management of health
care waste to be studied and appropriately incorporated
into the working of the Advisory committee to the Appro
priate Authority on Bio-medical Waste Rules in Karnataka.
Pollution of the environment re
duced.
deduction in pollution. Develop
ment projects are cleared after con
sidering their impact on health.
Bio-medical waste disposal is im
proved after learning from our own
and neighbouring States experi
ences. Health care personnel are
trained in proper separation and
disposal of waste.
i ■
452 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations
Outcome expected
- The waste management initiatives at the KHSDP Hospitals
should be strengthened and extended to all health care
institutions.
- Ensure proper segregation of waste and total waste man
agement at all health care institutions. The segregated
waste streams should not get mixed up with general solid
waste.
The segregated waste should be disinfected; sharps should be
destroyed / disfigured and plastics shredded before final
disposal through discharge into sewage systems, land-fills etc.
Recyclable material should be sent for recycling.
Ensure training of Healthe Care Personnel for proper waste
management practices.
5.4
COMMUNICABLE DISEASES
5.4.1
VECTOR-BORNE INFECTIOUS DISEASES
5.4.1.1
Establish programmes for control of all vector borne
diseases, including Malaria, Filariasis, Japanese Encepha
litis and Dengue fever / Dengue Haemorrhagic Fever and
Dengue Shock Syndrom, and KFD. Emphasise bio-environmental methods of control.
Control of vector borne diseases.
5.4.1.2
Establish a District Level Disease Surveillance System
and a State Level Diagnostic and Reference Laboratory
for mosquito borne infections and other communicable
diseases of public health importance.
Control of communicable diseases
Kyasanur Forest Disease
5.4.1.3
Strengthen the existing disease surveillance system for
Kyasanur Forest Disease with every case of human infec
tion or monkey death being reported and investigated.
Early detection of outbreak of
KFD.
5.4.1.4
Vaccination of the population at risk. Production of
adequate quantities of KFD vaccine must be ensured as
also timely supply through cold chain.
Prevention of KFD.
5.4.1.5
The latest method for diagnosis like ELISA test should be
introduced for quick and correct diagnosis.
Improved and early diagnosis.
5.4.2
TUBERCULOSIS______________________ ________
5.4.2.1
The quality of implementation of the Tuberculosis control
programme in all districts, including urban areas, under
both the National Tuberculosis Programme (NTP) and
10015
Improved diagnosis and care.
- ...... _______________ _
•• J
REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations 453
Outcome expected
the RNTCP needs to improve within the next year. All
staff involved will need to be held accountable for perfor
mance. The primary health centres should provide access
to good quality TB care for all, and should have
- laboratory technicians, whose skills are updated and
whose slides are cross checked regularly;
- microscope, stains, all records and registers;
- uninterrupted drug supplies;
- medical officers are trained by the District TB officers
regarding the organisation and functioning of the
NTP/RNTCP;
- close supportive supervision from the taluk health
officer and DTC in particular with problem solving in
the field.
5.4.2.2
The District TB Centre should have a qualified person in
public health or with a diploma in TB and chest diseases.
DTOs should undergo the training at National Tuberculo
sis Institute (NTI). Two medical officers are required at
the DTC — one to run the clinical service and the other to
undertake training in the field and to analyse reports etc.
The DTC is the referral centre for all aspects of the NTP/
RNTCP and should undertake orientation and training of
institutions and General Practitioners in the private,
voluntary and public sector regarding the programme. A
medical college department cannot replace the DTC.
The District TB Centre becomes
functional and effective.
5.4.2.3
The state should work towards
- Increased case detection to 75% of expected cases.
This will include cases detected by the public, private and
voluntary sector for which a system of notification may
be required. The expected number of cases may also have
to be recalculated based on recent epidemiological data.
Targets should not be used.
- Early case detection, with emphasis on sputum microsC0Py for diagnosis. The use of x-rays should be
rationalised to reduce over diagnosis and unnecessary
treatment. There should be an acceptable ratio be
tween sputum positive and sputum negative cases
Improved case detection and
completion of treatment.
• (1:D- Completion of treatment with cure rates (measurable
in sputum positives) of at least 85%. Two drug
regimes should be discontinued.
'4
454 REPORT Ol-THE TASK FORCE
SI.No.
Major Recommendations
Major Recommendations
Outcome expected
• Recording, reporting and analysis at DTC level to be
used for monitoring and planning the programme.
• Paediatric dosage forms of drugs to be made avail
able. Anganwadis could be centres for follow-up of
young children with TB.
• Supervised or directly observed therapy to be used
only when necessary. Active involvement of patients
and their families in the treatment process with ad
equate patient education.
5.4.2.4
5.4.2.5
The State TB Centre to be a model centre that is also used
for training and operational research, including social
science research into patients and peoples' perspectives.
Networking and training with NGOs and the private
sector to be facilitated by this unit along with the
Karnataka State TB Association.
The state should make greater use of the services and
advice of the National TB Institute.
The State TB centre conducts train
ing & research.
Services of NTI used better.
5.4.2.6
Given the co-infection of HIV and TB, training for phy
sicians and health personnel regarding specifics ofpresen
tation, access to treatment, developing working links with
the Karnataka State AIDS Society.
Health personnel trained for tack
ling co-infection.
5.4.2.7
The State TB Society should include professionals and
NGOs and regularly (annually) review the implementation of the programme.
More effective functioning of the
State TB Society.
5.4.3
5.4.3.1
VACCINE PREVENTABLE DISEASES
Review periodically the Immunisation Policies and Prac
tices with the help of experts. Establish Disease Surveil
lance System to measure the outcome of the Universal
Immunisation Programme. Any occurrence of vaccinepreventable disease, especially in a cluster of two or more
cases, must immediately attract public health attention,
and improve vaccination coverage locally
5.4.3.2
Include Hepatitis B vaccine, under Universal Immunisation
Programme for the immunisation of children.
Protection of children from Hepa
titis B infection.
S.4.3.3
Production of vaccine in the State to be modernized using
the latest technology, under guidance of a Technical
Steering Committeefor a) Kyasanur Forest Disease b) Cell
Culture Anti Rabies vaccine and vaccines against typhoid,
Japanese Encephalitis and other vaccine preventable dis
eases in collaboration with the Department of Animal
Husbandary.
Self-reliant, efficient and effective
vaccine manufacture system will
be established in the state.
Improved planning, monitoring and
evaluation of the Universal
Immunisation Programme
S3
REPORT OF THE TASK FORCE
Major Recommendations 455
Sl.No.
Major Recommendations
5.43.4
Maintenance of cold chain and utilising it for all drugs
and vaccines that require cold chain.
5.4.4
FOOD AND WATER BORNE DISEASES
5.4.4.1
The Health System must establish a functional disease
surveillance system and develop epidemiological, micro
biological and chemical analysis and expertise and facili
ties for early outbreak control.
Early control of food and water
borne epidemic out breaks.
S.4.4.2
The health system must establish routine periodic moni
toring of water for coliforms and chlorine content. Each
local area health authority must develop its own plan of
action to monitor water quality. At any point when
coliform is found in supplied water, that information must
be immediately made available to the local government,
the water supply agency and also to the public (consum
ers). Health System will also provide technical advice for
correcting the deficiencies and to monitor progress.
Provision of safe, adequate and
acceptable drinking water to the
public.
5.4.43
The Health Department must review and revise the regula
tions and legislative measures governing food safety.
Regulations must include allfbod servingfacilities including
street vending. They must check and prevent adulteration
and contamination offoods at various stages ofproduction,
processing, storage, transport and distribution..
Enhanced food safety.
5.4.4.4
The Health Department should develop guidelines for the
health check-up and immunisation offood handlers against
typhoid fever and hepatitis Ar
Control measures recommended include, training and cer
tification of food handlers in restaurants, hostels, hotels
etc.
Enhanced food safety.
5.4.5
HIV / AIDS, REPRODUCTIVE TRACT INFECTIONS
& SEXUALLY TRANSMITTED INFECTIONS
5.4.5.1
Prevention: Health education especially targeting adoles
cents, women’s groups etc. -The ‘men make a difference’
campaign, attempting to make men more responsible in
the control of the epidemic. The male and female health
workers should promote condom use as an infection
preventive measure in addition to their use for spacing of
pregnancies.
Outcome expected
Better coverage and effectiveness
of the Immunisation Programme.
Prevention of sexually transmitted
diseases.
456 REPORT OF THE TASK FORCE
c
Major Recommendations
Sl.No.
Major Recommendations
Outcome expected
5.4.5.2
STD services: Laboratory diagnosis and treatment of
STI/RTI from PHC upwards. HIV diagnostic facilities in
each of the 27 districts to run as Voluntary Testing
Centres with counsellors and social workers. Training of
Medical Personnel on counseling of the STD / HIV pa
tients as well as their sexual partners.
Improved diagnostic and treatment
facilities
5.4.5.3
Early diagnosis and treatment of Opportunistic Infec
tions. Treatment and admission should be possible at all
district hospitals. Provision of ethical and effective
antiretroviral therapies — antenatal, Post-Exposure-Pro
phylaxis & for HIV infected. The state/country could use
provisions under WTO for indigenous production, which
would lower costs.
Treatment of HIV
apportunistic infections.
5.4.5.4
A multi-tier system of networked continuum of care,
modeled on the Bangalore experience of NIMHANS,
Bowring Hospital, NGO-network based day care & hos
pice care and home based care, including use of herbal
medicine and other systems of healing with back-up
support from referral hospitals.
Continuum of care.
5.4.5.5
Capacity building within the Health & Family Welfare
Departments including training, Public-Private partner
ship etc. to effect prevention, treatment and continued
management of sexually transmitted diseases should be
undertaken.
Improvement in the management
of sexually transmitted diseases.
5.4.6.
LEPROSY
5.4.6.1
The Department of Health should maintain the expertise
and skills developed and sustained over the years in the
detection and management of leprosy even after integra
tion of leprosy into primary health care.
Expertise and skills retained.
5.4.6.2
The Leprosy incidence must be closely monitored so that
under-diagnosis, if any, due to the integration with the
primary health care system, may be identified and recti
fied without losing ground.
There is a view that incidence con
tinues. Care can be exercised by
monitoring.
5.4.6.3
Rehabilitation of leprosy cured persons with disability
to be taken up seriously.
Leprosy cured persons with dis
abilities rehabilitated.
5.4.7
RABIES
The responsibility of dogs on the streets belongs on the
legally correct agency. The health authority should imme-
Intersectoral collaboration for pre
vention of rabies.
i
5.4.7.1
and
REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
5.4.7.2
diately call a meeting of the relevant agencies: those who
manage roads, veterinarians, health personnel, local ad
ministration, Vaccine Institute, SPCA, animal activist lob
bies, ministry of environment etc. and prepare a compre
hensive action plan, within 6 months, defining responsi
bilities. The plan of action must be put to action, which
should include education of the public on rabies.
Decision to discontinue the use of animal brain rabies
vaccine, and to replace with a cell culture vaccine. Design
the transition from animal brain ARV to cell culture ARV.
Evolve a method to give cell culture vaccine at no
payment to poor people but leave the private sector
patients to purchase it. The price of cell culture vaccine
may come down drastically, if bulk orders are placed.
Explore manufacturing of cell culture vaccine.
5.4.7.3
Continuing Medical Education for correct management
of animal bites to all registered practitioners / hospitals,
and other personnel. State Institute of Health & FW to be
in charge. Material to be professionally prepared.
Major Recommendations 457
Outcome expected
Availability of cell culture vaccine,
with much less complications.
Improved management of animal
bites.
5.4.8 OTHER INFECTIOUS DISEASES
5.4.8.1
Active search to be conducted in the erstwhile endemic
districts with Guinea worm disease, to ensure its complete
elimination, and the result to be reported in the 20002001 Annual Report of the Department of H&FW.
Complete elimination of Guinea
worm diseases.
5.4.S.2
The expanded laboratory in the Public Health System, at
the State level, must develop expertise in the microbiology
of the following diseases and develop training, reagents
and standardisation of laboratory test for the District
Laboratories; Leptospirosis, Brucellosis, Anthrax, Plague.
Control of Leptospirosis, Brucel
losis, Anthrax and Plague.
5.4.S.3
After a disease surveillance system is established, a labo
ratory based information system must be developed in
order to pool and collate laboratory generated informa
tion in infectious and parasite diseases. This will give the
geographic prevalence of specific infectious diseases so
that intervention can be designed and applied.
Control of infectious diseases.
5.4.S.4
A mechanism to coordinate public health activities be
tween the Departments of Animal Husbandry and Health
and Family Welfare must be created. Such a mechanism
Co-ordination of Animal
Husbandary and Health Depart
ments to prevent infectious diseases.
3
458 REPORT OF THE TASK FORCE
Major Recommendatinn^
Sl.No. ____ __________ Major Recommendations
Outcome expected
will help m epidemiological investigations, development of
ci oratory skills, vaccine manufacture and development,
__ health education, and preventive intervention.
5.4.8.5
It is recommended that all primary health centres and
even sub-centres are provided with simple drugs to treat
skin infections.
5.4.8.6
Provision of antibiotics at PHCs and referral facilities for
other interventions at taluk hospital level. Audiometry at
least at district hospital level.
5.5
DISEASE SURVEILLANCE
All essential drugs are available
Impairment of hearing prevented.
5.5.1
An epidemiological disease surveillance system to be initi
ated in two districts in 2001 and then progressively ex
panded to cover the entire state over a period of two years.
. ThePurPose of the system is for public health action.
Disease Surveillance System in
place.
5.5.2
The State Public Health Institute (PHI) will be adequately
staffed and equipped with the State and District public
health laboratories reporting to it.
The State Public Health Institute is
fully functional.
5.6
non-communicable diseases
5.6.1.
DIABETES MELLITUS
5.6.1.1
Epidemiological surveys may be undertaken in rural, and
urban areas to understand the ‘'burden” of Diabetes
Mellitus andforproper planningfor control andprevention
of Diabetes Mellitus. The help of specialist association /
NGO’s may be sought. The survey may be confined to the
age group between 20-90 using fasting blood sugar level
above!26mg/dl as the criterion using the glucometer. (The
survey ofhypertension, coronary artery disease and stroke
may be undertaken along with diabetic survey).
5.6.1.2
5.6.1.3
Laboratory facilities: It is essential to provide minimum
necessary facilities to diagnose Diabetes mellitus even at
PUT level. This includes, a colorimeter, glucostrips or
Benedicts solution. (The calorimeter may also be usedfor
estimating Blood Urea & Creatinine).
~Constant supply of essential drugs like insulins and oral
hypoglycemic compounds are necessary. The conventional
insulin may be used instead of costly ones like purified /
Human Insulins except in certain special circumstances.
Better planning for control and pre
vention of diabetes mellitus.
Improved diagnosis of diabetes
mellitus.
Essential drugs and available.
■
..........................................................................................................................................................................................................................................................................................................
REPORT OF THE TASK FORCE
Major Recommendations 459
Sl.No.
Major Recommendations
5.6.1.4
Continuing Medical Education (CME) & other training
programmes: Doctors / nurses and technicians must be
exposed to CME programmes regarding the early detec
tion, treatment and preventive measures. The course may
be of 3-5 days duration.
5.6.1.5
Referral System: Most of the patients can be treated at
PHC level itself and occasionally patients need to be
transferred to the CHC / Taluka hospital for specialist
opinion and treatment. The patients with emergencies
like Diabetic Coma and gangrene should be transferred
to the higher level of care. Other patients with chronic
complications may be referred or specialist’s visits may be
organised at PHC’s on regular basis. Some guidelines
may be formed for referral / treatment.
5.6.1.6
Health Education: The health education is promoted
with regard to the early symptoms and complications
especially foot care and diet; prevention of disease & its
complications. There is a needfor orientation course for
health workers / IEC staff regarding various aspects of
Diabetes mellitus with special emphasis on diet, exercise
and foot care.
5.6.1.7
Develop District Diabetes Control Programme One
Specialist for all non communicable diseases at the dis
trict may be designated for supervision, detection, drug
supply and health education programme.
5.6.2.
CARDIOVASCULAR DISEASES
CORONARY ARTERY DISEASE (CAD)
5.6.2.1
Epidemiological sample survey regarding the risk fac
tors may be conducted especially for diabetes mellitus,
high blood pressure, positive family history and smoking
which will help in prevention strategies. Preventive mea
sures may be initiated now itself based on available data.
Health education programmes to be strengthened to re
duce risk factors.
5.6.2.2.
Case detection and emergency management of ischaemic
heart disease, to be done at PHC / general practitioner’s
level. The person has to be transported to CHC / Taluka
Level Hospital for confirmation of diagnosis and further
management.
Outcome expected
The capacities of health personnel
in the management of diabetes
mellitus improved.
Patients are managed at appropri
ate levels.
Better awareness of the disease
leading to action.
There is a designated Officer and
a district programme.
Prevention of coronary artery dis
ease.
Management of ischaemic heart
disease.
460 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
Major Recommendations
5.6.23
The essential drugs like Nitroglycerine tablets, Pethidine,
Morphine, parenteral diuretics, oxygen etc must always
be available. Well-equipped Ambulance services to shift
the patient to referral centres should be available.
______
.
Outcome expected
______
Improved patient management.
HYPERTENSION
5.6.2.4
There is need for multiple sample surveys to be con
ducted, to have some idea of the “burden” of the disease,
for proper planning of our strategy for the management
°f hypertension. There is need to take co-operation of
NGO’s and specialist organisations. Estimation of blood
pressure must be a part of routine examination by the
doctor.
Better management of persons with
hypertension.
5.6.2.5
Facilities: ensure availability of well maintained standard
mercury sphygmomanometer with standard cuff in all
centres. For investigations like ECG and chest X-ray the
cases may be referred.
Improved facilities for diagnosis.
5.6.2.6
Constant supply of antihypertensive drugs must be main
tained. Less expensive drugs with minimum frequency of
dosage are preferred which increases the patient's compli
ance.
Improved availability of essential
drugs.
5.6.2.7
Health education programmes are very essential for both
primary and secondary prevention. Special stress on
control of smoking, restriction of salt, saturatedfat intake
and reduction of weight has to be laid.
Health promotion, avoiding risk
factors.
RHEUMATIC FEVER / HEART DISEASES
5.6.2.S
Rheumatic fever may be detected at PHC level and
treated. Benzathine Pencillin should be supplied to PHC’s
for Rheumatic fever prophylaxis programme. (It is advis
able to give penicillin upto 25yrs).
Detection and management of
rheumatic fever at PHC.
5.6.2.9
Patients with Rheumatic Heart Disease are referred to
specialist / tertiary care hospital for special investiga
tions, surgery and other interventions.
Patient with rheumatic heart dis
ease gets specialist treatment.
THROMBO ANGITIS OBLITERANS
(BERGER’S DISEASE)
5.6.2.10
Discourage use of tobacco (a definite measure to prevent
disease).
Prevention of thrombo-angitis
obliterans.
r.
REPORT OF THE TASK FORCE
Sl.No.
5.6.3
5.6.3.1
Major Recommendations
Major Recommendations 461
Outcome expected
CHRONIC BRONCHITIS and ASTHMA
Every health centre / practitioner must have the drugs
and facilities always available to treat asthmatics. Drug
supply should include injections of Deriphylline, Amino
phylline, Adrenaline, Steroids and tablets of Salbutomol,
terbutaline. It is desirable to supply pressurised aerosol
nebuliser in every health centre, so that an acute attack
may be relieved, even at subcentre levels.
Availability of essential drugs as
sured to manage patients with
asthma.
5.6.S.2
Preventive measures and health education may be ad
dressed individually. Lowering environmental / industrial
pollution should be taken up as a part of wider health
issues. Preventive measures, health education regarding
smoking and control of air pollution are important from
individual / community angle.
Reduction in attacks of asthma
5.6.4
CANCER
5.6.4.1
Primary prevention
- Health promotion programmes in schools and colleges
to reduce use of tobacco and intensive anti-tobacco
campaigns by doctors, nurses, paramedicals, teachers,
social worker and anganwadi workers and voluntary
organsiations
- Orientation programmes in the problems of tobacco
use for all people's representatives and other decision
makers.
Legislation to reduce tobacco use
Prevention of use of tobacco
5.6.4.2
Secondary prevention: Have cancer detection camps
with the help of voluntary organisations to create aware
ness and detect cancers at early stage and have cancer
detection units in hospitals
Early detection of cancer.
5.6.4.3
Tertiary prevention: Have multidisciplinary treatment
facilities at Kidwai and other identified centers: surgical,
medical, radiation oncology and supportive systems
Effective treatment of cancer
patients.
Palliative care for terminally ill cancer patients.
Palliative care
Have a District Cancer Control Programme, consisting
of a field unit and a clinical team, with staff trained at
Kidwai Memorial Institute of Oncology and located at the
District Hospital. Extend the programme to all the dis
tricts in phased manner.
Early detection of cancer and
management
H-----5.6.4.4
5.6.4.5
462 REPORT OF THE TASK FORCE
Sl.No.
5.6.5
5.6.5.1
Outcome expected
OTHER NON-COMMUNICABLE DISEASES
FLUROSIS
_______
5.6.5.1.1
Make available alternate drinking water with less than
Ippm of fluoride to people living in areas where the
fluoride content is more than Ippm.
5.6.5.2
HANDIGODU DISEASE
5.6.52.1
Vacancies at the Handigodu Disease Unit at Sagar Hos
pital to be filled up and made fully functional along with
the mobile unit. Disease surveillance system should be
introduced for Handigodu Syndrome.'
All vacancies are filled up resulting
in improved quality of care.
A special component of the Dis
ease Surveillance System.
5.6.5.22
Genetic counseling regarding marriage, child bearing,
risk estimates on the basis of pedigree analysis.
Prevention of the disease.
5.6.52.3
Early diagnosis (By X-ray), treatment, surgical correction
and rehabilitation should be provided to all the affected
including those in Chikkamagalur district. Patients with
Handigodu Disease should be provided with supplemen
tary calcium in dietary and tablet forms.
Handigodu patients rehabilitated.
5.7
ORAL HEALTH
5.7.1
Have oral (dental) health promotion activity at every
level of health care and as part of the school health
programme.
Improved oral (dental) health
5.7.2
All vacancies of dental health officers to be filled up by
suitably qualified persons. All dental clinics should have
the necessary equipments and facilities, which should be
maintained in good working condition
Improved facilities at all dental clin
ics.
5.7.3
A designated post of Deputy Director to be in charge of
Dental Health Services and Dental Education, at the
Directorate.
A designated officer at the Direc
torate made responsible for oral
(dental) health.
5.8
____________ OCCUPATIONAL HEALTH__________
5.8.1
The use of pesticides must be reduced to the minimum.
Only such insecticides as are found to be not harmful
within the recommended dosage should be allowed to be
manufactured / imported and used. The cumulative
effects should be considered. Monitor continuously the
effect of the use of pesticide. Iffound harmful, withdraw
it.
■
i
Major Recommendations
Major Recommendations
Fluoride poisoning controlled.
Harmful insecticides eliminated.
REPORT OF THE TASK FORCE
SI.No.
____________ Major Recommendations
5.8.2
Ensure pre-employment and periodical health check-ups
of all workers.
5.9
CONTROL OF BLINDNESS
5.9.1
Strengthen the State Ophthalmic Cell, filling up vacan
cies, and long term continuity of Joint Director.
5.9.2
Ensure accountability of the ophthalmologist and ophthalmic units.
Improved performance.
5.9.3
Integrate school eye screening with the health check-up
of school children
Improved eye check up.
5.9.4
All Medical Colleges Eye Departments should take up inreach base hospital programme
Better blindness control.
5.9.5
All taluk hospitals (upgraded by KHSDP) should be made
base hospitals for conventional cataract surgery and be
allotted a fixed geographical area.
All districts should have at least two Government base
hospitals where IOL surgery is available.
The District Medical Officer should co-ordinate and de
pute the available surgical manpower to fixed surgical
centers on the operation days in the districts.
5.9.6
Screening in the community by the health worker to
identify and refer persons at risk of developing glaucoma
to ophthalmologist for evaluation and management.
5.9.7
Prevention, early diagnosis and intervention in persons
liable for corneal opacities causing blindness.
5.9.8
Establish speciality clinics: glaucoma, vitreo-retinal and
corneal grafting centre, one each for each region.
5.10.1
zz
463
Outcome expected
Detect occupational health prob
lems at the earliest.
___________
Improved activities of the State
Ophthalmic Cell.
Increased number of cataract sur
geries.
Improved early management of
glaucoma.
Better management of corneal
opacities.
Improved management of eye
problems.
___________ 5.10 TOBACCO CONTROL____________
BAN OF TOBACCO CONSUMPTION: Complete ban on smok Smoking is reduced including pas
ing in public places such as:
sive smoking
a. Hospitals and all other health care facilities and
Educational Institutions (Schools, Colleges, Univer
sity).
b. Transport facilities, including Air travel (domestic),
Buses and Trains: Separation of smoking and non
smoking compartments.
c. Waiting areas: Airports and Hotel lobbies (Segrega
tion) of smoking areas from non-smoking areas.
d. Theaters / Cinemas and Restaurants
\l464 REPORT OF THE TASK FORCE
SLNo.
Major Recommendations
Major Recommendations
Outcome expected
e. Sports arenas.
f Museums, libraries and closed areas of Tourist Inter
est:
g. Work site (segregated area for smoker at recreational
•/ eating facilities).
5.10.2
BAN ON TOBACCO SALE: Ban on sale of tobacco and
tobacco containing products to minors (below 18 years of
age) and in the immediate vicinity of educational institu
tions
Tobacco use by children and ado
lescents is reduced.
5.10.3
BAN ON TOBACCO ADVERTISMENT / PROMOTION. All
hoarding / poster advertisement to be banned, including
in / on all transport facilities.
Radio and Television ban on tobacco advertising should
be continued.
Advertisement in Cinema halls / Videocassettes / audio
and in print media.
Point of sale advertising should be prohibited. Warning
symbols and health warning should be prominently dis
played at the point of sale.
Ban on all forms of sports and arts sponsorships or
linkage with sports goods / accessories should be ef
fected. This ban should apply to all tobacco products and
to other products with the same brand name. Indirect
sponsorship through setting up of trusts, etc., should be
banned
All promotional activities for any tobacco product such as
free distribution, mailings, discount offer etc., should be
banned
Demand for tobacco products is
reduced.
5.10.4
STATUTORY WARNING ON PACKAGING / NICOTINE AND TAR
CONTEND
Notification of nicotine and tar content on all packages
of the cigarettes and beedies and all products with to
bacco should be made compulsory. Size of the statutory
warning should be as large (in letter size) as the brand
name and in the local (regional) language
Demand for and use of tobacco is
reduced.
5.10.5
Nicotine and tar content of cigarettes should be progres
sively reduced, in a specified time frame.
Adverse effects reduced.
5.10.6
TAXATION: Taxes on all tobacco products should be in
creased. A specified percentage of the tax revenue from
tobacco should be set aside for health education on
tobacco related diseases.
Demand for and use of tobacco is
reduced.
PORT OF THE TASK FORCE
Major Recommendations 465
.No.
Major Recommendations
Outcome expected
10.7
INCENTIVES: Farmers who change over from tobacco to
alternate crops should be provided monetary and other
incentives for three years.
Availability of tobacco is reduced.
10.8
Promote diversification of tobacco industry into other
industries such as information technology.
Availability of tobacco products
reduced.
10.9
ENVIRONMEMAL LEGISIATION:
Environmental legislation to provide for a targeted com
pulsory compensatory reforestation programme by to
bacco producers and industry to make up for a tobacco
curing related deforestation. A specific tax may be levied
for this purpose.
Deforestation is reduced.
10.10
MISCELLANEOUS '.Improve working condition of beedi
workers. Industry must providefor medical care ofthe workers.
Have alternate employment for beedi workers and
labourers now working in tobacco growing, curing, etc.,
Improvement of health of the work
ers.
0.11
Investment of public sector funds in the tobacco industry
must be stopped.
No encouragement to tobacco in
dustry.
11
ALCOHOL AND HEALTH
1.1
Training of all Medical Officers and especially at the
Primary Health Care level on screening the patient for
alcohol abuse problem with a simple questionairre, early
detection and interventions for alcohol-related health
problems. The training should include sensitization re
garding association of alcohol use with violence in the
family, and association with STDs & HIV/AIDS.
Medical officers are skilled in the
detection and interventions for al
cohol related problems.
1.2
Referral centres for treatmenr~6f~dIcdKolism should be
identified or set up at district levels. The treatment
programme should include detoxification, treatment of
withdrawal symptoms, psychological therapy and long
term relapse-prevention programmes to ensure abstinence
Alcoholism is managed effectively.
1.3
Referral to local self-help groups like Alcoholics Anony
mous should be encouraged as part of the relapse preven
tion programmes for treatment of alcoholism.
Alcoholism is reduced.
1.4
The model of(<camp-approach ” for treatment of alcohol
ics which is being successfully implemented by TTK
Hospital, Chennai, in some centres in Tamil Nadu could
be tried in Karnataka. Involve the local community in the
relapse-prevention programme.
Relapse of alcoholism is prevented.
466 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
Major Recommendations
Outcome expected
5.11.5
The departments of Excise (Finance), Health, Education,
Social Welfare and Police should work together to imple
ment and enforce the existing regulations and measures
applying to production, sales, retail, taxation and adver
tising of alcohol.
Better enforcement of regulations
controlling alcohol.
5.11.6
A differential Tax structure with a higher taxation on
liquors than on beer or wine will help in discouraging the
drinking of beverages with higher alcohol content.
Discouraging drinking of bever
ages with higher alcohol content.
5.11.7
A general awareness about (tdrinking and driving"
should be undertaken by the Transport department. This
should specify the type and amount of drink over which
the person should not drive, explained in lay terms and
not as percentage of alcohol. The laws against drinking
and driving should be strictly implemented and exem
plary punishment must be awarded to offenders.
Alcohol related road accidents
are reduced.
5.11.8
Measures to prevent production and sale of illicit li
quor should be enforced.
Harmful effects of illicit liquor are
avoided.
5.11.9
Health education programmes for children and adoles
cents should include substance (including alcohol) abuse
as well as Life Skills Education.
Children and adolescents learn to
avoid alcohol.
5.11.10
Community level interventions by Government and by
NGOs should include community awareness, Health Edu
cation, social support for battered women and children
following alcohol consumption and vocational rehabili
tation for reformed alcoholics.
Domestic violence following drink
ing is reduced.
5.11.11
Advertising agencies and media should be encouraged to
self-regulate and avoid even covert messages.
Demand for alcohol is reduced.
5.12
HEALTH ASPECTS OF DISASTER MANAGEMENT
5.12
The Government of Karnataka should commission a
competent group of experts, administrators and policy
makers including those in the field of health, to prepare
a multi hazard plan for all districts in the state of
Karnataka. This Plan should be completed before the
end of the year 2001.
Disaster management is a large
issue which must be tackled with
intersectoral cooperation.
REPORT OF THE TASK FORCE
Sl.No.
_________ Major Recommendations
Major Recommendations 467
Outcome expected
5. MENTAL HEALTH & NEUROSCIENCES
6.1
MENTAL HEALTH
[6.1.1
Train the medical officers and others at T
the Primary
Health Centres to recognize mental health problems early,
manage them effectively or refer them.
6.1.2
Have District Mental Health programmes in all districts
on the model of Bellary District Programme. All district
hospitals to have mental health units with qualified
psychiatrists and other trained staff and facilities for
outpatient and inpatient care of the mentally ill persons.
6.1.3
Ensure availability of essential drugs for the manage
ment of mental disorders. Have counseling centers with
qualified and trained personnel.
Effective management of mental
disorders.
6.1.4
All medical colleges should have qualified psychiatrists
and facilities for teaching medical students and for out
patient and inpatient care of mentally ill persons.
Training of medical students and
service is improved.
5.1.5
Upgrade the Dharwad Mental Hospital, converting it to
a centre of active treatment in a humane way.
The only state institute has up
graded facilities and patient - cen
tered care.
5.1.6
Encourage community based rehabilitation ofpersons with
mental disorders, who have recovered from acute illness.
Encourage community based rehabilitation ofpersons with
mental retardation, integrating them into the society.
Community based rehabilitation of
persons with mental retiirdation or
chronic mental disorder.
i.2
NEUROLOGICAL DISORDERS
.2.1
EPILEPSY
.2.1.1
Epilepsy Education: It is a key area that needs immediate
attention. These programmes should aim at relieving
stigma, and improving the compliance ofithe patient in
taking drugs. It must also highlight DO fs andDONT'S and
focus on positive outlook on epilepsy. Recognise different
types of epilepsy, including hot water epilepsy. Awareness
should be created on Hot Water Epilepsy particularly in
Chamarajanagar, Mysore and Mandya District.
Mental health problems are
recognised early and managed ef
fectively.
Every district has an effective men
tal health programme.
Better awareness of the problem
and improved compliance with
prolonged medication.
468 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
Major Recommendations
Outcome expected
6.2.1.2
The primary care physicians (both PHC doctor and
private practitioner) and auxiliary staff have to be trained
by a short term course, regarding diagnosis, treatment,
epilepsy education, record keeping and monitoring. There
must be a continuous supply of anti-epileptic drugs.
Improved early diagnosis and treat
ment.
6.2.1.3
Establish and strengthen epilepsy services at district
hospitals through out-patients clinics with adequate sup
ply of drugs. The district medical officers, physicians
and paediatricians may be trained by a short course as
it is done at NIMHANS under epilepsy control programme.
Have a District Epilepsy Control Programme for plan
ning, implementing, supervising and evaluating, epilepsy
services. The programme officer may be incharge of all
non-communicable disease.
Improved management of epilepsy
at the districts.
6.2.2
STROKE
6.2.2.1
Control of hypertension, discouraging smoking, reducing
intake of saturated fats, and control of obesity are
important measures to be instituted at all levels of health
care. Antiplatelet drugs like aspirin 100-325mg are pre
scribed, to prevent further attacks. It may be used as
primary prevention in a person who has a strong family
history and risk factors.
Stroke is prevented.
6.2.2.2
Majority of stroke may be managed at PHC level with
well-trained staff and certain specific cases to referred
secondary / tertiary level as an emergency
Effective management of patients
with stroke.
6.2.2.3
Training programmes for the management of all causes
of neurological disorders to be instituted at NIMHANS
for primary care physicians, both private and public. The
training should be practical and should include physio
therapy.
Improved training to deal with
‘stroke’.
6.2.3.
NEUROLOGY AND NEUROSURGERY SERVICES
IN GOVERNMENT MEDICAL COLLEGES
6.2.3
The Government of Karnataka must initiate immediate
and energetic steps to establish Neurology and Neuro
surgery services in all the four government medical
colleges.
Improved services in neurology and
neurosurgery available at the
Medical Colleges.
REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations 469
Outcome expected
Train physicians and general surgeons at taluka and
district hospitals to manage neurological disorders and
head injuries and refer patients, when necessary to the
Medical Colleges / NIMHANS, Bangalore.
6.2.4.
HEAD INJURIES AND TRAFFIC ACCIDENTS
6.2.4
The law regarding compulsory wearing of crash helmet
by riders and pillion riders of two wheelers must be re
introduced to protect them from severe head injury. It is
essential to educate the public regarding the road safety
measures and benefits of wearing the helmet.
Riders of two wheelers are better
protected from the effects of head
injury.
7. NUTRITION
7.1
Supplementary food supply to pregnant mothers be in
creased, based on the need; this can be assessed based on
the gain in weight, after excluding other causes.
Improved nutrition status of the
mother and the unborn child.
7.2
Breast feeding to commence soon after delivery, to use
the highly beneficial colostrums. Exclusive breastfeeding
during the first 6 months. Breastfeeding to continue for
18-24 months (Method: education of the mother).
Breast milk is wholesome food
and nourishes the child.
7.3
Semisolid weaning (supplementary) food, adequate in
quantity and quality, be given to the infant under the
ICDS scheme. In the case of the poor, weaning food be
supplied free to the infants above 6 months (Department
of Health Family Welfare services with the help of the
departments of Women and Child Welfare and Food
Supplies).
Supplementary food ensures ad
equate nutrition.
7.4
Growth monitoring to detect growth faltering, based on
weights taken by anganwadi workers, with well-cali
brated balances; follow-up action by the medical officers
of PHC. If malnutrition is severe, admission and man
agement.
Early detection of under nutrition
and intervention.
7.5
Free mid-day meals (nutritious) to poor school children.
(Department of Education).
Improved nutrition and perfor
mance at school.
7.6
PDS must be strengthened. More foods like ragi, other
Improved nutrition of the poor.
470 report of the task force
Sl.No.
Major Recommendations
Major Recommendations
Outcome expected
pulses and oil to be supplied to the green card holders
(Food and Civil Supplies).
7.7
Ensure supply of iron-folic acid to adolescent girls and
pregnant mothers. Ensure vitamin A prophylaxis. Cal
cium tablets to be supplied if indicated, to lactating and
older women.Iodised salt in goiter prevalent districts.
7.7
Nutrition and Health Education (Health and Family
Welfare Services, Medical and Nursing Colleges and
schools, University departments of Nutrition and Home
Sciences); Nutrition education of the public.
7.9
Prevent infection. If infection occurs, treat promptly.
Improve access to health care of infants, children and
pregnant mothers to PHCs and CHCs with the help of
Paediatricians and Obstetricians and Gynaecologists.
Safe drinking water and improved sanitation to pre
vent diarrheas and worm infestation. Periodical (once in
a year) deworming.
7.10
The District Nutrition Officer will co-ordinate the nutri
tion programmes in the district.
7.11
Encourage use of green leafy vegetables. Every house to
have a kitchen garden. The Department of Horticulture
to help with supply of seeds, seedlings, etc and promote
the development of kitchen (nutrition) garden with drum
stick plants, green leafy vegetables, etc. Every PHC to
consider possibility of developing a demonstration plot.
7.12
Constitute an interministerial co-ordination committee
(Health, food and civil supplies, agriculture, education,
rural development and social welfare) to tackle the
problem of malnutrition.
8.
8.1
WOMEN AND CHILD HEALTH
WOMEN’S HEALTH
ref°mmendations regarding Nutrition, STD
& HIV/AIDS; Cancer control among women etc, are
incorporated in the chapters <on these topics, specific
issues are emphasized here.
Micronutrients are made available.
Improved awareness leading to
action to reduce malnutrition.
The additve effect of infection on
undemutrition is prevented; so also
the effect of other diseases.
A designated officer is given the
responsibility to monitor and take
corrective action.
Improved nutrition at low cost.
Improvement in nutrition requires
multi sectoral coordination.
report of the task force
Major Recommendations 471
Sl.No.
___________ Major Recommendations
8.1.1
All Health -care personnel should be sensitized on issues
relating to gender inequalities. The curriculum for Medi
cal Education and for training programs for health care
personnel should include gender perspectives.
8.1.2
Gender dis-aggregated data and gender sensitive indi
cators to evaluate gender equity should be integrated in
all plans & programs. Examples of gender disaggregated
data would include birth and death details, actual con
sumption of the food and micro-nutrients supplied to
pregnant women through the RCH / ICDS programmes;
admissions & attendance at schools, hospital in-patient
J & out-patient records, immunization details, salary pat| terns for the same jobs and so on.
8.1.3
Violence against women and girls at societal and house
hold levels to be eliminated through strengthening of
| institutional capacity (especially Health, Police and Judi
cial Sectors); involvement of women, and review of
certain existing legal provisions
8.1.4
8.1.5
8.1.6
Outcome expected
All health care personnel become
aware of and sensitive to gender
issues.
Disaggregated data on various is
sues affecting the health of the
people become available for suit
able action.
Action to be taken to eliminate
violence against women.
Health Sector:
Privacy is essential when interviewing clients about do
Violence and sexual abuse are rec
mestic violence and this should be ensured. Health per
sonnel should be trained adequately and sensitively to ognized and appropriate advice is
given.
recognize and treat signs of domestic violence, sexual i
abuse & violence associated with alcohol abuse; give
legal advice and counseling. The hospitals should be
made women friendly.
Long term psychological support for sexually abused
children of a trained counseller / psychologist / psycho
social worker / psychiatrist should be identified within
the Health system.
Services of a counselor/ psycholo
gist/ psychosocial worker is made
available to sexually abused chil
dren.
Female foeticide & infanticide:
|
Actively look for female foeticide infanticide.. Gender
ratio at birth and other indicators to show trends, under Female foeticide and infanticide are
lying causes should be used for communitydevel control reduced and finally eliminated.
programmes. The services of religious leaders can be used
to strengthen the programme against foeticide and infan
ticide. IMA & other professional bodies should be en
couraged to sensitize doctors to the legal ^ethical aspects;
self-regulate and socially boycott known offenders.
*
472 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
Major Recommendations
8.1.7
The Prenatal Diagnostic Techniques Act,1994, should
be enforced strictly.
8.2
8.2.1
CHILD HEALTH_______________________________
Have an additional health worker appointed by the
Gram Sabha and trained to receive and resuscitate the
newly born along with other duties as an experimental
measure in the 7 northern districts found to have lower
health status and extended, if found useful.
8.2.2
Develop Indira Gandhi Institute of Child Health as the
apex body for training, service and research in child
health. Tackle the major childhood problems ofdiarrhoea
(leading to dehydration) and acute respiratory infections.
Reduced child mortality and im
proved referrel care
8.2.3
Health education for children and adolescents should be
the responsibility of the Health as well as Education
department. This should be integrated into the formal
school system and should include nutrition; sanitation;
reproductive health, RTI/STI; HIV/AIDS; substance abuse,
values & life skills and gender issues; Alternate mecha
nisms to reach school dropouts should be identified.
School health education for chil
dren and adolescents brings about
responsible behaviour.
8.3
REPRODUCTIVE & CHILD HEALTH PROGRAMME
8.3.1
Quality of Services
The general quality ofRCH services should be improved;
a Quality Assurance programme should be developed
and implemented. Changes in the procedure, equipment
specifications, new techniques etc. should go through a
specified evaluation process before being accepted for
implementation. The patient's comfort and dignity are of
first consideration. So the tilted laproscopy tables & other
such inconsiderate methodology should not be used.
Outcome expected
Female foeticide is reduced.
Neonatal deaths are reduced.
Quality and patients convenience
and satisfaction are assured
8.3.2
The attitude of doctors and other staff should be positive
and helpful. This can be ensured through periodic
internal audits, patient satisfaction studies and accredi
tation system with an external audit. Periodic auditing
of maternal and infant deaths should be implemented to
institute preventive strategies.
Periodic audits are in place to en
sure quality care.
8.3.3
Availability of safe abortion (MTP) services for all women
should be ensured. Sterilizations and MTPs should be
carried out only at first referral units (Fixed-Day strat
egy) and not at camps.
Safe MTPs are assured.
EPORT OF THE TASK FORCE
Sl.No.
<3.4
Major Recommendations 473
Major Recommendations
Outcome expected
Infrastructure-Staff:
The system of deliveries by Dais should be supported,
with enhanced training. Initial as well as periodic reori
entation training for all birth attendants to ensure quality
should be implemented. There should be periodic evalu
ation and up-gradation of the training courses.
Improved performance by the
trained birth attendant, resulting in
safe delivery.
<3.5
To solve the problem of safety and timely attendance of
ANMs: as far as possible, ANMs should be posted in their
home villages; given loan facility to buy a two wheeler.
Their workload needs to be rationalized- less paper work
and better use of their expertise and talent
ANMs have greater mobility and
are able to carry out their func
tions more effectively.
<3.6
Ensuring availability of trained staff: Government may
consider approved, training courses to provide services
in the absence of a Medical Office:, Nurse-Obstetrician
Practitioner at the PHC level and Short-term (6m to lyr)
training in anaesthesia for Medical Officers at the CHC
level.
The details of the course, feasibility etc. should be worked
out by an expert team.
In the absence of Lady Medical
Officer at PHC, have a nurse
obstetrician trained anaesthetist
helps in performing surgical, ob
stetric and gynaecological opera
tions.
:.3.7
Disposable delivery kits with good quality cost effective
components - with the expectant mothers.
Improved delivery
:.3.8
Subsidised menstrual cloth /pads may be supplied to the
poor, to promote personal hygiene and should be sup
ported with awareness programmes to ensure correct
usage.
Improved menstrual hygiene.
.3.9
Male Health Workers should be given adequate training
and skills to tackle gender issues and to ensure male
participation through individual counseling as well as
community education programmes.
Male participation improves in the
programme.
9. POPULATION STABILIZATION
.1
The unmet needs for family planning services should be
met, with options of choice and assured quality;
The needs for family planning ser
vices are met.
.2
Information, education and communication activities
should be enhanced to convey messages of the advantages
EEC programme in place.
....A....
474 REPORT OF THE TASK FORCE
SI.No.
Major Recommendations
Major Recommendations
Outcome expected
ofpostponing the second child, of a two child norm, and
of the health and familial advantages of spacing births
and of raising age at marriage.
9.3
There has to be regular and effective follow up of
acceptors after they adopt any of the family planning
methods to ensure that complications, if any, are at
tended to expeditiously. Such follow up would also en
courage the increasing acceptance offamily planning
Regular follow-up reduces com
plications; if complications occur,
they are attended to immediately.
9.4
There should be no element of compulsion or pressure,
particularly through camps or “pulse approach”. The
services should be such that their quality and availability,
with regularity and at all times, with choice encourages
voluntary adoption offamilyplanning; (CNA methodology)
Voluntarism and quality improve
acceptance.
9.5
New family planning technology should be adopted only
after careful consideration of the ethical aspects of use
of such technology, safety issues and cost effectiveness.
Ethics, safety and cost-effective
ness considered before adopting
new technologies.
9.6
Ensure legal requirement of registration of all mar
riages. This would enable the stricter application of the
law relating to restriction of age at marriage and assist
in organizing out-reach services;
All marriages are registered.
9.7
The community, particularly women's groups, should be
closely associated, in consultative and operational terms,
with family planning programmes to reflect the percep
tions and needs of the local community
Community needs are met.
9.8
The Population Policy for the State as part of Inte
grated Health Policy should be drafted. The draft policy
would have to be widely publicizedfor public awareness
and response, before it is finalized;
A State Population Policy as part
of the Health Policy becomes avail
able.
9.9
Districts may be prioritized on the basis of evaluation of
the current status of the family planning services avail
able and related social criteria, for enhancing the scale
Districts are prioritized to provide
family planning services.
of the programme;
9.10
For ensuring inter-sectoral coordination and monitoring
of the programmes relating to family planning and re-
A Commission on Social Devel
opment and Population is estab-
REPORT OF THE TASK FORCE
SI.No.
Major Recommendations 475
Major Recommendations
Outcome expected
lated sectors, a Committee on Social Development and
Population Issues may be established at the official level,
while at the Cabinet level a Commission on Social
Development and Population may be established.
lished at Cabinet level and a Com
mittee at official level.
10. FOCUS ON SPECIAL GROUPS
10.1
PERSONS WITH DISABILITY
10.1.1
Establish the role of the Health department in Disability
Prevention, Early detection, Intervention, corrective sur
gery and physiotherapy. Sensitise health-care workers on
identification, classification, records ofprogress and evalu
ation, referral and home-based stimulation training. Staff
from Leprosy control programs may be trained first.
The staff of the Department of
Health are sensitive to the issues in
disability.
10.1.2
Utilise Media to create awareness and training of par
ents and other caregivers on specific disabilities.
Awareness is created among all
caregivers
110.1.3
Shift from institutional approach to a Community Based
Rehabilitation-home-(parent) based approach; and from
single to a multi-disability approach.
Community Based approach is
adopted.
10.1.4
Networking initiatives — Get all people, Government as
well as NGOs, from all sectors to meet at a common
platform and plan out strategies.
All people are involved in the
programme for rehabilitation.
10.1.5
Make provision for the manufacture, distribution and
repair and maintenance of aids and appliances. Have an
orthotic and prosthetic centre at every district hospital
(as in Tamil Nadu).
Aids and appliances are available
as required.
10.1.6
Develop and implement a policy of inclusive education.
Train teachers for early detection and management of
learning difficulties. Include evaluation and management
of speech and hearing and other impairments in school
health programmes
Inclusive education is available.
LO.1.7
Ensure access to all health care institutions and other
buildings, transport, water supply, sanitation etc., by
incorporating necessary provisions in the statutes, rules,
etc.
Improved access to all buildings
476 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
Major Recommendations
Outcome expected
10.1.8
Implement the provisions of the existing legislation, in
cluding Persons with Disabilities Act, 1995 with respect
to protection of the rights of persons with disabilities.
Ensure equal opportunities in employment and training
for persons with disabilities, by enforcing current legisla
tion; enhance the provision for training and employment
Provisions of the Persons with Dis
abilities Act are applied, ensuring
equal opportunities.
10.2
HEALTH OF THE TRIBAL PEOPLE
10.2.1
A rapid survey of the health status of the tribals should
be carried out. Region specific and tribe specific health
plans should be made.
Health status of the tribal people is
known.
10.2.2
The norms for Primary Health Centres and Subcentres
in tribal areas should be based on geographical and
population basis and they should be flexible. The mobile
units should be made functional.
Improved primary health care ser
vices.
10.2.3
Tribal girls should be selected and trained as tribal
ANMs and they should be posted in tribal subcentres.
They should also be trained in traditional medicine and
health practices.
Improved health care.
10.2.4
Traditional healing systems must be encouraged and
documented in tribal areas and there should be integra
tion of Allopathic medicine with the Traditional systems.
Promote herbal gardens in tribal areas.
Preservation of traditional healing
systems and use for the benefit of
the people.
10.2.5
Genetic diseases like Sickle Cell Anaemia, G 6 PD
Deficiency, which are, specific to tribals should be given
special importance with adequate funds and expertise,
for their treatment, research and rehabilitation. Second
ary and tertiary care, transport facilities for emergency
services and obstetric care are essential. Community
financing for emergency transport and referrals Health
education, PRA exercises and micro planning, Conver
gent community action, training in communication skills
and mobilisation of local health resources.
Improved health of the tribal
people.
10.2.6
Ensure food security and encourage growing of nutri
tionally rich food crops. Public Distribution System should
distribute cereals like ragi, bajra and pulses instead of
polished rice and sugar. Promote kitchen gardens.
Better nutrition.
J
REPORT OF THE TASK FORCE
Major Recommendations 477
Sl.No.
Major Recommendations
Outcome expected
10.2.7
A HMIS of the health infrastructure, human resources,
vital statistics and other health indicators specially for
the tribals is mandatory and should be an on-going
process.
Health Management is improved.
10.2.8
There should be increased collaboration between the
government and the NGOs in tribal areas. The voluntary
agencies must be involved in the development activities
undertaken by the government.
Collaboration between Government
and Voluntary Organisations for im
proved health of the tribal people.
10.3.
THE ELDERLY
10.3.1
A policy for the elderly should be formulated, with
particular safeguards for women. The administrative
Department responsible for implementation of this policy
should be designated. The management of both public
and private institutions would need to be sensitized to the
special needs of the elderly. Single point counters to
avoid multiple trips to various counters in an institution,
elimination of long waits and personal interaction.
A policy for the elderly is avail
able.
10.3.2
The scale of user fees for health services, if charged,
should be reduced in the case of the elderly patients, so
as to lessen the burden on the household in availing of
medical assistance for the elderly
The burden on the family because
of medical care of the elderly is
reduced.
10.3.3
Geriatric care facilities should be provided at the sec
ondary and tertiary care levels. In addition, private
health institutions should be encouraged to provide such
facilities, and a per-patient payment system by Govern
ment could be considered.
Specialised care of the elderly is
available.
10.3.4
For sensitization to the health issues of the elderly and
training in providing health services to this group, (a) in
house training in geriatric care should be instituted
within the Department, (b) the associations of private
institutions could be requested to conduct similar courses,
and (c) the content of medical, nursing and paramedical
courses to be reviewed so as to train them in geriatric
issues.
Improved care of the elderly.
10.3.5
Health insurance schemes for the elderly need to be
Health Insurance of the elderly in
■
480 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
'
•
.
•
Major Recommendations
Outcome expected
12. HUMAN RESOURCE DEVELOPMENT
FOR HEALTH
2.1
EDUCATION:
12.1.1
The issuing of Essentiality Certificates by the Govern
ment and affiliation by the University for new Medical,
Dental, Nursing, Pharmacy and Physiotherapy Colleges
should be stopped for the next two years, the exception
being Colleges in underserved districts of Karnataka.
This is to ensure quality of education, with adequate
teaching staff and other facilities.
Extend the moratorium on new Ayurvedic, Unani and
Homeopathy Colleges for two more years.
Fill up all vacancies of teaching staff by suitably quali
fied persons
Improved quality of education of
health professionals.
12.1.2
Take up urgently the repairs of the building of the
colleges, hospitals, hostels, equipments and vehicles of
the Government teaching institutions. All equipments
must be maintained in good working condition.
Better facilities for the education
of health professionals J/
12.1.3
Improve the emergency and casualty services. There
should be available round the clock diagnostic (x-ray
and laboratory) services.
Improved emergency care
12.1.4
Medical Colleges should take up 3 PHCs for training
and service. Dental and Nursing Colleges should take
up 1-3 PHCs for the same purpose.
Improved training of students and
better service to the people.
12.1.5
Extra vigilance is necessary at the University examina
tions. Corrupt examiners should be debarred from
examinerships.
Corruption is eliminated.
12.1.6
Monitoring and evaluation (performance appraisal) of
teaching and other staff in the health professional col
leges and affiliated institutions should be carried out
once a year; the performance should be taken into
consideration for promotion and other benefits.
Performance is monitored and ac
tion taken.
12.1.7
Appropriate training and re-training of Heads of Depts,
Resident Medical Officers, Medical Superintendents, Prin
cipals and Directors in management, (personnel, finan-
The hospital administration is im
proved with better utilisation of
facilities.
REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations 481
Outcome expected
cial, materials and time) should be taken up on priority
basis.
The possibility of appointing qualified and trained hospi
tal administrators in teaching hospitals to be considered.
12.1.8
Every professional college should have an education unit
to improve the teaching capability of teachers. RGUHS
should organize teacher-training programmes. Make use
of the facilities at the National Teacher Training Institute
at JIPMER, Pondicherry.
Teachers are better trained; quality
of education improves.
12.1.9
The possibility of bringing the non-teaching staff in
Medical College Hospitals under the control of Depart
ment of Medical Education may be studied and action
taken to implement the decision.
The Officers in the Department of Medical Education
should have sufficient powers to take suitable disciplin
ary action even on staff who are on deputation from the
health department. An administrative manual setting out
the powers and duties may be brought out.
The Officers of the department of
Medical Education have sufficient
administrative and disciplinary con
trol over the staff seconded to the
department.
12.2
TRAINING
12.2.1
Have a detailed survey of the need for training of
paramedics and take appropriate action. Review the job
oriented paramedical courses.
There is co-ordination between the
needs and the availability of trained
personnel.
12.2.2
Auxiliary nurse midwives training to be taken up seriously.
Whether there is needfor extension ofperiod of training to
24 months (from 18 months) must be examined.
Auxiliary nurse midwifes are key
personnel in health and they are
trained well.
12.2.3
Use developments in Information technology for con
tinuing education of all health and allied professionals
and paramedical personnel.
Improved training
12.2.4
The State Institute of Health and Family Welfare
should be upgraded to become the apex training insti
tute, making it an institute of excellence.
The State Institute will be an autonomous body, with
adequate funds for its activities and maintenance
allocated from the State Health and Family Welfare
Department Budget directly.
The State Institute becomes the
nodal institute for all training and
has upgraded facilities.
*
482 REPORT OF THE TASK FORCE
SLNo.
Major Recommendations
Major Recommendations
Outcome expected
The post of Director of the Institute will be selection
post. The tenure will be 5 years. The Director will be
medically qualified and will have training and expe
rience in education technology and training of train
ers. It would be preferable to have persons with
some experience of having worked in the Department
of Health and Family Welfare Service.
The Institute will have full complement of training,
research, administrative and supportive staff with
appropriate qualifications.
- Considering the importance of social sciences and
communication skills, the Institute will have either
full-time / part-time staff for these departments or
engage the services of experts as and when required
for the training sessions.
The Institute will have all the necessary
necessary equipment
equipment
and facilities including teaching / learning space and
identified field practice areas.
- The Institute will have an up-to-date digital library
and documentation centre.
The State Institute will conduct induction and orientation
programems for medical officers and other staff and
arrange for continuing education for all the staff of the
Department of Health and Family Welfare Services and
the Department of Indian Systems of Medicine and Homeopathy.
-
12.2.5
The Regional Health and Family Welfare Training
Centre will be administratively under the State Institute.
- The regional centers will plan and execute the training
programmes based on the needs of the region; these
will be supervised and co-ordinated by the State Insti
tute.
- The Regional Centres should have adequate staff with
requisite qualifications, competence and suitability, as
also all necessary equipment and facilities.
The Regional Centres are able to
meet the specific needs of the re
gion.
.2.2.6
All Districts will have their own District Training Cen
tres to meet the training needs of the district.
The District Centres would be under thq State Insti
tute administratively
- The State Institute will plan (along with the District
The District Centres meet the train
ing needs of the district.
REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations I 483
Outcome expected
Centre), supervise and co-ordinate the training
programmes.
The District Centres will oversee the functioning of
the ANM training centers.
Adequate staff with necessary qualifications and com
petence and all necessary equipment and facilities will
be provided to the District Centres.
12.2.7
The State Institute will, along with the Strategic Plan
ning Cell of the Directorate of Health and Family Wel
fare Services, identify the training needs and draw up a
master plan for the training of staff at all levels. The
training should be in the State mostly. Fellowships /
scholarships offered by WHO, Commonwealth and other
similar organizations must be availed of. The State
Institute and the Planning and Monitoring Division should
work together to get the relevant information and have
the staff deputed according to the needs of the State and
the suitability of the staff member.
12.2.8
The State Institute must plan and conduct courses in
Public Health:
- short term orientation courses (2 weeks?) for all
medical officers and selected other staff;
- longer certificate courses (6 months?) for all medical
staff in the public health cadres, for the period of
transition till sufficient number of persons with DPH
or higher qualification are available.
DPH and higher courses, in collaboration with the Rajiv
Gandhi University of Health Sciences, to be started in 3
years.
13.
The needs of the State for training
are planned and offers for training
utilised.
Public Health regains its impor
tance in improving the health of the
people.
RESEARCH IN HEALTH
3.1
Develop Vision, Mission and Strategy Statement on
research at the primary health care level as also at the
secondary and tertiary levels and in public health.
3.2
Study the status of research projects (completed and
ongoing) managed by the Department of Health and
Family Welfare, Medical Education and Indian Systems
of Medicine and Homeopathy.
The process helps the State to
plan the research activities.
The study helps to improve the
quality of research.
484 REPORT OF THE TASK FORCE
Major Recommendations
Sl.No.
Major Recommendations
Outcome expected
13.3
Set up a Research Board and a think tank to identify the
problems. Invite experts to brainstorm, allocate funds
and resources from Government (state and central),
Universities, Indian Council of Medical Research, De
partment of Science and Technology (ICMR, DST) and
Pharmaceutical Industries.
Improved quality of research and
adequate funds.
13.4
Create infrastructure for digital library, information and
documentation center. Set up access to the Internet and
databases. Make available leading research journals and
publications.
Services of information are in
creased.
14. HEALTH SYSTEMS MANAGEMENT
14.1
14.1.1
ADMINISTRATION
Structure of Health Services:
The emphasis on public health should be revived and its
essentiality recognized; two separate cadres may be con
stituted relating to Public Health and Medical (clinical)
based on integrated and common functions.
Public Health gets its due impor
tance.
14.1.2
The Directorate of Health Services would be in charge
of a Commissioner / Director General of Health Ser
vices. This post would be filled by a senior IAS Officer of
the State Cadre or through contract appointment of an
eminent professional from within the department or out
side it.
More efficient and effective func
tioning.
14.1.3
The levels of health personnel up to the district level
should constitute district cadres, selection to State cadres
being made from these cadres on the basis of merit cum
seniority. Appropriate transitory mechanisms for exer
cise of options by the present staff.
A suitable recruitment mechanism should be established
for appointment of doctors and others at the basic level:
either a District Recruitment Committee or a State level
Local Services Recruitment Board, depending on the
level / grades of staff to be recruited;
District and State cadres come
into effect.
14.1.4
Recruitment doctors would be at the level of the PHC,
assignment to the Public Health or Medical Cadres being
Initial recruitment and subsequent
career in two streams.
„
REPORT OF THE TASK FORCE
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Major Recommendations
Major Recommendations 485
Outcome expected
made after a certain period and subject to qualifications
and training.
14.1.5
A Taluka Health Team under the Taluka Health Officer
may be constituted which includes the Block Health
Educators, Senior Health Inspector, the Refractionist and
the Senior Lady Health Visitor;
A Taluk Health Team is created
14.1.6
The District Health Officer and the District Medical
Officer would be designated as the district health chiefs
and be made responsible for all concerned activities in
the district;
The District health chiefs are iden
tified.
14.1.7
General Administrative Issues:
The restructuring of the health services would call for
amendment of the Cadre and Recruitment Rules and for
consideration of the transitory arrangements. A Commit
tee with the Commissioner as Chairman should be set up
for this purpose, with a mandate to complete the process
in a specified time so that the new structure is in position
in a year's time.
Amendments to C & R rules to
enable the re-organisation of the
health services.
14.1.8
The present system of annual appraisal reports needs to
be reviewed and made performance specific. Also, a
system of medical audit should be instituted for assessing
performance of hospitals;
Improved performance appraisal
so that action can be taken to
improve performance.
14.1.9
Private practice by health personnel would be subject to
the following conditions:
a) Hours of duty will be stipulated in all health / medical
institutions of the Directorate and prominently dis
playedfor public knowledge. The hours of work would
take regional, seasonal and other factors into consid
eration. All personnel should adhere to these hours
and the responsibility to ensure this would be that of
the superior officer;
b) Doctors may be allowed private practice outside these
stipulated duty hours and only when not on call or
required for emergency service, subject to the remis
sion every month to Government of one-third the
basic pay of the staff member who so practices;
c) The Directorate would identify and notify those posts
Conditions under which private
practice by doctors in government
service is permitted are set out
A
486 REPORT OF THE TASK FORCE
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Major Recommendations
where private practice is banned, based on criteria to
be evolved. The incumbents of these posts would be
paid a monthly “non-practicing allowance ” of onethird the basic pay of the post;
d) All doctors in the Directorate, at all levels, would
provide an affidavit at such periodic intervals as may
be specified affirming whether they are or are not
carrying on private practice. This would form part of
the service record;
Those found com ravening the affidavit would be subject
to disciplinary actions as may be prescribed in the
relevant rules. In the long term private practice all
government medical officers will be banned paying them
reasonable salaries.
.. ..:_ . _ . • . £
Major Recommendations
Outcome expected
Medical Officers will be available
for better service, training and re
search
14.1.10
Internal institutional mechanisms for detection of and
enquiry in cases of corruption should be set up for
expeditious detection and punishment;
Corruption is reduced significantly
14.1.11
All externally aided projects would be within the struc
ture of the Department, even if implemented by a distinct
Division within the Department, as suggested in the
restructuring of the Department;
The Department owns the projects
14.1.12
Morale needs to be built up by adoption of transparent
procedures with regard to transfers, selection for training
or courses, regularization of contract doctors, providing
soft loans for transport to PHC doctors and field person
nel and the like.
The morale of the staff is improved
14.1.13
The orders relating to delegation of powers, both finan
cial and administrative, need review. The Commissioner
may carry out such a review.
Better delegation of powers lead
ing to early and appropriate ac
tion.
14.1.14
All vacancies should be filled expeditiously. Vacancies in
a “service” Department result in serious reduction of
quality and availabilty of health facilities;
Budget cuts for health services should not be made since
these not only reduce the scale of the services but also
result in deterioration of existing ones. Such cuts are
counter productive.
Health services function efficiently
and effectively.
14.1.15
It is necessary to extend the technical authority of the
Director, Public Health / Director, Medical over health
The Department of Health Ser
vices provide technical guidance
........ ...........
REPORT OF THE TASK FORCE
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Major Recommendations
Major Recommendations 487
|
Outcome expected
matters m urban areas that are under the control of the
municipal authorities. This could be done through the
issue of orders under the existing Municipal Acts.
to the local administration
14.1.16
The existing mechanisms should be used effectively to
monitor and interact with the specialty institutions, in
cluding the Central ones;
Improved co-ordination.
14.1.17
The possibility of contracting out non-clinical services in
increasing degree should be explored;
Improved efficiency.
14.1.18
The Population Centre may be redesignated as the Cen The Centre for Population and
tre for Population and Health Studies, and its role ex Health Studies becomes a centre
panded. It may be placed under the Principal Secretary. | for evaluation and research.
14.1.19
The system of registration of births and deaths needs to
be reviewed to enhance its accuracy, coverage & utility.
14.2
PLANNING AND MONITORING
14.2.1
A Planning and Monitoring Division should be organized
incorporating the Strategic Planning Cell and vested
with the authority to call for information from all other
Divisions. This Division should be responsible for strate
gic 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 dis
tricts, talukas and Gram Panchayats are integrated into
the State Health Plan, and assessing budget resources for
current andfuture needs, taking into consideration popu
lation, level and norms for services and other relevant
parameters, and assessing human resources and all ma
terial resources on a continuing basis.
The Division would have to include a Reporting and
Monitoring Section, a Geographical Information Sys
tem, a Computer Division and a Perspective Planning
Section.
All reporting activities with regard to the HMIS
should be vested in this Division. The analysis of I
information and generation of monitoring reports for
various levels would be the responsibility of this Divi
sion, to enable assessing performance and initiating
corrective action:
I
Improved vital statistics
A planning and monitoring division
comes into function to plan,
prioritise, workout budget re
sources, monitor and evaluate the
activities of the Department.
-
488 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
■
■
Major Recommendations
Outcome expected
A website would have to be developed and main
tained with all information relating to health services,
including financial and performance details;
- This Division would function as the secretariatfor the
Commission on Health that has been recommended to
be established.
14.2.2
The statistical (HMIS) offices in the districts may be
established with adequate computer facilities. District
level monitoring reports must be produced for enhancing
management capacity at the district level;
14.3
HEALTH MANAGEMENT INFORMATION
SYSTEM (HMIS)
14.3.1
A comprehensive Health Management Information Sys
tem (HMIS) should be put in place by end of the year
2001 to enable the Health and Family Welfare Depart
ment to improve its service delivery. This should include
the following elements:
- Adequately fulfill human power requirements and avoid
mis-matches especially in the posting of Medical offic
ers, details regarding all personnel, at all levels, (viz.
Number of sanctioned posts & number filled; recruit
ment, transfers, leave etc) should be computerised
and monitored.
- Details regarding infrastructuralfacilities - buildings,
equipment; etc. should be monitored continually to
ensure adequate availability, timely repairs, civil works
and so on.
- A comprehensive Disease surveillance system should
be evolved. This should continually scrutinize, moni
tor, evaluate and plan for control &/ or eradication
of diseases, especially diseases of Public Health im
portance and should be useful at grass roots levels for
prevention and management of disease outbreaks.
- The HMIS should be an effective monitoring tool to
assess the performance of the system and which
provides for informed planning and decision by the
DHS. At the same time it should also support micro
planning and management at all levels where action
is essential. The performance indicators & protocols
required for objective monitoring of all health activi
ties up to the subcentre level should be worked out.
••
District planning and monitoring are
effected
Comprehensive Health Manage
ment Information System comes
into place to effectively assist all
activities of the Department.
.
.....
REPORT OF THE TASK FORCE
Major Recommendations 489
SLNo.
Major Recommendations
14.3.2
To increase the efficiency and validity of reporting mecha
nisms, the minimum required data that has to be col
lected should be identified; integrated reporting formats
should be developed and adequate supply of registers/
forms especially at the subcentre level should be ensured.
Reporting improves
14.3.3
The Human power and Infrastructure data, Disease sur
veillance system and a geographical information system
(GIS) should be integrated into one computerized system
Computerization which is envisaged at the District and
State level initially, should be extended to the Taluka and
PHC levels at the earliest.
The staff at decision- making levels should be trained to
use the HMIS & GIS effectively for micro-level action
and planning.
Training in basic computer literacy including GIS System
and data entry and analysis of all categories of staff
involved should be effected.
Connectivity and communication systems between the
different health institutions, offices and levels should be
established. To start with all 27 Districts and Directorate
should be connected. Later all Talukas could be con
nected.
An expert panel should monitor and upgrade the system
to keep up with the constant and rapid evolution in IT.
All data are computerized helping
prompt and easy action.
14.3.4
The present system concentrates on information on com
municable diseases. It should also get geared up for
management of non-communicable diseases, especially
with the changing patterns of diseases due to urbaniza
tion, industrialization, pollution, changing life styles and
life expectancy.
All information regarding commu
nicable and non-communicable dis
eases become available.
14.3.5
The web page of the department should be constantly updated. It should be maximally utilized not only for aware
ness and information but also as a means for promotion
of transparency.
The information is made available
to all
4.3.6
In the long run mechanisms to utilize the computer
networking for “Distance-Learning” programmes, “Tele
Medicine” etc. for the health personnel, and for Health
Education and Health Promotion activities for the com
munity could be identified and implemented
The information is utilised effec
tively for education and promotion
of health.
Outcome expected
9 ■
490 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
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Outcome expected
15. HEALTH FINANCING
15.1
A study of the availability and financing of health
services provided by the State, by local authorities and
by the private sector should be carried out;
Reliable data become available of
the financing of health services.
15.2
Parameters should be evolved for rational allocation of
funds to districts and sub-regions to ensure a degree of
equity in availability of services, with flexibility being
built in for special circumstances, taking into account
the health plans of the Zilla Panchayats;
Greater equity is assured.
15.3
An internal review of specific allocations is necessary to
reflect the needs of certain essential activities in a
realistic manner. This would be particularly necessary in
the case of supporting and infrastructure services. Some
of the critical areas which would need enhanced alloca
tions would include repairs of vehicles, equipment and
buildings, touring for better supervision and administra
tive charges of the PHCs;
Improved allocations to critical
areas.
15.4
Budgetary cuts should not be made in allocations for
health services. Such cuts destroy continuity and levels
of services built up over time and only prove counterpro
ductive in the long run;
Continuity of services at optimum
level is assured.
15.5
It should be ensured that release offunds and sanction
orders are issued well in time and that the quantum of
funds released should be adequate since such releases, in
combination with sufficient financial delegations, would
ensure maintaining and improving health services;
Improved utilisation of finances in
time and, therefore, optimum ser
vices.
5.6
It is necessary to ensure coordination in the budgeting of
the various Departments and Divisions of the health and
medical services. This responsibility may be assigned to the
Commissioner as a coordinating officer, with authority to
callfor informationfrom associated Departments /Direc
torates. The Planning and Monitoring Division to be
established directly under the Commissioner may be
assigned this role. To assist this Division apost ofFinancial
Adviser be created in this Division. This post could befilled
by a health economist or by selection, based on experience,
from the State Accounts Department or Planning cadres of
Government;
Improved budgeting
REPORT OF THE TASK FORCE
Major Recommendations 491
Sl.No.
___________ Major Recommendations
15.7
The need for the current large number of distinct ac
counts offices in various Directorates / Departments of
the health services results in lack of coordination. The
possibility of their integration would have to be studied.
The study will bring out informa
tion, based on which action can be
taken on integration of the ac
counts offices
15.8
The adequacy and implementation offinancial delega
tions within the health services would need review. This
may be done by a Committee under the Chairmanship of
the Commissioner.
Nonperformance due to non-utilization of delegated au
thority should be one of the parameters for assessing
annual performance;
Delegation of financial powers ap
propriate to the level of responsi
bility; the officers will be account
able for performance.
15.9
Internal procedures for monitoring expenditure, par
ticularly in the case of acquisition of equipment and
infrastructure, would need to be reviewed to ensure
expeditious utilization of allocations in the best manner
possible;
Better utilisation of the funds.
15.10
The reporting system andformats prescribedfor the field
level officials, particularly the ANMs, would need to be
reviewed to rationalize them and reduce workload.
Rationalisation of the reporting sys
tem at the field level
15.11
A comprehensive review of the financial reporting sys
tem is necessary so that it becomes part of the HMIS
that has been recommended;
A rational financial reporting sys
tem is in place.
15.12
The system of user fee is a good feature and should be
periodically reviewed to enhance both the base and the
scale of fees, if called for. It would be necessary to
reiterate that the collection of user fee by a hospital
would be exclusively meant for its improvement;
15.13
Schemes for community insurance based on Self Help
Groups for non-hospitalization cases or with involve
ment of national insurance companies for hospitalization
cases should be formulated and tried out on a pilot basis
to develop a replicable model;
15.14
A scheme for liability insurance for doctors in the
Department, including group insurance schemes, needs
to be formulated in consultation with public sector
insurance companies, including the Karnataka Govt
Outcome expected
Periodical review and revision of
user fee to be used by the hospi
tal, where the fees are collected
Community insurance to be tried
out on a pilot basis.
A scheme of insurance against
claims of damages to be worked
out.
492 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations
Outcome expected
Insurance Department. The scheme may stipulate that
doctors meet half the costs of the premium;
15.15
Norms for health services based on adequacy of ser
vices and quality should be developed as guidelines for
formulation of budget requirements. These norms would
also provide guidance for assessment of the financial
elements of the perspective plan for health services;
Norms in terms of both quality and adequacy, with
regard to expected outcomes of expenditure need to be
evolved for monitoring of efficiency of use of funds.
Such norms must be developed for various functional
levels, including the Zilla Panchayats;
The long-term requirements of health services would
need to be assessed on the basis of the norms suggested
above and on the basis of the perspective plan for health
services. In assessing these requirements, the require
ments to sustain the assets and services created at
considerable cost through externally aided projects must
be built in.
Norms would be available for bud
geting and other requirements.
15.16
Test audit through chartered accountants may be tried
on a pilot basis for evaluating the performance of health
services at PHC and taluka levels and also to induce a
sense of financial discipline. A pilot audit could be
instituted in consultation with the Institute of Chartered
Accountants. The Planning and Monitoring Division
could be the nodal office for this pilot study;
Auditing of PHC would be done,
first as a pilot study and extended
if found feasible and useful.
15.17
A study is necessary of the scale of health services and
the financial outlays on such services in Municipal
Corporations and other municipal bodies to assess the
total health expenditure on health in the public domain.
Such a study would help in assessing the needs in urban
areas.
The financial and other needs of
the urban areas become known.
15.18
A study of costs on health services to families may be
conducted, after an evaluation of the results of studies
already available, for guidance regarding enhancement
of services for the economically weaker section of soci
ety at affordable costs;
A major part of the health expen
diture is met by the family, which
makes the family impoverished;
affordability of services must be
known.
REPORT OF THE TASK FORCE
Sl.No.
15.19
15.20
___________ Major Recommendations
The staffing pattern would need to be reviewed at
intervals to determine both adequacy and excess and
critical shortages. A Staff Inspection Unit trained in
Organization and Management principles could be as
signed this task;
A financial database may be built up as part of the
composite HMIS that has been recommended for the
health services. The system of computerization offinan
cial information and of the accounts should be built up
without delay.
16.
16.1
Major Recommendations 493
_____ Outcome expected
Adequate staffing is critical in the
optimum functioning of health care
services.
The financial needs and utilisation
will be known.
RATIONAL DRUG MANAGEMENT
Procedures should be established for quantifying the
essential drugs required for the State, to optimize the
pooled procurement through the Rate Contract.
The Zilla Panchayats may make use of the rate contract
for 90% of their requirements, reserving 10% for discretionary purchase.
The quantity of the essential drugs
required are known to get advan
tage of the bulk purchases through
the Rate Contract System.
16.2
Procedures should be e: ” ' ’
diLSerni~
nating, utilizing & revising Standard Treatment Guide
lines.
67
Pi ocedures. should be establishedfor developing & revisontreatment'^hoi^r^e
F
Essential Drug Lists based on level
of expertise available and Formu-
secondary, tertiary, speciality and tedcliing:
lary for institutions at different lev
els become available.
16.4
Every hospital should have a Drugs & Therapeutics
Committee for monitoring & promoting quality use of
medicines. Specific guidelines for Rational Use of drugs,
especially, Antimicrobials and Analgesic are a must.
Use Generic names of drugs for procurement, supply and
prescribing.
Implement problem based training in pharmacotherapy
in undergraduate medical & paramedical education based
on Standard Treatment Guidelines to promote Rational
use of Drugs.
Encourage problem-oriented in-service educational pro
grams by professional societies, universities, & the min-
Standard Treatment Guidelines are
worked out to improve the out
come of treatment.
Rational Use of Drugs will be as
sured.
494 REPORT OF THE TASK FORCE
SI.No.
Major Recommendations
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Outcome expected
Istry of health & require regular continuing education for
licensure of health professionals.
Stimulate an interactive group process among health
providers and consumers to review <&. apply information
about appropriate use of medicines. Train pharmacists
to be more active members of the health care system &
to offer better advice to consumers about health &
drugs.
The concept of Drug Information should be popularized
among the health care professionals & the public. Drug
Information Centre must be accessed for unbiased, ob
jective information.
The Services ofjhp State Karnataka Pharmacy Council
may be utilized for all the above purposes.
16.5
Monitor adverse drug reactions so that appropriate and
early measures can be taken to ensure safe use of drugs.
Encourage active involvement by consumer organiza
tions in public education about drugs and allocate gov
ernment resources to support these efforts.
Procedures should be established to ensure proper label
ing of drugs. The packages and the inserts should be
adequately labeled to enable people to use drugs prop
erly. It should also mention most common side effects
and danger signals, special precautions in case of chil
dren, pregnant and lactating mothers, and old people.
The labeling should be printed in adequately bold size.
The labeling in case of O.T.C. drugs should be more
detailed, giving all indications, contraindications, com
mon side effects and danger signals. The labeling should
be made in English, Hindi and the regional language.
Improved safety in the use of drugs.
16.6
The Government Medical Stores and the District Stores
to be re-organised to ensure proper and on-time distribu
tion of all essential drugs. Monitoring of drugs to be
received from the centre, their actual receipts and supply
to be monitored vigorously.
The Medical Stores at the State
headquarters and districts are re
organised for greater efficiency and
effectiveness.
6.7
The Drug Control Department to be re-organised with
sufficient number of Drug inspectors and Drug testing
laboratory. Regulation of Drug Company's Promotional
Activities is important. Promotional literature for phar-
The Drug Control Department is
able to perform its duties better.
REPORT OF THE TASK FORCE
Major Recommendations 495
Sl.No.
___________ Major Recommendations
Outcome expected
maceuticals, guidelines for sponsorship of Symposia and
Other Scientific Meetings, Advertisements, Free samples
of prescription drugs for promotional purposes, Post
marketing scientific studies, surveillance and dissemina
tion of information should conform to guidelines.
16.8
6.9
16.10
A strategic approach is to be developed to improve
prescribing in the private sector through appropriate
regulation & long-term association & collaborations with
professional associations.
In view of the trends in increased use of traditional
medicines, it is essential to facilitate the establishment of
regulation and registration of traditional medicines.
The services of the Karnataka Antibiotics and Pharma
ceuticals Limited to be made full use of, for the produc
tion of quality drugs needed by the State.
More rational use of drugs in the
private sector also.
Better regulation of the use of tra
ditional medicines.
Better use is made of the facilities
of Karnataka Antibiotics and Pharmaceuticals Limited.
17. LAW AND ETHICS
17.1
17.2
7.3
7.4
7.5
Implement effectively the existing laws affecting health
and health care, and especially the laws such as the
Human Organs Transplant Act, 1994 and the Prenatal
Diagnostic Techniques Act, 1994.
Renew the registration of health professionals in the
Stateoncejn^years, With evidence of sufficient credits
oj having participated in approved continuing education
programmes.
The respective professional councils should ensure that
the members of the profession practice ethically, follow
ing their codes of conduct.This may be done through an
amendment of the respective Acts.
Enact a comprehensive law to ensure registration and
quality assurance of all health care institutions in the
state, on the lines suggested by the Task Force and
forwarded to the Government. Promote accreditation.
Enact a comprehensive Public Health Act, based on the
Effective implementation of the ex
isting laws is assured.
---------------------------- ------------------ -
Prevention of obsolescence and
upgrading of competence.
It is the duty of the professional
councils to ensure that the mem
bers practise ethically.
Quality assurance and continuous
quality improvement.
An effective and comprehensive
496 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations
Outcome expected
Model Public Health Act (1987) with suitable modifica
tions.
Public Health Act is in place.
17.6
Examine in depth the problem of quackery and take
effective steps to stop it.
Quackery, which is a hazard to the
health of the people, is reduced.
17.7
Arrange for monitoring of the activities under the Hu
man Organs Transplant Act, by an independent agency,
to stop the sale of organs. The Institutions should ac
tively promote cadaveric transplants and those perform
ing more than 20% unrelated live donor transplant of
kidneys should not be re-certified. There should be dialy
sis in all district hospitals.
The Appropriate authority for Organ Transplantation
may be reconstituted with inclusion of representatives of
voluntary organisations.
The sale of organs is reduced;
more cadaveric transplants are
encouraged.
17.8
Every health care institution to have a Charter of
citizens rights and rights of patients. The Charter
should be displayed prominently.
Greater transparency and integrity.
Rights of patients are honoured.
17.9
Update the Prohibition of Smoking Act”. Ensure the
welfare of tobacco growers when cultivation is restricted
& of beedi workers when manufacture & use are reduced.
Use of tobacco is reduced and
thereby, the harmful effects on the
health of the people.
17.10
Make the teaching/leaming of ethics as part of health
professions education.
Make the health personnel aware of the codes of conduct.
Have training programmes in medical ethicsfor all health
care personnel and particularly the doctors and nurses.
The health care personnel practise
ethically.
18.
INDIAN SYSTEMS OF MEDICINE AND
HOMOEOPATHY
8.1
The sanctioned post of Joint Director is to be filled. In
the absence of C & R rules the senior person may be
placed in charge and duties may be assigned. Existing
senior doctors may be designated as District level offic
ers of the respective districts. In 11 districts where there
are already hospitals, it can be implemented immedi
ately. These district level officers posts are to be filled
by selection based on merit-cum-seniority.
A senior, experienced experienced
person is in charge, at the same
time ensuring competence.
8.2
Dispensaries and hospitals are to be renovated after a
survey by the Department. Develop uniform norms for
Improved facilities in the units of
ISM&H.
A.
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REPORT OF THE TASK FORCE
Major Recommendations 497
Sl.No.
___ ________ Major Recommendations
dispensaries and hospitals, with regard to plan, space
infrastructure and staff.
’
Construct special wards with all amenities atleast in the
major hospitals attached to teaching institutions at Bangalore, Mysore and. Bellary.
18.3
8.4
Establish or relocate units of ISM&H with necessary
infrastructure at CHCs, Taluka and District hospitals.
Establish herbal gardens in ISM&H units, PHCs and
U‘lllSatlon and demonstration for the public
with the help of forest department (social forestry).
Outcome expected
Availability of modern medicine
and Indian Systems of Medicine
and Homeopathy, at the same
place, choice is left to the people.
Improved use of herbal medicines.
8.5
Provide residential accommoation near the place of
work for physicians of ISM&H. If Government accom- Availability of doctors of ISM&H
is improved.
modation is not available, houses may be
taken on rent.
18.6
There is an urgent need to make available the facilities
for investigahve procedures with qualified and technical
staff in all the hospitals. This can be done in collabora
tion with the hospitals of modern medicine at various
18.7
18.8
18.9
18.10
The services of contract doctors need to be regularized
based on performance appraisal
Improved availability of diagnostic
procedures.
Improves the morale of the doc
tors.
The Boards of Visitors are to be re-constituted immediately in order to improve the functioning of the hospitals.
Better people’s involvement.
Provide all dispensaries and hospitals with a working
telephone
6
Improved communication.
Establish the speciality units of panchakarma and
hospiC
!ahra m
h°SpitalS firSt and then taluk
jhe major hospitals are to be upgraded and enlarged to
meet the requirements and demands with adequate hu
manforce, equipments and other accessories, after a
need assessment.
J
Well-planned OP blocks in all the major hospitals of
Bangalore, Mysore and Bellary.
Have speciality treatment available.
Major Hospitals are upgraded.
498 REPORT OF THE TASK FORCE
Major Recommendations
SLNo.
Major Recommendations
Outcome expected
18.11
Fill up the vacant post of Siddha Physician in the 10bedded Siddha ward at Sri. Jayachamarajendra Institute
of Indian Medicine, Bangalore.
The post of Siddha Physician is
filled.
18.12
There is a need to enhance the budget provision for
procurement of medicines in dispensary atleast to a sum
of Rs.36,000/- p.a.
Increased availability of essential
drugs
18.13
Steps have to be taken to provide hostel facilities in all
the major medical colleges.
Improved accommodation for the
students.
18.14
The disparity in pay scales of doctors and stipend for
internees ofISM&H and modern medicine may be studied
and action taken on priority, to remove the inferiority
feeling or low esteem prevailing amongst doctors and
students of ISM&H
Disparity reduced.
18.15
Study the needfor developing appropriate training courses
with special modules for paraclinical staff such as Mas
seurs, Nurses ,Health extension workers and pharma
cists and take necessary action
Paramedical staff become avail
able, with improved quality and
numbers.
18.16
The facilities of the State Institute of Health & Family
Welfare should be made use offor the training of ISM&H
personnel. The training should include hospital manage
ment for those in charge of hospitals.
Improved training in all aspects
including management.
18.17
CME courses must be periodically conducted to update
knowledge and skills of the practitioners of ISM&H.
Sufficient credit hours must be earned for the renewal of
registration by Karnataka Ayurveda and Unani Practi
tioners Board and Karnataka Council for Homeopathic
Medicine. Professional and Technical support may be
obtained from the teaching institutions (Both Private
and Government).
Constant upgrading of the knowl
edge and skills of the doctors.
18.18
10 seats may be reserved in MBBS course in the Govern
ment Medical Colleges for eligible ISM&H graduates, 7
for Ayurveda, 2 for Homeopathy and 1 for Unani, to
bring about integration.
There is greater integration and
possibility of research into the ef
ficacy of different systems of medi
cine.
18.19
All the teaching institutes of ISM&H must take up
defined geographic areas in order to effectively execute
Improved involvement of ISM&H
in primary health care.
REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations 499
Major Recommendations
Outcome expected
public awareness programmes and for primary health
care (through the dispensaries and mobile units). The
need for trained ISM&H health workers for extension
work may be studied and action taken so that they can
take up health promotion work in the villages.
18.20
Tntroductory lessons on ISM&H systems viz., Ayurveda,
Unani, Naturopathy, Yoga, Siddha and Homeopathy
should be included in the curriculum of schools and
colleges, which would create awareness among the chil
dren. The institutes of ISM&H should take up school
health programmes in the neighbouring schools.
18.21
An expert committee may be appointed to consider the
upgradation of the Government Pharmacy after studying
TAMPCOL of Tamil Nadu or AUSHADHI of Kerala.
A Homeopathic Drugs Manufacturing Unit may be started
to make medicines in sufficient quantities to meet the
demands of the entire state.
8.22
To meet the increasing needs of ISM&H, a post of
Assistant Drug Controller may be created and filled up
by suitably qualified candidate
Qualified homeopathic doctor may be appointed as drug
inspector to inspect the Homoeopathic manufacturing
units.
The department of ISM&H must prepare essential drug
lists for each system. A medicinal plant board may be
established which would ensure quality, consistency and
price.
18.23
Encourage research. Appoint a Senior Research Officer
in ISM&H. Reconstitute the research advisory commit
tee. Rajiv Gandhi University of Health Sciences may be
requested to establish interdisciplinary research board,
comprising of experts of ISM&H, modern medicine and
scientists of basic sciences. RGUHS may be requested to
frame standard guidelines for protocols for thesis / dis
sertations for postgraduate courses in ISM&H.
The financial support to PG researches may be enhanced
to Rs.2,500/- p.a.
Encourage research in ISMH through financial support
Greater respect for all systems of
medicine; improved health of school
children.
Greater availability of quality medi
cines.
Quality assurance of the drugs
under ISM&H.
Research in ISM&H is improved.
.... .
500 REPORT OF THE TASK FORCE
SI.No.
Major Recommendations
Major Recommendations
Outcome expected
for interested and dedicated practitioners and private
academic institutions.
18.24
Government should provide about 50-100 acres of land
for ISM&H in each district for cultivation of medicinal
plants, which should be harvested and utilised by the
Government Central Pharmacy.
Improved availability of medical
plants.
18.25
The government should effect immediately the promo
tions that are due and implement time bound promotions
Improved morale and better func
tioning of the department.
18.26
Appoint a qualified person competent in editing / pub
lishing to effectively bring out publications including
health promotion materials
Publications are brought out on
time.
18.27
Doctors qualified in particular system of medicine should
practice only that system; cross practice must stop in the
interest of the public and to develop the particular
system of medicine.
Doctors practise only that system
in which they are competent.
18.28
Have a comprehensive HMIS for all the institutions and
services under ISM&H.
Improved availability of informa
tion for better management.
19. PANCHAYAT RAJ AND EMPOWERMENT
OF THE PEOPLE
19.1
The involvement of the Panchayat institutions and of
the community in providing health services should be
encouraged for improvement and enhancement of these
services based on real needs. For enhancing such
involvement, information should be available to the
community and a forum must be developed. It would
also be necessary to sensitize the officials in this regard;
Greater involvement in Panchayat
Raj institutions and people for im
proved health services.
19.2
Sec. 61 of the Karnataka Panchayat Raj Act may be
amended to establish a separate Committee for health,
sanitation and education in the Gram Panchayat;
The committee concentrates its at
tention on health, sanitation and
education.
19.3
Training courses in health for empowering women mem
bers of the Panchayats and women community leaders
need to be organized. Such empowerment would improve
the effectiveness ofprogrammes such as RCH, children's
and women's health in the community;
Improved involvement of women
members in health and family wel
fare.
REPORT OF THE TASK FORCE
SLNo.
_________ Major Recommendations
19.4
Model health plans need to be formulated by the
Panchayat institutions. Such model plans would assist in
developing the health component of the District Develop
ment Plan;
19.5
The health hierarchy needs to be oriented regarding its
role in the Panchayat system and its relationship with
these bodies; monitoring of implementation of State
funded activity, supervision and inspection continue to be
a direct responsibility of the hierarchy;
A system of monitoring the health activities of the ZPs by
the Commissioner needs to be established;
The Rural Development and Panchayat Raj Department
and the Health Department may develop a system of
feedback from the health hierarchies in order to render
the mutual inter-active role between the Health Depart
ment and the Panchayat bodies more productive;
It would be necessary to conduct orientation courses /
workshops for the health hierarchy so that there is a
better understanding of both their role and responsibility
in the Panchayati Raj system. The Rural Development
and Panchayati Raj Department could organize such
courses.
19.7
The meetings of the ZPs may be regulated according to
the circulars of the Department of Rural Development
and Panchayti Raj regarding frequency, so as to permit
district health personnel, particularly the DHO, to carry
out inspections and supervision more intensively;
19.8
Village communities should be encouraged to form Vil
lage Health Committees with wide membership, includ
ing representatives of women's groups, the youth, the
ANMs, the Anganwadi Workers, and others. The Gram
Panchayat is empowered to constitute such committees
under Sec. 61 - A of the Act.
These Village Health Committees would have to be
trained in the conduct of meetings, prioritizing local
health issues, preparation of health plans, etc. Institu
tions such as the Institute for Social and Economic
Change could be assigned this function;
The formulation of a pilot project for the formation of
Major Recommendations 501
Outcome expected
Improved health plans as part of
Development Plan.
Better co-ordination between the
department of Health and Family
Welfare Services and the local au
thorities, with clear responsibility
of the department in all technical
matters.
The DHOs can plan and imple
ment their other activities effec
tively.
Greater involvement of the people
in all health activities.
502 REPORT OF THE TASK FORCE
Sl.No.
Major Recommendations
Major Recommendations
Outcome expected
such Committees, developing necessary training mate
rial and sensitization could be assigned to the Institute
for Social and Economic Change, Bangalore. The State
Institute for Health and Family Welfare should also be
involved in the process of sensitization of the official
hierarchies.
20.
STRENGTHENING PARTNERSHIPS
PRIVATE / CORPORATE SECTOR,
, GENERAL PRACTITIONERS AND VOLUNTARY
ORGANISATIONS
20.1
Enhance the scope/importance of collaboration with
the private and voluntary sectors in primary, secondary
and tertiary level of health care.
Involve private sector in preventive and promotive care
in addition to curative care.
Promote partnership between public, private and volun
tary organisation.
Improved collaboration between
public, voluntary and private sec
tors in all aspects of health care.
20.2
Evaluate and monitor quality of services in the private
and voluntary sectors.
Quality assurance is a must which
ever be the sector.
20.3
NGO cell should 'be created directly under the Commissioner/DGHS and representatives ofvoluntary organisations
working for the health sector should be members of it. The
cell should register all organisations & bring out the annual
report of the activities of voluntary organisations. The
grant-in-aidprocedures must be simplified and the bottle
necks removed, to help better collaboration and remove the
feeling offrustration.
The logistics ofpartnership concept between the govern
ment and voluntary organisation has to be worked out
by the central cell and the government. Voluntary agen
cies should be invited to participate in the preparation of
health policies by the Government.
Co-ordination and credibility.
Greater involvement of credible
voluntary organisations in health and
development.
20.4
The agencies, have to be used more and more for the
effective implementation ofNational Programmes, spread
ofhealth education & act as a watch-dog over the provision
of health services within the public/private sectors.
Better performance of the National
and other programmes.
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REPORT OF THE TASK FORCE
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Major Recommendations
Major Recommendations 503
Outcome expected
21. MULTISECTORALITY AND
INTERSECTORAL COORDINATION
21.1
The State must establish administrative machinery and
Co-ordination committees at the State, district and local
levels for intersectoral action for health. These groups
must be involved in the preparation of the State plan.
Have a High Power Core Committee (intersectoral)
headed by the Chief Secretary at the state level and
committees at the district level with participation by
D.Cs and C.E.Os. The Committees should have repre
sentations from Health, Education, Women and Child
Welfare, Agriculture, Horticulture, Animal Husbandry.
Irrigation, Housing, Industry, Pollution Board and Envi
ronment. Subcommittees can be formed to reflect and
take action on specific matters.
21.2
All developmental programmes must have inputs from
the health sector to make use of the opportunity to
.improve health and prevent problem'.ms.
Better collaboration between all
health related sectors
Some development programmes
might have adverse effects on
health; these can be avoided by
action during planning, and imple
menting.
Health personnel (Public Health) should be trained to
anticipate andfind solutions to possible health hazards of
developmental programmes. They should continue their
association during implementation, monitoring and evalu
ation of the programmed
22. THE KARNATAKA STATE INTEGRATED
HEALTH POLICY 2001
22.1
>2.2
The draft integrated health policy should be adopted
after dialogue with Directorate of Health and Family
Welfare Services, other Government Departments and
Public.
Wide circulation and debates
among all stakeholders can im
prove the policy and its implemen
tation for better health for all.
A Commission on Health would be constituted to provide ]Enhancing responsiveness of
policy inputs and expert guidance to the Directorate of health Services to meet c'urrent
Health
Health Services.
Services.
needs and expectations.
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£
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