KAR NATAKA TOWARDS EQUITY, INTEGRITY AND QUALITY IN HEALTH
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- Title
- KAR NATAKA TOWARDS EQUITY, INTEGRITY AND QUALITY IN HEALTH
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KARNATAKA
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TOWARDS EQUITY, INTEGRITY AND QUALITY
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IN HEALTH
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Focus on
Primary Health Care
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Public Health
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SUPPLEMENT TO THE FINAL REPORT
VOLUME -1
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APRIL 2001
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TASK FORCE ON HEALTH AND FAMILY WELFARE
GOVERNMENT OF KARNATAKA
PHI Building, Shcshadri Road,
Bangalore 560001.
Ph: 2271021, email; khsdp@vsnl.com
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CONTENTS
VOLUME -1
I
Research studies conducted by the Task Force on Health and Family Welfare
1.
Proposal for Review of Organisation Structure and Design of Job Responsibilities for 1
Health and Family Welfare Department.
2.
Review of Externally Aided Projects in the context of their integration into the
Health Services Delivery in Karnataka.
137
©
Training Programmes for Health Personnel in Government Service in Karnataka.
200
©
Public Health Care Services under Panchayat Raj System in Karnataka.
321
©
/
be
CX
Disparities in Health and Health care Services.
360
Review of Role of Private Sector in Health Services (Access and Quality).
381
VOLUME - H
7.
Health Expenditures in the State Budget.
1
8.
Peoples Perceptions of Public Health Care Services in Karnataka.
28
9.
Research Study on the Feasibility and Modalities of application of principles of 73
Health Promotion and its integration with Health Education.
n
Does Karnataka State need more Medical Colleges?
148
III
Indian Systems of Medicine and Homoeopathy.
212
IV
Rational Use of Drugs.
234
V
Alcohol Use and Misuse in Karnataka.
289
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1. ACKNOWLEDGEMENTS
1.1
This study is funded by World Bank aided Karnataka Health Systems
Development Project (KHSDP) for the Task Force on Health - Government of Karnataka.
We would like to express our sincere thanks and appreciation for the support and
constant guidance provided at various stages of the study.
1.2
In particular, we would like to thank Dr. H. Sudarshan, Mr. P.Padmanabha IAS
(Retd) and Dr. C.M.Francis for their valuable guidance, comments and suggestions
during the study.
1.3
We are grateful to Mr. Arvind Risbud, IAS, Project Director- KHSDP & his staff for
giving us an opportunity to carry out this study for the Task force on Health by funding
and providing us with valuable data.
1.4
We are indebted to Dr. G.V.Nagaraj - Director of Health Services and his entire
staff at the Directorate, at the District level both urban and rural for providing us all the
support in completing the study through their inputs, suggestions, data etc.
1.5
We would like to express our appreciation to the following who have spared their
valuable time to give their suggestions for the study especially the office bearers of
KGMOA.
Members, Task Force on Health - Dr. Ramesh Bilimagga Dr. Maiya
Dr. Latha Jagannathan, Dr. Thelma Narayan & Others
Prinicpal Secretary (Health) - Mr.Abhijit Sengupta, IAS
Commissioner of Health - Mr. Sanjay Kaul, IAS
Project Director, IPP-IX - Mr. G.V.K.Rau, IAS
Deputy Secretary - Mr. Mohan Chakravarthy, KAS
Director of Medical Education - Dr. Seethalaxmi
Project Administrator, IPP-VIII - Dr. Jayachandra Rao
Directorate Staff- Additional Directors, Joint Directors, Deputy Directors,
Chief Administration Officer, Administration Officer & Others.
Divisional Joint Directors - Bangalore, Mysore & Gulbarga
Office bearers - Karnataka Government Medical Officers Association
Staff of IPP-VIII, IPP-IX, KHSDP & AIDS Society
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District Health Officers & District Surgeons of Gulbarga, Mysore, Kolar,
Belgaum, Bangalore - Urban & Rural Districts
Medical Superintendent & Staff - Jayanagar General Hospital
Director & Staff - State Institute of Health & Family Welfare
CEO - Zilla Panchayat - Mysore - Mr. Sundar Naik, IAS
Medical Superintendent & staff - K R Hospital, Mysore
Deputy Director, Indian System of Medicine & Health, Bangalore.
Dr. David Peters - Public Health Specialist, World Bank, India Office, Delhi
Staff at Office of Task Force especially Dr. Deepak & Lakshmi
Administrative Medical Officers and Staff at PHCs/CHCs/Taluk Hospitals
and District Hospitals in Gulbarga and Bangalore Rural Districts.
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2. EXECUTIVE SUMMARY
2.1
This study is instituted by The Task Force on Health, Government of Karnataka,
to study if any anomalies in the organization structure and present reporting system in
the hierarchy of the Dept, of Health & Family Welfare Exist and the possible ways of
addressing them and improve system to face the challenges posed by the external
environment of the day to deliver quality health services with equity.
2.2
M/S. A.F. Ferguson & Co. (AFF) has been assigned the task to study the above
mentioned tasks and also the possible work areas or the essential job descriptions of the
unique positions in the organization. This part of the report forms the Volume I (Review
of Organization Structure) of the report.
2.3
The methodology has been a qualitative approach of data collection and
discussions with various people involved in the system. The key issues addressed in the
process of study are:
•
Increase focus on Promotive and Preventive Health (Public Health)
•
Equal promotional avenues for Clinical staff
•
Increase the morale of the people working in the system
•
Increase the accountability of the personnel on the performance of the
system
•
Bring all round development in the state in the area of Health care to remove
regional disparities
•
Identify the key training areas required for keeping the technical personnel
abreast with contemporary knowledge and thus contribute for the success of
the department
2.4 The key issues observed during the study are :
•
Very wide span of control for DHS / commissioner, to the extent of handling
the national and state health programs directly
•
More importance to the stream of Public Health personnel during certain
period, thus providing more promotional avenues for personnel with DPH
qualification
•
Improper division of functions to Public Health specialization people and the
clinical people has lead to skewed promotional avenues.
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•
Subsequently, after having brought both Public Health (both preventive &
promotive) and Medical (curative / clinical) into the same stream, the
importance for public health has diminished.
•
The reliance on clinical personnel on carrying out the public health programs
leading to dilution of both clinical and public health activities
•
Improper coordination among the main Health & FW department and the
Externally Aided Projects (EAPs), leading to duplication of certain activities.
•
Dual reporting at which the administrative reporting has taken more
importance
•
Reporting to peer groups for lack of promotional posts at certain levels in the
hierarchy leading to lack of authority in such posts.
•
Neglected North Karnataka region
•
Redundant DJD position
•
Lack of Health directed leadership from ZP
•
Imperative need for clearly defined job roles at all levels
•
Poor health management and programme management skills among senior
health staff at all levels
•
Multiple training programmes leading to duplicity without clear objectives and
outcomes
All the above issues are looked at primarily from the structure point of view and
are addressed accordingly. The key recommendations are given as below:
•
Bifurcate the Directorate of Health Services of the Department of Health &
Family Welfare into two basic functions of Clinical & Curative health (Medical)
and Preventive & Promotive health (Public Health) and merge all the activities
accordingly to these functions.
•
Have a common entry point at PHC level for all cadres and divide into Medical
and Public Health from Taluka level hospital onwards or from the Primary
Health Centre itself as suggested by Jungalwalla Committee report in mid
seventies
•
Personnel to be sent to specialisation courses depending on the requirement
of the department
•
Have lateral entry for the specialist cadre if found imminent. However, the
option of hiring external doctors on contractual basis can also be considered.
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Enhance the capabilities of the planning wing to work on the issues of short
term and long-term avenues / strategies for the organization
All the future External aided Projects under the control of
Commissioner/DGHS, with a Director as head of EAP and thus converting the
projects into programmes mode to be executed by the relevant functionaries
in the department itself
•
Emphasis for the NGO participation in the activities of the health Dept. esp.
related to Promotion and Preventive Health. To have a Nodal Officer/
Consultant on Advisor in the NGO Partnership Cell in DHS who will coordinate
all the enquiry's, execution and monitoring of NGO activities through a single
window at the DHS.
•
A separate cell for all procurement, maintenance and construction activities as
part of the Directorate of Health which follows the World Bank Aided KHSDP
norms
•
Create an autonomous institute in form of State Institute of health & Family
Welfare (SIHFW) and provide all inputs to manage it independently.
•
To create mechanisms to improve capacity building by induction training,
retraining in clinical skills at periodic intervals, management training for all
Administrative posts, create incentive mechanisms, increase pay scales,
motivational programs at regular intervals, reward outstanding workers and
provide proper infrastructure both at the health institution and official
residence.
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3. INTRODUCTION
3.1
A.F.Ferguson & Co. - MCS division (AFF) have been retained by Karnataka Health
Systems Development Project (KHSDP) to review the structure and functions of the
Health & Family Welfare Department and to design of job responsibilities for
offices/posts in the said Department.
Background to the Study
3.2
Karnataka State has had an impressive record of development and has indeed
been a pioneer in public health development. The present basic structure which has
evolved from the system in vogue in the Princely state of Mysore, has been remarkable
for its approach to primary health care.
3.3
The planned focus of the health department has eroded over the years leading to
the following key concerns of the department as mentioned by the Task Force on Health:
•
Neglect of public health
•
Distortion in Primary Health care implementation
Poor Governance
•
Human Resources Development Inadequately addressed
•
Lack of integration of Externally Aided projects with the mainstream
3.4
A need was felt to bring about higher emphasis in public health care and resolve
the key issues outlined for effective implementation of National Health programmes.
Health care and public health thus being one of the thrust areas for development and
improvement, the Government of Karnataka has considered the need for review of the
current state of Health System so as to ensure 'Health for all' with equity and quality.
3.5
In order to propose measures to improve the public health care systems in the
State of Karnataka, the Department of Health Services and Family Welfare (DHS) has set
up a Task Force, consisting of eminent persons in various fields, which will examine the
issues involved and propose measures which could be adopted by the Government.
3.6
In this regard, the Task Force has conducted a preliminary study and presented
an interim report dealing mainly with short-term recommendations, which can be
implemented within a period of 6 months. It has also identified areas of concern, which
can be accomplished in the medium and long term. The Task Force invited AFF for
consultation in review of structure and functions and design of job responsibilities for
offices/posts in the Health & Family Welfare Department.
Terms of Reference
3.7
The Terms of Reference (ToR) for the study is as follows :
•
To collate the available job descriptions and related information from various
offices visited and submit the same to the task force
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•
To review the present structure and functions of offices in the Health &
Family Welfare Department
•
To determine improvements/changes and to design job responsibilities for
various posts of Health & Family Welfare Services
Scope of Work
The scope of work for the study covered :
3.8
Collation of Information
Collection & submission of existing job descriptions and related
information from the various offices visited. These will subsequently be
collated and submitted to the Task Force.
Review of Structure
-
Understanding existing organisation structure and reporting relationships
of the directorate
-
Reviewing the authority-financial and administrative powers for the
various posts and suggesting changes to facilitate transaction processing.
-
Review of existing cadres and identification of new cadres/levels such as
vigilance cell, selection posts etc and redundant positions
-
Re-organisation of staffing pattern to facilitate equitable distribution of
work in line with seniority, span of control, job responsibilities.
Redefining Job Roles wherever applicable
-
•
Determining the need for review of procedures
Defining Job Responsibilities
-
Identifying the key qualifications and experience required for various
posts defined in the structure recommended
-
Determining the key result areas of these posts
Defining the job roles and activities to be performed by the personnel
manning the post
-
Determining the training requirements in line with the job roles envisaged,
the requisite qualifications for training, whether they should be cadre
options (clinical/public health) etc.
-
Identification of working hours, stay in quarters and volume of work (if
applicable)
Approach & Methdoloqy
3.9
The study commenced in first week of October, 2000 and the AFF's team visited
the Directorate of Health Services (DHS) and had discussions with the Commissioner,
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Director, various Additional Directors (ADs), Divisional Joint Director, District Health
Officers, District Surgeons Joint Directors (JDs), covering their responsibilities, reporting
relationships, operational constraints etc. In addition we met various officers of the
Primary Health Centre (PHC), Community Health Centre (CHC), Sub-Centres, Taluk
Hospital, District hospitals for both rural and urban areas. Table 1.1 provides list of
officers/offices visited.
Table 1.1
Gulbarga Rural
Bangalore Rural
Area
Category^
Sub-Centre
PHC
CHC
Taluk Hosp
District Hosp
PHO__________
Teaching Hospital
Shanmangla_______
Bidadi____________
Magadi___________
Ramanagara /
Channapatna
Mysore (ED Hospital)
General Hospital,
Jayanagar, Bangalore
Bangalore Rural
KRHospital, Mysore
Kadacharala
Malkhed
Mudhol
Sedam
Gulbarga, Raichur
Gulbarga, Mysore,Raichur
3.10 The study involved detailed discussions with the above members and the Task
Force members covering various aspects of the study. Focused group discussions were
held with the Task Force and DHS and also representatives of KGMO for confirmation of
observations. Our observations and recommendations are provided in two volumes
covering :
Volume I
:
Volume II :
3.11
Review of Organization Structure
Detailed Job Responsibilities
This report (Volume I) covers the following :
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Section 3 :
Introduction
Section 4 :
Review of Organisation Structure and Job roles
Section 5 :
Proposed Organisation Structure
Section 6 :
Review of Cadre rules
Section 7 :
Re-alignment of staffing patterns
Section 8 :
Observations on Need for Procedure Review
Section 9
Recommendations and Conclusion
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4. REVIEW OF ORGANISATION STRUCTURE AND JOB ROLES
4.1
This chapter covers briefly the existing and proposed activities of the Department
of Health, Government of Karnataka (GoK) followed by a review of the organisation
structure and job roles of key functions. This chapter will conclude with the
recommended top organisation structure for the DHS, GoK and its salient features.
4.2
The Department of Health is responsible for providing health care services in
Karnataka. The major programmes undertaken and services provided by the department
are:
•
Primary Health Care
•
RCH programmes (family welfare and related programmes)
•
Various National programmes for prevention and control of Vector Borne
diseases such as Malaria, Filaria etc, Leprosy, Tuberculosis (TB) and Blindness
Prevention and control of communicable and diarrheas diseases
4.3
•
Clinical services (Curative Services)
•
Immunization programmes - Universal programs of Immunization
•
Nutrition programmes - Nutrition education and demonstration
•
Health education and training programmes
•
School health programmes and educational and environmental sanitation
•
Laboratory services
The above health services are provided through a network of
Sub - Centres
8143
•
Primary health centres (PHCs)
1670
•
Primary Health Units
583
•
Community Health Centres (CHCs)
249
•
Taluk, Teaching, Specialised,
General/Maternity and District Hospitals
177
* Source Annual report of Department of Health & Family Welfare, 1999-2000
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4.4
The above institutions are determined by the facilities provided in terms of
number of beds.
4.5,
With the objective of direct involvement of people in health care, the 'Panchayat
Raj', introduced in Karnataka in 1983, a number of schemes were transferred from the
state level to the district level under the Zilla Parishad(ZP), effective from April 18, 1987.
Thus the responsibility of management of Taluk Hospitals downwards is under the ZP.
4.6
The Department of Health and family welfare is headed by the Principal Secretary
(PS) - Health who reports to the Minister of Health and Family Welfare. The PS - Health
covers the following areas :
•
Autonomous Institutes
•
Indian Systems of Medicine
•
Directorate of Health and Family Welfare Services(DHFWS)
•
Drug controller
•
Externally Aided Projects
•
Deputy Secretaries (Secretariat)
4.7
The present top structure of the Department of Health and Family Welfare is
provided in Exhibit 4.5
4.8
The DHFW activities and the organisation structure review is presented under the
following categorization:
•
Externally Aided Projects (EAP)
•
Indian Systems of Medicine
•
Directorate of Health and Family Welfare Services (DHFWS)
Divisional Level
•
District Level
Externally Aided Projects (EAP)
4.9
The Department of Health has created independent, separate cells for the
externally aided projects with each Project Director reporting to the Principal Secretary Health. The ongoing EAPs under the Department of Health (DHFW) are :
IPP IX - This is being implemented in the state of Karnataka since 1994 with the
assistance from Government of India and World Bank. The specific objective of the
project is to implement a programme sustainable at village level to reduce crude
birth rate, infant mortality rate and maternal mortality rate and increase couple
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protection rate to reach the national targets. IPP-IX carries out following functions
for achieving the set objectives of the project.
-
To involve the community in promoting and delivery of family welfare
services.
-
To strengthen the delivery of services by providing
-
Equipment kit and supplies to TBAs, subcentres and PHCs
Make ANMs at subcentre mobile by providing loans for purchase of
two wheelers.
-
Building of subcentres with provision of residential accommodation for
ANMs
-
Building for Primary Health Centres
-
Residential quarters for Medical Officers.
Improve the quality of services by providing training to personnel, official
and non-official at various levels including TBAs, Community leaders and
voluntary agencies.
Strengthen monitoring and evaluation by developing and installing MIES
from District to State level.
The IPP-IX has implemented Civil components in 17 districts of the state
and IEC and Training components in all the districts.
The organization structure of IPP IX is showed in exhibit 4.1
IPP VIII - This was launched during 1994-95 to cover the Bangalore
Metropolitan Area with financial aid from the World Bank under Family
Welfare (Urban Slums) Project. The main objectives of this project are:
Deliver family welfare, maternal and child healthcare services to the urban
poor and to promote safe motherhood and child survival
-
Reduce fertility rate among eligible couples, promote consciousness
against early marriage of the daughters
Promote male participation in family planning with a view to reduce the
burden on women
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-
Create awareness of personal hygiene and to maintain a better
environment for prevention of diseases
-
Non-formal education and vocational training for women to help them in
self-employment
-
Promote female education
11
Organization Structure - IPP - IX
Exhibit 4.1
I
Joint Director
Projects
______ I
Deputy Director
IEC
Procurement Officer
Project Director
Z
I
I
Superindent Engr
PWD
Deputy Director
MIES
I
Chief Accounts Officer
I
Additional Director
SIHFW
.
I______
Under Secretary
Joint Director
Deputy Director
PHM
Deputy Director
OBG
Deputy Director
PHN
Deputy Director
Communication
Deputy Director
Poulation
studies
Deputy Director
Communication
J
Organization Structure - IPP VIII
Exhibit 4.2
Commissioner
BMP
Project
Coordinator
I
Demographer
I
Director
IEC
I
Director
Training
Programme Offer
Accounts
I
Programme Offer
Civil Works
i
:
Programme Offer
Health
I
Women Devpt
Officer
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This project completes its life period by June, 2001 and all of its present activities
were planned to be shifted to the Bangalore Mahanagar Palike which manages
the hygienic conditions in the slums in the capital.
The organization structure of IPP VIII is showed in exhibit 4.2
AIDS Society of Karnataka - This is a 100% centre sponsored scheme
under the guidelines of national AIDS Control Organization, Ministry of Health
and Family Welfare, Government of India, as the national AIDS Control
Programme in Karnataka. The Present Phase - II of the AIDS Control Project
is officially launched during December - 1999, for a period of five yeas (from
1999 to 2004). The objectives of Phase - II of AIDS Control Project are:
•
-
Reduce the spread of HIV infection in Karnataka State
-
Strengthen Karnataka State's capacity to respond to HIV/AIDS on long
term basis.
This project has many officers deputed from the Department of Health &
Family Welfare and a hand-in-hand working is required among all the relevant
functionaries for effectively combating the AIDS. The organization structure
of Karnataka AIDS society is showed in exhibit 4.3
Karnataka Health Systems Development Project (KHSDP): The
Karnataka Health Systems Development Project (KHSDP) is a World Bank
aided project setup in 1996 with a project base of Rs. 546 Crores spread over
a period of 6 years to improve the secondary level of health care in
Karnataka. KHSDP has been setup with the following objectives:
•
Improvement in the performance and quality of health care services at
the district and sub-district and sub-district level of the health care system
-
Narrowing the current coverage gaps by facilitating access to health care
delivery, and
Achievement of better efficiency in the allocation and use of health
resources
The project components and sub-components are :
Management Development and Institutional Strengthening:
•
Improving the institutional framework for policy Development
Strengthening management and implementation capacity; and
Developing surveillance capacity for major communicable diseases.
•
Improving Service Quality, Access and Effectiveness
Extending/ renovating Community, Taluka and District hospitals
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Upgrading their clinical effectiveness
12
Karnataka AIDS Prevention Society
Exhibit 4.3
Project Director
AIDS
______I
Joint Director
Surveillance &
Trng. (Medical)
I
~
Procurement
Officer
I
'
Deputy Director
Blood Safety
Statastical
Officer
I
I
'
Additional
Project Director
Medical
I
— I
Finance
Controller
Joint Director
-------- L
Deputy Director
Blood Safety
I_____
Deputy Director
STD
I
Finance Officer
I
Deputy Director
STD
I
NGO
Advisory Cell
Organization Structure - KHSDP
Exhibit 4.4
Project Administrator |
_______ I
Additional Director
Medical
I
Additional Director
CMD
I
Additional Director
SPC
I
~
Cheif Engineer
Civil
CAO
I
Cheif Finance
Officer
I
Joint Director
Equipment
I
Consultnats
I
Financial
I
Projects I
~1
KFW
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Improving referral mechanism and linkage with primary and tertiary level;
and
Improving access and equity to disadvantaged sections
The following functions are being carried out for achieving the objectives of
the project:
-
Civil Works: The project is working for renovation and expansion of 74
Community Hospitals, 104 Sub- Divisional Hospitals and 21 District
Hospitals
-
Procurement: The project undertaking procurement of Medical and other
equipment, Vehicles and Medicines.
-
Training: Project is also working towards the training of doctors in
different specialties, Pharmacists, Technicians and Nurses.
The organization structure of KHSDP is showed in exhibit 4.4
The Reproductive & Child Health Programme (RCH) funded by World Bank is being
carried out by the Department itself and so also the Blindness Control programmes
funded by Danida.
Indian Systems of Medicine and Homeopathy (ISMH)
4.10 ISMH is rendering medical relief to the public in Ayurveda, Unani, Naturopathy,
Siddha and Homeopathy systems of Medicine and regulates Medical Education, Drugs
manufacture and practice of medicine in these systems.
4.11 The Director of ISMH is independent of Directorate of Health Services. The
current study being focused on the working and reorganization of Directorate of Health
Services, the details of the ISMH are not covered in this report.
Directorate of Health and Family Welfare Services (DHFWS)
4.12
The key activities performed at the Directorate summarized below are :
•
Planning:
Scrutiny of planned proposals at pre-budget stage before submission to
Secretariate
•
Budgeting:
Scrutiny of budget proposals
schemes/institutions under DHS
•
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and
release
of
budget
to
all
Accounting and Finance:
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of statement of Expenditure
received from
various
Reconciliation with Accountant General's records
Countersignature of DC and NDC bills drawn by Government Medical
Stores (GMS) and Public health institutions
•
Payroll and Personnel
•
Programme Monitoring and Implementation-.
-
Monitoring of National and state level health programs
-
Assessing community needs regularly and ensuring their addressal
through different hospitals.
-
Curative preventive and promotive health programmes through its
network of PMC's, CHC's, Taluk, subdivision & District hospitals
-
Purchases and Stocks:
-
Procurement of all drugs and equipment (except that for TB, Malaria and
Leprosy) by GMS
-
Requisition and obtain drugs for TB,
Government of India
-
Participating in finalisation of rate contracts
-
Supply and distribution of drugs, instruments and surgical equipment to
institutions under its control and contraceptives and Family Welfare drugs
throughout the state.
Malaria and
Leprosy from
4.13 The DHFW is headed by the Commissioner who reports to the Principal Secretary
(Health). The present top organization structure of DHFW is given in Exhibit 4.5
4.14 The post of Commissioner, Department of Health & Family Welfare Services (held
by an IAS officer) was created during 1997-98 for effective delivery of health services
both preventive and curative to the people of the state. All the functions related to DHS
apart from the ones managed by different projects are routed through Commissioner.
Divisional Level
4.15 The health care service delivery network for the state of Karnataka is grouped
under four divisions namely,
•
Bangalore
•
Mysore
•
Belgaum
•
Gulbarga
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4.16 The Divisional Joint Director (DJD) is the officer in-charge for Health and Family
Welfare Services for each of the above divisions. The key activities of the DJD are :
4.17
•
Technical guidance to district level authorities in implementation of Health
and Family Welfare programmes
•
Monitor the performance of hospitals of more than 100 beds, which are not
being managed by any District Surgeon or not a teaching hospital
•
Inspection of various schemes in Health and Family Welfare sectors being
implemented by the district authorities
•
Countersignature of DC Bills and NDC bills of district hospitals and other
specialised hospitals
The organisation structure at the divisional level is given in Exhibit 4.6
District Level
4.18 The District Health and Family Welfare Officer (DHO) is the head of the
department at the district level and functions at the Zilla Parishad as posted by the State
Government. He is responsible for the implementation of the health programs of the
district both to the Zilla Parishad and the Directorate.
4.19
The key activities at the District level are :
•
Implementation of national programmes at the primary and secondary level
of healthcare delivery system
•
Health education to the public on the various health programmes conducted
by the DHFW
•
Planning and implementation of various health programmes (preventive and
promotive) through community needs assessment approach and also based
on guidelines issued by Government of India and State Department of Health
& Family Welfare
•
Provision of curative services at the various health centres and hospitals
under the DHFW
The present organisation structure at the district level is provided in Exhibit
4,7
The present staff structure from the village level onwards is shown below :
Village
:
VHF - Anganwadi - Dai
Sub Centre : JHA ( F ) / ( M ) , Dai / Ayah
: MO / LMO, Staff Nurse, Pharmacist, Lab.Tech, SHA ( F / M ), FDC, D Group
PHC
: Physician, Surgeon, OBG, Paed, Anaesthetist,Dentist ( Specialists ), GDMO,
CMC
Staff Nurses, Pharmacist
AFF ~MC
15
Organization structure at Divisional level (Gulbarga) - current
Exhibit 4.6
This structure is not uniform in all divisions
Divisional
Joint Director
I
I
Medical Offer
Optha &
Dental
=F=
Deputy
Director
(NMEP-Zone)
Deputy
Director-CMD
Inv & Trg
I—
Deputy
Director
(NMEP)
I
I
Medical
lecturer cum
demonstrator
I
Health
Education
Instructor
I
Social
Welfare
Instructor
I
Public Health
Nursing
Instructor
I
Health
Supervisor
(Gazzetted)
I
Deputy
Director
Virus Lab
I
I
Gazzetted
Assisstant
I
I--------
I
Entomologist
Statastical
Officer
I
Statastical
Officer
I
Medical
Lecturer
Deputy
Surgeon
Vac. P rd n. unit
I
Senior
Training
Officer
Senior
Trng. offer
(nursing)
I
• Deputy
Surgeon
I
______
!
District
surgeon
I
Superindent
Medical
Officer
I
I
I
Health Offer
cum
Asst. Surgeon
Nursing
Superindent
ZZI__
Lay
Secretary
Medical
Offcr-KFD
Divisional DHFW - Current
Exhibit 4.7
Divisional
Jt. Director (4)
Dy. Director
HQ (4)
I
Dy. Director
’(NMEP) (4)
I
District Surgeons
(26)
I
Superitendents of
100 bedded
Hospitals (5)
— I
Superintendents cf
TB Hospitals (6)
I
Health Officer
(SSP UNIT) (4)
I
Surgeons of
women & Childrer
Hospital (3)
I
Surgeons of
PPG (3)
I________
Superintendents cf
major Hospitals (3;
Primary Health Centre
Organisation Structure - Current
Exhibit 4.7
Structure varies from PHC to PHC - District wise
DJD
CEO - ZP
JD Prog.officers
(HQ) '
| District Health Officer
Taluk Health Officer I
1
7
PHO - MOH
FDA & Other Staff
Driver
BHE
Refractionist
Lab Technician
Sr. HA (M)
Sr.HA(F)
~
I
| Jr.HA M/F |
Pharmacist
PHU
ZE
MOH
~T~
J Pharmacist |
I
SDA
I
Jr.HA (F)&
Other staff
Taluk Health Office
Org. Structure - Current
Exhibit 4.7
DJD
CEO - ZP
| District HggitfTOfficer]
JD Prog.officers
(HQ)
I
Taluk Health Officer/
AMO
I
I
PHC-MOH
FDA
I
Sr. H. A. (M)/(F)
SDA/Drivers
I
FDA & Other Staff
Driver
BHE
Refraction ist
Lab Technician
Sr. HA (M)
Sr.HA (F)
PHU
Pharmacist
MOH
~ I
;
Pharmacist
I
i
SDA
,
|
Jr.HA (F) &
Other staff
I
Specialists
& Other Staff
ZE
Jr.FA (FD)
Dy. CMO
I
District Health & Family Welfare Office
Administration Control Chart - Current
Exhibit 4.7
CEO-ZP
District
HFW Offer
_____ I
Prog.Offers
DHO office
Field supervision
I
RCH
Offer (1)
ASO
I
Family welf.
Offer
Mental Health
Offer
•I
District
Program level
officers
I
I
Admnistration
&
Finance
_ 1
-----1
District
Nursing
Offer
DHEO
(Mass Edn)
Dy KEO
ASO
Technical
Service Engr
District Health & Family Welfare Office
Administration Control Chart - Current
Exhibit 4.7
CEO - ZP
I
Prog.Offers
DHO office
Field supervision
I
District
Program level
officers
District
HFW Offer
I
I
Administration
&
Finance
G.A
FDA
I
Administration
Superindent
I
~
I
ZZEZ
SDA
Typist
Technical
Service Engr
----- 1
Accts
Accounts
superindent
I
Mechanic
Electrician
Cold Chain
Engineer
I
Group D
Drivers
Asst.Engr
Department of Health & Family Welfare - Govt of Karnataka
Organization Structure - Current
Exhibit 4.7
Commissioner
DHS
I
CAO-Admin 1
I
I
AD-PD
(RCH)
AD-HET
JD - RCH
JD - HET
CAO-Admin 2
CAO-Fin
CAO-Vig
I
--- 1
AD-PHC
r
I
I
I
DJD(4)
I
I
JD-TB
JD-LEP
|
JD-H&P
I
JD-MED
I
I
JD-GMS
JD-OPTH
JD-Vac
JD-LABS
JD-CMD
Department of Health & Family Welfare - Govt of Karnataka
Organization Structure - Current
Exhibit 4.7
MHFW
|
r~
I
PS
SME
I
Secr-ME
□z
I
Commissioner
I
DME
I
—I
Autonomous
Institutes
Dy Seer
Director
ISM
■
DHS
Drug Controller
I
Govt/Pvt Med Coll
CAO-Admin
CAO-Fin
4
CAO-Vig
AD-PD(RCH)
|
IPPIX PD
IPPVIII PD
I
KHSDP PD
I
_______ I
AD(Director-SHFV\/)
AD-HET
AIDS PD
CAO
AD-PHC
I
I
I
I
I
I
DJD(4)
JD-TB
I
JD-LEP
I
JD-H&P
JD-MED
JD-GMS
JD-OPTH
JD-Val
I
JD-LABS
~
I
I JD-CMD
CFO
AD-SPC
AD-MED
AD-CMD
AD-KFW
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Review of Organisation Structure
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The basic primary healthcare concept consists of one CMC with 3-4 PHC's. The staff of
CMC will have the dual role of executing both clinical as well as public health care to the
community through the Taluk Health Officer.
Observations in Current Organisation Structure
4.20 The notable observations arrived at after detailed discussions with key personnel
of Department of health and members of Task Force and analysis of the organisation
structure are given below :
Span of Control
4.21 The DHFW is a complex Health service set-up with key activities of
administration, public health care and clinical health care having high differentiation and
specialization
4.22 . Such set-ups require limited span of control especially at the top for optimum
supervision and functioning. However, the Director of Health and Family Welfare has 18
functional personnel including 3 Additional Directors and 10 Joint Directors directly
reporting to him, thereby having a wide span of control.
Curative Vs Preventive
4.23 The role of public health programmes is designed to be primarily focussed on the
preventive and promotive aspects wherein a need has been determined for improving
the basic health of the society and prevention of illness. However, it has been observed
that there is more emphasis on the curative aspects of health vis-a-vis preventive /
promotive health by the Department of Health (GoK). As observed most of District
Health Officers are clinicians without any training in public health. There is severe
mismatch of specialists to their place of posting. Senior specialists are still serving at
PHC's.
4.24 Further the public health staff at the Taluk hospitals and District hospitals do not
have separate infrastructure for conducting their activities. There is a lot of reliance on
the medical wing personnel for implementation of public health programs. This results to
overload of activities/responsibilities on the medical wing personnel further leading to
dilution of role either on Public health or on clinical due to lack of time. There is also
lack of managerial and administrative capabilities of Senior Personnel of the Dept from
Taluk level onwards
In-equality in Promotion Opportunities between Public Health & Clinical
4.25 Around 1976, during the emergence of public health in the DHFW, the promotion
opportunities for the Public Health qualified personnel rose tremendously with the result
of clinical personnel higher on the seniority list positioned way below in the organisation
structure. This was mainly due to the mandatory requirement of Public Health
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qualification from the post of DHO onwards, i.e. role of DPH qualification as criterion for
promotion to DHO/JD/AD/DHS created imbalance. This being rectified in 1992, the
growth opportunities became equal for both Public Health and clinical personnel.
4.26 Thus, in the district level the career opportunities are equal for both Public Health
personnel as well as Clinical Personnel. However, going by the need of specialisation at
the senior levels, the promotional path for a District Surgeon (DS) is limited to 3-4 posts
at the JD level as against around 12 JDs posts for the DHO.
Multiple authority for certain functions
4.27 It has been observed that the same function is assigned to more than one JD/AD
leading to non-optimum utilization of resources and duplication of efforts. Especially
while planning Externally Aided Projects (EAP), number of imbalances occurs in staff
positioning, training, etc as the activity is in project mode and constraints in terms of
availability of time exist. Certain examples are given below :
•
AD (HET) handles health training for the public while training for public as
well as personnel of DHFW is also conducted by the RCH cell, IPP, KHSDP and
SIHFW.
•
Research/Studies are organized by PRC, KHSDP, IPP VIII, and IPP IX
Improper Positioning of Functions
4.28 It has been observed that there is no streamlining of functions in terms of
reporting hierarchy and departmental responsibility in the organisation structure of the
DHFW. Thus while the planning, funding and review is done by certain section of
personnel, another conducts the actual implementation with no reporting relationship
defined between both sections. This will result in in-effective implementation of the
various programs. Certain examples of the same are given below :
•
KHSDP as an EAP, created a position of AD (CMD) who is to cover all public
health activities for the state relating to communicable diseases. This AD post
reports to the Project Director (KHSDP) and is expected to work with the staff
of the Department of Health. In the DHFW structure, there is a JD (CMD) who
reports to the DHS and has no reporting defined to the AD (CMD), till
recently. Only recently a government order has been issued asking three Joint
Directors (CMD, Lab and M& F) to report to AD - CMD. Moreover there seems
to a lack of co-ordination between the AD(CMD) and DHS office.
•
Similar to the above, there is a AD (Medical) reporting to the Project Director
(KHSDP) while the JD Medical reports to the DHS office. Nearly all new posts
created in the EAP (project mode of functioning) work in isolation from main
DHS, thereby creating duplication and confusion in the roles and
responsibilities.
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Dual Reporting
4.29 Discussions with a cross-section of personnel of DHFW revealed that there is an
overlapping of authority and lack of clarity in responsibility. E.g. the DHO being under
the District cadre, reports administratively to the CEO, Zilla Parishad, while functionally
he reports to the DJD. Many were of the view that in this context of multiple line of
command, the one through which the inputs for Confidential Report are taken is the
most responsive one. Thus, the DJD, a department functionary, couldn't contribute to
the development of the respective district.
Peer Reporting
4.30 As per cadre policies, in certain cases, the post of administrative head is held by
the senior most person in that office. E.g. the senior most Sr. Specialist holds the post of
the District Surgeon (DS). As these posts are not promotion posts, the personnel holding
these offices find it difficult to effectively discharge their duties due to non-reporting by
other peer personnel.
Disparity of Health care development in Northern Karnataka vis-a-vis other
regions
4.31 Field visits to the Gulbarga district health centres revealed a very low health care
reach and infrastructure for services. It was found that the situation was very grim when
compared with national health standards
4.32 The regional disparity between Northern Karnataka and other regions are
outlined below:
•
High number of vacancies due to non reporting of personnel deployed/posted
•
Abysmally low health care awareness amongst the public
•
Distance from directorate leading to ineffective governance
•
Low Morale amongst staff
Poor health infrastructure including poor maintenance of existing infrastructure
(building, Equipment etc.)
Externally Aided Projects
4.33 The externally aided projects function distinctly from the DHS office despite
having the same objectives and operating mechanisms. E.g. the KHSDP was initiated to
design and implement various health programmes in co-ordination with the DHS office
to improve secondary level health care. However, the KHSDP is considered to be a
separate entity with minimal/no co-ordination with the DHS office, thereby resulting in
similar activities being conducted parallely by the DHFW and under utilization of various
funds at the disposal of KHSDP.
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4.34 According to the planning of different Externally Aided Projects, majority of EAPs
come to a end of their stipulated period of working while creating a number of new
additional posts as dictated by the project modalities. This gives a challenge of
repositioning of the personnel at appropriate levels/positions in the hierarchy at the end
of the project.
Role of Divisional Joint Director
4.35 The DJD is the overall in-charge of the divisions under him and have the
functions of technical guidance and inspection of implementation of various national
programme schemes. However, it has been observed that the DJD functions mainly as a
co-ordinator between the district and the headquarters and performs the functions of
collating information from the various offices under him and submitting the same to the
DHS. The DJD does not exercise any administrative or functional powers leading to the
redundancy of the post in the overall functioning of the DHFW
Sanctity of certain posts
4.36 The original organisation structure has been modified by creation of new posts
based on requirements for a specific activity. However, due to lack of clearly defined
roles and reporting relationships, lack of proper authorities and non-cooperation from
other members in the system, these personnel holding these posts cannot function
effectively, leading to their redundancy e.g. Director - Training. In addition, posts such
as Officer on Special Duty (OSD) are created from time to time for specific
projects/activities.
Lack of integration of functions
4.37 Currently, the various duties of the staff in the lower level of hierarchy, are
defined at a program level. E.g. Lab Technician-Malaria, Lab Technician- TB etc. This
lack of integration of functions often leads to under-utilisation of personnel as given
below :
•
Overload on a certain function while under utilisation of the other personnel
•
Lab technicians not interested in doing duties assigned to them, due to higher
learning opportunities in other functions. E.g. Lab Technician of TB prefer to
do malaria related activities
Similarly the ANM's are overloaded and the male health worker underutilized.
Role of ZP in Public Health Care
4.38 ZP being the administrative authority at the district level has a vital role to play in
delivery of health care in the district. Various personnel in the DHFWS were of the view
that there exists a misuse of financial and administrative powers by the ZP. This has led
to a de-motivation in the department. The various forms of abuse of power indicated by
the personnel are :
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•
Use of Public Health Care facilities for other purposes or for personal work
•
Use of Force/pressure tactics to achieve their needs. E.g.:
-
In the event vehicles reserved for public health are not provided to ZP for
other use, the personnel are threatened with cuts on vehicle allowance.
-
Delay in payment of salaries
•
The ZP has powers to post personnel of the 'C' and 'D' category staff at the
district level. However, quite often, such personnel have been posted by the
ZP against non-sanctioned posts into the health department.
•
Procedural delays such as pending electricity bills, delay in maintenance of
equipment and buildings etc.
4.39 Further to the above, the personnel of the DHFWS feel that health programmes
are not a priority for the ZP as the ZP personnel do not appreciate the criticality of
successful implementation of proposed national/state health programmes. The ZP
regularly insists on the DHO and other staff of the DHFWS to be present for all meetings
being conducted by them, irrespective of the connection of these meetings to health.
These meetings are often of the nature of absenteeism, administration etc.. This results
in lack of time for personnel of DHFWS to conduct their basic duties of health care
thereby providing scope for productivity reduction.
4.40 There is a lack of morale amongst the personnel of DHFWS at the district level
due to the authoritative attitude of ZP and the misuse of power. It has been brought to
our notice that very often the interference of ZP in the day-day functioning of the DHO
and their support to the lower cadres of personnel, result in ineffective use of such staff
by the DHO for implementation of health related programs.
Need for Re-defining of Job Roles
4.41 Discussions with various personnel in the DHFWS have brought out a need for
clear definition of Job roles at each level. Certain lacunae identified in the current system
are :
•
The role demarcation of Strategic Planning Cell (SPC) vis-a-vis JD (H&P) in
DHS needs to be clearly reviewed in depth and outlined
•
The present SRC at KHSDP has not been able to deliver the objectives for
which it was set up through KHSDP
•
Lack of program orientation in officers
•
Specialists of District Hospitals attached with medical colleges are given
minimal / no responsibility or authority such as :
No additional units/beds provided for their clinical work
Only MLC cases and casualty are given to specialists
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Despite senior DHFW doctors in premises, casualty is referred to the
Orthopedic units , PG and Junior residents
Senior personnel are not involved in strategy and planning. E.g. :
-
DHO/DS not involved in technical micro planning of District Health
programs or hospitals, current role being administration driven
-
Role of senior personnel currently reduced to transfer of correspondence
or provision of data
-
No analysis of information conducted even at certain JD levels on data
collated
Specific demerits of the structure
4.42
Key demerits observed in the existing structure are summarized below:
•
Very wide span of control for DHS / commissioner, to the extent of handling
the national and state health programs directly
•
More importance to the stream of Public Health personnel during certain
period, thus providing more promotional avenues for personnel with DPH
qualification
•
Improper division of functions to Public Health specialisation people and the
clinical people has lead to skewed promotional avenues.
•
Subsequently, after having brought both Public Health (both preventive &
promotive) and Medical (curative / clinical) into the same stream, the
importance for public health has taken a back seat.
•
The reliance on clinical personnel on carrying out the public health programs
leading to dilution of both clinical and public health activities
•
Improper coordination among the main department and the EARs, leading to
duplication of certain activities.
•
Dual reporting at which the administrative reporting has taken more
importance
•
Reporting to peer groups for lack of promotional posts at certain levels in the
hierarchy leading to lack of authority in such posts.
•
Neglected North Karnataka region
•
Redundant DJD position
•
Lack of Health directed leadership from ZP
•
Imperative need for clearly defined job roles at all levels
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5. Recommendations on Organisation Structure
Principles Behind Proposed Organisation Structure
5.1
The proposed organisation structure has been designed in line with the following
principles :
•
Equal emphasis for both Public Health as well as Clinical from the District level
onwards
•
Optimum utilization of all resources across the DHFW
•
High priority on Rural health development
•
Health MIS and Planning is significant for the functioning of the department
•
Role clarity and well defined Job Responsibilities/Key Result Areas
A Bureaucratic structure
A Professional Domination
•
Accountability to public
•
Equity of treatment
VISION STATEMENT
QUALITY HEALTH CARE DELIVERY SYSTEM WITH EQUITY
The Department of Health and Family Welfare is committed to act as a catalyst for
progress that will result in healthier people in a healthful environment.
The department will incorporate strategic management to implement a core set of values
that are integral to public health. We will translate science and technology into action to
safeguard the public's health. We will apply innovative, sound, and reasonable solutions
to traditional public health challenges and emerging issues. At the same time, we will
retain that, which is good with public health in the state. We will expand knowledge
through epidemiology and applied research on health and environmental issues.
The department recognizes its tie with other health and human service agencies to
respond to global, national, state, and local public health concerns. We will forge
alliances with public and private sectors to ensure that timely, cost-effective, public
health interventions are planned and implemented. We will strengthen our commitment
to collaborate with other departments.
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Our employees are out most valuable resources. We will provide an environment in
which our employees strive for excellence, display initiative, and demonstrate
achievement. Our employees will continue to promote health; work to prevent diseases,
disability, and premature death; and help to assure access to health care for all
populations.
This vision of the future is one in which the Department of Health & Family Welfare,
communities, local health agencies, Special Institutions, and the private sector across the
state cooperate to develop plans, programs, and resources. It guides our work to
increase the span of healthy life, to reduce health disparities among different
populations, and to assure access to preventive services for all.
MISSION STATEMENT
The Department of Health & Family Welfare is dedicated to promoting health and
wellness among people in Karnataka through planning, prevention, service, and
education. DH&FW serves to help people attain the highest level of health possible. The
DH&FW is a proactive leader and collaborator in assessment, policy development, and
assurance, based on science, innovation, and efficiency.
DH&FW affirms that health includes physical, mental, and social well-being, and is
dependent on economic and environmental factors, access to health care, and individual
responsibility and choice.
Although the DH&FW primarily serves people within
Karnataka's geographic boundaries, we recognize our interdependence with the larger
world.
To achieve our mission, the DH&FW supports :
•
Training and technical assistance
•
Disease prevention and health education programs
•
Epidemiology for surveillance and analysis of health data for intervention and
program evaluation
•
Development of policies and regulations to optimize health
•
Planning and evaluation
•
Staff recruitment and development to accomplish our mission, and
•
Collaboration with the public, local health departments, other governmental
agencies, the scientific community, and special populations.
The DH&FW is dedicated to quality service, innovation, respect for every individual,
affirmative action, personal integrity, trust, and high ethical standards.
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Quality care for all
5.2
Good health is necessary to the well being of every individual and the society is
dedicated, therefore, to providing care for all ages, regardless of race or creed and
regardless of their circumstances and ability to pay.
Equity in health
5.3
An atmosphere of equity in health is the stone to progress in the state with all
members of society availing healthcare.
Treatment of the whole person
5.4
The patient is entitled to more than physical care, his worth as an individual and
his spiritual well being are equally important and treatment must take into consideration
the whole person-his mental and emotional welfare as well as his deep - seated spiritual
needs.
Emphasis in the Best
5.5
The maximum advantages of modern medicine are possible only through
comprehensive healthcare encompassing the best medical staffs, working in close
harmony with its hospitals; the most highly trained personnel, the most advanced life
saving equipment, the most up-to -date facilities and the widest possible range of
services.
Consideration for Employees
5.6
The loyalty and enthusiasm of its employees are among its most valuable assets
and realising this, the Government seeks to provide fair compensation, excellent benefits
and working conditions and a chance to advance in accordance with skills and ability.
Stress on Training and Continuing Medical Education
5.7
Training and Continuing Medical Educational programmes must be perpetuated
and expanded to train health personnel for today and for the future, serving the best
interests both of hospitals and the community
Interest in research
5.8
Research is essential for life and health in support of this belief, the Society
maintains and furthers major research projects and constantly explores additional areas
of interest in which to establish activities for the eventual betterment of others.
Concern with Costs
5.9
The patient comes above all and must receive the finest care at the lowest cost
consistent with quality and equity.
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Responsibility to the Community
5.10 Government hospitals must be responsible to its citizens, participating in
activities, projects and organisations which strive to improve the quality of life wherever
they exist.
Cooperation with Others
5.11 The voluntary health system must be preserved and strengthened and
consequently, the Government (Dept of Health & Family Welfare) devotes its best
energies to championing the cause of hospitals throughout the State and in joint
planning to avoid duplication and unnecessary expense so that community health needs
may be met most effectively and efficiently.
Belief in Excellence
5.12 There should be a constant striving toward excellence and the Government (Dept
of Health & Family Welfare) seeks to achieve this through dynamic management coupled
with a sense of participation and responsibility by individual employees, aiming at the
highest possible standards of performance in all endeavors.
Features of Proposed Organisation Structure
5.13 The key features of the proposed
consideration the principals behind it are :
organisation
structure
keeping
into
•
The proposed structure introduces two main cadres from the Taluk level
namely, the Public Health Cadre and the Medical Cadre. This provides equal
opportunity for promotion and growth for the clinical as well as public health
specialists
•
A hierarchical structure has been defined at the senior levels facilitating focus
on planning and strategic issues.
•
The proposed reporting structure incorporates program based hierarchy. The
program officers at the district level to report to Zilla Parishad directly
(administratively) and to have more financial authority and to report
functionally (for technical inputs and coordination with others) to DHO and
respective JD of the program.
•
Various positions are re-organised within the DHFW to facilitate streamlining
of reporting relationships and functions
•
The proposed organisation structure has abolished the post of the DID
•
Opportunities are provided in the proposed structure for continuing service in
rural areas without loss of pay benefits
•
There is a position created in the proposed structure for specific thrust of
health development in Northern Karnataka regions
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•
The proposed structure recognizes the imperative need for a focused and
dedicated approach towards training for personnel and has for this purpose
divested the role to an autonomous training body (SIHFW).
•
The various externally aided projects have been moved into the mainstream
structure thereby converting them to the program mode of implementation
rather than project mode. This will facilitate high acceptance of the various
programs across the DHS office and District offices
Proposed Organisation Structure
5.14 The proposed organisation structure is discussed in detail under the following
heads :
District Structure
Divisional Structure
Directorate Structure
District Structure
5.15 The district structure will administratively be under the control of the ZP while
functionally it will be under the DHFW. The recommendations on the district structure
are given in the ensuing paragraphs.
Introduction of Public Health Cadre at the District Level
5.16 Emphasizing the need for additional thrust to Public Health and equal promotion
opportunities for the medical wing, it is proposed to introduce two distinct cadres from
the Taluk Level. This proposal is outlined below :
•
The entry level for the medical officer in the Department of Health & Family
Welfare is the post of Medical Officer (Primary Health Centre). The minimum
requirement for this post is an MBBS degree. This is true for all candidates
irrespective of whether they have postgraduate degree as added qualification.
•
The specialists will be categorized into two distinct cadres namely,
Public Health constituting
Degree/Diploma in
>
of
personnel
holding
Post
Graduate
Public health
> Community Medicine
>
Health Management
> Any other equivalent programme as decided by the DHFW/MCI/
GOI/Health University
Clinical specialists such as personnel holding
Degree/Diploma in various clinical specialties such as
/\FF -MC
Post
Graduate
26
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Review of Organisation Structure
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>
Opthamalogy / ENT
>
Pediatrics
>
Obstretics and Gynecology
>
Intenal medicine
>
General surgery
>
Hospital Management
>
Any other equivalent programme as decided by the DHFW/MCI/
GOI/Health University
•
For promotion to taluk level the following scenario will be applicable:
However, the recruitment of specialists will be based on the needs of the
department.
•
For MBBS + PG clinical specialisation) - allocation to medical cadre minimum of 2 years of service at Primary Health Centre level to which growth
will on the clinical side. ( Specialists who enter the service under direct
recruitment may be posted to CHC's need based after probationary period at
the PHC level)
•
For MBBS + PG ( Public Health) - allocation to minimum three years of cadre
service and subsequent growth will be on public health side.
•
The MBBS medical officers will have the following options :
-
Acquire Post Graduate Degree/Diploma qualification while in service at the
PHC and follow the growth path of the specialists
Promotion avenues in the GDMO cadre upto the District Hospital as a
family physician
-
Continue service in the PHC as a Family Physician with time bound scale
extensions/gazetted promotion that will be on par with their peers.
Another future option in the coming years may be for MBBS graduates to directly take
PG Specialisation in Health or Hospital management only. A career planning and
promotional avenue will be needed to be worked out by suitably modifying the C & R
rules. These Doctors will be suitable for the managerial positions taluk level upwards.
5.17 An appropriate structure in terms of numbers of specialists in each cadre will
need to be designed by the DHFW. This should be done taking into consideration
equality in growth pattern and promotion opportunities across the cadres, (certain
studies done internally to the organization like Halagi report may also be considered for
any review in the system)
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Review of Organisation Structure
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5.18 Lateral entry for certain specialists posts such as Anesthetist, Pathologist,
Radiologist, etc may be considered for lateral entry at Taluka / District Level, failing
which a provision may be created for contractual positions. However these Specilaists
will also need to fulfill probationary period of one year at Primary Health Centre for field
experience. The cadre and recruitment rules will have to be suitably modified after
seeking legal opinion on the same.
5.19
The above proposal is depicted in Exhibit 5.1
Exhibit 5.1
5.20 Alternatively the DHFW could consider introduction of the above sub-cadres at
the PHC level, after determining the effectiveness of such a structure.
Organisation Structure at the District Level
5.21 Keeping in line with the above mentioned proposal, the proposed growth path of
medical personnel at the district level is depicted in Exhibit 5. 2
Exhibit 5.2
Sub-Centres
5.22 The sub-centres will continue to have the existing structure with the Female
Health Worker and the Male Health Worker carrying out the functions of registering the
cases of pregnant women, administering immunisation dosage and attending to minor
ailments and first aids and refer to PHC, the cases beyond their competence. These
personnel will report to the Medical Officer at the respective PHC.
PHC Structure
5.23 The PHC will have at least two Medical officers (incl. one lady medical officer)
with the senior Medical Officer being the administrative head. These medical officers will
have a team of one Pharmacist, Junior and Senior Health Assistants, a Lab Technician
and related support staff. All these staff report to the Administrative Medical Officer.
The Jungalwalla Committee report of mid seventies had suggested Public Health Officer
at the PHC level in addition to a regular Medical Officer for public health work. This
could be implemented with the Task Force of Govt, giving serious thought to this
suggestion of clinical / public health cadre starting from the PHC level itself and both the
streams having their own seniority list.
A composite primary health care concept will now consist of one CHC with 3-4 PHC's.
The specialists of the CHC will assist the PHC Staff in the execution of public health
activities under the guidance and monitoring of the Taluk Public Health Officer. The
routine clinical work of the specialists at the CHC will be monitored by the AMO of the
CHC.
A.FF -MC
28
Exhibit 5.1
Clinical/Medical
Public Health
Family Physich n
Gyna
Lateral entry (one
year probationary
period) Field
experience at PHC
Ortho
Opthal
AMO
THO . ◄Taluk <
Need based on numbers
GDMC
FP <
MBBS
Inservice
Inservice
PG
PG
PHC (MO) <
▲
MBBS
MBBS + PG
Lateral entiyneed based
District level - Department of Health & Family welfare
Organization structure - Proposed : Exhibit 5.2
______ Medical______
DMO (DS)
PG in Clinical Discipline
ST——-
District Maint.Unit
District Laboratory
District Medical Store
District HMIS
. ............................
Dy DMO/RMO
Public Health
DHO
PG in Public Health
i
i
T
i
i
i
i
i
i
i
i
i
i
i
i
i
State cadre
PG qual. compulsory
Merit cum seniority
□
Prog. Offer
i—k •
00
•—■» •
a
•
i
AMO (CHC/THC/
Specialists
Tajuk
CHC
p
THO
ex
o
N
^5
GDMO
MOH - PHC
MDBS min.qualification
PGs can also enter j
Review of Organisation Structure
-Vol I
Confidential
CHC/Ta/uk Hospital
5.24 As discussed in the earlier paragraphs, the distinction between Public Health and
Medical is initiated at the Taluk level. Each of the two streams will have their own
infrastructure and will draw upon the other's resources in terms of consultation and
expertise. Thus, the medical specialists will primarily be responsible for providing clinical
care to the patients of the hospital and the public health specialists will be involved in
implementation of the various health programs initiated by the DHFW. The common
seniority list of PHC entry level will have to be reworked with 2 independent seniority
lists of Medical Public health.
5.25 In the medical wing, the specialists will look after curative work. A THC/CHC will
be headed by the Administrative Medical Officer-CHC (AMO). The post of the AMO will
be a promotional post from the Specialists post. Among the seniors of the AMO's of the
Taluk, there will be a Taluk Medical Officer (promotional post) who will monitor and
evaluate all the CHC's and Taluk Hospital.
5.26 The Taluk Public Health Officer (TPHO) will head the public health wing of Taluk
and will have Public Health officers and program officers, assisting him to carry out
various national and state national programmes. These are monitored by district
programme officers who in turn report to Zilla Parishad (administratively) and DPHOs &
concerned JDs (functionally). TPHO must have a public health PG qualification ( atleast
DPH ) . He will be assisted by Taluk Health assistants ( promoted Jr/Sr HA's from the
PHC level ), Block Health Educators, Assistant Statistical Officers for HMIS, Refractionist
and clerical staff.
District Hospitai/DPHO office
5.27 The District hospital will conduct the functions of clinical service. The district
hospital is headed by the District Hospital Medical Superintendent and is supported by
the RMO, specialists and other, staff. The district office will also have a post of the
District Medical Officer (DMO) who will look after all medical hospitals ( CHC's and
TLH,DH ) in the district other than the district hospital. The DMO is a promotional post
and he will be the senior-most specialist with managerial/ administrative qualifications
and experiences. This cadre is above the District Surgeon & necessary C & R rules will
have to be framed. Similarly the DHO post will also be upgraded. The senior most
programme Officer becomes the DHO.PG qualifications in public health is must for this
post. He must have additional managerial/ Admininistrative Qualifications & experience,
necessary C & R rules to be framed.
5.28
A detailed work motion study may be carried out for the DHO and indepth
analysis to be carried out about his time utilisation. Based on this report a necessary GO
in Consultation with the ZP authorities to be framed permitting the DHO to attend only
the most important meetings. Programme Officers at District level to be given more
autonomy (financial and administrative) with technical directions from the DHO. These
officers should be accountable financially also for their respective programmes to the ZP.
Presently only DHO operates all the financial matters. Suggest a joint account of
Programme Officer with another ZP official to use the programme funds effectively.
Details need to be worked out on the monitoring of these issues.
"aff-/WC
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Review of Organisation Structure
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5.29 The DHO which is upgraded as a promotional selection post will be assisted by a
ADHO who will be the senior most programme Officer. ADHO will represent the DHO at
the ZP meetings and also his major responsibilities will include health planning ( micro
planning at District level ) with implementation / monitoring of HMIS. The Gulbarga and
Belgaum Districts will have 2 DHO's each in view of the large size of the District and
number of PHC's.
5.30 The following Programme Officers will report to the ADHO for smooth functioning
at the District level : a) DLO with STD/HIV b) Health Promotion with 2 Officers ( one for
nutrition - new post and other for health education - DHEO ) c) RCH d) Vector Borne e)
TB Officer . Programme Officers for urban health and STD/HIV can be added later as
and when these programmes are launched.
5.31 The District Surveillance Officer with his staff of the District Lab etc ., the District
Pharmacist - warehouse incharge , District Maintainance Unit for vehicles, equipment
and civil will report directly to the DHO for efficient and smooth functioning and
monitoring.
Both the DHO and DMO will be responsible for an efficient surveillance system of
communicable diseases and referral systems respectively in their areas of operations
The DHO and DMO will be trained in applying epidemiological skills for microlevel
planning to the dynamic and changing health scenario both at the public health &
hospital lelvel.
5.32 Though the District Public Health Officer and District Medical Officer / District
Surgeon are made to belong to state cadre, it is observed that they cannot escape the
influence of Zilla Parishad for having to work in the same territory and for obvious
reasons to work closely for common mandate. But, in the present reporting standard,
the DHO represents the DHFW in all the meetings of Zilla Parishad, including the ones
not about health programs. It is proposed that the DHO may not attend such programs
and the authority levels of district programme levels have to be enhanced to be
accountable to Zilla Parishad directly.
5.33 The DMO will be a promotional selection post. His office will be located within the
District Hospital. The Medical Suptd. ( earlier DS) of the District hospital , all the
Administrative Medical Officers of the CHC / Taluk and other hospitals in the district will
report to the DMO.The DMO will monitor the quality of care in all the hospitals in the
district. The Program Officers for Ophthalmology and NCD will also report to the DMO.
Presently there will be a separate program officer for Ophthalmology and a combined
Program Officer for CVS / Diabetes/ Mental Health / Oncology of the rank of senior
specialist till these programs are launched as independent programs with funds
allocation. The physician at the District hospital will monitor the TB Centre in the District
hospital in coordination with the DTO. Training in public health and program
management will be given to all Program Officers. The DMO will also have a
maintainance unit of civil, equipment and vehicles under him.
5.34
The proposed re-organisation of the district level structure is depicted in Exhibit 5
AFF -MC
30
Proposed Org.Structure at District Health Office
Exhibit 5.1
District Health &FW Officer
DHO
Selection Post
ADHO
ISenlormosl Pry Officer
| Dlst Prgm Co-ord
I
Plannlng/HMIS
District
Maintenance
Unit
District
Surveilance
Officer
I
ROH
Prog.
Officer
1.AEE (Civil)
2. Vehicles
3. Equipment
ZJ
_
District
Pharmacist
Warehouse
I
District Lab
Bio-chemist
Pathologist
Microbiologist
Entomologist
Statistical 0 fficer
Vector
Borne
Prog.
Officer
District
TB 0 fficer
Prog.
Officer
Health Promotion
Prog.
Officer
Nutrition
IEC
DHEO
DIO
STD
HIV
Prog.Officer
Familywelfare
Officer
Note: The District Lab staff - Microbiologist/Bio-chemist/Pathologist will be shared
by the District Surveillance Office and the District Hospital
District Medical Office - Proposed
District Medical Officer
DMO
Dy. DMO/CMO/RMO
District Surgeon
DHO
/
District Hospital
/
r______ I
Admin.
: Medical. Officer
, Taluk/CHC/others
I
Prog. Officer( P.O)
Opthal
(Senior Specialist)
I
CVS/ Diabetology
Senior Specialist
P.O.
I
Mental Health
Senior Specialist
P.O.
I
ONCOLOGY
Senior Specialist
P.O.
—I /
Maintainance
Unit
Equipment
Vehicle/Civil
District Surveillance Officer
Review of Organisation Structure
-Vol I
Confidential
Divisional Structure
5.35 As discussed in the previous chapter, the DJD post has become redundant in light
of transfer of all district level supervision to the ZP and is recommended to be abolished.
It is proposed that the various district level officers under the DJD will report functionally
to the respective Joint Directors and administratively will continue to report to the ZP..
Directorate Structure
5.36 The Directorate of Health will be headed by Commissioner / Directorate General
of Health Services (DGHS), who will report to the Principal Secretary. The proposed
directorate structure is shown in Exhibit 5.5
Commissioner / Director Genera! of Health Services
5.37 The main function of the Commissioner of Health and Family Welfare presently
filled by IAS Cadre Officer) to bring about better internal and inter-sector co-ordination
and to achieve a greater degree of accountability in health services both in financial and
administrative terms. The key activities of this post are :
•
Monitoring, supervising and implementing all National and State health and
family welfare programmes in the State
•
Ensuring co-ordination among the various directorates and divisions within
the Health system and also with related departments
It is proposed to rename the Commissioners Post to Director General of Health Services
- DGHS to be held by a Senior Technical Officer of the Dept who has risen from the
ranks. Also this is a selection post
5.38 The key qualifications for this post ( DGHS ) will be managerial, administrative
and financial skills as well as health systems exposure to carry out their functions
effectively. In the current DHFW, it is observed that there are hardly any health
personnel skilled in managerial/ administration and related areas. Moreover the exposure
to government functioning is minimal. It is proposed that the senior personnel of the
DHFWS are given opportunities for attaining the requisite skills such that they meet the
qualifications of this post. Till such time, it is proposed that the Commissioner (of IAS
cadre) continue to hold the post till such time a suitable technical person is available to
fill the post of DGHS.
Reporting Structure to Commissioner/DGHS
5.39
him:
The Commissioner/DGHS will have the following functional heads reporting to
Director - Medical
Director - Public Health
•
'aFF-MC
Director - External Aided Projects
' ........
31
Organization Structure at District Level - Proposed
Taluk Health Office - Proposed
Taluk Health Officer
DPH Qualification Must
________ I
T. Health Asst
M/F (prom from Jr. HA)
I
BHE ’S
(Shift from PHC
Pattern to Taluk Level)
-
I
Refractionist
(Shift from PHC
Pattern to Taluk Level)
I
ASO
(Statistics person must
forHMIS
Zj__
FDC
Proposed Org. Structure DHFW
Exhibit 5.5
Drug Controller
. Principal Secretary
SIHFW
I
ISMH
I
CAO
Finance
x Sec - II (ME)
DME
Commissioner/DGHS
I
CAO
Vigilance
I
Director
Public Health
Director
Medical
AD -SPC
Planning and
Monitoring
JD
Special Groups
I
Director
EAP
I
Di rectoe
Procurement/
Maintainance
AD
N. Karnataka
I
NGO Cell
Consultant
Proposed Health Org.structure at HQ
Director
Public Health
r~
AD
AIDS
7
I
AD
Health Promotion
r~ I ZJ_
JD
AIDS
I
I
ACYPD
RCH
Primary
Health Care
JD
RCH
JD
Primary
Health
Care
r
~|
JD
IEC
JD
NUT
I
~1
~
AD
CMD
State Sirvelllance
Officer
r~
ZE
JD
Vector
Borne
JD
TB
JD
Leprosy
CAO
1
I
~l
JD
Vaccine
JD
Lab
Deputy Director
Disease Surveillance
Proposed Medical Org. Structure at HQ
DIRECTOR
Medical
I
I
AD
Medical
r
JD
Medical
I
JD
Pharma
=F=
JD
Hospital
North
I
AD
NCD
IJD
Hospital
South
I
JD
Trauma
Emergency
Medicine
I
JD
Opthal
I ~ ~
JD
CVS & Diab
1...
CAO
2
—-I
JD
Dental Health
JD
Mental Health
I
JD
Oncology
Proposed HQ Org. Structure
I
I
________
DIRECTOR
Procurement & Maintenance
______
Director
EAP
r~
JD
Procurement
JD
Bio-Medical
Equipment
Maintenance
Secy PWD
I /
Superintendent
Engineer
Civil
Civil Engg.Staff
as in
KHSDP
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Review of Organisation Structure
-Vol I
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Director - Procurement and Maintenance
•
NGO Partnership Cell
•
AD - Planning
AD - North Karnataka
•
CAOs (Administration I & II, Finance and Surveillance)
5.40 This division of work among the key functions of Commissioner / DGHS keeping
in view the dynamic nature of the work and effective monitoring of the activities. The
structure and functions of the office of each Director's office are discussed below:
Public Health Vs Medical
5.41 Continuing the proposal for two main cadres namely Public Health and Medical at
the District level, it is proposed to have a similar structure at the Directorate. Thus, he
key preventive, promotive and curative functions of the Directorate of Health are divided
split among two directors, i.e. Director - Medical (for curative and clinical services) and
Director - Public Health (Preventive and promotive services).
5.42 This will ensure equal commitment from the Directorate to the District for both
Public Health as well as Medical. Further, it will provide focused supervision in each of
the areas. It will also address the promotional opportunity to each cadre to be their
respective Directors
Director - Medical
5.43 This functionary heads the clinical and curative services of the Directorate of
Health. The Director - Medical is reported to by two ADs, namely, AD - Medical and AD
- NCD.
5.44 AD-Medical: The AD- Medical currently exists in the KHSDP and due to need for
integration between externally aided projects and the DHFWS, it has been brought under
Director - Medical. The AD - Medical will look after the Hospital and Hospital
management aspects in the Directorate.
He will ensure that a proper referral
mechanism is in place in the state to ensure speedy treatment at various levels of
hospital care. This post will be assisted by the following JDs:
JD - Medical
•
JD - Hospital
JD - Pharma
5.45 The JD - Hospital is a new post created for focused supervision of hospitals
under the DHFWS. The JD (GMS) has been re-named to JD (Pharma) with emphasis on
distribution of drugs and pharmaceuticals. The detailed reporting relationships and duties
and responsibilities of the above are provided in Volume II of this report.
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5.46 AD-NCD: To bring about greater emphasis and co-ordination in identification
and treatment of Non- communicable diseases, it is proposed to have an AD post who
would look after non-communicable diseases likes Cancer, Opthalmology, Diabetes, etc.
In addition, it is proposed to have the following JD posts reporting to the AD-NCD :
•
Joint Director - Opthalmology
•
Joint Director - NCD (Cardiovascular and Diabetology)
•
Joint Director - Emergency Medicine / Traumatology
Joint Director - Mental Health
•
Joint Director - Oncology
Joint Director - Dental Health
5.47 Recent studies Murray & Lopez: WHO and other reports - Nimhans, AIIMS,
NCAER etc) have shown the rising incidence of NCD cases. This will necessiate that the
Dept of Health have senior officers of the rank of JD's in each of these specialiities to
monitor the identificationzcurativez preventive and promotive aspects of the NCD's.
5.48 Taking into consideration the future requirements of Health care delivery, it is
proposed to have focussed attention in these areas. The various JDs will primarily be
responsible for the curative and research aspects of these specialisations. The detailed
reporting relationships and duties and responsibilities of the above are provided in
Volume II of this report.
Director - Public Health:
5.49 The Director -Public Health will be overall in-charge of the Public Health
development in the State of Karnataka. He will utilize his resources for effective
implementation of the various National and State level public health programmes. He will
be assisted by the following ADs :
AD - RCH / Primary Health
AD - Health Promotion
AD - CMD
AD - AIDS
5.50 AD -RCH is an existing post and will continue to perform the current key
functions. He will be assisted by the JD - RCH. He will also look after Primary Health
Care which is essentially a part of RCH and assisted by JD - PHC.
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5.51 AD - Health Promotion: The current AD (HET) is renamed as AD - Health
Promotion and will handle the functions of Information, Education and Communication
(IEC) along with other health promotional activities. He will be assisted by the following
JD:
JD - IEC
•
JD - Nutrition ( new post)
5.52 JD (IEC) currently is under AD (RCH). As the main function of the JD (IEC) relate
to communication of health related programs to the public it is proposed to re-locate this
post to be under AD - Health Promotion. Thus, bringing all health communication
activities under a single head will facilitate higher level of integration and maximum
utilization of resources.
5.53 AD — CMD is re-located from the KHSDP and will supervise the activities of
various national and state programs relating to vector borne diseases, TB, Leprosy as
well as the Vaccine Institute and the Laboratory. Each of the above functions are
managed by the Joint Directors He will be nodal officer for the State surveillance Unit,
the detailed job description is in Vol II of the report. The JDs reporting to AD- CMD are .
JD -Vector Borne
JD-TB
JD - Leprosy
JD - Vaccine Institute
•
JD - Labs
5.54 The JD (Vector Borne) post is renamed from JD - Malaria & Filaria with the scope
to incorporate additional vector borne diseases.
AD - North Karnataka
5.55 In view of the existing backwardness in the districts specified in terms of the
medical & public health standards, there is a need in the DHFW for focused attention on
the development of this region It is proposed to have a post namely AD - North
Karnataka, held by a senior person with exposure to both public health (programme
management) as well clinical, reporting directly to the Commissioner/DGHS).
5.56 The key role of this post will be to monitor the Dept. Of Health & Family Welfare
activities at Bijapur, Raichur, Gulbarga, Belgaum, Bidar, Bagalkot, Bellary, Koppal ,Gadag
districts. His office acts as a nodal office for all the activities of Dept. Of Health & Family
Welfare. He acts as a coordinator t 'tween different functionaries in the department and
also liaison with the directorate n behalf of the districts mentioned, (detailed job
description is given in Vol II of the report)
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Review of Organisation Structure
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AD - Planning
5.57 The need for integration of planning at the Directorate Level necessitates a post
of AD - Planning (reporting directly to Commissioner / DGHS). This post replaces the
existing Strategic planning Cell and will take up the activities of long-term ,short-term
and perspective planning for the department, with the inputs from different national and
international agencies as well as the Management Information Systems (MIS)
functionary of the department. He will monitor the changing epidemiological profile, the
burden of disease, recommend cost effective measures to achieve best use of limited
resources. Also carry out studies on a continuos basis and interpret , analyse trends
initiate policy initiatives for reform and change. Will also review the annual plans, five
year plans and MMR. Will edit the nnual report of the department. He will be assisted
by the following personnel :
JD -MIS
•
JD -Planning
5.58 The JD -MIS will be the nodi! point for all information relating to the DHFWS. He
will collate information from all medical, hospital and public health functionaries in the
department and interprets for any inferences or corrective actions. The bureau of health
intelligence, demography cell and all statistical units in some divisions will function
under the JD ( MIS ).
The JD ( Planning ) will be the nodal Officer for preparation of annual plans, five
year plans and annual report of tl department. Detailed JD's are in volume II of the
report.
5.59
Director - External Aided Pi jects
5.60 The various operations of the Externally Aided Projects is proposed to be
conducted in the main stream of t* DHFWS. However, a need was felt to introduce a
functionary reporting to the Com mi ioner/DGHFW to oversee the management of these
projects and to handle any co oid ation with external agencies, if any. The Director EAR will have the following key h nclions :
•
Monitor all the existing External Aided Projects, if needed by having different
reporting authority for each. He stands the overall responsibility for the
financial accountability of the Projects
•
Identify new areas
reality.
•
Work in close assoc tic n with mainline department in carrying forward the
objectives of all Exte lai Aided Projects with a programme mode of approach
rather than a project no 'e.
AFF -MC
35
laboration with other agencies and bring them to
b
Review of Organisation Structure
Vol I
Confidential
Director - Procurement and > A intenance
5.61 In the current structure, the procurement and maintenance of various equipment
and civil works are distributee a joss the various departments. It is proposed to
centralize these activities by creating a separate cell reporting to the
Commissioner/DGHS. It is proposed to place an IAS person to head this department
since this is administratively and technically the key functionary for the department. He
will be assisted by the following pe< le:
JD - Procurement
JD - Equipment & Mainti nance (Bio-Medical)
•
Chief Engineer - Civil
5.62 JD - Procurement's key functions include receiving the indent for any equipment
from all respective functionaries in the department about their requirement, placing
tenders for acquiring those equipm nt and finally acquiring them from the most feasible
bidder. The person to hold thi position can be one with engineering/logistics
background since it involves apprai mg of tender documents, acquiring equipment^and
- destined
•
well" versed
in all the ;procurement
supplying to the
location> He
li- should 'be
------- - ' procedures of World Bank and othei funding agencies.
5.63 JD — Equipment and Maintenance (Bio-Medical) takes care of all the machinery
and equipment including the veh. s of Directorate of Health Services. He will be
assisted by
DD - Equipment
DD - Equipment (trainin
•
DD - Transport
These posts are already xi ng under KHSDP and same to be transferred to the
Directorate of Health am Family Welfare.
5.64
Chief Engineer
Engineer - Civil
Civil nas
5.64 Chief
administrative relationship to th.
incharge of all the civil related con
Health services. He appraises the
eligible persons. He is assisted by
•
Superindent Engineei
•
Dy. Cheif Architect
AFF -MC
unctional reporting to the Secretary - PWD and
mmissioner through Director - Procurement. He is
action and maintenance work of the Directorate of
•nders for construction and allots the work to the
vil
36
-Vol I
Review of Organisation Structure
Confidential
Director SIHFW
5.65 Currently, he is a functionary reporting to Project Director - IPP - IX. It is
proposed that henceforth he will head the training function of the department and
SIHFW which will be a Autonomous and report functionally to the Principal Secretary of
Health. The hierarchy of the prop sed structure of the office of Director SIHFW includes:
JD
DD
•
District Training Officers
•
Other training persos nel involved in training in Health & Family Welfare
throughout the state
NGO Partnership Cell
NGO participation in Heach Care has become very essential at levels of Public
Health Care and first referral. Tl ese need to be supported and encouraged with special
focus esp. in the backward and remote region of the State. A number of NGO are
registered with the Health Department under various schemes and various programmes.
It is important that all NGO's ha e a single source of interaction, coordination with the
Health Department. It will alsc enable the Government to monitor and evaluate the
activities of the various NGOs pc rticipating with the Health Department.
Hence it is
suggested to have a NGO Partne: >hip Cell as a single window in the department headed
by preferably by a Advisor/ Co ultant to coordinate the activities of this cell with the
Commissioner/ DGHS to simplify roceclures for grant in Aids avoiding delays.
Joint Director ( Special Gn
fs)
A new post needs to be created ro cater to the problems of women ( gender sensitivity
/Tribals, Elderly and the Disabled). M will report directly to the DGHS and coordinate
with other departments and sec: s.
Benefits of proposed structure
5.66
The key benefits of the
ipose 1 structure are outlined below :
The structure is Proc mmc based thereby leading to more accountability for
m Ta uka level itself
programme officers
•
The split of DHFW unctions into Public health and medical for better
monitoring and exe ion of duties and responsibilities, thus increasing the
scope for accountab / at e ch stage
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•
Equal promotional avenues for all medical professionals in the department
•
Scope to have seniority cum merit during promotions
•
Removal of divisional structure, leading to concentrating the activities at
district level
•
Direct monitoring of all national and state programs from the directorate
itself, thus paving way for better coordination among districts and with the
directorate
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Review of Organisation Structure
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5. Review of Existing Cadre
5.1
The study involved determining the various cadre-related concerns as expressed
by the personnel met during detailed discussions and offering suggestions for the same.
In addition the cadre and recruitment rules were reviewed in brief to determine
conformance to the proposed structure. This cadre review is presented under the
following :
Introduction of sub-cadres
•
Promotion, Postings and related Policies
•
Qualification and Training
Private Practice
•
Adherence to working hours
Introduction of Sub-Cadres within Specialist cadre
5.2
As proposed in the previous chapter, the DHFW has two distinct cadres namely
Public health and Medical. One of the considerations taken into account was the
introduction of sub-cadres for the various specialists under the medical cadre. The
drawbacks of such a consideration are :
•
Complex cadre management
•
Blocking of levels based on growth
•
Skewed requirement across specializations
5.3
There is thus a need to determine senioritis and growth path for each sub-cadre
and its implementability and acceptance prior to introduction. In the interim it is
suggested that the DHFW determine the number of posts under each specialization
instead of introducing sub-cadres. Identify the need for specialists in the state and
thereby send doctors to acquire postgraduate qualification in those specializations only.
This will avoid mismatch of specialists to number of posts in the department.
5.4
The DHFWS has already identified the posts of Dy Chief Medical Officers/Senior
Specialists/Senior Medical Officers/Specialists and General Duty Medical Officers in April
1993 and documented the same in an official memorandum (No 378). This can be used
as a reference for determining the number of posts at each specialist post.
Subsequently, it was reworked recently. And known as Dr. Halagi report which is yet to
be accepted by the Government for implementation.
Promotion, Postings and Related Policies
5.5
The existing policies on promotion, postings and related areas have been
reviewed in light with the current issues faced by the various personnel and our
proposed organisation structure.
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Postings
5.6
It is the view of a cross section of personnel in the DHFW that very often postings
though accepted by the candidate, are subsequently not filled up mainly due to :
•
State cadre recruitment leading to selection of urban candidates (specifically
women candidates) who are unwilling to take up postings in rural areas
•
Unwillingness to withdraw from offer as they are sure of getting a posting of
their choice
5.7
This leads to a lot of posts being vacant for long duration's thereby defeating the
very objective of DHFW of continuous health care especially for the rural areas.
5.8
Suggestions to the same were offered in terms of introduction of criteria of native
place/permanent residence of candidate in the merit determination specifically for
postings for rural areas. However, this may lead to the higher merit candidates not
getting opportunities in the place of their choice. It is suggested that a counseling form
of posting the candidates (similar to the CET counseling) be introduced with the
following measures :
•
Mandatory rural posting for a minimum defined period in the initial years of
service (e.g two years)
•
Posting once accepted cannot be revoked except under extra-ordinary
circumstances such as on medical or humanitarian grounds (which need to be
clearly stated and proved)- any attempt to do the same to result in expulsion
from service
5.9
A move towards district recruitment for the district cadre was considered and the
view was that this would lead to certain issues such as imbalance of posts required vis-avis available candidates in the district and lesser opportunities for merit candidates
resulting in the decision for central recruitment policy with counseling. DHFW will need
to review the legal implications for implementation of counseling mode of posting
Specialty based Posting
5.10 The postings at the various CHC/Taluk Hospital and District hospital should be
done taking into consideration the various specialties at these centres and their
requirements.
5.11 Specialisations of the various candidates need to be considered during postings.
Currently for example Orthopedic specialists are posted at PHCs where there are no
facilities to provide their specialists service in addition to the routine PHC activity.
Further, additional qualification attained by the candidates between application to service
and joining DHFW is recommended to be considered while posting.
5.12 The posting policies should also incorporate specialization based requirements at
each health centre. E.g. currently there are surgeons posted in hospitals without
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Review of Organisation Structure
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Confidential
anesthetist, three ENT specialists in a one centre while there are no surgeons etc leading
to mis-match between requirements and postings.
Promotion/Transfers
5.13 Currently transfers are mostly promotion based, which is on the basis of seniority.
It has been observed that very often the promotion/transfer mechanism is not effective
due to the following factors :
Lack of rotational transfers
Non-conformance to transfer order
•
Consideration of pending service period prior to transfer
Promotions Table
Village
SC
Trained.Dai
ANM
JHA-F/M
JHA F/M
PHC
CHC
SHA F/M
TLH
District
THA
F/M
DHA F/M
State
Staff Nurse
Junior
SN
Staff Nurse
Senior
SN
DNO
DD
Nursing
Pharmacist
Junior
Pharmacist
Senior
District
Chief/DD
BHE
DHEO
DD
Senior
Senior
BHE
Lab.Tech.
Lab.Tech
Junior
Rotational Transfers
5.14 The review of cadre policy has brought to light that very often personnel are
based in the same health centre for long periods extending upto around 20-23 years.
Introduction of rotational transfers will facilitate spread of experience across different
regions. Rotational transfers can be done through counseling with the support of
manpower planning details.
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•
-Vol II (Job Descriptions)
Be a part of the team conducting eye related operation, atleast on 15 occasions in a
year
• Programme evaluation of blindness control
Training Areas:
• New areas of development in proper eye care
•
Exposure to new equipment related to opthalmology
•
Programme Management
•
Health Management
Job Title:
JOINT DIRECTOR - NCD (Cardiology & Diabetology)
Reporting To:
Additional Director - NCD
Immediate Level Subordinates:
• District Surgeon
•
Superintendents of major hospitals
•
Other specialists in the area of Cardiology and Diabetology
Basic Function:
Overall incharge for the diagnosis and possible treatment of Cardiac and Diabetes
related ailments to the people of the state. Monitor the basic referral system in the state
with reference to the above mentioned ailments and conduct medical audit of the cases
wherever found necessary and asked for.
Duties, Responsibilities and Authorities:
• Conduct different awareness building camps about Cardiology and Diabetes including
prevention factors, risk factors and patient education
•
Monitor proper availability of life saving drugs related to Cardiology and Diabetes
•
Monitor referral system in the state with respect to the above ailments
•
Ensure conducting of medical audit for some operations on a sample basis and
compulsorily for critical and controversial operations
•
Planning, implementation and monitoring of programmes connected with National
Programme for control of cardiac cases and diabetic cases
•
Identify the magnitude of the problem of blindness cases
•
Training of Assistants in the field of cardiology and diabetology.
•
Matters pertaining to calling for tenders for drugs, equipment related to cardiology
and diabetology.
•
Ensure conducting of medical audit for some operations on a sample basis and
compulsorily for critical and controversial operations
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Review of Organicetior; Structure
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•
Coordinate with District Officers in spreading the message of good nutrition for
control of diabetes and cardiac cases among the people of the state
•
Review of working of Major equipment
•
Continuous monitoring of the performance of the personnel at different hospitals and
recommend for any training required.
•
Monitor the effectiveness of camps conducted
•
Review the hygienic conditions in the operation theaters and wards
•
Coordination with NGO's
Main Accountabilities:
• Medical audit of eye operations conducted either at special camps or hospitals
•
Visit all hospitals which have the facility for treating cardiac and diabetes, atleast
once a year.
•
Programme evaluation of control programmes
Training Areas:
• New areas of development in cardiology and diabetology
•
Exposure to new equipment related to cardiology and diabetology
•
Programme Management
•
Health Management
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Review of Organisation Structure
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Job Title:
DIRECTOR - PUBLIC HEALTH
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
• Additional Director - RCH
•
Additional Director - Urban Health
•
Additional Director - Health Promotion
•
Additional Director - PHC
•
Additional Director - CMD
Basic Function:
Effective Implementation of all national and state public health programmes. Preparation
of a public health policy for the State._Overall responsibility for establishing, managing
and development of health infrastructure in the state. Is responsible for the public
health services delivered in the state.
Duties, Responsibilities and Authorities:
• Develop a comprehensive strategic plan for the public health
wing of the
department which includes vision, mission, objectives, goals of the department
•
•
•
Ensure that quality public health care services are available to the target population
Ensure adequate popu/ation/bed ratio, physician/bed ratio as per norms is
maintained (Government ofIndia/ WHO/state government)
Ensure that the primary health centers and referral hospitals are easily accessible to
the population, review need for rationalisation and relocation of some health units as
well as setting up new health units in order to improve accessibility and service
coverage.
•
Review and evaluate the existing policies and procedures and work methods by
means of periodic and special studies
•
Review the MIS reports generated by AD - Primary Health / Planning and take
corrective actions
•
Review and recommend the upgradation of primary health infrastructure in the state
•
Work out improved methods and procedures to achieve the objectives and Develop
standards, methods and measurements of the PHC activities
•
Monitor the utilisation of public health
means of bringing optimum utilisation
•
Ensure periodic health promotion activities (quantifiable) are carried out in the
community
•
Visit all districts esp PHC's at random and review the Public health programmes in
the state, atleast once a year.
•
Ensure that medical audit and internal audit has been carried out in as many PHC's
as possible at periodic intervals
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Review of Organisation Structure
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•
Submit all relevant material which can be hosted on the department website
•
Ensure that full economy and expenditure control is observed in all public health
related operations and activities in the state.
Recommend transfer and postings of District Health Officers.
•
•
Overall responsibility for the prevention of diseases of any kind and promotion of
health throughout the state by training the department cadre
•
Monitor each national and State health programmes and their implementation with
special emphasis to Maternal & Child Health and Primary Health Care
•
Suggest for the continuation or stopping of different national and state health
programmes according to the need of the state.
•
Monitor the training needs identification of the personnel in the department and
nominate for the respective programmes to be conducted by State Institute of
Health and Family Welfare or other institutes from time to time
•
Monitor the Information, Education and Communication department activities in the
state in terms of educating / bringing awareness among the people
•
Monitor the treatment and curbing the spread of vectorborne diseases in the state
with the coordination of corporations and municipal authorities in the state with
emphasis on disease surveillance and epedemiology
•
Monitor the norms of blood safety as specified by concerned authorities/boards from
time to time
•
Monitor the functioning and activities of Vaccine Institute, Belgaum.
•
Monitor and Review the methods of combating the spread of Communicable diseases
in the state
•
Monitor the working of urban health programme and slum improvement programme
•
Receive and review the MIS reports on the status of health in the state and take up
any remedial actions either in terms of interim review of existing programmes or
new programmes.
•
Work for the coordination between all the reporting functionaries
•
Work for the effective coordination with external and autonomous agencies in
implementing the health mandate in the state.
•
Monitor effective implementation of various public health programme
Main Accountabilities:
• Visit all districts and taluks
which conduct the national/state public Health
programmes in the state atleast once in a year
Address all programme officers in the districts atleast once in a year and appraise
them of the expectations of the government and their deliverables
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Review of Organisation Structure
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•
Ensure quality of care in all PHC's through periodic medical audit and patient
satisfaction surveys
•
Achievement of Health goals of state
•
Ensure optimum capacity utilisation of hospital infrastructure through periodic review
of MIS reports (hospital efficiency indicators) of all hospitals
•
Increase of health infrastructure (need / technology based) in the state in
coordination with planning cell
Training Areas:
• Attend Management Development Programmes at international institutes such as
Harvard, John Hopkins, etc in areas of Public Health Policies, health policies, New
business models in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international and to share the experiences of
Karnataka and get a feedback.
•
Awareness of different kinds of Public Health Programmes in the developed and
developing countries
•
Project execution methodology of international agencies
•
Health Management
Job Title:
ADDITIONAL DIRECTOR - RCH
Reporting To:
Director - Public Health
Immediate Level Subordinates:
• Joint Director - RCH
Basic Function:
Overall responsibility for all Maternal and child health in the state. Ensure proper
implementation of RCH / Family Planning programme in the state
Canalso look after the work of AD - primary health.
Duties, Responsibilities and authorities:
•
He is the overall head of the RCH project office of Directorate of Health & FW
Services.
•
He is responsible for planning of RCH programme
•
He is responsible for effective achievement of the laid down projects under FW &
MCH programme.
•
He is overall supervisory authority for training of various field staff like Dais, Para
Medical staff and Medical personnel.
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Review of Organisation Struck1 re
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•
Coordinate with municipal and corporation authorities in spreading the message of
Maternal and Child Health
•
He is responsible for acting as liaison between Govt, of India/ Internal agencies like
UNICEF, World Bank and State Government for various projects from preparation to
implementation stage.
•
He is responsible for procuring and equipping the public health institutions and Taluk
institutions, with various types of equipment & apparatus for effective
implementation stage.
•
Ensure the increase in deliveries in PHC or other hospitals to decrease the risk of
infant mortality and maternal mortality
•
He is responsible for monitoring and supervising the activities of the demographic
cell, IEC activities of RCH project office.
•
Recommend construction of subcenters for RCH programme
Main Accountabilities:
•
Visit all district Hospitals, some PHC/CHC's (quantifiable number) and specialty
hospitals atleast once a year
•
Ensure the increase in de/iveries in PHC or other hospitals to decrease the risk of
infant morta/ity and maternal morta/ity
•
He is responsible for monitoring and supervising the activities of the demographic
cell, IEC activities of RCH programme
Training Areas:
• Programme management
•
Health management
•
Pediatric care
•
Community Health
•
Issues in Maternal & Child Health, their addressal in different parts of the world
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Review of Organisation Structure
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Job Title:
JOINT DIRECTOR - RCH
Reporting To:
Additional Director - RCH
Immediate Level Subordinates:
• Deputy Director - RCH
•
Deputy Director - IUD & PPP
Basic Function:
Responsible for proper Maternal and child health in the state. Ensure proper
implementation of RCH programme in the state
Duties, Responsibilities and authorities:
•
He is the nodal officer of the RCH project office of Directorate of Health & FW
Services.
•
He is responsible for implementation of RCH programme
•
He is responsible for effective achievement of the laid down projects under FW &
MCH programme.
•
He is overall supervisory authority for training of various field staff like Dais, Para
Medical staff and Medical personnel.
•
Coordinate with municipal and corporation authorities in spreading the message of
Maternal and Child Health
•
He is responsible for acting as liaison between Govt, of India/ Internal agencies like
UNICEF, World Bank and State Government for various projects from preparation to
implementation stage.
•
He is responsible for procuring and equipping the public health institutions and Taluk
institutions, with various types of equipment & apparatus for effective
implementation stage.
•
Ensure the increase in deliveries in PHC or other hospitals to decrease the risk of
infant mortality and maternai mortality
• Implement construction of subcenters for RCH programme
Implementation, monitoring and reviewing of all activities connected with RCH
programme, immunization of children against vaccine preventable diseases and other
MCH activities.
• Procurement of UIP vaccines, distribution and follow-up of the vaccines &
maintenance of Cold chain equipment/ articles.
•
Monitor the timely administration of vaccines to pregnant women and infants
throughout the state
•
Ensure the availability of doctors, nurses and ANMs at the respective hospitals to
attend to any kind of medical help regarding Maternal and child health
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Review of Organisation Structure
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•
Work in coordination with the IEC functionary in spreading the message of Mother
and Child Health and the precautions to be taken during pregnancy and child birth
•
Submit the reports regularly to the office of AD-planning for developing a
comprehensive MIS reports on the status of Maternal and Child Health in the state.
•
Supply of material to IEC functionaries regarding the material to be prepared about
Maternal and Child Health
•
Recommend for construction of RCH sub-centres, postpartum centres and other
buildings coming under RCH programmes.
•
Payment of Grant-in-aid to the voluntary agencies who are implementing the RCH
programme.
•
Coordinate with the office ofJD - IUD & PPP to spread the message of RCH
•
Monitor the effective implementation of Universal Immunization Programme.
•
Ensure the increase in child deliveries in PHC or other hospitals to decrease the risk
of infant mortality
Main Accountabilities:
• Increase in deliveries in PHC or other hospitals to decrease the risk of infant
mortality and maternal mortality
•
Visit all district hospitals atleast once in a year and other community health and
primary health centres on a sample basis
•
Conduct atleast one meeting of all the district family planning and RCH officers in a
year
•
He is responsible for monitoring and supervising the activities of the demographic
cell, IEC activities of RCH programme
Training Areas:
• Programme management
•
Health management
•
Pediatric care
•
Community Health
•
Issues in Maternal & Child Health, their addressal in different parts of the state
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Review of Organisation Structure
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Job Title:
DEPUTY DIRECTOR - IUD & PPP
Reporting To:
Joint Director - RCH
Immediate Level Subordinates:
• District Health Officer
• District Family Planning Officer
Basic Function:
Overall incharge of family planning operations in the state and implement the
national and state level programs in relation to IUD & PPP. Convey the decisions taken
at the directorate regarding IUD & PPP programs to the district officials
Duties, Responsibilities and Authorities:
•
Responsible for planning, supervision and guidance of IUD programme oral pill
programme and All India Hospitals Post Partum Programme under the supervision
of Joint Director - RCH
•
Provide guidance and supervision to the field operations in relation to Family
Planning Programme in State at various levels especially in the field of IUD & PPP
and oral pill programme.
•
Secure cooperation and assistance of related departments for family planning work
at State level.
•
Review programme operation from time to time, identify problems, provide help in
finding situations and seek assistance of Govt, of India, to solve them when
necessary.
•
Ensure arrangement to follow up of each case of IUD in the region allocated.
•
Maintain administrative liaison with all official and non-official family planning
organisations in the State.
•
Coordinate with the office of JD - RCH and spread the message about Family
planning
•
Conduct special family planning camps to men and women throughout the state
•
Coordinate with IEC functionary in spreading the message of family planning and
misconceptions about different kinds of family planning methods
•
Formulate field instructions and operative manuals.
•
Function as a clearinghouse for up to-date information on achievements and
progress in the State as a whole for IUD & IPPP and oral pill.
•
Attend to such other items of work as may be assigned and the Joint Director - RCH
and other superior authorities.
27
AFF -MC
Si
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Review of Organisation Structure
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Descriptions'.
Job Title:
DEPUTY DIRECTOR - RCH
Reporting To:
Joint Director - RCH
Immediate Level Subordinates:
Basic Function:
His office acts as nodal centre for all the districts regarding different national and state
RCH programs. Monitors the RCH and particularly the reproductive and child health
programs in different parts of the state. Conveys different decisions taken at the
directorate regarding the above programs to the district officials.
Duties, Responsibilities and Authorities:
• Work towards integrating maternal & child health and family planning.
•
Work in close liaison with the Deputy Director - IUD & PPP and other officers of
State Family Planning Bureau.
•
Ensure that all maternal and child health staff fulfil their required responsibilities in
family planning and that the MCH clinics are equipped with the necessary supplies
and facilities for family planning work.
•
Assess the in-service training needs of all MCH personnel and arrange for their
training.
•
Coordinate and guide family planning training in the nurses and ANM training
courses to ensure that proper training in family planning is imparted.
•
Help to supervise the MCH services to ensure that there are adequate physical
facilities, equipment and drugs and to see that proper educational and clinical
procedures are carried-out.
•
Convey the decisions taken regarding RCH activities to the district officials.
•
Convey the suggestions and problems of the district level officials to the JD/AD
RCH
Help to guide and supervise proper follow-up of women who have adopted family
planning methods.
Take action to organise the ANM training centres and LHV training centres and see
that the centres function properly.
•
•
•
•
Arrange to see that selection to the ANM and LHV training centres is done in time
and as per rules.
Arrange to conduct the training according to prescribed syllabus and arrange for
conducting examinations periodically and to announce the results.
•
Take action to organise the dais training.
•
Supervise work of District Nursing Supervisors, check and review their diaries,
inspect the work of LHVs and ANMs.
28
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Review of Organisation Structure
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•
Take action to organise the programme of immunisation of pre-school children and
expectant mothers and prophylaxis against nutritional anemia vitamin A deficiency.
•
Attend to such other items to work as may be assigned to him by the Joint Director
(RCH) and other superior authorities.
Job Title:
ADDITIONAL DIRECTOR - HEALTH PROMOTION
Reporting To:
Director - Public Health
Immediate Level Subordinates:
• Joint Director - Health promotion
•
Joint Director - IEC
Basic Function:
Responsible for educating the different functionaries in the department about national
and state health programmes. Oversee the Information, Education and Communication
activities in the state and their affectivity in reaching to the people of the state with
special emphasis to the rural, slum and school children and liasion with different
agencies of mass media in the state in spreading the message of health to all.
Duties, Responsibilities and Authorities:
• Liaison with AIDS society in spreading the message of prevention measures against
AIDS
•
Coordinate with all the functionaries in the Health Department and receive
requisitions regarding any kind of spread of prevention message for the public
regarding public Health and medical health
•
Emphasis of positive health, school health and use of captive audience in hospitals
•
Oversee the activities of the publication division of the department
•
Review the process of sending requisition of publication from IEC cell to the
publisher.
•
Set standards and monitor the quality assurance in the publications of the
department
•
Guide the respective Joint Directors in setting targets to the Health Promotion and
IEC cells of the department and attain the goals
•
Coordinate with the office AD - planning in generating reports about the status of
health in the state and planning for the future in attaining good health standards
•
Suggest methods of using the special occasions of melas and exhibitions to spread
the message of Public Health
•
Monitor the activities involving bringing awareness among the general public and
children about the public health.
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Review of Orga rvsabon Structure
•
•
-VC/-
lob Descriptions}
Identify the areas of development among the department functionary about public
Health and appraise the State Institute of Health and RCH about them and ensure
nominating eligible persons as and when such programmes are announced by any
institute
Liasion with All India Radio, Doordarshan and other authorities in spreading the
message of Public Health
•
Intersectoral coordination with information and broadcasting, labour ,education,
women and child department
•
Emphasis on patients charter of rights
•
Head of State health Education Bureau
Main Accountabilities:
Visit all major exhibitions where the department participates with its stall in it
Public perception of IEC activities
Post programme evaluation
Training Areas:
Mass media education
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Review of Organisation Structure
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Job Title:
JOINT DIRECTOR - LEX.
Reporting To:
Additional Director - Health Promotion
Immediate Level Subordinates:
• Deputy Director - Information
Basic Function:
Overall responsibility for spreading the message of preventive health to the
people of the state through different platforms. Use all such opportunities wherein which
the message of Public Health can be spread.
Duties, Responsibilities and Authorities:
•
Monitor all matters relating to information, education and communication related to
Health of the people of Karnataka.
•
Responsible for procurement, distribution and utilisation of educational materials
related to RCH and Maternal and Child Health
•
Incharge of the publication of KUTUMBA, every fortnight
•
Conduct the field verification of RCH acceptors and incentives paid to the RCH
beneficiaries.
•
Coordinate with State Institute of Health and RCH in formulating the content of the
course about Public / Preventive Health and its allied areas
•
Post programme evaluation and its impact on the public (quantifiable)
•
Conduct in-service training to the RCH staff on I.E.C. activities.
•
Head the department press and its activities
•
Coordinate with different Medical and health departments in the contents related to
the publication and distribution
•
Spread the message of drug addiction / alcohol and educate people for being away
from smoking, drinking and other forms of drug addiction.
Main Accountabilities:
Error free distribution IEC material and other publications from the department
Training Areas:
a)Mass communication bJConducting exhibitions c)Multi-media
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Review of Organisation Structure
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Job Title:
DEPUTY DIRECTOR - INFORMATION
Reports To:
Joint Director (Information, Education & Communication)
Immediate Level Subordinates:
•
Field Publicity Officer
Basic Function:
Ensure the spread of the error free desired information among the public of the state,
organise exhibitions at small/big congregations to bring awareness in the areas related
to Health. Liaison with other agencies in production of films related to educational
aspects of health
Duties, Responsibilities and Authorities:
• Responsible for entire Mass Media and Mass education programmes of Family
Planning in the state.
•
Co-ordinate the family planning mass education programme in the state, districts
with the help of all other states and Government of India Publicity units.
•
Plan and design for production and distribution of publicity material for Mass
education, and extension education in the state.
•
Collect information on all districts about the newspapers in circulation, cinema
theatres in operation, audio-visual units of State and Government of India available
and other mass media education items, so as to use them effectively for education.
•
Liaison with the press, radio, field publicity units and mass media to provide
necessary background material to them.
•
Guide and supervise the work of District Mass Education and Information officers
and District Health educators.
•
Bring out success stories of individuals adopting family planning methods by visiting
services, camps, wherever held in the districts.
•
Prepare digests of critical newspaper comments and bring such comments to the
notice of the administrative head of the department and technical officers of the
State Family planning Bureau and also arrange for issue of any clarification to
remove the mis-apprehension or doubts in the minds of the people.
•
Plan for the production of sufficient printing matters for running the offset press.
•
To stimulate and coordinate the effective use of all types of educational material by
all categories of Family Planning field workers as well as others.
•
Monitor the out door publicity programmes.
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Training Areas:
•
Conducting exhibitions
•
Effectiveness of theatre arts
•
Multi-media
•
Effective use of print media
•
An internship with DAVP, GOT
Job Title:
FIELD PUBLICITY OFFICERS
Reporting To:
Deputy Director — Information
Immediate Level Subordinates:
• Programme Assistant
•
Health Education Officer
Basic Function:
Incharge of all the publicity material procured by the IEC functionary of the Directorate
of Health Services. Plan and implement the ways to take the message even to the rural
areas in the state.
Duties, Responsibilities and Authorities:
. Encourage production of family planning films in the state with the help of available
official and or private agencies.
•
Arrange production and distribution of family planning filmstrip, slides, recordings
and distribution thereof.
•
Supervise the functioning of audio-visual units in the districts.
•
Maintain effective liaison with the media units
•
Assist in the organisation of Family Planning campaign at the State/District level
•
Initiate and supervise design and fabrication of all exhibits for the exhibition
•
Direct and supervise the activities of Exhibition in the Districts/Rural centres
•
Guide and help the district MEIO's Extension Educators
•
Supervise effective use of display publicity, hoardings, bus-boards, wall paints and
metallic tablets etc. in the state
•
Such other allied duties as may be assigned by the AD (RCH)
Main Accountabilities:
• Number of exhibitions conducted
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Training Areas:
•
Conducting exhibitions
Communication in mass media
Job Title:
HEALTH EDUCATION OFFICER
Reporting To:
Field Publicity Officer (Functionally)
District Health Officer (Administratively)
Immediate Level Subordinates:
Basic Function:
Primary responsibility to establish working relationship with NGOs and local bodies in
spreading the message of Health, taking stock of the available material and plan for
procurement and distribution of the same.
Duties, Responsibilities and Authorities:
•
Develop and maintain a close working relationship with the State Health Education
Bureau in order to utilise fully the technical and physical resources of the bureau for
the family planning programme.
•
Develop and maintain close working relationship with different agencies that can
contribute to the educational programme like the education department, information
department, All India Radio, Development and Panchayat Raj Department etc. and
utilise their resources.
•
Promote the educational activities of the voluntary agencies and local bodies
•
Co-ordinate the efforts of honorary, education leaders and assist them in their work.
•
Assess the educational needs and recommend educational programmes for district
and state Training institutes.
•
Responsible for planning and operating a statewide information programme utilising
all available channels and media of mass communication.
•
Provide technical guidance to the District Family Planning Bureau.
•
Assess the needs of educational material and equipment and arrange for their
procurement and distribution.
•
Assist the AD - RCH in assessing training needs in health education and develop a
plan for detaining personnel for training.
•
Organise seminars, workshops, conferences and periodical staff meetings.
•
Attend to such other functions as may be assigned from time to time.
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Training Areas:
• Conducting health campaigns
•
Conducting exhibitions
•
Effective use of theatre arts
Job Title:
PROGRAMME ASSISTANT
Reporting To:
Field Publicity Officer
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
• Assist Field Publicity Officer in compiling organising and production of field
programmes, exhibitions songs and drama programmes, traditional media
programme and other cultural activities to communicate Family planning programme
to the people.
•
Assess the programmes sponsored and consolidate them.
•
Assist in selection of artists and types of programmes which the audience prefer.
•
Assist in selection of movie films on Family planning, exhibits for exhibition purposes,
production of family planning films to be produced by State Family Planning Bureau.
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Job Title:
DEPUTY DIRECTOR - SCHOOL HEALTH
Reporting To:
Joint Director - Health Promotion
Immediate Level Subordinates:
Basic Function:
Spread the message of good health among school children and arrange to
conduct periodic health check-ups to school children. Also monitor the hygienic
conditions around the schools and suggest corrective actions to the municipality
authorities and heads of respective schools/institutions
Duties, Responsibilities and Authorities:
• Coordinate with the District Education Officers and organise for periodical health
check-up for the students in different schools
•
Coordinate with District Health Officers in spreading the message of Public Health
among the students of different schools in the state
•
Ensure proper hygenic conditions around the premises of schools in the state and
suggest corrective actions to the heads of institutions
•
Encourage literary activities among the students of different schools
•
Spread the message of special days (world health day, AIDS day, day for the
physically handicapped, etc) among the students of different schools and educate
the pupils about them.
Send reports to the MIS functionary for any interpretation regarding the health of
•
school going children in the state.
Main Accountabilities:
Number of school health programmes
Evaluation of the programme
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ADDITIONAL DIRECTOR - PRIMARY HEALTH
Director — Public Health
Reporting To:
Immediate Level Subordinates:
• Joint Director - Primary Health
Basic Function:
Effective Implementation of all national and state public health programmes. Preparation
of a primary health care policy for the State. Overall responsibility for establishing,
managing and development of health infrastructure at the primary level in the state. Is
responsible for the public health services delivered at the primary level in the state.
Monitor and evaluate the basic programs at all the Primary Health Centres in the state,
availability of basic infrastructure facilities offered to all the Primary health centres and
effective patient care at PHCs. Also monitor the referral system .
Duties, Responsibilities and Authorities:
• Ensure that quality public health care services are available to the target population
•
Ensure that the primary health centers and referral hospitals are easily accessible to
the population, review need for rationalisation and relocation of some health units as
well as setting up new health units in order to improve accessibility and service
coverage.
•
Review and evaluate the existing policies and procedures and work methods by
means of periodic and special studies
•
Review the MIS reports generated and take corrective actions
•
Review and recommend the upgradation of primary health infrastructure in the state
•
Work out improved methods and procedures to achieve the objectives and Develop
standards, methods and measurements of the PHC activities
•
Monitor the utilisation of public health
means of bringing optimum utilisation
•
Coordinatr periodic health promotion activities that are carried out in the community
•
Visit all districts esp PHC's at random and review the Public health programmes in
the state, atleast once a year
Ensure that medical audit and internal audit has been carried out in as many PHC's
as possible at periodic intervals
•
resources throughout the state and adopt
•
Submit all relevant material which can be hosted on the department website
•
Ensure that full economy and expenditure control is observed in all public health
related operations and activities in the state at the PHC's level.
Ensure that full complement staff are available at all the PHC's
•
•
Monitor the training needs identification of the PHC personnel in the department
and nominate for the respective programmes to be conducted by State Institute of
Health and Family Welfare or other institutes from time to time
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•
Monitor effective implementation of various public health programme
•
Coordinate with AD-planning on the budgeting activities
Main Accountabilities:
• Visit all districts and taluks
which conduct the national/state public Health
programmes in the state atleast once in a year
Address all PHC officers in the districts atleast once in a year and appraise them of
the expectations of the government and their deliverables
•
Ensure quality of care in all PHC's through periodic medical audit and patient
satisfaction surveys
•
Achievement of Health goals of state
•
Ensure optimum capacity utilisation of hospital infrastructure through periodic review
of MIS reports (hospital efficiency indicators) of all hospitals
•
Increase of health infrastructure (need / technology based) in the state in
coordination with planning cell
Training Areas:
• Attend Management Development Programmes at international institutes such as
Harvard, John Hopkins, etc in areas of Public Health Policies, health policies, New
business models in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international and to share the experiences of
Karnataka and get a feedback.
•
Awareness of different kinds of Public Health Programmes in the developed and
developing countries
•
Project execution methodology of international agencies
•
Health Management
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Job Title:
ADDITIONAL DIRECTOR - CMD
Reporting To:
Director — Public Health
Immediate Level Subordinates:
• Joint Director - Vector Borne
• Joint Director - Leprosy
• Joint Director - TB
• Joint Director - Vaccine
• Joint Director - Lab
Basic Function:
Nodal Officer for the State Surveillance unit. Ensure proper implementation of
various national and state programmes related to Leprosy, Vector borne diseases and
TB. Ensure proper maintenance of laboratories in the state.
Duties, Responsibilities and Authorities:
•
Evolve strategies for Surveillance
•
Set up procedures for collection, analysis and reporting of morbidity and mortality
data.
•
Monitor the functioning of the District Surveillance Units
•
Co-ordinate with other related Departments at the State level, Indian Medical
Association, Programme Officers, Voluntary Organisations, etc.
•
Conduct surveys, compile morbidity and mortality data, by disease, for planning and
working out priorities and strategies.
•
Evaluate the effectiveness of interventions instituted to control epidemics.
•
Carry out research studies and suggest innovative and the effective methods of
intervention
•
Act as the nodal Surveillance unit at the district level and provide the missing link
between the primary and secondary level sub-systems
•
Provide early warning of outbreak of epidemics of all the major communicable
diseases through continuos Zilla Panchayat, PWD, Fisheries, Irrigation, Agriculture,
Rural Development, Indian Medical Association, Programme Officers, Voluntary
Organisations, etc.
•
Planning, implementation, reviewing and monitoring of communicable diseases such
as Diarroheal diseases, Kyasnoor Forest Disease, Guinea Worm etc.
•
Monitor the running of Diagnostic Laboratory, Shimoga, Vaccine Institute, Belgaum,
communicable diseases investigation and Training Centre, Mandya.
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•
Monitor all activities relating to manufacture (at Vaccine Institute), supply and
distribution of vaccines
•
Monitor the precautionary measures and preparedness of state machinery in tackling
with any natural calamities
.
All matters relating to Air, Water and Environmental pollution, and Slum Clearance
board
Monitor the National Leprosy Eradication programme implementation throughout the
state
•
Monitor the overall performance of National TB Control Programme and Lady
Wellington TB Demonstration & Training Centre, Bangalore
•
Work in coordination with the office of Additional Director - Urban Health in control
of Malaria & Filaria and such other diseases.
Main Accountabilities:
• Conduct surveys, compile morbidity and mortality data, by disease, for planning and
working out priorities and strategies.
•
Evaluate the effectiveness of interventions instituted to control epidemics.
•
Carry out research studies and suggest innovative and the effective methods of
intervention
•
Set up procedures for collection, analysis and reporting of morbidity and mortality
data.
•
Monitor the functioning of the District Surveillance Units
•
Co-ordinate with other related Departments at the State level, Indian Medical
Association, Programme Officers, Voluntary Organisations, etc.
Training Areas:
Health management
Epidemiological methodology
Programm management
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Job Title:
JOINT DIRECTOR - VECTOR BORNE
Reporting To:
Additional Director - CMD
Immediate Level Subordinates:
•
District Malaria Officer
•
District Filaria officer
•
District Health Officer
Basic Function:
Ensure proper planning and implementation of national and state programmes related to
all Vector Borne diseases and proper utilisation of funds allotted for each unit/district.
Liaison with the municipal authorities in ensuring hygenic living conditions for the people
in the state and appraise them of better methods of sanitation and the importance of
that.
Duties, Responsibilities and Authorities:
•
Planning, implementation, reviewing and monitoring of communicable diseases such
as Diarroheal diseases, Kyasnoor Forest Disease, Guinea Worm etc.
•
Planning, implementation, monitoring of all matters connected with the Ecology,
Malaria, Filaria and other mosquito borne diseases.
•
Process the reports generated through to Central Malaria Laboratory and take
preventive measures to curb the spread of the disease.
•
Planning the activities like budget allocation and key sustenance factors related to
various Diagnostic Laboratory, Shimoga, Vaccine Institute, Belgaum, Communicable
Diseases Investigation and Training Centre, Mandya.
•
All matters relating to manufacture, supply and distribution of vaccines
•
Work in coordination with various civic bodies relating to natural calamities.
•
All matters relating to Air, Water and Environmental pollution, and Slum Clearance
board
•
Overall incharge of curing and arresting the spread of Malaria & Filarial diseases in
the state
•
Work in coordination with the office of Additional Director - Urban Health in control
of Malaria & Filaria and such other diseases.
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Main Accountabilities:
• Planning, implementation, reviewing and monitoring of communicable diseases such
as Diarroheal diseases, Kyasnoor Forest Disease, Guinea Worm etc.
•
Planning, implementation, monitoring of all matters connected with the Ecology,
Malaria, Filaria and other mosquito borne diseases.
•
Process the reports generated through to Central Malaria Laboratory and take
preventive measures to curb the spread of the disease.
Training Areas:
Health management
Epidemiological methodology
Programm management
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Job Title:
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JOINT DIRECTOR - TB
Reporting To:
Additional Director — CMD
Immediate Level Subordinates:
• District Health Officer
•
District TB and AIDS Programme Officers
Basic Function:
Carry forward the different national and state programs related to Tuberculosis and
AIDS in the state, treatment of the respective patients and monitor the processes of
control of TB
Duties, Responsibilities and Authorities:
• Monitor different national and state programs related to Tuberculosis and AIDS in
the state
•
Coordinate with the office of AD - IEC for any material or inputs for the publicity
material to educate the people in the areas of TB and AIDS
•
Monitor the process of treatment for some chronic TB patients in the state
•
Coordinate with AIDS Society in the state to educate the people regarding the
precautions to be taken about AIDS
Main Accountabilities:
• Monitor different national and state programs related to Tuberculosis and AIDS in
the state
Training Areas:
Health management
Epidemiological methodology
Programm management
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Job Title:
JOINT DIRECTOR, VACCINE INSTITUTE, BELGAUM
Reporting To:
Additional Director - CMD
Immediate Level Subordinates:
• Deputy Director - Epidemiological surveillance Unit
•
DHO
• Deputy Director - Pharma
Basic Function:
Manufacture ARV vaccine and its distribution to the institutions of the State and
ensure proper procurement, storage and distribution of DIP / Vaccines in the districts of
Gulbarga and Belgaum divisions
Duties, Responsibilities and Authorities:
• Manufacture of ARV vaccine and its distribution to the institutions of the State.
•
Coordinate with all NGO's and department agencies
•
All matters relating to the UIP/ Vaccines, procurement, storage and distribution to
the districts of Gulbarga and Belgaum divisions.
Training Areas:
Health management
Epidemiological methodology
Programm management
Job Title:
Reporting To:
JOINT DIRECTOR - LABORATORIES
Additional Director - CMD
Immediate Level Subordinates:
• Deputy Director - Viral Diagnostic Lab, Shimoga
• Deputy Director - Bacteriological lab, PHI, Bangalore
• Chemical Examiner
• Chief Chemist
Duties, Responsibilities and Authorities:
•
Planning, implementation, monitoring and reviewing of various activities of Public
Health Laboratories in the State including district Laboratories, Divisional
laboratories, Divisional Food Laboratories and laboratories at various levels
•
Implement Food Adulteration Act procedures in coordination with the municipal and
corporate functionaries at different locations in the state.
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Non-Conformance to Transfer Orders
5.15 Transfer orders are not necessarily followed by the personnel. The personnel is
given a choice to refuse transfer in lieu of losing his promotion. However it has indicated
that personnel use references to get transfers of their choice. This leads to non-favored
locations not being posted for long duration of time.
5.16 It has been suggested by a cross section of personnel that specific measures
need to be undertaken to control in-discipline regarding transfer orders. These measures
include :
•
Recording use of any reference for transfer of choice, in the service book,
which will be reflected in the future career growth of the personnel
•
Delay in PG admission etc
Consideration of Pending Service Period
5.17 The current policy of minimum period at a post is in the range of 6-7 years
leading to a personnel to have at least 17 years of experience prior to the post of Deputy
Director. This policy has led to various personnel being promoted (especially at senior
levels such as JD, AD etc) having around 6 months to one year of pending service
period. The roles of the senior posts being mainly in the form of strategy and planning,
this period is not sufficient for effective implementation of plans.
5.18 Considering the importance of prior field experience for the directorate posts, it is
recommended that the promotion policy in terms of minimum period of service be re
looked to facilitate Senior Personnel being promoted to a post having at least two years
of pending service. Alternatively, the personnel can be given the option of in-service
promotion with requisite compensation benefits whereby he will continue to remain in his
previous post.
Qualifications and Training
5.19 This section covers observations and suggestions on matters relating to
qualification of personnel and the need for training.
Qualification Related
5.20 The qualification related matters discussed in the ensuing paragraphs are
primarily of :
•
Post-Specific Qualifications
•
PG Course Selection
Post-Specific Qualification
5.21 The proposed structure pre-requisites the need for post - specific qualifications
for the various personnel manning these posts. The division of the department into
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Public Health and Medical wings necessitates the need for respective qualification.
Further, for the function based posts such as JD (Optha) under the medical wing,
specific specialization e.g. MD /MS (Optha) will need to be mandatory.
PG Course Selection
5.22 The medical personnel of the DHFW are provided sponsorship for post graduate
qualification after completion of three years of service. They are selected into the course
on the basis of their seniority. The key concerns brought to our notice were :
•
Postgraduate subject selection is driven by the candidate preference instead
of the DHFW requirements leading to mismatch of specialists' vis-a-vis state
needs.
•
Certain percentage of candidates do not complete the course in the specified
duration leading to on one hand blocking of seat of a more deserving
candidate and on the other under-utilization of DHFW expenditure.
5.23 In order to maximize the benefits of postgraduate course sponsorship, it is
suggested that the DHFW consider a merit based selection into the programme as
compared to a seniority based selection. The proposed selection procedure can
incorporate the following standards,
•
Introduction of PG course selection examination similar to that held for the
non-government students. However, it must be noted that the seats reserved
for the government students will still remain the same.
•
The merit selection should also incorporate field and academic experience
including the performance evaluation conducted through the Confidential
Report (CR) procedure.
•
The subject selection should be on the basis of expected vacancies under
each specialization in the DHFW. Candidates to be permitted to indicate
preference, however admissions to PG programme to be done through the
counseling process. Further, on non-acceptance by the candidate of the
subject offered, the candidate will lose his chance of DHFW sponsorship
unless he re-visits the selection procedure in any future period. Can opt for
only one clinical speciality with option for Management training if required.
5.24 In addition the DHFW may consider charging the candidates an appropriate
penal fine (in lieu of expenditure incurred by the DHFW) on non-completion of course in
the specified period due to in-discipline or failure in the examinations.
Training
5.25 Management / Administration training and induction programme for new entrants
into the department is currently not a thrust area in the DHFW leading to lack of
motivation and uncertainty of the various procedural issues. The average personnel has
limited / poor programme management abilities of national health programs especially
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that of public health and also poor administrative management of hospitals. This has
been observed across all categories of staff.
5.26 As discussed in the previous chapter, specific thrust for training of DHFW
personnel is one of the key features in the proposed organisation structure. It is
recommended that the training emphasis may begin with the following initiatives :
•
Administration training to be provided to all personnel holding administrative
posts such as head of PNC, TPHO,DPHO,TMO,DMO etc
•
Short-term and extensive training programs to be conducted for awareness of
all national health programs
•
Clinical training in areas of specialization / job role requirements for
familiarizing with latest technology and clinical skills
•
The minimal knowledge of public health amongst the staff requisites training
in public health to be at least of 6 - 10 weeks duration.
A beginning in this direction has been made by KHSDP but these programmes need to
be thoroughly evaluated and renewed.
Private Practice
5.27 The private practice being conducted by the staff after duty hours is a routine
matter for most of the doctor personnel of the DHFW. This issue has been much debated
upon and a decision is yet to be arrived at on the same. Some of the suggestions given
by members - Task Force on Health is given below :
•
Though private practice is banned, certain medical personnel carry on private
practice to the detriment of their official responsibilities
•
Factors affecting decision on permitting private practice are :
•
-
Need to ensure availability of medical services at all hours
-
Essentiality of such services at the local level specifically in rural areas
Recommendations on private practice :
MOs at the PNC level to be given rural allowances in lieu of private
practice
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Specify duty hours, publicly announce them and attendance during these
hours to be strictly followed and monitored by the community
-
Ban private practice at all levels
-
Prohibition of association of doctors as consultants to private nursing
homes
-
Public health cadre and Administrative Officers to be given special
allowances
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5.28 Few of the reasons offered by the various doctors on the private practice is that
the non-practicing allowance offered as part of compensation is in no way close to what
the doctor would earn in private practice. Banning private practice at senior levels
without adequate compensation, would result in movement of highly skilled practitioners
to private service. An appropriate mechanism should be designed by the DHFW whereby
public service and doctor motivation will be at the acceptable level.
5.29 While private practice after duty hours may seem acceptable taking into
consideration factors outlined above, it has been observed that private practice is
conducted even during duty hours. This may be in the form of accepting consultation
fees from the patients visiting the DHFW's health centres or conducting external private
practice during official duty hours
5.30 Control measures need to be adopted by the DHFW with regard to private
practice, especially during duty hours through stringent disciplinary actions.
Adherence to Working Hours
The working hours for the different health centres are given below :
5.31
•
PHC/CHC/Taluka
8.00 a.m. to 12.00 p.m.
2.00 p.m. to 5.00 p.m.
At Taluk level Duty Doctor has night shift of 5.00 pm to 8.00 am
•
District Hospital
9.00 a.m. to 1.00 p.m.
2.00 p.m. to 5.00 p.m.
Directorate
10.00 a.m. to 5.30 p.m. (General Shift)
-
Lunch break: 1.30 p.m. to 2.00 p.m.
5.32 It has been brought to our notice that as certain medical staff do not stay in the
quarters, they may not be available during emergencies. Moreover, in health centres
situated around urban centres, the working hours are not necessarily adhered to as the
staff spend a lot of time on travelling to work.
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6. Re-alignment of Staffing Pattern
6.1
The study of review of organisation structure involved identifying any concerns
addressed by personnel on the staffing pattern and any re-alignment of the same arising
out of the proposed organisation structure. A detailed study is being conducted by
CESCON
wherein the terms of reference are to determine Manpower Planning
requirements .
6.2
As the above study is a detailed manpower planning exercise, it was suggested to
us that we limit the staffing pattern to the top management structure.
Observations
Key concerns addressed by various personnel on the staffing pattern are given in
6.3
the ensuing paragraphs.
Manpower shortage
6.4
Sanctioned manpower is defined for each section/function within the department.
However, it has been brought to our notice that in most departments, quite a few of the
sanctioned posts are vacant. These could be due to various reasons such as transfer
posts not taken up by the personnel etc.,
Shortage of Staff Nurses
6.5
There is an indicated shortage of staff nurses at the District Hospital visited.
Nurses forming a critical part of para-medical staff, shortage of the same will lead to
lesser assistance to medical staff in their functioning.
Shortage ofANM (Female Health Assistant)
6.6
The training for future batches for the ANM post has been stopped leading to an
expected shortage of ANMs at a later point of time.
Mismatch of requirements vis-a-vis personnel
6.7
As covered in the previous chapters, the staff assigned to various health centres
do not necessarily meet the professional/specialization requirements at these centres.
There is a need to implement facilities based posting.
Unequal distribution of Staff
6.8
It has been observed that there is an unequal distribution of staff especially in
the group D category across the health centres. It has been observed that contracting
out services for non-clinical work of hospital, especially hospital hygiene and cleanliness
has been successful under KHSDP. This will definitely reduce the burden of the state of
maintaining these hospitals through Group D.
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6.9
Further, as indicated earlier, in a single hospital there are 3 ENT specialists while
none at another.
Skewed utilization of staff
6.10
The current utilization of staff is found to be skewed or under-utilized. E.g.
Over utilization of Female Health Assistant
Under utilization of Male Health Assistant
Lab assistants posted at PHC, etc without requisite material to conduct their work
Non-availability of Allocated Staff
6.11 In certain situations, the allocated staff for a department is assigned other duties
leading to non-availability of the staff for the concerned department's activities. E.g. In
the HET cell, certain staff are utilized by the CAO as a result of which HET activities are
under staffed.
Proposed Senior level Staffing Pattern
6.12 On the basis of the proposed organisation structure, the Senior Level Staffing
pattern is given below :
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Director
4 nos
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7. Need of Procedure Review
7.1
As a part of the organisation structure review, detailed discussions were held with
a cross section of personnel across various categories of health centres (PHC, CHC etc)
covering both rural and urban areas and the directorate. From these discussions, certain
areas where identified wherein there is a need to conduct a detailed procedure review
for improving the functioning of the department. The key areas identified are :
•
Planning and Budgeting
•
Drug Procurement and Disbursal process
•
Register/Record maintenance
•
Management Information Systems
Planning and Budgeting
7.2
Planning for the various national and state level health programs and their
distribution across the entire network of the DHFW is one of the key activities of the
DHFW. Planning and budgeting are critical to the overall success of implementation due
to the vastness and complexity of these programs. However, it has been observed that
the planning and budgeting exercise is conducted in a mundane manner as highlighted
below :
•
There is no scientific need based process e.g. Epidemiological basis, morbidity
pattern etc., utilized for planning and budgeting
•
The budgeting exercise is conducted in the form of re-allotment of figures
based on expenditure pattern
•
Further, budgeting for programs are ad-hoc with no consultation from
program officers. More often, the budgeting is seen as a directive from a
department rather than a consultative form.
7.3
As reiterated in the previous paragraphs, planning and budgeting being critical
functions, for efficient implementation of various programs a scientific based approach to
planning needs to be considered. Thereby, it is imperative that a detailed study be
conducted to suggest an effective planning and budgeting mechanisms and procedures.
Drug Procurement and Distribution
7.4
Drugs at the health centres of DHFW are received from the following sources :
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60 %
GMS
40 %
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7.5
The various concerns raised by the DHFW personnel with regard to Drug
procurement and Disbursal are :
•
Planning and processing of drugs are inot need based leading to shortage of
certain supplies in case of emergencies
•
Though funds are provided for ASV for procurement of emergency drugs,
these funds are unavailable for utilization
•
Complaints have been received regarding high pilferage of drugs through the
entire supply chain i.e. from the GMS store to the PHC via the DHS
•
Delays in supply or non-supply of essential drugs have led to the various
centres to claim the cost from the patients. Normally the drugs received on
the annual quota are sufficient only for one month. This in effect defeats the
very objective of Public Care.
7.6
A detailed procedure review on the drug procurement and disbursal cycle will
determine the gaps in the process that subsequently lead to delay in receipt of supplies.
The procedure review will also provide recommendations on internal control policies and
procedures.
Register / Record Maintenance
7.7
Detailed registers have been prescribed for recording implementation details of
the National Health Programmes. However, it has been observed that there exists a
certain delay in register updation and information flow. More often there is a short
supply of registers especially at the PHCs leading to the ANMs procuring them at their
cost. Though the cost incurred is subsequently reimbursable, the entire procedure
causes delay and inconvenience to the ANMs.
Management Information Systems (MIS)
7.8
The MIS exists to the extent of collating information from all sub-ordinate levels
and the submission of the same to the superior. Currently, no analysis is conducted on
the data available, at any level in the DHFW with the exception of the senior-most levels.
It has been observed that even at the DJD and JD levels, the role of the personnel is
restricted to collation of data.
7.9
Strategic planning being a thrust area for decisions on National Health Programs,
it is imperative to have an effective MIS system that will provide information support for
decision making. There is thus a need to conduct a detailed process review to determine
information needs at each level.
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8. Recommendations & Conclusion
8.1
This section provides a summary of the issues discussed about in the previous
chapters. The recommendations are provided keeping in view the following points:
•
Increase the efforts on preventive and promotive health
•
Increase the promotional avenues for the personnel (preferably doctors) in
the department and thus increase their morale
•
Making the personnel accountable for the success of the department by
enlisting the key accountability areas
•
Better implementation of the projects planned and in the future
•
More thrust for training the personnel and thus equip them with
contemporary technical and managerial skills
8.2
The recommendations (possible solutions) for the above issues are devised after
thorough discussions with the members of task force, office bearers of the Karnataka
Medical Officers Association, doctors in the department and others, directly involved in
the department. The key recommendations and conclusions about the reorganization of
the Department of Health & Family Welfare are enlisted below:
Top structure".
8.3
Commissioner/Director General of Health Services (DGHS): He reports to
the Principal Secretary. Three options were considered with relation to this position in
the department: they are:
•
Continue the occupancy of a senior IAS officer in this position for the present
till an alternative is achieved.
•
Place a doctor who rises from the ranks in the department and has the
functional knowledge of Public Health and Medical along with good project
management and administrative management skills. Then, this post may be
renamed as Director General of Health Services. Until a person with utmost
caliber within the department is identified, an IAS functionary may only
continue as Commissioner, Directorate of Health Services. But once a DGHS is
instituted, it must be the regular exercise of the government to groom his/her
successor to occupy the senior most position next. The continual change from
DGHS to the IAS officer may only effect the morale of the department people
and thus the functioning of the department.
•
Create a contractual position at the top who can be called the Chief Executive
(Health) and specify the qualifications background and experience for the
person.
He should have extraordinary lleadership abilities, managerial
capabilities, capacity for strategic thinking and planning, skills for change
management and enhanced communication. The key result accountability
areas can be specified. The profile of the person to occupy this position
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Review of Organisation Structure
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should really be of greatest standards since the operations include mammoth
size and the acceptability of the person from outside the system is also
difficult.
•
Creation of an advisory board consisting of eminent health and administrative
professionals who will be the monitoring and evaluation body for the
department and also advice on strategic planning with future perspectives for
the department. The DGHS will report to this advisory Board at regular
intervals.
Directorate structure:
8.4
The activities of the directorate are basically divided into two streams of Medical
and Public Health.
8.5
Medical functionary looks after the hospital administration in the state, which
inc udes even the Non Communicable Diseases. All the specialist cadre personnel report
to the head of this functionary (Director - Medical)
8.6
Public Health functionary looks after the preventive and promotive health of the
people of the state. This includes the Primary Health Centres, the RCH Communicable
Diseases, the IEC and the Urban Health components.
8.7
It was thought to give more emphasis to the programs and other activities in the
N. Karnataka region for all the existing state of affairs of health in that region. A set of
seven districts are identified in that region to give more emphasis on and a position has
been proposed (Additional Director) to coordinate and monitor the activities in that
region.
8.8
Emphasis was also proposed to be given to the present nascent area of future
planning and research activities. An Additional Director post is proposed to head the
functions of Planning, Research and MIS activities
u r.11 was observed that there was lack of coordination between different External
Aided Projects and different functionaries in the department. For this reason, it is being
proposed to introduce a directoral level person to head and monitor all the External
Aided Projects in the state (Director - EAP).
8.10 For better coordination between the numerous NGOs working hand-in-hand with
various functionaries of Department of Health and Family Welfare, a special cell for NGO
participation and coordination is proposed to be head by a directoral level person
(Director - NGO participation).
8.11 It is also proposed that a special wing be created to form the procurement and
depart nante
t0
activities of equipment, machinery and civil works of the
8.12 The DHO and DMO should carry out monitoring visits regularly on a continous
basis with a check list and enforce disciplinary action wherever required.
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8.13 More financial and functional autonomy be given to programme officers so that
they are also responsible for the programme as much as the DHO / DMO.
trahing^r Jn long teave6^6 D°CtOrS P°Sted 3t
DiStr'Ct HQ t0 rep'aCe Staff P°Sted for
State Institute of Family Welfare and Training (SIHFW):
8.15 This Institute founded under the project IPP - IX for training the required
personnel in the department is proposed to play a larger role in their development.
Keeping in view the dynamic nature of the circumstances the personnel of the
department are required to work and the pace of decision making, it is proposed to have
an autonomous institute as SIHFW.
H p
8.16 The new organization set-up of SIHFW will be head by Director who reports
functionally to Principal Secretary - Health will be assisted by:
•
JD
DD
•
District Training Officer
•
Other training personnel involved in training in Health & Family Welfare
throughout the state
S-1? ft isK proposed that hitherto training function of Health Education and Training
SS
“ SIHFW- A"
P—i invoived in
an8 d? IS .proposKed.thaLt a" the functionar/ heads in the department and the office of
ad - Planning submit the training areas required for the personnel working in their
section to SIHFW. SIHFW in turn prepares the modules of training to b7cond9uc?ed for
/,?rSOnnel In the dePartment- The structure of SIHFW may be designed such
that the following processes can be handled smoothly:
Rooeive requisition for training areas from different functional and sectional
heads (efforts should be made towards self-appraisal of the people in the
deand the areas ident'fied during that process too can be forwarded
to SIHFW). Most of the times, clarifications are sought from the reporting
authority about the training area specified. The individuals may also be
counseled to fill any gaps during the training need identification process
within each functionary. Directions should also be taken from the office of DD
- Training, reporting to JD - Planning since he is responsible to identify the
process of linking the organization's long-term and short-term goals to the
individuals development, identify career planning processes for the
department people, recommend the format and module for orientation
programme for new-recruits and any refresher courses for doctors and others
rrom time to time.
AFF -MC
52
Com
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Review of Organisation Structure
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•
Analyse the inputs from different sources and cluster them so as to offer the
programme in easy modules at different places easily
•
Train the internal training staff (TOT)
to enable them to conduct programs
more effectively
’
S™ to eShal ^nerS' "St and thelr
management, Sts
eto^'
in different areas
refeving authority to pion beSVtoa? the6 genXSisnS S a^
Coordinate the training programme at the place determined Other
randidate?™
'S provldin2 the accommodation for outstatton
“o'S’* '3 rKide"“ Pra9ra"™ iS
«"
•
Inform the trainers about the
expectations from them should also be done
much prior to the programme.
•
Have a feedback mechanism on t_
the quality of inputs provided, for effective
monitoring and plan for any improvements.
'
8.19 ;Apart from
___ f the new organization set-up should also take care of three
the above,
tier training system for better n
’ '
------- - each t0 the People in the department. This includes:
•
State level
•
Regional level
District level
- level,
“ndU<:t “UreeS in the areas
of Medtal
s~«PUtS in
8.22
of
people
The financial sustenance of the department can be derived by different
means:
of'tmiS0 bUd9et f°r th'S autonomous institution depending on the number
of trainmg programs to be conducted and the number of peonle to he
to beeeacqnuiJed,deetcartment'
nUmber °f trainerS required, the infrastructure
AFF -MC
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Review of Organisation Structure
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•
Training fees can be charged for the training programs even for the
X thebill for eHaechthprognrtmme pla™^
9nd
•
Open the facilities of SIHFW for other institutions as well to train their
personnel as well
8.23 Whatever maybe the structure and status of SIHFW, more coordination is
of teXourS a^d 7enalize?tsOnhS/fUnCt'OnarieS in the dePartment for Active utilization
training
C PUrP°Se °f exiStence as a sin9le nodal a9ency for
2nn?te rnoraie of the department needs to be uplifted through impartial promotions
Shew s' transfers selection for PG Courses incentives etd. As mentioned earlier the
allSs
n°dal trainin9 Centre in CapaCity building of:the hea,th Personnel at
AFF MC
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GOVERNMENT OE KARNATAKA
TASK FORCE ON HEALTH AND FAMILY WELFARE
A Commissioned Research Study
REVIEW OF ORGANISATION STRUCTURE AND DESIGN OF JOB
RESPONSIBILITIES FOR HEALTH AND FAMILY WELFARE
DEPARTMENT
VOLUME - H
By
A. F. FERGUSON & CO
MANAGEMENT CONSULTANT DIVISION
Bangalore.
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00000000000000000000^0^000000000000000000^
*
a
Preview of Organisation Structure
-Vol II (Job Descriptions)
Introduction
The following pages form the Volume II of the organization restructuring study report.
This volume contains the job descriptions of the unique and identified positions at the
Directorate and different hospitals and other offices of Department of Health & RCH,
Government of Karnataka.
Methodology
•
Collating information available in different documents about the basic functions and
the responsibilities and duties of different personnel in the department
•
Discussions with different functionaries in the department about their basic functions
and duties along with any modifications required in the existing set-up to meet any
future requirements.
•
The salient features of the proposed structure are also discussed with people at
different functions and representatives of Medial Officers Association and certain key
functions were evolved
•
The gaps in the existing manuals and other departmental orders were identified and
utmost care is taken to address them.
Terminology: Job description for each identified position was explained under different
headings. They are:
Job Title:
The position / designation for which the job description relates to.
Reporting to:
This position for which a person is responsible to and it is at most of the
occasions, the appraiser of the person handling the above referred position /
designation. At certain instances, dual and multi relationship was reported. To have
better monitoring of the envisaged procedures and policies, these were imminent. Also
to have functional inputs and proper care to follow the authority schedules, dual
reporting was envisaged.
Immediate Level Subordinates:
This explains the reach of work of the incumbent and the basic logic of division
of work among the subordinates. However, only the medical profession designations are
only given as part of the subordinates' list. This doesn't include the staff reporting at the
office of the incumbent
Basic Function:
This explains in brief the function of the person handling the position and the
relationship with other functionaries in the department.
5G
Review of Organisation, Structure
-Vol II (Job Descriptions)
Duties, Responsibilities and Authorities:
These are the expected deliverables and the guidelines for the incumbent in
performing to the expectation of his/her senior (superior). These form the basis in his
one's approach in taking up a job or division of work in the department. The
responsibilities are split among the functionaries in the department, with the overall
responsibility lying with the head of the department.
The Financial, administrative and disciplinary powers are enclosed as
annexures and these are as per the KSCR rules and regulations.
This list may just guide the head of department in dividing the work
(delegating the work) among his subordinates.
Main accountabiiities/Key Result Areas/Performance Areas:
These are the reference points for the performance evaluation of the incumbent.
The duties, responsibilities and authority were considered to decide the accountabilities
Training Areas:
With reference to the duties and job responsibilities of the incumbent, and to
raise to the expectations of the concerned authorities and people at large, a set of
generic areas for training and possible methods of training for overall development of
the incumbent. This does not refer to any training needs assessment done but the
essential skill set of the incumbent.
Disclaimer: proformas submitted thro ugh the DHS to all personnel — have
still not been received but however we have still compiled the job
descriptions based on discussions with the senior staff of the Directorate .A
limited number of job descriptions are presently available with the
department.
AFP -MG
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Review of Organisation Structure
V r II (Job Descriptions)
Job Title:
COMMISSIONER/DIRECTOR GENERAL OF HEALTH
SERVICES
Reporting To:
Principal Secretary - Health & Family Welfare
Government of Karnataka
Immediate Level Subordinates:
•
Director - Medical
•
Director - Public Health
•
Director - External Aided Projects
•
Director - Procurement & Maintenance
•
Additional Director - Planning
•
Additional Director - N.Karnataka
•
CAO - Finance
•
CAO - Vigilance
Basic Function:
Responsible for effective functioning of the Health Systems in the state to deliver
quality health care. Responsible for integrating the entire Medical health function
throughout the state and provide appropriate professional leadership for continual
improvement and upgradation of medical health services in the state including Hospitals,
health Units, preventive Health, etc. Also responsible for the management and
functioning of Medical and Health infrastructure of the state and ensuring their optimal
utilisation. Develop necessary strategies as well as policies, procedures and systems for
curative and preventive health throughout the state. Overall responsibility for the
Preventive and Curative Health of the people of the state and the best use and
development of available infrastructure.
Duties, Responsibilities and Authorities:
•
Develop a comprehensive strategic plan for the department which includes vision,
mission, objectives, goals of the department
•
Ensure that quality curative health care services are available to the target
population , Ensure adequate population/bed ratio, physician/bed ratio as per norms
is maintained (Government of India / WHO / state government
•
Handle all the policies relating to the administration and implementation of Various
National Health programmes in the state such as RCH, Leprosy eradication and
control of TB, Malaria and Blindness.
•
The DGHS office will maintain a functional relationship with Directorate of Medical
Education and Directorate of Indian System of Medicine regarding their activities.
AFF -MG
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Review of Organisation Structure
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•
Co-ordinate with the Commissioner of Public Education, Director for Development of
Handicapped and the Heads of Municipalities and Corporations on all the matters
relating to Public Health.
•
Co-ordinate with the Project Administrators of the various externally aided projects
with various departments of Directorate of Health & Family Welfare to ensure
smooth functioning of these projects.
•
Ensure efficient administration and implementation of policy issues for
computerisation and Management Information Systems at Department of Health &
Family Welfare
•
Responsible for submission of various policy and project proposals to the
government. Commissioner of Health to receive the reports from Additional Director
- Planning and after review submit the same to the Principal Secretary - Health &
Family Welfare Department.
•
Administer the matters relating to service and transfers of Group "A" officers of the
department and also responsible for taking disciplinary action against them.
•
Responsible for constitution of various committees from time to time and frame
policies for nominations.
•
To function as a member on all the programme implementation committees of the
Department of Health & Family Welfare.
•
To collect the documents pertaining to the Assets and Liabilities and implementation
reports from the Joint Directors.
•
Approve capital expenditure proposals within the powers delegated to him, put up
other proposals for approvals by the respective authorities, periodically review the
capital expenditure projects and ensure that the original plans are being adhered to
•
Responsible for administration of the vigilance cell in the state.
•
Provide the professional leadership, guidance and support to his immediate
subordinates as well as other senior officers who work with them and enable the
building up of a cohesive team that works in the overall interests of the state
Main Accountabilities:
• Overall quality of health care in the state
• Balanced and equitable availability of basic health facilities
•
•
•
•
•
Proactive measures for epidemic control
Controlling cost of services of providing health
Development of norms / standards for service quality
Professional delivery of medical and public health services
Budget performance of the department
•
•
Achievement of state health goals such as IMR.MMR.CPR etc
Number of problems resolved effectively
•
Functioning and timely completion of externally aided projects
AFF -MC
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Review of Organisation structure
•
-Vi;/ // (Job Descriptions)
Timely address to the natural calamities and effective gearing up to meet any
untoward incidents
Training Areas:
• Attend Management Development Programmes at International Institutes such as
Harvard, John Hopkins, etc in areas of Public Health, health policies, New business
models and management techniques in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international seminars and conferences and
to share the experiences of Karnataka and get a feedback.
Job Title:
DIRECTOR - MEDICAL
Reporting To:
Commissioner
Immediate Level Subordinates:
•
Additional Director - Medical
•
Additional Director - NCD
Basic Function:
Overall responsibility for establishing, managing and development of hospital
infrastructure in the state. Is responsible for the curative services delivered at hospitals
in the state. He is also responsible for developing and implementation of rational drug
policy including the essential drug list for the state. Monitor distribution of drugs
throughout the state in the hospitals.
Duties, Responsibilities and Authorities:
• Develop a comprehensive strategic plan for the medical wing of the department
which includes vision, mission, objectives, goals of the department
•
•
•
Ensure that quality curative health care services are available to the target
population
Ensure adequate population/bed ratio, physician/bed ratio as per norms is
maintained (Government of India/ WHO/state government)
Ensure that the hospitals, dispensaries, Maternal homes and referral hospitals are
easily accessible to the population, review need for rationalisation and relocation of
some health units as well as setting up new health units in order to improve
accessibility and service coverage.
•
Review and evaluate the existing policies and procedures and work methods by
means of periodic and special studies
•
Review the MIS reports generated by AD - Medical / Planning and take corrective
actions
•
Review and recommend the upgradation of health infrastructure in the state
AFF -MC
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Review of Organisation Structure
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•
Work out improved methods and procedures to achieve the objectives of the hospital
•
Develop standards, methods and measurements of the hospital activities
•
Monitor the utilisation of hospital resources throughout the state and adopt means of
bringing optimum utilisation
•
Ensure periodic health promotion activities (quantifiable) are carried out in the
hospital
•
Be a member of the accreditation board to certify standards in hospitals, both in
private and government hospitals
Ensure that all hospitals have a disaster management plan of action
Visit all district and major hospitals in the state, atleast once a year
•
•
•
Ensure that medical audit and internal audit has been carried out in all hospitals at
periodic intervals
•
Submit all relevant material which can be hosted on the department website
•
Ensure that full economy and expenditure control is observed in all clinical (curative)
related operations and activities of hospitals in the state.
Recommend transfer and postings of District surgeons and
Superintendents of Major Hospitals.
•
Main Accountabilities:
• Ensure quality of care in all government hospitals through periodic medical audit and
patient satisfaction surveys
•
Ensure optimum capacity utilisation of hospital infrastructure through periodic review
of MIS reports (hospital efficiency indicators) of all hospitals
•
Increase of health infrastructure (need / technology based) in the state in
coordination with planning cell
•
Ensure that there is no mis-match of specialists and all posts are identified in
hospitals as per norms of the bed capacity of the particular hospitals and also ensure
full complement of staff
•
Visit all District hospitals atleast once in a year to monitor their functioning and
utilsation of resources
Training Areas:
• Attend Management Development Programmes at international institutes such as
Harvard, John Hopkins, etc in areas of Public Health Policies, health policies, New
business models in Health care.
•
Study Health care facilities and delivery system in both developed and developing
countries and also attend national and international and to share the experiences of
Karnataka and get a feedback.
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Review of Organisation Structure
Job Title:
-Vol II (Joo Desaiplions)
ADDITIONAL DIRECTOR - MEDICAL
Reporting To:
• Director - Medical
Immediate Level Subordinates:
•
Joint Director - Medical
•
Joint Director - Pharma (GMS)
• Joint Director - Hospital
Basic Function:
Overall responsibility for effective medical care at different hospitals in the state, looking
after the transfer policy of the state cadre doctors including the specialists. Monitor the
effective utilisation of hospital and medical facilities throughout the state and following
the drug policy guidelines throughout the state.
Duties, Responsibilities and Authorities:
• Upgradation of facilities at district level institutions and other institutions having bed
strength of 200 and above other than those institutions coming under the control of
the Directorate of Medical Education.
setting
•
Adhering to wherever statutory obligations
up/maiptaining of hospitals in the state
•
District hospitals attached to medical colleges will also be under the perview of office
of Director - Medical Services
•
Planning, implementation, Monitoring, reviewing evaluation and all matters relating
to upgradation, sanction of additional beds, sanction of additional staff etc.
•
Policy matters related to establishment of hospital pharmacy Units, Govt. Medical
stores, Health equipment, Drugs & matter relating to Department rate contracts on
drugs and equipment.
•
Assists the government in the implementation of medical staff by laws.
•
Matters connected with non-communicable diseases such as Cancer control, Hospital
psychiatric clinics, diabetes control programme and other similar diseases.
•
Responsible for coordination in all areas of operation in the hospital
•
Monitor effective implementation of hospital infection control
•
Policy matters relating to medical reimbursement, constitution of medical
boards etc.
•
Monitor medical care facilities to VIPs (as organised by JD)., visiting the State
and arranging medical facilities in the various special functions (Sports/
congregations of Spl. Festivals/ Melas etc.,).
•
Work in coordination with Additional Director - Planning to identify the number of
specialist posts for the next five years at regular intervals in different hospitals of the
'F -MG
G2.
applicable
regarding
8
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Review of Organisation Structure
-Vol II (Job Descriptions)
state and take steps to groom the existing doctors by recommending for Post
Graduate Course or any refresher course.
•
•
Ensure optimum utilisation of the manpower resources attached to him, organize
and / or arrange to organize training programmes to augment skills and attitudes,
appraise performance of employees, counsel employees and contribute to overall
growth and development of the staff directly attached to him, recommend
increments, promotions, transfers, etc.
Continuous monitoring of the performance of the personnel at different hospitals and
recommend for any training required.
•
Monitor the utilisation of hospital resources (space planning, physical infrastructure,
capacity utilisation of beds, etc) and equipment.
•
Study the MIS reports and decide on any corrective actions.
•
Responsible for conducting medical audit by appropriate personnel
•
Hold periodical quality assurance meetings for effective r&new
•
Aware of all legislative provisions which affect his work area. Ensure that the
reporting staff is also doing this. Also ensure that all tasks and operations of his
departments are carried out within the framework of the laws, statues, rules, orders
and procedures as may be stipulated from time to time.
•
Monitoring the policy matters relating to organ transplantation, and matters relating
to Corpus fund
Main Accountabilities:
• Pay visit to all District hospitals and other major hospitals atleast once in a year to
check the proper usage of allotted resources and find out reasons for need for
upgradation of resources.
•
•
Complete the record of medical audits conducted on a sample basis in the state and
show the corrective actions taken
Conduct internal audit for the processes related to a particular functionary in the
department in a major hospital and suggest means to improve that.
•
Suggest for proper demand estimation for the specialists in different hospitals of the
•
state
Plan and indent for the equipment required for diagnosing and treatment of different
kinds of NCD cases
•
Monitor the working of referral system in the state
•
Coordinate with the office of AD - Planning in identifying the number of specialists
required from time to time
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Review of Organisation Structure
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Training Areas:
• MDP in hospital administration from reputed institutes and study tours of well
managed hospitals abroad
Process of conducting internal and medical audit
•
Job Title:
JOINT DIRECTOR - MEDICAL
Reporting To:
Additional Director - Medical
Immediate Level Subordinates:
. Deputy Director - Medical
Basic Function:
Oversee the treatment and availability of doctors for all kinds of human ailments and
their effectiveness in delivering the best medical care
Duties, Responsibilities and Authorities:
. Recommendation for establishment of hospital pharmacy Units, procuring health
equipment, Drugs and other matters relating to Department rate contracts on drugs
and equipment in coordination and consultation with Joint Director Pharma, Joi
Director - Procurement, Joint Director - Hospital and Joint Director - Equipment &
Maintenance as and when the need arises
Arranae infrastructure for non-communicable diseases such as Cancer control.
Hospital psychiatric clinics, diabetes control programme and other s'mi'ar a^^ente
andPof mental health, de-addiction programme, old age programme anti-smok g
de-addiction, hypertension, etc, in coordination with Procurement division of the
.
department.
.
Matters relating to medical reimbursement, constitution of medical boards etc.,
.
Constituting medical boards for first appointment of all appointments in the state.
.
Constituting medical board for unauthorised absence or long leave certification,
change of cadre, etc
•
Medical audit and quality assurance of hospitals
•
Monitor effective implementation of hospital infection control
•
Inspection of hospitals to monitor their■ physical / equipment / staff for
implementation of special programmes such as organ transplant, etc. (special acts as
member of the appropriate authority)
•
Inspection regarding customs duty exemption
GM-
10
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Review of Organisation Structure
Vo/ // (Joi} Descriptioi’s'i
Monitor the ho» of inforMtion
^^n^n
.
ifZer for soctn! selenee reseorch onh ony
interpretations for better service
• Study the MIS reports and decide on any corrective actions.
. Monitor the process of handling the medico-legal cases in different hospitals.
Melas etc.,).
Monitor all matters relating to Corpus fund (Chief Minister's fund)
•
doctors during speoa. fesdvais and melas. To see that no
disease spreads due to the lapses from the doctors.
•
Effective utilization of Corpus fund
•
a year and report
Visit all district Hospitals and atleast -■ CHC/TH (quantifiable) in
the existing facilities there to AD Medical
Training Areas:
• conducting medial audit and internal audit
. Hospital Personnel management (emphasis on Organizational Behavior/motivation)
Job Title:
Reporting To:
DEPUTY DIRECTOR - MEDICAL
Joint Director - Medical
Immediate Level Subordinates:
•
District surgeon
•
Superindent of major hospital
government sponsored schemes for the poor and needy in the state.
Duties, Responsibilities and Authorities:
provided at various health units in the
• Regularly review the quality of health care
dispensaries and referral hospitals by
ctatP such as clinics, Maternal homes,
,
undertaking regular visits to them along with the heads of those units.
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Review of Organisation Structure
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generating MIS information and using it further for social science research and any
interpretations for better service.
•
Review the working of different schemes of government for the poor to avail good
treatment at the government hospitals
•
Ensure proper maintenance of all medical records, documents and files in his
department.
•
Ensure proper up-keeping and maintenance of assets assigned to the department
situated at all locations
•
Support any activity related to medical audit initiated anywhere in the department
•
Recommend medical audit for the cases involving any irregularity specifically found
out on routine inspection
•
Monitor effective implementation of hospital infection control
•
Monitor the cleanliness of hospital programme to maintain the hygienic conditions
•
Monitor all matters relating to Corpus fund (Chief Minister's fund)
Main Accountabilities:
•
Visit all district hospitals and major hospitals atleast once in a year and conduct
enquiries about availability of specialists at the required time
•
Suggest ways and means of availing the specialists' services at remote places in the
state (by means of transfers which can be worked out)
Training Areas:
• Conducting medical audit
•
Administration of personnel
Job Title:
JOINT DIRECTOR - PHARMA
Reporting To:
Additional Director - Medical
Immediate Level Subordinates:
• Deputy Director - Pharma
Basic Function:
Functionally the reference authority in the department for any drugs and
pharmaceuticals related issue. Oversee the functioning of Government Medical Stores
and pharmacies handling different volumes located at different hospitals in the state
including the staffing matters at the respective locations.
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Review of Organisation Structure
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Duties, Responsibilities and Authorities:
•
Monitor the process of taking requisitions from different hospitals for replenishing
the stocks of pharmaceuticals and the other related policy matters.
•
Planning, implementation, monitoring and reviewing of various activities connected
with the procurement and disbursement of drugs.
•
Review of Stock position of drugs and equipment in the pharmacies located in the
government hospitals and Government Medical Stores and distribution as per
annual indents.
•
Oversee the mandatory guidelines in employing the pharmacists in hospitals
•
Work in coordination with and directions from Drug Controller regarding the policies
and regulations.
•
Approve setting up of pharmacies in different hospitals
•
Provide information as required to Drug Controller
•
Proper documentation of matters relating to Expert committee and High Power
Committee meetings and finalisation of rate contracts on drugs and equipment and
follow up action.
•
Preparing / updating essential drug lists for use at various levels such as PHC / CMC
/TLH / DH and other hospitals.
Main Accountabilities:
•
Proper logistics in procuring the drugs and vaccines
•
Proper logistics in disbursing the drugs as the requirement is, at different places
•
Conduct inspection visits to all district hospitals and major hospitals in the state to
monitor the working of pharmacies in those respective locations.
•
Effective addressing of any sudden requirement of life-saving drugs or problems
during epidemics/natural calamities
Training Areas:
•
Statutory obligations with the Drug Controller's office
•
Logistics in handling drugs and related materials
AFF -MC
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Review of Organisation Structure
-Vol II (.'nt) Descriptions)
Job Title:
JOINT DIRECTOR - HOSPITAL
Reporting To:
Additional Director - Medical
Immediate Level Subordinates:
•
•
Deputy Director - Hospital (N)
Deputy Director - Hospital (S)
Basic Function:
Monitor basic infrastructure facilities in all the hospitals and review the
requirements for any upgradation to meet the specified standards. (Coordinate with
(strict Medical Officer in taking up this activity). Monitor the working of nursing staff
and address to their requirements and suggestions in upgrading the delivery of health
services to the people of the state.
Duties, Responsibilities and Authorities:
•
Recommendation for establishment of hospital pharmacy Units, procuring health
equipment, Drugs and other matters relating to Department rate contracts on drugs
and equipment in coordination and consultation with Joint Director - Pharma, Joint
Director - Procurement, Joint Director - Hospital and Joint Director - Equipment &
Maintenance as and when the need arises
•
Overall incharge of hospital functioning,
throughout the state.
•
Responsible for inter-hospital coordination at all occasions, especially during any
exigencies or outbreak of epidemics in the state.
•
Responsible for nursing activity and any coordination with external agencies like Red
Cross (India) whenever the need arises.
•
Monitor the cleanliness of hospital programme to maintain the hygienic conditions
•
Plan regarding the hospital waste disposal in consultation with the office of AD
Urban health and Commissioner, municipal authorities
•
Up-keeping of district level institutions and other institutions having bed strength of
100 and above other than those institutions coming under the control of the
Directorate of Medical Education.
•
Planning, implementation, monitoring, reviewing evaluation and all matters relating
to upgradation, sanction of additional beds, sanction of additional staff etc.,
•
Monitor the flow of information regarding the availing of medical information at
different hospitals to the office of Additional Director - Planning's office for
generating MIS information and using it further for social science research and any
interpretations for better service.
•
Monitoring of Medical audit and internal audit of all the hospitals
•
Ensuring the patients charter of rights
AFF -MC
infrastructure and patient facilities
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Review of Organisation Structure
Vol II (Job Descriptions!
Main Accountabilities:
*
AI-'J±eJnfrast™cturre related requirements within the budgeted framework are met
10 u
°f ra,s,n9 the requirement from any District surgeon / DHO, routed
through DD Hospital
•
Hygenic conditions in the hospital and effective hospital
waste disposal norms as
specified by the concerned authorities from time to time
•
Planning implementation, monitoring, reviewing evaluation and all matters relating
to upgradation, sanction of additional beds, sanction of additional staff etc.,
•
Monitor the flow of information regarding the availing of medical information at
different hospitals to the office of Additional Director - Planning's office for
research a"d a"*
JSSiSSusin9 if fl,,,her for
• Monitoring of Medical audit and internal audit of all the hospitals
Training Areas:
•
Hospital planning (any designs, apart from functioning)
•
Hospital administration
•
Hospital waste disposal and treatment
Job Title:
DEPUTY DIRECTOR - HOSPITAL
Reporting To:
Joint Director - Hospital
Immediate Level Subordinates:
• Coordination with District Surgeons
•
Lay secretaries of hospitals
Basic Function:
s^dTs^
govemmente from bmeSSe3^^’09 *
Duties, Responsibilities and Authorities:
Ensure that the health care services available to the target population is adequate
•
Ensure that the dispensaries. Maternal homes and referral hospitals are easily
accessible to the population as per the directives of central government
’
unVnlW ^ee^Or
ionalizJation and relocation of some health units as well as setting
up new health units in order to improve accessibility and service coverage.
Monttor the cleanliness of hospital programme to maintain the hygienic conditions
Ai~F-MC
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—. -....... —.... -.... -.......-... —
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Review of Organisation Stru- ‘t'jre
•
•
-Voi I! (Job Descriptions)
Ensure the flow of information regarding the availing of medical information at
different hospitals to the office of Additional Director - Planning's office for
generating MIS information and using it further for social science research and any
interpretations for better service.
Continuous monitoring of the performance of the personnel at different hospitals and
recommend for any training required.
Main Accountabilities:
• Proper utilization of hospital resources / infrastructure
•
Visit all government hospitals and major hospitals atleast once a year and monitor
the utilization of hospital resources by the concerned people
•
Ensure proper hospital waste disposal
Training Areas:
• Hospital administration
•
People Management
•
Monitoring technology improvements in other parts of the world
Job Title:
ADDITIONAL DIRECTOR - NCD
Reporting To:
Director — Medical
Immediate Level Subordinates:
• Joint Director - Opthalmology
•
Joint Director - NCD (Cardiology and Diabetology)
•
Joint Director - Traumotology
•
Joint Director - Mental Health
• Joint Director - Oncology
Basic Function:
Implementation and Monitoring of national programmes of NCD, proper treatment for all
kinds of NCD diseases such as Cancer, diabetes, heart ailments and trauma in different
hospitals in the state.
Duties, Responsibilities and Authorities:
• Suggest for proper demand estimation for the specialists in different hospitals of the
state
•
Identify the magnitude of the problem of NCD cases
•
Plan and indent for the equipment required for diagnosing and treatment of different
kinds of NCD cases
•
Monitor the working of referral system in the state
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•
Coordinate with the office of AD - Planning in identifying the number of specialists
required from time to time
•
Ensure proper storing of radio-active material at different hospitals, used in the
treatment of cancer
•
Inform the target number of posts in the fifth successive year to Director - Medical
and suggest the means of getting such numbers into the system.
•
Review the MIS reports from time to time and suggest corrective actions to the
concerned Surgeons and other officials in the department
•
Study the developments around the world in the treatment of different kinds of
Human ailments and pass on the knowledge to different functionaries in the
department
•
Encourage participation of the doctors in their related national and state health
programmes and work hand-in-hand with the office of District Health officer
•
Identify the potential levels of the doctors in the Medical health department and
suggest for any refresher/continuous learning courses for them from time to time
•
Conduct medical audit on sample basis for some cases and compulsorily for all the
controversial cases.
•
Monitor effective implementation of hospital infection control
•
Coordinate with the office of Additional Director - Planning
•
Ensure implementation of Blindness Control Programme, Mental Health Programme
Main Accountabilities:
• Visit all the district and other major hospitals in the state atleast once a year
•
Ensure implementation of Blindness Control Programme, Mental Health Programme
•
Identify the magnitude of the problem of NCD cases
•
Conduct medical audit on sample basis for some cases and compulsorily for all the
controversial cases
Training Areas:
• Health Management
•
Hospital management
•
Programme management
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Re vie w of Orga n isatio n S tructu re
-Vol II (Job inscriptions)
Job Title:
JOINT DIRECTOR - OPHTHALMOLOGY
Reporting To:
Additional Director — NCD
Immediate Level Subordinates:
•
District Surgeons
•
Eye specialists in the state
•
Other National Blindness Control Programme officers of the district
• District Health Officer
Basic Function:
Oversee the National Blindness Control Programme in the state and ensure proper
staffing pattern in the ophthalmology department in different hospitals in the state. Also
ensure adequate care for the ophthalmology related patients and high success rate
during any operation. Identify the magnitude of the problem of blindness cases
Duties, Responsibilities and Authorities:
• Planning, implementation and monitoring of programmes connected with National
Programme for control of Blindness.
•
Identify the magnitude of the problem of blindness cases
•
Training of Ophthalmic Assistants.
•
Matters pertaining to calling for tenders for drugs, equipment related to
ophthalmology.
Ensure conducting of medical audit for some operations on a sample basis and
compulsorily for critical and controversial operations
•
•
Coordinate with District Officers in spreading the message of good nutrition for
control of blindness among the people of the state
•
•
Review of working of Major equipment
Continuous monitoring of the performance of the personnel at different hospitals and
recommend for any training required.
•
Monitoring the activities related to District Blindness Societies
•
Monitor the effectiveness of eye-camps conducted
•
Review the hygienic conditions in the eye-operation theaters and eye-wards
•
Monitoring the eye transplantation operations performed in different hospitals
•
Coordination with NGO's working in the field of blindness control
Main Accountabilities:
• Medical audit of eye operations conducted either at special camps or hospitals
•
Visit all hospitals which have the facility for eye-operation in the state, atleast once a
year.
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•
Imparting training to Laboratory Technicians and Food Inspectors.
•
Dispense the authority and submit reports pertaining to consumers protection Act.
•
Monitor the activities pertaining to food and water analysis in coordination with
pollution control board and local-self bodies.
•
International certification on Health related matters for issue of passports and Visa
•
Generate and submit analytical reports on various samples of epidemiological
importance including samples received from Lokayukta.
Job Title:
ADDITIONAL DIRECTOR - URBAN HEALTH
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
Basic Function:
Coordinate with local self bodies in planning to create hygenic conditions in urban areas
and slums. Work in coordination with pollution control authorities in planning for anti
pollution activities. Passing of stringent norms from time to time regarding the disposal
of hospital waste.
Duties, Responsibilities and Authorities:
• Promote urban sanitation among all the municipalities and corporations in the state
with special emphasis on urban slums
• Be in touch with corporation/municipalities commissioners and Chief Executive of
Zilla Parishad through the department functionary and monitor the sanitation/health
activities throughout the state
• To create awareness of personal hygiene and to maintain a better environment for
prevention of diseases
• Recommend policies in handling the waste generated from different hospitals.
• Create amicable platform for interaction between the department of health and
Public Health Engineering functionary of different corporations and municipalities
• Coordinate with the Project Directors of different national Programmes
Training Areas:
Health management
Programm management
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Review of Organisation Structure
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Job Title:
DIRECTOR - EXTERNAL AIDED PROJECTS (EAP)
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
Basic Function:
Guide the department in securing the national and international projects by concerned
bodies and see thay they are properly executed without any mis-appropriation of funds.
Duties, Responsibilities and Authorities:
• He/She and his team of officers are responsible to implement the project. He is also
designated as ex-officio Additional Secretary to Govt to enable to issue Government
orders on all the related matters.
• Shall carryout such of the functions which are assigned by the steering committee
and Project Governing board
• Coordinate with different functionaries / departments in Central / State government
in meeting the project requirements.
• Monitor the usage of funds released for the purpose of the project
• Monitor the effectiveness of different Externally Aided Projects in the state
• Appraise different project reports which are submitted by state department of health
which are prepared to seek financial/any kind of help from outside the government
functionary
Main Accountabilities:
Effective usage of funds released
Timely completion with desired / planned results
Training Areas:
• Project management
•
Coordination and Administrative skills
Job Title:
DIRECTOR - PROCUREMENT & MAINTENANCE
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
• Chief Engineer - Civil
• Joint Director - Procurement
• Joint Director - Equipment & Maintenance (Bio-Medical)
Basic Function:
Being overall incharge of the physical asset base of the department should take utmost
care in procuring as per the requirement and properly maintaining them. Procurement
skills as per the norms of the funding agencies
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Review of Organisation Structure
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Duties, Responsibilities and Authorities:
• Pass the bill ofpayment for the land accumulated / procured for different
constructions to be taken by the Department of Health & RCH
• Approve the procurement and release payment for hospital equipment which are of
value above the level of authorisation by the Joint Director in the department
• Monitor the effective utilisation of all machinery/ equipment/buildings, etc and
their longevity.
• Provide managerial inputs in selection of any kind of construction or procurement of
equipment
• Work for coordination between all the technical functionaries of the department
• Monitor the procurement procedures and processes from time to time
• Monitor and approve for Procure, install, commission, maintain and service bio
medical and other hospital equipment for diagnosis, monitoring, analysis and
therapy, etc
• Work in coordination with funding agencies and manufacturers of equipment and
follow the conditions agreed upon.
• Oversee the transfer of works from procurement functionary to the maintenance
functionary.
Main Accountabilities:
• Monitor the effective utilisation of all machinery/ equipment/buildings, etc and
their longevity.
• Provide managerial inputs in selection of any kind of construction or procurement of
equipment
• Work for coordination between all the technical functionaries of the department
• Monitor the procurement procedures and processes from time to time
• Monitor and approve for Procure, install, commission, maintain and service bio
medical and other hospital equipment for diagnosis, monitoring, analysis and
therapy, etc
• Work in coordination with funding agencies and manufacturers of equipment and
follow the conditions agreed upon.
Training Areas:
• Appraising global tenders
•
Coordination & Administrative skills
Procurement skills as per the norms of the funding agencies
AFF -MC
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Poi
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Review of Organisation Structure
-Vol h ■' 'ob Descriptions)
Job Title:
JOINT DIRECTOR - PROCUREMENT
Reporting To:
Director - Procurement & Maintenance
Immediate Level Subordinates:
Basic Function:
Procure all kinds of equipment other than related to pharmacy and Government medical
stores, after properly studying the reliability of the manufacturer and efficient after-sales
service. Ensure the requirement of the equipment to be procured by suggesting a better
indenting, sanctioning and approving authority to procure them. Procurement skills as
per the norms of the funding agencies
Duties, Responsibilities and Authorities:
1. Understand/ study the equipment needs and provide atieast basic utilities wherever
required
2. Select the equipment based on technical evaluation
3. Ensure proper chanellisation of indenting, approving and sanctioning of the
procurement of equipment.
4. Monitor the installation, commissioning and acceptance of the machinery and
equipment for the department
5. Signing the service provider contract for training wherever applicable before
purchase of equipment and inform Deputy Director - Equipment training.
Main Accountabilities:
Procurement skills as per the norms of the funding agencies
Training Areas:
• Apprising of Global Tenders
•
Logistics
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Review of Organisation Structure
Job Title:
-Vol II (Job Descriptions)
CHIEF ENGINEER - CIVIL
Commissioner / DGHS (Administratively)
Secretary PWD department (Functionally)
Immediate Level Subordinates:
• Superindent Engineer (Bangalore)
• Superindent Engineer (Dharwad)
• Dy.Chief Architect
Reporting To:
Basic Function:
Ensure quality construction and maintenance work for the Department of Health in the
state. Ensure proper appraisal of tender documents for allotment of construction work to
the eligible parties. Work in coordination with appropriate authorites in finalisation of the
design of hospitals
Duties, Responsibilities and Authorities:
• He receives the indent for work from the department of Health and RCH and
executes that with the help of his functionaries in coordination with the concerned
officials in the department
, .
• He is the overall incharge of all the civil works in the state which are related to the
Department of Health and RCH
• Obtaining architectural drawings estimates and sanctioning administrative and
technical approval to execute the works
• Coordinating various departments on land and civil works
• Monitoring construction programme and suggest necessary mid-term corrections and
.
actions
Planning for maintenance of existing buildings
Job Title:
DEPUTY CHIEF ARCHITECT
Reporting To:
Chief Engineer - Civil (Administratively)
Chief Architect - Karnataka (Functionally)
Immediate Level Subordinates:
• Executive Engineer - Civil
Basic Function:
Prepare drawings and designs of the department constructions in connivance of the
concerned authorities in the department
Duties, Responsibilities and Authorities:
• Heads the design wing of the Department of Health & RCH, Government of
•
Prepares the plan for the structure of buildings as per the felt need and allotted
budget by the department
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Review of Organisation Structure
I/O,' II (Job Des< iptioi . 'J
Main Accountabilities:
• Optimum space utilisation in the civil works of the state Department of Health & RCH
Training Areas:
Hospital architecture
Job Title:
SUPERINDENT ENGINEER - CIVIL
Reporting To:
Chief Engineer - Civil
Immediate Level Subordinates:
• Executive Engineer - Civil
Basic Function:
Monitor the construction work of Department of Health & RCH as per the specifications
given and ensure the quality in construction
Duties, Responsibilities and Authorities:
• Executes the approved civil work from the department of Health and RCH and
executes that with the help of his functionaries in coordination with the concerned
officials in the department
• He is the overall incharge of all the civil works in the region specified which are
related to the Department of Health and RCH
• Obtaining architectural drawings estimates and sanctioning administrative and
technical approval to execute the works
• Suggest for release of payment for satisfactory completion of works according to the
norms of the state PWD department
• Coordinating various departments on land and civil works
• Supervising and Monitoring construction programme and suggest necessary mid
term corrections and actions
• Planning for maintenance of existing buildings
APR -MG
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Review of Organisation Structure
-Vol II (Job Descriptions)
Job Title:
MEDICALRECTOR ~ EQUIPMElMT & MAINTENANCE - BIO
Reporting To:
Director - Procurement & Maintenance
Immediate Level Subordinates:
• Deputy Director - Equipment Training
•
Deputy Director - Equipment (DHS)
•
Deputy Director - Transport
Basic Function:
Organize for periodic schedules of preventive maintenance of the equipment of the
department, monitor the response time in attending the breakdown enquiries and take
corrective action. Organize for training the internal technicians to work on the new
machinery and follow-up with OEMs for maintenance and training.
Duties, Responsibilities and Authorities:
•
a?l.V,ty relating t0 after installati°n of equipment, like conveying the precautions
to be taken in operating certain equipment, etc to the technicians
°r,he 0EMs re9a,dm9 the opera“on
’
•
Monitoring the periodic schedules of preventive maintenance
•
Less response time for breakdown mainti nance
•
Organize for training the internal technicians itself in tackling the minor breakdowns
•
Plan for alternative equipment in case of a major shutdown of one equipment
Release of budget for regular maintenance and any such other activities
Main Accountabilities:
Effective training by Original Equipment Manufacturers for whatever the commitment
has been at the time of purchase
•
Less response time in attending to any maintenance / shutdown problem
Training Areas:
• Coordination with external agencies
•
Preparation of maintenance schedules
AFF -MC
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Review of Organisation Structure
Vol li (Job Descrip lions)
Job Title:
ADDITIONAL DIRECTOR - N.KARNATAKA REGION
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
• District Health Officers of Bijapur, Raichur Gulbarga, Belgaum, Bidar, Bagalkot,
Bellary, Koppal districts
•
All national and state Programme officers of Bijapur, Raipur, Gulbarga, Belgaum,
Bidar, Bagalkot, Bellary, Koppal districts
•
The Joint Directors handling different national and state health programmes at the
directorate
Basic Function:
The office of Additional Director - North Karnataka Region acts as a nodal officer for
coordinating the efforts of various functionaries in the department in showing the special
emphasis for a faster upliftment of the health conditions in the region. His office also
identifies various special programmes as and when required to bring development in the
area specified
Duties, Responsibilities and Authorities:
• Overall coordinating authority of all the programmes and projects in the districts of
Bijapur, Raipur, Gulbarga, Belgaum, Bidar, Bagalkot, Bellary, Koppal both in the
areas of Medical Health and Public Health
•
Identify the additional budget allocation areas for the region allotted
•
Head the office of the nodal office for the districts specified as a group
•
Coordinate with the offices of all national and state programmes and monitor their
implementation in the districts specified
•
Coordinate with the office of AD - Planning and obtain the MIS reports about the
health standards from time to time to review the progress in the districts specified
•
Frequently visit the District and other speciality hospitals in the state and review the
public health and medical care in the districts specified
•
Coordinate with the municipal and other local bodies and monitor the urban health
activities.
•
Identification of any new projects and programs for speedy upliftment of health
standards in the districts specified
Main Accountabilities:
• Should visit all the district hospitals and other major hospitals in the districts
specified atleast twice in six-months period
•
Speedy implementation of all health programmes
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Review of Organisation Structure
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Job Title:
ADDITIONAL DIRECTOR - PLANNING
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
•
Joint Director - Planning
•
Joint Director - Research
• Joint Director - MIS
Basic Function:
Oversee the planning process in the department regarding the different areas of health
and hospital management in the state of Karnantaka. Obtain and review MIS reports
related to different aspects in managing the department like availability of doctors, bed
occupancy, population-bed ratio in a particular region, etc. Plays visionary role to the
department and suggest future plans periodically. Suggest any improvements/corrective
actions in managing the department to the concerned functionaries according to their
job responsibilities
Duties, Responsibilities and Authorities:
• Review the growth pattern in the state and plan the requirements in the health
sector accordingly
•
Develop strategic and perspective plan for the department
•
Develop short-term and long-term budgetary plans for the department
•
Suggest the appropriate authorities about the corrective actions to be taken if any
shortfall is observed in their functioning
• Approve the areas for research
Receive the information on Health of people and different hospitals in the state and
review them for preparing proper MIS .
Main Accountabilities:
Training Areas:
Planning methodology
Medical systems
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Review of Organisation Structure
Job Title:
- Vol II (Job iJ-}scnptions)
JOINT DIRECTOR - PLANNING
Reporting To:
Additional Director - Planning
Immediate Level Subordinates:
•
Deputy Director - Planning
•
Deputy Director - Training
Basic Function:
Obtain reports from different functionaries regarding the status of medical and
public health in the state and suggest for improvements along with the path to follow.
Collates all the information generated through MIS activity and process for future
planning.
Duties, Responsibilities and Authorities:
• Plan for the issues pertaining to institutions coming under the control of the District
Health and RCH and Zilla Parishads as regards upgradation, improvement and
strengthening of existing facilities and the outlayed budget for them.
•
All service matters relating to the District Health and RCH officers Class I Senior and
Deputy Directors
•
Formulate the inputs required for National Nutrition Programme in coordination with
all the functionaries in the department at the district level
•
Suggest the health projects under the State Plan Programme
•
Review and suggest actions based on monthly multilevel review reports and
Karnataka 20 point programme
•
Review the follow-up of special component plan and tribal sub-plan
•
Suggest issues and review the draftnotes for Governor's address and finance
minister's budget speech
•
Preparation of Annual Administrative Reports, Annual Report, Status Report and all
matters relating to Bureau of Health Intelligence including Sushrusha Programme.
•
Formulate matters relating to Tribal Sub Plan, Special component plan and
Karnataka Twenty Point Programme.
Job Title:
JOINT DIRECTOR - RESEARCH
Reporting To:
Additional Director - Planning
Immediate Level Subordinates:
Basic Function:
Identify the areas of contemporary importance to the department and recommend for
research by various agencies / persons
Duties, Responsibilities and Authorities:
• Follow the trends in medial and health care in the state
•
Recommend for research / action research in the areas identified
• Follow up with the findings
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Review of Organisation Structure
•
-Vol II (Job Descriptions)
Recommend for any future directions or corrective actions for policy makers or other
people concerned
Main Accountabilities:
Training Areas:
• Research methodology
•
Action research
Job Title:
JOINT DIRECTOR - MIS
Reporting To:
Additional Director - Planning
Immediate Level Subordinates:
•
Statastician
•
Demographer
•
All programme officers at the district level (administratively)
Basic Function:
Collate all the hospital, medical and health related information in the state
through different hospitals and analyse them for any interpretation.
Duties, Responsibilities and Authorities:
• Head of office to analyse the information about all hospitals in the state
•
Monitor the information generation at different hospitals regarding the treatment of
patients, availability of beds for inpatients, population-bed ratio, etc
•
Collate and interpret information about occurrence of epidemics in different parts of
the state
•
Coordinate with all the programme officers at districts in the state and collate
information they generate about the status of programme and the health condition
in the state
•
Coordinate with all the DHOs and District Surgeons in collecting the information
about the status of their work and inturn the health systems in the state
Training Areas:
• Research Methodology
•
Primary and secondary data collection
•
Report writing
•
Coordination skills
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Job Title:
CHIEF ADMINISTRATIVE OFFICER
Reporting To:
Commissioner / DGHS
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
• Guide the relevant authorities relating to Cadre strength of the department.
•
Preparation of Annual programme of inspections in the state
•
Maintenance of inspection reports after the inspection of officers.
•
All matters relating to establishment of all the cadres of the department, obtaining
sanctions of the Director and other officers of the Directorate such as Additional
Directors, Joint Directorate etc., wherever such sanctions required as per the
delegation of powers issued by the Government from time to time.
•
All matters relating to filling up of the vacancies promotions, declaration of
probationary period disciplinary proceedings, compassionate appointments, time
bound advancements, sanction of leave etc., after obtaining sanctions of the
Director/ Additional Directors/ Joint Director, where such sanctions are required.
•
All matters relating to Legislative Assembly/ Council including answering Legislative
Assembly/ Council questions and parliamentary questions, and all standing
committee meetings of the Legislature
•
furnish replies to the other house committees of the Legislature.
•
Constitution of board of visitors in the Department
Main Accountabilities:
Training Areas:
Public Administration
Cadre management
Transfer policy
Office organization
Time management
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Job Title:
CHIEF ACCOUNTS OFFICER (FINANCE)
Reporting To:
Chief Administrative Officer - Finance
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
• Report all matters relating to financial aspects of the Department both plan and non
plan to the higher officials in the finance/accounts department
•
Reconciliation of expenditure of plan and non-plan schemes.
•
Obtain reimbursements from Govt, of India, pertaining to Centrally sponsored
schemes, Externally
•
Report about the expenditure regarding aided projects and Central sector schemes.
•
Settlement of House building advance, vehicle advance, L.T.C., HTC., sanction of
pension, DCRG, issue of No due certificates etc.,
•
Payment of salaries of the staff of the Directorate of Health and F.W. Services.
•
A udit of expenditures in different sections of the department
•
Report about the transactions from the treasury to the higher officials
•
Public Accounts Committee, Estimate committees and other House committees,
relating to finances.
•
Monitoring of Plan schemes including MMR and preparation of performance budget.
Main Accountabilities:
Training Areas:
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Job Title:
JOINT DIRECTOR - TUBERCULOSIS
Reporting To:
Additional Director - CMD
Immediate Level Subordinates:
•
Deputy Director - Bactriology
•
Deputy Director - Epidemiological Surveillance Unit
•
DHO
•
District TB officer
Basic Function:
Effectively monitor the National TB Control Programme and Aids control programme.
Duties, Responsibilities and Authorities:
•
Plan the activities to be taken up regarding National TB control programme
•
Coordinates with IEC department in educating the masses about the care to be
taken against the spread of Tuberculosis
•
Monitor the activities under the TB control Programme at the district level
•
Coordinate the NTBCP activities at different districts and strive for their joint efforts
wherever possible
•
Monitor the treatment of AIDS patients in the state
•
Submit the reports to the MIS department for proper evaluation of the effectiveness
of different activities under the programme
•
Look after the activities of Lady Wellington TB Demonstration and Training Centre
and other TB related programmes or institutes in the state
•
Monitor the treatment to Aids infected patients in the state.
•
Get aware of the social hazards being faced by the Aids patients and pass the
information to IEC unit and other departments to educate the masses in avoiding
those
•
Monitor and evaluate the effectiveness of treatment to the TB infected patients
•
Monitor proper usage of funds allocated for treatment of TB patients and for various
activities under National TB control Programme
Assess the requirement of personnel in handling the TB related activities from time
to time, as the requirement of District Surgeon and District Health Officer and
communicate to the appropriate authority
Main Accountabilities:
•
Training Areas:
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Job Title:
DEPUTY DIRECTOR (PHARMACY)
Reporting To:
Joint Director (Medical)
Immediate Level Subordinates:
Basic Function:
Monitor the functioning of different dispensaries and pharmacies situated in all
the hospitals in the state. Monitor timely distribution of pharmaceuticals to the
dispensaries and their proper storage as per the mandatory norms. Plan for the
availability of pharmacists wherever required
Duties, Responsibilities and Authorities:
• Follow-up of matters connected with Pharmacy units at different locations regarding
sending proposals for establishment of Pharmacy/ units, maintenance of pharmacy
equipment / blood banks, etc.
•
Monitor the maintenance of standards in preserving blood, drugs and medicines at
the government pharmacies.
•
All matters relating to selection of drug samples in Govt. Medical stores, District
stores and other institutions for maintenance of quality standards and arranging
analysis in the drug controller's office
•
Receive requisitions from different pharmacies in the state.
•
Monitor the financial limits of each pharmacy in the state and disburse the drugs
Obtaining permission for procurement of drugs and medicines for different
pharmacies in the state.
Main Accountabilities:
• Timely distribution of drugs to the pharmacies and dispensaries in government
hospitals in the state
•
Training Areas:
•
Logistics management
•
Indian Drug and Cosmetics Act
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Job Title:
DEPUTY DIRECTOR - TRAINING
Reporting To:
Joint Director - Planning
Immediate Level Subordinates:
Basic Function:
Identify the means of aligning the Department's short-term and long-term goals with
that of the individual's aspirations and development, offer career planning options and
provide induction training and as well the refresher programmes for the people in the
department
Duties, Responsibilities and Authorities:
• understand the organization's short-term and long term goals and the expectations
from the people in the department
•
understand the people's aspirations and provide options to link it to the career
planning
•
counsel the individuals and provide options for their growth
•
Plan for the induction training for the new entrants into the system, coordinate with
SIHFW
•
Plan for any refresher courses for the technical as well as non-technical people in the
department to keep them abreast with the latest knowledge
Main Accountabilities:
• Conduct induction training programme for all the new entrants into the system
•
Cover atleast 5 % of the doctors strength in each year for the refresher training
course
Training Areas:
•
Career counseling methods
•
Knowledge about the options available for further growth of the doctors
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DISTRICT LEVEL
Job Title:
Reporting To:
DISTRICT HEALTH AND FW OFFICER
Respective Program Directors and joint Directors of
different functionaries of the department.
Immediate Level Subordinates:
•
District Malaria Officer
•
District Cholera Combat team officer
•
District Leprosy Officer
•
District Training officer (to coordinate with SIHFW)
•
District Surveillance Unit Officer (District epidemiologist)
•
District TB Officer
• Regional Assisstant Chemical Examiner
Basic Function:
Head of all the activities related to Department of Health & FW of Government of
Karnataka at the respective district level. Acts as the single reference point for any
information related to public and medical health in the district. Would be coordinating
between different functionaries and program / project offices for effective
implementation in the district.
Duties, Responsibilities and Authorities:
• All matters relating to Medical institutions in the district except those which are
controlled by the Dist. Surgeons and Director of Medical Education.
•
Responsible to carry-out activities relating to Health and RCH programmes in the
State
•
Responsible for Administrative and technical aspects of all the activities and
programmes of the directors of different functions in the department.
•
Responsible for state government for any queries regarding the health (e.g: spread
of epidemic) of the people in the state
•
Work as per the instructions issued by the Director of Health & FW services, from
time to time.
•
Overall responsibility of all the Family Planning activities in the district, in addition to
the other Health programmes. Responsible Administratively and technically to the
Commissioner - Health
•
In consultation with the M.O.H.F. (FW & MCH) he will draw up advance annual and
monthly programmes in order to achieve the targets fixed.
•
He will visit the IUD and Sterilisation camps and satisfy himself that proper
arrangements are made.
•
He will see that timely action is taken by the M.O.H. (Family Planning & MCH)
regarding stocking and distribution of supplies and equipment.
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•
He will be responsible for the proper use of all the departmental vehicles for the
Family Planning Programme without hindering the programmes for which the
vehicles are allotted .
•
During the visits to the various Primary Health Centres apart from paying attention
to various other schemes, pay particular attention to the Family Planning Programme
to see that progress of work is achieved and to take action against such of those
who are slake, with a view to gear up the work.
•
Arrange for one of the senior members of his staff namely Asst. Director Health
Officer, Medical Officer of Health (FP), District Extension Educator, Health Supervisor
or District Nursing Supervisor to attend the monthly conference of each primary
Health Centre and review the physical progress achieved.
•
Arrange a quarterly conference of all Medical Officers under his/her control and
review the progress of the Family Planning Programme.
•
Responsible to see that the required reports are sent to the State Family Planning
Bureau every month by the due date.
•
In coordination with the Medical Officer of Health (FP & MCH) he/she will arrange
job orientation training for the peripheral staff.
•
Responsible for the random check-up of atleast 5% of persons who have IUD
placements or sterlisation operations done in the district by Government
Institutions). Voluntary organisation and Private practitioners to ensure that the
incentives are not misused, and that proper follow up has been ensured.
He will have full control of his annual budget and will be responsible for expenditure
therefore within his powers without recourse to higher authorities thus ensuring that
the budget provisions do not lapse.
Main Accountabilities:
•
Training Areas:
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Job Title:
HOSPITALS
DISTRICT SURGEONS/SUPERINTENDENTS OF MAJOR
Reporting To:
District Health Officer
Immediate Level Subordinates:
• Respective specialists in the hospitals
•
Administrative Medical Officer
•
Functionaries at CHC and THC
•
Nursing supervisor
• Chief pharmacist (Functionally)
Basic Function:
Duties, Responsibilities and Authorities:
•
He will be the head of institution and exercise administrative and technical control
over the staff of the institution.
•
Maintain the quality of patient care according to the standards laid down by the
medical care / state government
•
Submit to the state government (Office of AD / JD) at intervals, reports on the
quality of medical care and working of the medical staff
•
Act as an ex-officio member of the management team, be involved in the day-to-day
decisions of the hospital at the operating level (can a management team comprising
of DHO, DS, CEO ZP and ZP chairman to work at the district level)
•
Schedule duties, help scheduling of operating room and any other medical or
paramedical services under his/her administration
•
Enforce staff rules and discipline the doctors in consultation with the DHO
•
Sign hospital medical certificates, reply to correspondence and queries about
patients, medical services and paramedical services under his jurisdiction
•
Conduct performance review of doctors in consultation with the DHO
•
Sanction of leave for Doctors and other functionary who are under his/her office and
reporting to him.
•
Out patient and in-patient services, Diagnostic services of day-to-day patients.
•
Procurement of drugs as per the requirement received from the chief pharmacist in
the district/hospital, in consultation with the DHO.
•
Issue fitness certificates, old age pension eligibility certificates and physically
handicapped to whoever eligible and required
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Job Title:
RESIDENT MEDICAL OFFICERS
Reporting To:
District Surgeon / Superindent of major hospitals
Immediate Level Subordinates:
Basic Function:
Duties, Responsibilities and Authorities:
•
Monitoring of the maintenance of Drug stores in the hospitals and the availability of
medicines as per the requirement of doctors and patients
•
Diet supplies of the institution to the inpatients as per mandatory stipulations
(clarify)
•
Addressing the medico-legal cases and be responsive to the requirement of law &
order authorities in answering the queries along with district surgeon.
•
Arranging of Casualty services outpatient services, maintenance of cleanliness in the
institutions.
•
Maintenance of punctuality, discipline, maintenance of environment sanitation in the
institution.
•
Posting of staff for day-to-day work, providing Ambulance services on requisition,
maintenance of Log book etc.,
•
Maintenance of the equipment in the institution.
Main Accountabilities:
Training Areas:
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Review of Organisation Structure
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Job Title:
TALUK HEALTH OFFICER
Reporting To:
District Health Officer
Immediate Level Subordinates:
• TLH/CHC/PHC- AMO/MOH/LMO
Basic Function:
Duties, Responsibilities and Authorities:
•
Implement all National Health programmes in the taluks through a net work of
primary Health centres and other institutions.
•
Report day-to-day status of Health condition prevailing in the taluk including
epidemics to higher authorities.
•
He/she is the reporting authority of all the periodical returns the Taluk duly received
from the peripheral institutions and provide feed back to the peripheral institutions &
the DH & FWO.
•
Exercise supervisory control of all the institutions in the Taluk.
•
Represent DHO in Taluk / Panchayat meeting and Gram Panchayat meetings
wherever necessary and co-ordinates all the activities of the department such as
organising. Eye camps, control of communicable diseases, Sushrusha programme,
Malaria control programme, RCH camps, Immunization, T.B. Leprosy and other
related matters.
•
Arrange for proper distribution of drugs, equipment, materials as supplied by DH &
FWO and maintain inventory of all articles received in the Taluk and its proper
maintenance.
•
Conduct periodical inspection of the institutions and report the matter to the DH&
FWQ on all observations made.
•
Plan, manage and implement national health & RCH programmes in the Taluk
•
Inspect all health organizations on regular basis
•
Developmental planning of health institutions
•
Sanction casual, normal and restricted leave to all Medical Officers as and when
required.
•
Prepare confidential reports on Medical Officers and statistical reports of the Taluk.
•
Plann steps to prevent the communicable diseases and report the same to District
Health & RCH Officers and revenue officers in the Taluk.
•
Inspect stores of all health institutions and raise indents with District levels offices
for the various medicines and chemicals required for these institutions.
•
Organise family planning and eye test camps
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•
Conduct monthly meetings with Primary Health Centre (PHC), Primary health Unit
(PHU) and Community Health Centre (CHC) and review the implementation of
various plans.
•
Conduct meetings with other departments in the Taluk and co-ordinate in their
functioning
Issue certificates for conducting the various festivals and fairs in the Taluk and take
steps to ensure control on diseases.
Any other duties assigned by DH&FWO.
•
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JOB TITLE:
SENIOR HEALTH ASSISSTANT
REPORTS TO:
Medical Officer (PHC)
IMMEDIATE LEVEL SUBORDINATES
•
Junior Health Assistant (Male)
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Supervise and guide Junior Health Assistant (Male) in rendering the health care
services to the community.
•
Strengthen the knowledge and skills of the Junior Health Assistant (Male) and also in
planning and organising his programme of activities and also prepare assessment
reports on him.
•
Co-ordinate the activities with those of Junior Health Assistant (female) and other
health personnel including Health guides and Dais.
•
Assist the medical Officer of the PHC in conducting training programmes for various
categories of health personnel.
•
Check and indent for the procurement of supplies and equipment at the subcentres.
•
Responsible for proper storage of drugs and maintenance of equipment at the
subcentre.
•
Responsible for scrutinising the maintenance of records by Junior Health Assistants
and consolidation of the reports to the Medical officer of the PHC.
•
Supervise the work of Junior Health Assistant (Male) during concurrent visits and
check 10% of the houses in the village to verify the work.
•
Responsible for taking blood smears, radical treatment and spraying of insecticides
for controlling Malaria
•
Responsible for identification for Kala-azar, Communicable diseases, Leprosy,
Tuberculosis and ensure that appropriate control measures are taken.
•
Inform the Medical Officer PHC about the defaulters to treatment in cases of
Leprosy, tuberculosis etc.
•
Help the community in the construction of soakage pits, manure pits, compost pits,
sanitary latrines, and safe water sources and also supervise the chlorinating of wells.
•
Supervise the immunisation of all children from one to five years and pregnant
women.
•
Assist Medical Officer PHC in organising Family planning camps and drives and
motivate & follow-up cases for family planning.
•
Ensure that all cases of malnutrition among children are given necessary treatment
and refer serious cases to the PHC.
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•
Carry out educational activities for control of communicable diseases, environmental
sanitation, MCH, Family planning, nutrition, immunisation, dental care and other
national health programmes.
•
Collect and compile the weekly report of births and deaths occurring in the area and
submit them to the Medical Officer PHC.
•
Organise and conduct training of community leaders with the assistance of the
health team.
Provide treatment for minor ailments and first aid for accidents and emergencies and
refer cases beyond his competence to the PHC.
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC
•
•
Fortnightly meetings with Junior Health Assistants at subcentres.
MAIN ACCOUNTABILITIES
JOB TITLE:
SENIOR HEALTH ASSISTANT (FEMALE)
REPORTS TO:
Medical Officer (PHC)
IMMEDIATE LEVEL SUBORDINATES
• Junior Health Assistant (Female)
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Supervise and guide Junior Health Assistant (Female), Dais and female health guides
in the rendering of health care services to the community.
•
Strengthen the knowledge and skills of the Junior Health Assistant (Female) and also
in planning and organising her programme of activities and also prepare assessment
reports on her.
•
Carryout supervisory home visits in the areas under National health programmes.
•
Supervise a referral of all pregnant women for VDRL testing to CHC/Sub-divisional
hospital.
•
Assist the medical Officer of the PHC in conducting training programmes for various
categories of health personnel.
•
Check and indent for the procurement of supplies and equipment at the subcentres.
•
Responsible for ensuring that the Junior Health Assistant (Female) maintains a
general kit and midwifery kit and Dai kit and the clean and proper maintenance of
subcentres.
•
Responsible for scrutinising the maintenance of records by Junior Health Assistant
(Female) and consolidation of the HMIS reports to the Medical officer of the PHC.
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•
Supervise the work of Junior Health Assistant (Female) during concurrent visits and
check 10% of the houses in the village to verify the work.
•
Conduct weekly MCH clinics at each sub centres with the help of Junior Health
Assistant (Female) and Dais.
•
Conduct deliveries when required at PHC and provide necessary domiciliary and
midwifery services.
•
Conduct weekly family planning clinics at each subcentre and motivate resistant
cases for family planning.
•
Provide information on services for medical termination of pregnancy, sterilisation
and refer the cases for MTP to the approved institutions.
•
Help Medical officers in school health services.
•
Supervise the immunisation of all children from one to five years and pregnant
women.
•
Assist Medical Officer HC in organising Family planning camps and drives and
motivate & follow-up cases for family planning.
•
Ensure that all cases of malnutrition among children are given necessary treatment
and refer serious cases to the PHC.
•
Carry out educational activities for control of communicable diseases, environmental
sanitation, MCH, Family planning, nutrition, immunisation, dental care and other
national health programmes.
•
Organise and utilise Mahila Mandals, teachers and other women in the community in
the RCH programmes including ICDS personnel.
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC
•
Fortnightly meetings with Health Workers at subcentres.
MAIN ACCOUNTABILITIES
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R&v/evi/ of Organisation Structure
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JOB TITLE:
JUNIOR HEALTH ASSISSTANT (FEMALE)
REPORTS TO:
Senior Health Assistant (Female)
IMMEDIATE LEVEL SUBORDINATES
N.A,
BASIC FUNCTION
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Register and provide care to pregnant women through out the period of pregnancy
•
Ensure that the pregnant women undergo all the necessary tests like VDRL test
•
Conduct about 50% of the total deliveries, supervise deliveries conducted by Dais
and refer the cases of abnormal pregnancy to Health Assistant Female or the PHC.
•
Responsible for post delivery visits and advise the mother about the maternal and
child health, family planning, nutrition and immunisation and diarrhoea control.
•
Assess the growth and development of infant and take necessary action to rectify
the defect.
•
Responsible for spreading the message of family planning to the couples and
distribute conventional and oral contraceptives to the couples.
•
Identify women leaders in the area for promoting RCH programmes and participate
in Mahila Mandal meetings and utilise such gatherings for educating women in RCH
programmes.
•
Identify women requiring medical termination of pregnancy and refer them to the
approved institutions and educate them about the services.
•
List the dais in the area and help the Health Assistant in training them.
•
Notify the Medical Officer PHC about the abnormal increase of communicable
diseases and administer presumptive treatment wherever necessary.
•
Maintain all the records relating to register of pregnant women from three months
onwards, Maternal and child care records and submit prescribed monthly report to
the Health Assistant (Female)
•
Co-ordinate the activities with Health Worker (Male) and other health workers
including the Health guides and Dais.
•
Help the medical officers in school health services.
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC/Community Development Block
MAIN ACCOUNTABILITIES
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JOB TITLE:
JUNIOR HEALTH ASSISSTANT (MALE)
REPORTS TO:
Senior Health Assistant (Male)
IMMEDIATE LEVEL SUBORDINATES
N.A.
BASIC FUNCTION:
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Identify the people affected with Malaria and take the blood smears and begin
presumptive treatment under NMEP.
•
Co-ordinate with the village health guides about the spray dates for the insecticides
and intimate the houses in the village.
•
Enquire about the presence of Kala-azar, Japanese Encephalitis etc and will guide
the suspects to the PHC or CHC for diagnosis and treatment.
•
Identify the cases of communicable diseases, Tuberculosis and Leprosy inform the
Health Assistant (Male) and Medical Officer (PHC) about these cases and also
undertake the control measures.
•
Undertake chlorinating of public water sources at regular intervals and educate the
community on environmental sanitation.
•
Administer DPT vaccine, oral polio vaccine, measles vaccine ancj BCG vaccine to all
the infants and children in his area in collaboration with Health Worker Female.
•
Assist the Health worker female in administering the immunisation to all pregnant
women, and also for school immunisation programme
•
Educate the people in the community about the importance of immunisation against
the various communicable diseases.
•
Responsible for spreading the message of family planning to the couples and
distribute conventional and oral contraceptives to the couples.
•
Identify male community leaders in the area and train them for promoting RCH
programmes.
•
Identify women requiring medical termination of pregnancy and refer them to the
approved institutions and inform the Health Worker (Female)
•
Identify cases of malnutrition among the children and arrange for necessary
treatment and educate the parents about the nutritious diet.
•
Provide treatment for minor ailments and first aid for accidents and emergencies and
refer cases beyond his competence to the PHC.
•
Enquire about births and deaths occurring in his area and report to the Health
Assistant (Male)
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Prepare maintain and utilise family and village records, maps and charts of the
village, record of people undergoing treatment for TB and Leprosy and submit
periodical reports to Health Assistant (Male)
PARTICIPATION IN COMMITTEES / MEETINGS
• Staff Meetings at PHC/Community Development Block
MAIN ACCOUNTABILITIES
JOB TITLE:
LABORATORY TECHNICIAN
REPORTS TO:
Medical Officer - PHC
IMMEDIATE LEVEL SUBORDINATES
N.A.
BASIC FUNCTION
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Maintain the cleanliness and safety of the laboratory
•
Ensure that the glassware, microscope and equipment are kept clean and well
maintained.
•
Ensure Sterlisation of equipment as and when required.
•
Ensure the safe disposal of specimens and infected material.
•
Maintain the necessary records of investigations done and submit the reports to the
Medical Officer, PHC.
•
Prepare monthly reports regarding his work and submit to the Medical Officer, PHC.
•
Indent for supplies required at the laboratory through the Medical Officer, PHC and
ensure the safe storage of the received material.
•
Carry out examination of urine, stools, blood, sputum, skin and smears for leprosy
patients, semen, throat swabs, drinking water and aldehyde test.
•
Responsible for maintenance of all records and slides examined by him for Malaria
and get them confirmed by the Medical Officer, PHC
•
Maintain the daily progress and output register of blood slide examination and a
backlog chart of pending radical treatment under NMEP.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Staff Meetings at PHC
MAIN ACCOUNTABILITIES
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JOB TITLE:
MEDICAL OFFICER - PHC
REPORTS TO;
Taluk Health Officer / District Health Officer
IMMEDIATE LEVEL SUBORDINATES
Health Assistants (M/F)
DUTIES, RESPONSIBILITIES AND AUTHORITIES
1. Organise the dispensary, outpatient department and allot duties to the ancillary staff
to ensure smooth running of OPD.
2. Attend to the cases referred to him by Senior Health Assistants, Junior Health
Assistants, Health guides and Dais from sub-centre level and refer the cases needing
specialised medical attention to referral institutions.
3. Visit the subcentres in the area once in a fortnight to supervise the work and provide
curative services.
4. Ensure that the health team is fully trained in various national health & RCH
programmes and prepare the operational plans for ensuring effective implementation
as per the targets.
5. Provide basic MCH services, implement nutrition and universal immunisation
programmes
6. Responsible for proper and successful implementation of Family Planning
programmes like Vasectomy, Tubectomy, IUD and MTP in the PHC area.
7. Responsible for administrative and technical matters relating to Malaria Eradication &
Vector control programmes in the PHC area.
8. Responsible for all anti Kala-azar and anti Japanese Encephalitis operations in his
area.
9. Responsible for regular reporting to District Malaria Officer/Civil Surgeon in terms of
monitoring, record maintenance and maintenance of adequate provisions of drugs
etc.
10. Provide facilities for early detection and cases of Leprosy, Tuberculosis, and
blindness and ensure that all cases take regular and complete treatment.
11. Responsible for control of communicable diseases and the proper maintenance of
sanitation in the villages and take action in case of any outbreak of epidemic.
12. Ensure that all the cases of STD are diagnosed and properly treated and provide
facilities for VDRL test for all pregnant women at the PHC.
13. Visit various schools for ensuring health programmes,
14. Proper management of cases of diarrhoea and referral of serious cases to the
hospitals.
15. Responsible for organising and conducting training under Medical and Para Medical
personnel scheme and school health service schemes.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Staff Meetings at PHC
MAIN ACCOUNTABILITIES
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JOB TITLE:
LADY MEDICAL OFFICER
REPORTS TO:
Medical Officer, PHC
IMMEDIATE LEVEL SUBORDINATES
Workers
Health Assistants & Health
DUTIES, RESPONSIBILITIES AND AUTHORITIES
1. Ensure that all the necessary steps are being taken for the control of communicable
diseases in the village and report the outbreak of an epidemic to Medical Officer incharge.
2. Responsible for diagnosing and treating Kala-azar and Japanese Encephalitis patients
and also for arranging spray activities in the area under the supervision of Medical
Officer in-charge at PHC.
3. Supervise and guide Health Assistants and workers in effective implementation of
Maternal and Child Health, immunisation programme, family planning and nutrition
programmes.
4. Arrange for the medical check-up at schools and treatment of students found to
have defects.
5. Ensure that all the steps are being taken for provision of safe drinking water and
improvement of environmental sanitation at the villages.
6. Participate in community involvement in the nutrition programme and safe water
supply and environmental sanitation programmes.
7. Responsible for organising camps, meetings, health education talks, and involve
Health Assistants and workers in these activities promoting health education.
8. Organise and conduct training for health guides, primary school teachers and dais
for field training in community health programmes.
9. Assist Medical Officer, PHC in staff development and training programmes for staff at
PHC, subcentres
10. Assist Medical Officer, PHC in conducting field investigations for planning changes in
strategy for effective delivery of health services.
11. Ensure adequate supply of kits, medical drugs, contraceptives, vaccine, equipment
etc at PHC and subcentres.
12. Obtain the reports from the periphery, analyse and interpret the data and utilise the
finding for successfully implementing the health programmes in the area.
13. Scrutinise the work plans of Health Assistants and Health workers and supervise the
maintenance of the prescribed records at the subcentre level.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Village Health Committee/Village Panchayat Meetings
♦ Monthly Staff meetings at PHC
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JOB TITLE:
BLOCK EXTENSION EDUCATOR
REPORTS TO:
District Health Education Officer
IMMEDIATE LEVEL SUBORDINATES
DUTIES, RESPONSIBILITIES AND AUTHORITIES
1. Collate information on MCH, Rural development education, social welfare and other
programmes and utilise the same for programme planning.
2. Collect and maintain data on mortality, protection and immunisation rates and utilise
the same for work under FW & MCH programme.
3. Co-ordinate with the local voluntary agencies for training in health and RCH and will
assist the Medical health officer in conducting these programmes.
4. Maintain complete set of education aids for training purposes.
5. Act as a resource person at the block level FW committee and ensure proper
functioning of these committees in the catchment area of PHC.
6. Liason with the media units of other departments, NGOs and organise mass
communication programmes like film shows exhibitions, lectures, dramas with the
help of District Health Education Officer.
7. Responsible for all educational, motivational and communication programmes in PHC
area.
8. Ensure supply and utilisation of information and educational material to health
workers and development functionaries including those of voluntary agencies.
9. Support, guide and supervise the field workers in the area of information
dissemination, education and motivation.
10. Give special attention to resistant couples and drop out by problem solving methods
and committees.
PARTICIPATION IN COMMITTEES / MEETINGS
♦ Block level RCH Meetings
♦ Monthly Staff meetings at PHC
MAIN ACCOUNTABILITIES
JOB TITLE:
DISTRICT PUBLIC HEALTH EDUCATION OFFICER
REPORTS TO:
District Public Health Officer
IMMEDIATE LEVEL SUBORDINATES
• Block Health Educators
• Block Extension Educators
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BASIC FUNCTIONS:
Evaluate the requirement, plan and execute the health education among the
people in the district. Should use his offices to educate the people and thus suggest any
precautionary/remedy measures for sort of issue, which can be addressed easily. Should
effectively use any melas / any big gatherings of people in spreading the message.
All the matters relating to the Health Education will be routed through him/her to
the District Health & F.P. Officer. He/she is the Technical Assistant to the District Health
& FP. Officer, in Health & Family Education matters.
DUTIES, RESPONSIBILITIES AND AUTHORITIES
I. Evaluate the health education related requirements among the people in the district
and submit reports to the office of Joint Director - Health Promotion and DHO
2. Plan and co-ordinate all the health education activities in the district in collaboration
with official and non-official agencies.
3. Determine the relative applicability of the different communication methods including
traditional media, in relation to the local circumstances and ensure through feedback
to All India Radio, State Health Education Bureau, State Mass Media Wing the
contents of such communication are locally relevant and effective.
4. Guide the Block Health educator in preparing talking points.
5. Assess the needs of the educational equipment and materials and arrange for their
procurement/ production, maintenance, distribution and utilisation in the Health
Centre.
6. Plan alternate approaches in Health Education and arrange for extra inputs through
different media depending upon the needs.
7. Assist the State Health Education Bureau and Mass Media wing in identifying the
areas of concern and conducting studies
8. Develop one Primary Health Centre as a Field study demonstration area in the
District, preferably near to the district headquarters.
9. Solicit technical guidance and direction from the State Mass Media Wing and the
State Health Education Bureau for reaching out to the people more effectively.
10. Arrange and conduct in-service training Qob orientation) to the newly appointed field
staff making use of the field study and demonstration material.
II. Identify special groups such as factory workers, plantation labour, government
employees, teachers, etc and conduct orientation training involving medical officers
of Health and paramedical workers in the Primary Health Centres.
12. Organise education campaign on occasions such as epidemics, family planning,
immunization etc.
13. Organise exhibitions and cultural programmes at important centres during special
occasions like festivals and fairs.
14. Supervise and guide the Block Health Education Officers and Block Extension
Educators and arrange for the quarterly meeting.
PARTICIPATION IN COMMITTEES / MEETINGS
• Quarterly meeting with Block Health education officers and Block extension
educators.
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Monthly meeting with the DHO to draw his attention for coordination between
different functionaries in the district (PHC level to the district hospital).
Quarterly meeting with the Joint Director (Health Promotion) along with other
District Health Education Officers to know the progress in other districts vis-a-vis
theirs and discuss about any joint / mutually complementary programmes among
themselves
Arrange for quarterly meeting of the Block Health Educators at the District
under the Chairmanship of District Health & F,P. Officer,
• Obtain and review the reports of Block Health Educators and Deputy Health
Education Officers and submit a consolidated report to the District Health & FP.
Officer
•
•
Tour at least 15 days in a month and make ten night halts.
•
Visit each PHC at least once in three months.
Training Areas
STAFF NURSE
JOB TITLE:
REPORTS TO:
• Nursing Supervisor (Sister)
•
Medical Officer in-charge PHC/CHC
•
District Surgeon in District Hospitals
IMMEDIATE LEVEL SUBORDINATES
• Ward Staff
BASIC FUNCTION
Staff Nurse is a first level professional nurse who provides direct patient care to one
patient or a group of patients assigned to her/him during duty shift, and assist in ward
management and supervision.
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Responsible for admitting and discharging patients and maintain clean and safe
environment
•
Maintain personal hygiene and comforts of the patient and attend to the nutritional
needs of patient and feed helpless patients.
•
Perform technical tasks like administration of medication, assisting doctors in various
medical procedures and the patient care.
•
Update case sheet of patients under their care as per prescribed norms.
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•
Follow doctors' rounds and help them in diagnosis and treatment in the absence of
Nursing Supervisor.
•
Co-ordinate patients care with various health team members.
•
Responsible for keeping the ward neat and tidy.
•
Handover and takeover the patient and ward equipment and supply.
•
Maintain safety of the ward equipment.
•
Assist ward supervisor/sister in ward management and officiates in her/his absence
and assist in taking inventories.
•
Supervise students and other junior nursing personnel working with her/him and
maintain ward record and reports assigned to her/him.
•
Participate in clinical teaching both planned and incidental.
•
Teach and guide domestic staff and help in orientation of new staff.
•
Participate in staff education programmes and guide student nurses.
PARTICIPATION IN COMMITTEES / MEETINGS
MAIN ACCOUNTABILITIES
JOB TITLE:
NURSING SUPERVISOR (SISTER)
REPORTS TO:_________________
•
Nursing Superintendent (hospitals above 400 bed strength) or
•
Medical Officer in-charge (PHC/CHC) or
•
District Surgeon (Other hospitals including District Hospital)
IMMEDIATE LEVEL SUBORDINATES
• Staff Nurse
BASIC FUNCTION
Nursing Supervisor is accountable for the nursing care management of a ward or a unit
assigned to her. She is responsible to the Nursing Superintendent/Assistant Nursing
Superintendent for her ward management. She takes full charge of the ward and
assigns work for various categories of nursing and on-nursing personnel working with
her. She is responsible for safety and comfort of the patients in her ward. In a teaching
hospital she is expected to ensure good learning fields.
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DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Plan nursing care and make patients assignment as per their nursing needs.
‘
Sh ‘nppd! dfhCt
°f the Patient 35 and When required and t0 see
health needs of her patients are met.
•
ensure safety, comfort and good personal hygiene of her patient.
rec^rds^of nt9hp°nS^th
total
an? Stud4
ents and to ensure that proper obsen/ation
,nf°rma“On impa,ted to the
concerned
•
Review case sheets updated by the staff nurses on a regular basis
•
make rounds with doctors and assist him in diagnosis and treatment of his patients.
•
implement doctor's instructions concerning patient treatment.
rnnSrdSien?
their ralatives to adjust in the hospital and its routine and also
co-ordinate patient care with other departments.
•
ensure safe and clean environment for the ward
•
Responsible for preparation of duty and work assignment plans, ward statistics
indent ward stores and check inventory at regular intervals.
'
•
make list for condemnation of articles and submit to all the concerned.
nfethlbllShHand^TlnfurCe Ward standards Prescribed in the procedures and manuals
of the ward and the hospital and policies that are in force.
’
maint-Ain
T,betwT ward staff and hospital administration and also
maintain good public relation in her ward.
•
write confidential reports of her reporting staff.
‘
ca°rp snPr°9ramTeS f°r neW Staff and guides in formulation of nursing
care studies and nursing care plans etc.
y
•
evaluate nursing students performance
and submit reports to the school
authorities.
•
help in medical and nursing research.
PARTICIPATION IN COMMITTEES / MEETINGS
•
Ward conferences and meetings
MAIN ACCOUNTABILITIES
•
Hospital infection control
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JOB TITLE:
NURSING SUPERINDENT
REPORTS TO:
Medical Superintendent
IMMEDIATE LEVEL SUBORDINATES
•
Nursing Supervisor (Sister)
BASIC FUNCTION
Nurang superintendent is responsible to the Medical Superintendent in a hospital havino
safa aad—
for
DUTIES, RESPONSIBILITIES AND AUTHORITIES
Responsible for setting up the higher standard of professional conduct.
Plan and administer rules and regulations to maintain efficient nursing services.
DHS/1?MeEntr MpSndadOnf aad re9ulations that are issued from time to time by
UHb/DME or Medical superintendent of the hospital.
y
’
aTdepartmenT “ tePte'
•
Secure the necessary equipment, linen and ensure good nursing care.
comlZeeaPcTonsfr°m
and SUPerViSl°" r°u"ds °f a“
"-ds
nUrSin9 SUpervisors and ana|yse them for any
H'9^
Organise in-service education programme and orientation to new staff.
•
eZnmeT916 SUPP'y °f ^h^9 materialS and ensure clea"li"ess of hospitals and
environment.
and HIV ete.the Pr°Per diSP°Sal °f h°Spital WaSte esPecial|y in relation to Hepatitis
Prepare budget for the nursing services in collaboration with the other staff.
•
Sanction casual leave arrangements for warned leave and days off etc. for ????
•
Conduct the following activities for school of nursing attached to the hospital
' we^XS'S"'0" °f "UrSeS'
and attend t0 the
Counsel and guide the staff members and ensure discipline at nurses' hostel.
heaHXkup03"6 °f StUdent nUrSeS dUrin9 "lneSS and arrange for regular
■
•
Assist school of nursing in selection of student nurses.
Arrange for teaching programme, practical experience and
examinations in
collaboration with the School of nursing.
Responsible for maintaining attendance
register, leave register, duty rosters and
health records of the staff members.
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JOB TITLE:
SENIOR PHARMACIST
REPORTS TO:
Chief Pharmacist
Administrative Medical Officer / Resident Medical Officer
IMMEDIATE LEVEL SUBORDINATES
• Junior Pharmacist
DUTIES, RESPONSIBILITIES AND AUTHORITIES
•
Responsible for Main stores, Sub-Stores, Dispensary and I.V. Fluid sections.
•
To ensure preparation and updation of the indents, day book of receipts issue
register, inventory stock book. Bin card, expiry date register, drug sampling,
statistical data of demand and supply of drugs and test reports and inspection book
at mam stores, sub-stores, dispensary and LV.Fluid manufacturing section.
•
To verify in random the items received in respect to order placed, label specification
volume/weight/measurement with respect to label claims and for consistency.
To carry out qualitative simple physico - chemical tests to ascertain the quality of
drugs and maintain a record of such works and submit his observations to the Chief
testsmaCiSt/ RM° AM° and alS° aboiJt such drugs failing t0 Pass the qualitative
•
To maintain the stores in clean and hygenic conditions.
To keep all Poisonous drugs, expensive drugs, narcotic and psychotrophic drugs
separately under lock and key as per technically viable administrative directions.
Responsible for preparation of annual expenditure programme within the budget
allocations and needs of the hospital.
•
Responsible for disposal of expired drugs.
•
T?/
Shief Pharmacist/Graduate Pharmacist in manufacturing and testing of
Tv.Fluid including animal house maintenance.
mixutres and formulations and dispense the drugs as prescribed by
the Medical Officer.
7
•
To participate in various Health education programmes of the institution and in the
therapeutic assessment of quality of drugs in the hospital.
•
To attend to emergencies in the absence of Medical officer in
rendering first aid and
common ailments.
•
Tf m's.pen,seAhe 0PD drugs f°r common ailments without prescription in the absence
or Medical officer in-charge.
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DISTRICT HEALTH AND FAMILY PLANNING OFFICER,
a. He will be in overall charge of all the Family Planning activities in the district, in
addition to the other Health programmes.
Responsible Administratively and
technically to the Director of Health & FP. Services and state Family Planning Officer.
b. In consultation with the M.O.H.F. (FP & MCH) he will draw up advance annual and
monthly programmes in order to achieve the targets fixed.
c. He will visit the IUD and Sterilisation camps and satisfy himself that proper
arrangements are made.
d. He will see that timely action is taken by the M.O.H. (Family Planning & MCH)
regarding stocking and distribution of supplies and equipment.
e. He will be responsible for the proper use of all the departmental vehicles for the
Family Planning Programme without hindering the programmes for which the
vehicles are allotted.
f. During his visits to the various Primary Health Centres apart from paying attention to
various other schemes, he will pay particular attention to the Family Planning
Programme to see that progress of work is achieved and to take action against such
of those who are slake, with a view to gear up the work.
g. He will be responsible to arrange for one of the senior members of his staff namely
Asst. Director Health Officer, Medical Officer of Health (FP), District Extension
Educator, Health Supervisor or District Nursing Supervisor to attend the monthly
conference of each primary Health Centre and review the physical progress
achieved.
h. He will arrange a quarterly conference of all Medical Officers under his control and
review the progress of the Family Planning Programme.
i. He will be responsible to see that the required reports are sent to the State Family
Planning Bureau every month before the due date.
j. I connection with the Medical Officer of Health (FP & MCH) he will arrange job
orientation training for the peripheral staff.
k. He will be responsible for the random check up of atleast 5% of persons who have
IUD placements or sterlisation operations done in the district by Government
Institutions). Voluntary organisation and Private practitioners to ensure that the
incentives are not misused, and that proper follows up has been ensured.
l. He will have full control of his annual budget and will be responsible for expenditure
therefore within his powers without recourse to higher authorities thus ensuring that
the budget provisions do not lapse.
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GOVERNMENT OF KARNATAKA
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TASK FORCE ON HEALTH AND FAMILY WELFARE
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A Commissioned Research Study
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0 REVIEW OF EXTERNALLY AIDED PROJECTS IN THE CONTEXT OF
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THEIR INTEGRATION INTO THE HEALTH SERVICE DELIVERY IN
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KARNATAKA
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By
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Dr. Ravi Narayan
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Community Health Cell
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367,1st
Main, Jakkasandra
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Koramangala, Bangalore - 34
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I33
List
A - Introduction
1
B - General Description of Externally Aided Projects (EAP’s)
4
C - Project Goals, Focus and Distribution
7
D - Overview of Programmes and Activities
15
E - Overall Strengths and Weaknesses of EAP’s
17
F - Lessons from some Case Studies
26
G - Some Policy Imperatives Including Integration and
Sustainability
30
H - Some Reflections on Financial / Economic Implication of
EAP’s
38
I — General policy concerns : Are we reinventing the wheel ?
43
J — Final Conclusions and Recommendations from a future
policy point of view
46
K - Limitations of the Review Exercise
50
L -- Acknowledgements
51
M —Bibliography
52
V.
N — Tables
I Externally Aided Projects - General Description
II Objectives / Focus / Regional Distribution
III Programmes and Activities by - Review of Budget Heading
IV Some Strengths and Weaknesses
5
8
15a
19
O - Case Studies
A. Training Experience in a Northern District
B. An Urban Health Centre
P — Appendices
i)
ii)
Project Proposal
Some issues and questions addressed in the review and
A conceptual framework for review - Diagrammatic
presentation.
!3^
27
29
PROJECT REPORT: Review of Externally - Aided - Projects (EAPs) in the
context of their integration into Health Service Delivery
in Karnataka.
A: Introduction
Since the early 1970’s the Karnataka Government has negotiated and received
various grants and loans from international funding agencies, including the World
Bank, for health related projects that supported the growth and strengthening of
primary and secondary health care services in the state. These externally aided
projects have had their own particular focus; objectives; framework; operational
strategies; and management information systems geared to support and or enhance
both quantitatively and qualitatively, different aspects of Health Sector
Development in the state. Each of them has their own cycles of mid-term reviews
and concurrent reviews. The Human Development in Karnataka Report 1999
described five of these (see box).
Currently there are however atleast ten major externally aided health projects in the
state- IPP VIII, IPP IX, KHSDP, OPEC, KfW, RCH, RNTCP, NACO, NLEP,
DAN-PCB being implemented through the Government and Directorate of Health
and Family Welfare Services. In addition UNICEF has provided project support to
different health related sectors including Child Development and Nutrition; Water
and Environmental Sanitation; Education; Child Protection; Communications and
Strategic Monitoring. For the purpose of this Review all UNICEF Projects have
been taken together as one and NLEP has been left out for unavoidable reasons.
Health related externally aided projects, e.g. for nutrition, water supply and
sanitation, implemented through other departments are not included under the scope
of this review.
The Karnataka Task Force in Health, while reviewing these projects in their
interactive and informal discussions and deliberations have raised some important
questions for review and enquiry:
i)
ii)
iii)
What are the learning points from each of these projects?
How can they be integrated into the health system incorporating beneficial
points and avoiding distortions.
What has been their experience concerning issues of sustainability,
accountability and transparency.
In the late 1990’s, policy researchers, academicians and decision-makers have also
begun to seriously review the “piecemeal pursuit of separately financed projects” as
against The evolving options of more appropriate sector wide approaches’. This is
linked to the growing recognition of some of the problems associated with single
133
t
u
Important externally assisted health projects
Karnataka Health Systems
Development Project
(KHSDP)
Kreditanstalt fur
Wiederaufbau (KfW)
India Population project
(IPP) VIII
India Population project
(IPP) IX
Reproductive and Child
Health Services (RCH)
Project
The Karnataka Health System Development Project is proposed to be
implemented over five years (1996-2001) with assistance from the
World Bank.
Its main objectives are improvement in the
performance and quality of health care services at the subdistrict and
district levels, narrowing current coverage gaps and improving
efficiency.
Major components include improvement of the
institutional policy framework, strengthening implementation
capacity, development of a surveillance system, extension and
renovation of all secondary level hospitals, improvement of their
clinical effectiveness and establishment of a properly functioning
referral system. The project outlay is Rs. 546 crores.______________
The KfW of Germany is financially assisting a project in the four
districts of Gulbarga division with objectives similar to those of the
KHSDP. The project outlay is Rs.59 crores of which 90% is being
provided by KfW as a grant. The project was launched in 1998._____
IPP VIII is being implemented in the slums of Bangalore since 199394 with World Bank assistance. Major objectives are improvement in
maternal and child health and reduction of fertility among the urban
poor.
Strategies adopted include involving the community,
improving the quality of services provided by the City Corporation,
strengthening existing delivery services, establishing new facilities
and providing services at the doorsteps of the urban poor. The
project cost is Rs.39 crores.___________________________________
This is the fourth in the series of India Population projects following
IPP I and IPP III. The project is under implementation since 1994 in
13 districts. The main objectives are reduction in the crude birth and
death rates as well as the infant and maternal mortality rates and
increase in the couple protection rate. Strategies adopted include the
promotion, strengthening and delivery of services through the
involvement of the community and improvement in the quality of
services by providing training and strengthening the monitoring and
evaluation systems. The project outlay is Rs. 122 crores.___________
The Reproductive and child Health Services Project marks a change
in the existing culture of achieving targets by shifting to a policy of
provision of quality services. The project helps clients meet their
own health and family planning needs through the full range of
family planning services. It is a natural expansion of the earlier child
survival and safe motherhood programme which was under
implementation till 1996.
It also includes the treatment of
reproductive tract infections, sexually transmitted infections and the
prevention of AIDS. All the districts of the state are proposed to be
covered under the project.
The budget for RCH project for five years (1997-98 to 2002-03) is
Rs. 190 crores.
Source : Human Development in Karnataka - 1999
1-^-0
focus sector project assistance, which include:
• Fragmentation;
• Conflict and or duplication;
• Donor driven agendas;
• Recurrent operational costs;
• Undermining of national capacities,
• Lack of flexibility,
• Varying standards of provisions, and
• Issues of ownership.
This short-term interactive review has been undertaken to explore some of these
issues and address these concerns in the context of the Task Force recommendations
for the Health Sector development policy for the state.
Within the time constraints, the researchers have tried to achieve the following:
a)
Review all the externally aided projects not just individually but in their
collective context reviewing available documentation as well as interacting
with programme managers.
b)
Using a SWOT approach, trying to identify the key strengths, weaknesses as
well as opportunities and threats (distortions) from all these projects.
c)
Trying to do this review in such a way so that the stakes of programme
managers and hopefully the Health Directorate to learn from project
experience and address seriously the concerns and issues of sustainability
and integration are enhanced especially by improving in-house capacity and
system development.
(See Appendix ”A" for Project protocol and issues and questions to be addressed.)
IM
B: General Description of EAP's
Table I shows the 10 EAPS included in the review. From the table the following
key general observations on EAP's in Karnataka can be made.
1. Number
•
There are ten EAP's which contribute to the Health Service Delivery in the state.
(NLEP has not been included in the review fully).
2. Programmes / Projects
•
While some are state components of GOI programmes (RCH, RNTCP, NPCB,
KSAPS, UNICEF); others are state level projects (eg. KHSDP, IPP - VIII,
IPP - IX, KfW, and OPEC)
3. World Bank : Main player
•
While UNICEF and DANIDA have been long standing partners since 1970’s the
World Bank has become the key partner now supporting six out of the ten
projects (this is particularly so since the 1990's) and there is reason to believe
that since the World Bank takes over as the key player the other funding partners
are getting some what sidelined or ignored.
4. Grant to Loans in the 1990’s
•
While the earlier bilateral donors were providing grants like UNICEF and
DANIDA, the trend in the 1990’s has increasingly moved towards more loan
component in the projects with varied interest rates and associated
conditionalities. The World Bank support being mainly in this category it is
therefore even more important today to ensure that these funds are utilized
efficiently with greater accountability and transparency since if they were
misutilised then we would have the double problem of ineffective utilization
coupled with a debt burden.
•
The German government (KfW) and the Organisation for Petroleum Exporting
Countries through the OPEC fund have joined World Bank in supporting
primarily infrastructure development. The former is a grant and the latter is a
soft loan to be paid over a twelve year period after a five year initial gap.
5. Stand alone
• DEach of these projects are relatively distinct entities with clear cut objectives,
framework, programmes and though they have to be complementary or
supplementary to each other due to overlap at the field level (similar districts,
health centres, health teams) this is not at all emphasized in the project reports or
Mot
d
built into their outlines. There is a fair degree of compartmentalization and
hence they mostly stand alone with little dialogue between projects and seldom
visualized as smaller components of a larger strategic plan. Even though
presently the KfW project utilizes the engineering division and other resources
from KHSDP, this linkage was not originally planned and took place only
because the ZP engineering divisions envisaged to make decentralised decisions
could not maintain requisite standards.
TABLE -1
Externally Aided Projects in Health Service Delivery in Karnataka
GENERAL DESCRIPTION
S.No / Name
India Population
Project
IPP VIII
(Family welfare - urban
slums project)
1.
2.
India Population
Project
IPP IX
Year of
Starting
1993-94
1994
(Strengthening of Family
welfare and MCH services)
3. Karnataka Health
Systems Development
Project (KHSDP)
1996
4. Kreditanstalt fur
Wiederaufbau(KfW)
1998
Main Source of Funds*
World Bank
a. Improvement in MCH
& Fertility Reduction in
Bangalore's urban slums
b. Extended to 11 cities
and towns due to savings
and differences in
Foreign exchange
conversion rates.______
World Bank
Reduction in CDR/ CBR
& IMR in Rural areas
through PHC Strategy.
(13 Districts)
Total Project
Size**
39 Crores
(387.2million)
Part Loan / Part
Grant
122 Crores
(1220.9million)
Part Loan / Part
Grant
World Bank
Improvement of Quality
and Performances of
Health care at District
and subdistrict level
546 Crores
(109 per year)
Part Loan / Part
Grant
KfW of Germany
Improvement of Quality
and Performance of
Health care at District
and subdistrict level
(Gulbarga Division 5
backward districts)
59 Crores
( 0.38 million
DM)
Grant
Period
1993-2001
(in phases)
Launched in
1994
1996 -2001
5 yrs
Launched in
1998
S.No / Name
5. Organisation of
Petroleum Exporting
Countries Fund for
International Development
(OPEC)________________
6. Reproductive and Child
Health Services (RCH)
Project
Year of
Starting
1991
1997
Main Source of Funds
OPEC Fund
350 Bed Multi specialty
hospital in Raichur.
World Bank
Improving Quality of
Family Welfare Services
Total Project
_____ Size
29.25 Crores
(OPEC - 90%
25.7 crores)
Soft loan
190 crores
38 crores/year.
Part Loan / Part
Grant_________
7 Crores
(2000-01)
Part Loan / Part
Grant
Period
Agreement
in 1991
1997-98 2003
1999-2004
7. Karnataka States AIDS
Control
(Karnataka State AIDS
Prevention society)
1999
World Bank
Reducing the rate of
growth of HIV infection
in the state and in
strengthening the states
capacity to respond to
HIV/ AIDS
8. Revised National TB
control programme
(RNTCP)
1994
World Bank
Supporting new
approaches to effective
TB control in state using
SCC/ DOTS and other
components.
Phase III
18.3 Crores
Part Loan / Part
Grant
1994Neelasandra
1998
Entire
Bangalore
corporation
1996 Chitradurga
Bellary
Raichur
Bijapur
1999Davangere
Koppal
Bagalkote
9. National Programme for
control of blindness
(DANPCB) now NPCB - K
1990
DANIDA
To reduce prevention
of blindness from 1.4%
to 0.3% by 2000 AD
3 Crores
30 million
Grant
Till 2001
10. UNICEF-GOK
Programme of Cooperation
in 2001.
1970's
UNICEF
To promote
comprehensive and
holistic survival, growth
and development of
children in the state
6.3383 Crores
(2001)
Grant
UNICEF
has
been
supporting
concurrently
since 70’s.
*
All these projects have a contribution from state or central government
respectively.
** See Table V and VI for further details.
ItA-
h
C: Project Goals, Focus and Distribution of EAP’s
A perusal of Table II on the project goals, focus and distribution helps to identify
certain significant trends.
1. Primary Vs Secondary
•
7 out of 10 projects support Primary Health care level while 3 out of 10
projects support secondary care level (one of three also support Tertiary
care).
•
If the project costs / budgets are taken into account as a sign of priority or
emphasis then only thirty three percent (386 crores) is on primary care and
sixty six percent (634 crores) focussed on secondary and tertiary care.
(Using project size as a general indicator)
2. Comprehensive Vs Selective
•
Within the Primary Health Care group two of the projects IPP IX and
UNICEF are more comprehensive in their design focussed on 'Urban and
Rural' primary health care and child health (and social development)
respectively, but the remaining five are more selective primary health care
strategies with RCH being a slightly more composite package and the
remaining three being focussed vertically on single disease problem of
AIDS, TB, and Cataract Blindness.
3. Population agenda
•
> 7^'
4
I
Even IPP VIII and IPP IX are strongly driven by the Family planning or
population agenda with health needs other than fertility related, getting much
less focus.
4. Diversity and overlap
•
When the objectives and goals of these EAP's are reviewed collectively then the
following observations can be made (refer Table II)
Each project is relatively multidimensional with different components
and strategies. At the implementation level some components get more
emphasized than others.
The objectives vary from very general ones to very specific outcome
oriented ones as seen in AIDS, TB, and Blindness control.
7
J
TABLE - II
Externally Aided Projects in Health Service Delivery Karnataka
OBJECTIVES/ FOCUS / REGIONAL DISTRIBUTION
S.No/ Name
1. IPP VIII
2. IPP IX
Objectives/ Goals
• Delivery of FW &
MCH to urban poor
and promote CS & SM.
• Reduce Fertility
rate and promote late
marriages.
• Promote male
participation in FP.
• Awareness and
action for personal
hygiene, better
environment and
prevention of diseases
• Non Formal
Education (NFE) and
vocational training for
women
• Promote Female
Education
Focus
• Urban Poor /
Selective Primary
Health Care focussed on
FW+MCH+CSSM+
• Implement a
program sustainable at
village level to reduce
CBR, IMR and MMR
and increase CPR
(Couple protection rate)
through
• Involve community
in promoting delivery of
family welfare services.
• Strengthen delivery
of services by support
to drugs, kits, supplies
to TBA's SC and PHC,
mobility of ANM's;
buildings of center and
residential
accommodation.
• Training to
Personnel and TBA's,
Community leaders and
voluntary workers.
• Strengthen
Monitoring and
evaluation by MIES
(from district to state
level)
• Rural
(Family welfare
and MCH)
Primary Health care
Focus
Regional Distribution
Bangalore urban slums.
• 0.851 million
population of urban poor in
about 500 slums in an area
of 225 sq. kms.
• Civil works Focus
Bellary, Chickmaglur,
Dakshina karmada, Hassan,
Kodagu, Mandya, Mysore,
Uttar karmada, Shimoga,
Chitradurga, Belgaum,
Bijapur, Gulbarga
• IEC / MIES Focus
In all districts
1-^6
S.No/ Name
3. KHSDP
________ Focus
Objectives/ Goals
• Secondary level
• Improvement
health
care
in performance and
Quality of Health
Care services at District - To provide critical
support to PHC Networks
and Subdistrict level
• Narrowing
- Establish essential
the current
linkages with tertiary
coverage gaps by
level.
facilitating access
to health care delivery.
• Achievement of
better efficiency in
the allocation and use of
health resources.
By
-Strengthening
implementation
capacity.
- Strengthening delivery
of service.
- Improving
functioning of referral.
- Establishing effective
surveillance system.
- Improvement
of cost recovery
mechanisms.
- Improving access to
disadvantaged
sections SC/ST/women
Regional Distribution
• Renovating = 70
CHC- 14
Taluk Hospital - 34
Sub Dist HQ Hospital - 9
District Hospital - 6
Women & Children
Hospital - 5
Epidemic Diseases
Hospital - 2
• Extending =131
CHC - 28
Taluk Hospital - 71
Sub Dist. HQ. Hospital - 16
District Hospital - 9
Women & Children
Hospital - 6
Epidemic Diseases
Hospital - 1
Grand Total = 201
S.No/ Name
4. KfW
5. OPEC
6. RCH
Objectives/ Goals
• Significant
Improvement in the
Health status of socio
economic backward
region / state.
• Setting up a
Comprehensive referral
system in the division
through strengthening
and
revamping
secondary hospital
network.
• Sustainability of
Infrastructure and
Equipment.
• Increase
Sustainability of
Health care.
________ Focus______
• Secondary level
Gulbarga district.
(Northern disadvantaged
districts)
• To build a 350 bed
multi speciality hospital
which will cater to
Raichur District and
four districts around.
(Med/Surg/ENT/ ortho
Physiotherapy,
Cardiology /
Cardiothoracic,
Ophthal, Dental,
Nephrology, Urology,
Burns wards,
Gastroenterology,
Biochem, Path,
Microbiology
Radiology and CSSD).
• Secondary and
Tertiary health care
• To meet individual
client health and family
planning needs and to
provide high quality
services through a
gender sensitive and
responsive client based
approach.
• Aim to reduce the
burden of unplanned
and unwanted child
bearing and related
mortality and morbidity
• Reducing 'unmet
need' increasing 'service
coverage' ensuring
quality of care.
Regional Distribution
• Gulbarga Division
Bidar
- 6 hospitals
Bellary - 10
Gulbarga - 18
Raichur - 13
47 hospitals
Renovation
and upgradation of
facility.
Improvement
Maintenance
26 in Phase One
21 in Phase Two
of
Improving
Sustainability through
fee collection.
• Old District hospital
will remain as a women
and children hospital with
skin, psychiatry, Leprosy
and TB (250 beds)
• Selective Primary
Health Care with focus on
Reproductive and child
health.
• Prevention and
Management of unwanted
pregnancies.
• Maternal care
- Antenatal
- Natal
- Post natal
- Child survival
- Treatment of
Reproductive tract
infections and STDs.
• Raichur - / Gulbarga,
Bidar, Gadag, Bijapur (and
some neighbouring districts
of AP will be benefited.
•
•
1 All districts in 3 years.
Districts categorized
into A, B, C category
A = better off
B = average
C = weaker
1st year = 9 District
A2, B1,C3
2nd year = 8 Districts
Al, B4, C3
3rd year = 3 Districts
B3
(Rationale of selecting
districts not clear).
I
S.No/ Name
7. KSAPS
Objectives/ Goals
• To assist state in
reducing the rate of
growth of HIV infection
and strengthen capacity
to respond to HIV /
AIDS on a long term
basis.
This includes:
- Delivering cost
effective prevention
against HIV / AIDS
- Promotive intervention
for general community.
- Low cost AIDS care.
- Institutional
strengthening.
- Intersectoral
coordination.
________ Focus_______
• Selective Primary
Health Care /AIDS / HIV
Control
- Surveillance and clinical
Management.
- Sentinel Surveillance
- Blood.safety
programme.
- STD control
-IEC
- NGO coordination
- Training programmes
Regional Distribution
• 14 sentinel sites in 10
districts
• 25 NGO's in 9 districts
(15/25 in Bangalore)
• 3G STD clinics in 21
districts.
8. RNTCP
• Detect atleast 70%
of estimated incidence
of smear - positive
cases through quality
sputum microscopy.
• Administer
standardized SCC
under DOT during
intensive phase and
quality supervision
during continuation
phase.
• Achieve 85% cure
rate among all newly
detected sputum
positive cases.
Selective Primary Health
Care including
• Strengthening and
reorganizing state TB
control unit.
• Rigorous method for
detection treatment and
monitoring.
• Strengthening
training research capacity
• Targeting smear
Positive cases.
• SCC with DOT
• Decentralizing
service delivery to
Periphery
•
Rigorous system of
patient recording and
Monitoring.
• Initially Bangalore
Urban only Now 7 districts
of Chitradurga, Bellary,
Raichur, Bijapur, Mandya,
Bangalore urban (excluding
BCC area)
I
i
S.No/ Name
9. DANPCB
Now NPCB-K
10. UNICEFGOK
Objectives/ Goals
Reduction in the
prevalence of cataract
blindness from 1.4% to
0.3% by 2000 AD
• To promote
comprehensive and
holistic survival, growth
and development of
children in state through
- Improved new born
care.
- Development
protection and early
stimulation of
vulnerable 0-3 years.
- Enjoyable and quality
education for pre
school and primary
level.
- Access to clean water
and sanitary
environment.
- Protection from child
labour.
- Improved Nutritional
status.
- Better child care
practices.
________ Focus________
- Selective Primary
Health Care and
Secondary care.
- State Opthalmic Cell
- Upgradation of Medical
colleges, District
hospitals, Taluk
hospitals, mobile units
and PHC's
- Eye Bank
- Training of surgeons and
ophth assistants.
- District Blindness
control societies.
- Cataract surgeries
- Microplanning
IEC, MIS, SES
- Multidimensional child
health care and social
development. (Primary
Health care)
• Community,
convergent action (CCA)
• Health Action
• Child Development
and Nutrition.
• Water and
Environmental Sanitation.
• Education
• Child Protection
(Sericulture and Bonded
labour)
• Communication and
strategic planning.
15b
Regional Distribution
Focus on all districts in all
divisions.
(Performance very good in
Bangalore urban Udupi,
Bagalkot, Dharwar,
Gulbarga.
Very poor in Chitradurga,
Chamrajnagar, Kodagu,
Gadag, Haveri, Belgaum,
Bijapur, Davangere).
• Different Districts
• CCA - Mysore,
Chitradurga, Gulbarga
and Raichur.
• Health - Bidar, Raichur,
Gulbarga and Bijapur.
• School sanitation
Mysore, Tumkur,
Chitradurga. and Raichur
• Other Activities
In all districts
There is overlap between projects in different areas e.g
• IPP IX and RCH have fair degree of overlap
• Training overlaps in many of them, (see also case study)
• Also IEC and MIS
• Surveillance and Health Management Systems especially since
they often focus on same districts, same categories and same
health centres and teams. (This will be considered again later).
5. Equity Focus
•
The focus on disadvantaged or marginal groups in the community varies from
explicit to ambiguous. In IPP VIII (Urban poor) and KHSDP (disadvantaged
sections /ST/SC/women) it is more explicit while in all the others it is
ambiguous, mostly with a sort of 'reaching all' focus. In RCH there is specific
reference to 'Gender sensitivity' and in UNICEF's programmes focus on 'child
labour' is emphasized, which are significant.
•
In terms of addressing Regional disparities in health structures and systems in
the state, EAP’s have a very varied contribution
KfW and OPEC are specifically focussed on the disadvantaged
Northern Karnataka (Gulbarga Division), though the donor decided
this focus in the latter loan, not the state.
IPP VIII is focussed on urban poor in Bangalore being the largest
urban conglomeration in the state though in the next phase other
cities and towns are being covered.
KHSDP, KSAPS, NPCB-K focus more widely.
Others like IPP IX, RCH, RNTCP and UNICEF do focus selectively
on some districts more than others for different components, but
while the disadvantaged Northern Districts of Karnataka do get
included quite often, the focus is not based on data for regional
disparities or need, but seem more adhoc, responding to more
extraneous pulls and pushes for selection including districts
patronized by politicians or other ‘lobbies’ or other such non
technical reasons.
6. Local and National Agendas
• OFinally except OPEC and KfW which are only Karnataka determined and
focussed; and KHSDP which is Karnataka focussed but has counter parts in
Punjab, West Bengal and now Orissa; all the other projects are similar to those
promoted by the funding agencies in other states as well. Many like RNTCP,
AIDS, NPCB-K, perhaps even RCH and IPP IX are evolved as framework /
1^-
073bS
packages at National level and then offered to the state as a ‘fixed package deal’.
Sometimes the state directorate and experts have tried to modify or review these
national level prescriptions and tried to adapt them to state level realities but by
and large this process of adaptation is rather weak and adhoc.
• DHowever while the sense of ownership by the state was very strong in KHSDP /
OPEC / IPP VIII it was relatively much less in the others and very little perhaps
in RCH which showed absence of stakes in planning and formulation.
Incidentally in IPP VIII especially in the sector of innovative schemes there are
different approaches and schemes being tried out in Bangalore, Hyderabad,
Delhi and Calcutta - a diversity which was both welcome and significantly
different from the usual ‘central top down’ prescribed packages.
•
Regional disparities between states and within states are so stark that greater
emphasis on District level planning in the context of local socioepidemiological evidence and situation analysis is an important policy
imperative. EAP’s could well be an instrument to experiment with such diversity
of approaches.
•
SI. i
Noi
Status of Bank Group Operations in India (March 31,1999)
Original Amount with USS (Millions)
Project
Fiscal IBRDi IDA Cancel i
Un
year
disbursed
I
Develop Implemental
Obj
Projects
t-----------
l'iPop^ionW’^-PE^9963)'' 1992
f'19‘93
|
21 National Leprosy Elimination
i(INPE-10424) *
31 Karnataka Water Supply and
iEnvironment Sanitation
i(IN-PE-10418) *
i993
I 1994"]"
4!Population (IN-PE-10457) *
SlBlindness Control (TN-PE-id455) | 1994 I
9707
92.00
.I---------- 1
i 88.60!
T'117’80!
'55.86
S
”"24.'7‘r" " " S
S
31.64
S
8
1
50.16
S
s
81.38
S
S
!
263.11
S
S
■233716’
S'
'8
152.45
S
S
I
■--------------------------------------------------------- 1
61 State Health System II
[(INPE-35825) *
71Reproductive Health
J(IN-PE-10531) *
8iMalaria Control (IN-PE-I OSi i) *
■"■79.00'
””‘85.0'67
I 1996 i
Tsso
’ootI
I
i 1997 I
1'248'30 ’
[T997'T'
9
ITuberculosis Control (IN-PEQiTuberculosis
-!---------1 1997 I
110473)*
|
J
164.80
142'46't
4
128.63
S - Satisfactory, U - Unsatisfactory and HS - Highly {Satisfactory
Note: This table is not specific to Karnataka but is an overview of the All India situation. Projects
which are relevant to Karnataka are shown by an asterisk.
Source: Report No. 18918-1 N Project Appraisal Document May 13 1999.
I
U
U
I
D: Overview of Programmes and Activities
•
Table III provides an overview of the overall focus of the programmes and
activities using budget headings including special programmes and allotments.
About 34 components were identified of which 13 were the commonest in all
the 9 projects (UNICEF was excluded in this table). These were
6 and more than 6 out of 9
Construction;
Furniture;
Equipments;
Drugs and supplies;
Local training;
Local Consultancies;
Maintenance of Vehicles and Equipment;
Contingencies.
4 and less than 6 out of 9
Staff salaries
Vehicles
Management Information System (MIS)
Information - Education - Communication (IEC)
Project management
NGO support.
Hardware over Software
The main focus of most of these have been hardcore infrastructure development
(Buildings, Equipment, Vehicles etc) and though software- like training, IEC, MIS
and NGO support were included and envisaged, at the operational level, hardware
always got greater focus than software. Also hardware was seen as absolute
necessity so often as in IPP IX and KHSDP, constructions were focussed upon
rather than initiating some of the software using locally available facilities and
resources concurrently. Also hardware investment was substantial and needed
greater supervision and control distracting from software development which
however is probably more important if long term sustainability is to be thought off.
Inadequate quality improvement focus
Another feature of the overview findings are that some elements which contribute to
improving quality especially at operational or performance level were not always
included in the project design and cost allotments.
0
These included
Provision for books and training materials;
Training material development;
-153
/fT
Innovative schemes;
Revolving funds;
Evaluation studies;
Documentation.
Very few projects had them as special allotments. No doubt some may have spent
on these items under other budget heads but allotment of a budget need for any
programme activity is definitely a sign of priority or significance.
Equity focus
Finally special focus on poor, disadvantaged and on women was mentioned in many
projects but only in IPP VIII and KHSDP were their specific programmatic
allotments for women orientation and involvement (IPP VIII and KHSDP) and for
safety net for the disadvantaged (KHSDP). Only a special allotment can ensure that
the thrust is part of operational policy.
Additional items
However since there were variations in the focus of the health problems addressed
by different projects specific allotments for specific additional themes were
observed. These included waste handling (KHSDP); Blood safety and voluntary
testing and counseling (KSAPS); Adolescent Health (RCH); School Health
(NPCB-K) all very important and significant. Some elements like school as a focus
of health activity should be a compulsory component of all health projects because
preparing / orienting future citizens is a policy imperative.
Learning from previous experience and each other
—?
While UNICEF schemes were not included in the table their allotment to a range of
themes around child health exemplified a much more holistic; practical and
operational approach. The programme highlights included convergent community
action; border cluster strategy for MCH and ICMI (Integrated Management of
Childhood Illness); Child development and nutrition; Water and environmental
sanitation; Janashala, programme jdiild labour protection; HIV / AIDS prevention
activities, etc.
NB: It is unfortunate that UNICEF’s longer experience of moving from
‘biomedically defined technological approaches’ to more 'holistic initiatives
responding to broader socio-economic cultural realities' has been totally ignored and
World Bank's 'selective prescriptions and initiatives' allowed to distort health
planning and in many cases leading to a reinventing of the wheel. Dialogue
between project funders and building on past experiences is crucial otherwise EAP’s
could be a wasteful distortion and also being ‘loans’ rather than 'grants' could be
wastefully counter productive.
15^
J
E : Overall Strengths and Weaknesses of EAP’s
Table IV lists out the key strengths and weaknesses of different programmes as
identified by literature review and endorsed by interactive discussions. They vary
from programme to programme and cover wide range of sectors and issues.
Strengths
Taken as a composite group the key strengths of these projects are:
1. Infrastructure development
They have focussed primarily on infrastructure development, which includes
buildings for hospitals and health centres, operation theatres, staff quarters etc.
While these were necessary since the directorate had not invested in adequate
maintenance of existing infrastructure nor invested in adequate construction to fill
up the lacunae in the past, the demands of infrastructure often have tended to
overshadow all aspects of the project.
2. Support field action
In the situation when programme action budgets are shrinking with salaries taking
over greater and greater percentage these projects help to promote specific action
components and field activities.
3. Framework of strategy : planning capacity enhanced
Conceptually whether primary or secondary, comprehensive or selective, many of
these projects have led to generation of some framework of strategy and action and
have been supported by a degree of background homework. Though the data base is
often patchy it is better than some of the adhoc decisions in the past which were
often repetitive without adequate evidence or data. Project formulation including
setting objectives; outlining strategies; identifying action plans; identifying outcome
and impact indicators and benchmarks all have helped build planning capacity even
though the compartmentalization causes overlap and some distortions.
4. Innovations
Project autonomy, which is relative has allowed many innovations to be
experimented with, which is a change from the routine generalized top down
prescriptions thrust on the whole system in different districts uniformly and at all
levels in the past. All the innovations cannot be listed out here but from the table
some of them need to be highlighted. These are
a. Link workers (IPPVIII)
b. Women’s clubs (SHE clubs) - IPP VIII
c. Gender sensitivity and women’s orientation - IPP VIII
L
d.. Herbal gardens - IPP VIII
e. Help desks and Boards of visitors - IPP VIII
f. Tribal ANM training - IPP IX
g- Partnership with NGOs to run centres, (IPP VIII, IPP IX, RCH and KSAPs)
h. Special interventions for disadvantaged - yellow card, KHSDP
i. Comprehensive MIS being evolved - KHSDP
j- Improvement of referral links - KHSDP
k. Good mechanisms for construction and supervision - KHSDP
l. Efforts at quality improvement (IPP VIII, KHSDP)
m.. Focus on women specific and budget heading (KHSDP)
n. Decentralization of accounts (KfW)
o. Focus on Northern disadvantaged districts (KfW, OPEC, RCH, UNICEF)
P- Links with Literacy campaign (RCH)
q- Focus on adolescent age group (RCH)
r. Partnership with private sector - some contract services (KHSDP)
s. Involvement of Medical colleges (RCH, UNICEF)
t. Newsletters (KHSDP)
Many more may be there but these are a representative sample. However there
seemed little effort at documenting these ‘innovations’ and even less on monitoring
or evaluating them in any sort of methodical or rigorous way. It is important to
ensure that they add value in quality and efficiency to the existing PHC option
programme before they get adopted by the whole system as an added innovation..
This element of operational research was significantly absent.
Weaknesses
The key overall weaknesses of EAPs were
1. Overemphasis on infrastructure
While focus on infrastructural development was a strength as pointed out earlier, it
also tended to overshadow all the so called ‘software’ or action / programmatic
components.
2. In house Planning Capacity not enhanced
Many of the projects used external consultants who helped to improve project
planning capacity but this did not necessarily get internalised in to the existing
health system.
-1^6
M
TABLE -IV
Externally Aided Projects in Health Service Delivery in Karnataka
SOME STRENGTHS AND WEAKNESSES
S.No/EAP
1. IPP VIII
___________ Strengths_________
• Comprehensive Conceptual
Framework
(Family Welfare, MCH, CSSM
Water supply and sanitation
Education, Community
Development).
• Involvement of Community
through Link Workers, Women's
clubs (SHE clubs) (Social Health
and Environment) etc.
• Establishing creches, NFE and
Vocational training.
• Involvement of NGOs
• Gender sensitivity and women
orientation
• Flexibility e.g. different
innovative schemes in Bangalore,
Calcutta, Delhi and Hyderabad.
• Social paradigm awareness
stronger at all levels.
• Operational guidelines for
most aspects of project quite good.
• Some good practices:
- Help desks in centres.
- Herbal gardens in all
- Overall morale and
discipline of staff good.
- Contract for cleaning /
security efficient
- Board of visitors.
- NGO participation.
• Citizens charter
• Slum based centre (more
accessible)
• Human Resource Development.
1^4
____________ Weaknesses__________
• Focus on Family Welfare
predominant other programmes present
but adhoc and not adequately integrated
perhaps even inconsistent. (Need to
actively convert from FWC to urban
Primary Health care centre).
• Long term sustainability especially
regularization of centre staff not
adequately addressed.
• Partnership and Liaison of project
team with Corporation Health Centres
problematic (ownership by corporation
inadequate)
• IEC more material preparation than
field use.
• Orientation and motivation of
Doctors not maintained after initial
training (need for more problem solving
sessions)
• Many innovative schemes built upon
but not in a sustained way.
• Involvement of NGO's and
community and G Ps patchy. Not
adequately evaluated or monitored.
• Lab facilities and services to be
improved.
\l
S.No/EAP
2. IPPIX
____________ Strengths___________ ____________ Weaknesses___________
• Hardware(civil works)
• Focus on rural Primary Health
Moved better than software.
care - Filling gaps.
• Overall implementation
• Flexibility in project formulation
delays with complacency in the initial
and utilization across financial years
stages and some lack of clarity/ capacity.
without lapsing of funds.
• Ownership by District Health officers
• Software inputs like IEC,
Training included in project
Inadequate.
components
• Centralized implementation except
• Innovations like
for building aspects.
- Tribal ANMs for tribal area (relaxed
• Operational guidelines for many
requirements strengthened training)
aspects were not initially catered for e.g.
- NGO take over of PHCs
(two
Fund flow mechanism to ZPs.
experiments)
• Monitoring mechanism
- In some activities like IEC focus on
not adequate to support effective
Northern Karnataka based on regional
implementation.
disparities has been project emphasis
• Community involvement of village
(at proposal level only)
committees - not adequately
- Short listing of NGO's done through
implemented. Involvement of NGO
a planned / realistic procedure
equivocal.
though time consuming.
• Lack of continuity of
key personnel in the project handicapped the project.
• I EC virtually a non
starter
• Training process direction given to
NIHFW (National) rather than SIFHW
(State) which led to delays.
• Government level
decision making bureaucratic - 3 standing
committees delay decision
3. KHSDP
• More than just secondary
Care. Conceptually also focuses on:
- Special interventions for
Disadvantaged (Yellow card scheme).
- Comprehensive Surveillance system
- Trauma centre
- Hospital Waste Management.
- Blood Bank modernization.
- Improvement of Referral links.
• KHSDP, OPEC, KfW
share capacity building initiatives.
• Good mechanisms for
Construction and infrastructure
development has been organised that
can be used by other projects as well.
• Some areas of focus relevant for
Quality development - Equipment
maintenance, Quality, Women and
disadvantaged, Drug procurement
policy, Medical waste management. _
• Delay in construction
and civil works continue and 'local
problem solving' to get over constraints
not yet adequately decentralised.
• Huge cost over runs affecting
planning and process. Contracting out
and partnerships with NGO's and others
not being adequately monitored (Are the
effects really better?)
• Strategic planning cell has not been
developed adequately at capacity level
and from the point of sustainability of
planning process it is adhoc, marginal.
• Ownership problems especially for
long term sustainability not adequately
addressed. DHS or ZP who will
maintain?
S.No/EAP
4. KfW
____________ Strengths___________
• Focus on a disadvantaged
Region.
• Linked to KHSDP for most
of software development.
• Account in Gulbarga
(helped decentralised utilisation by
Additional director for project
stationed there.
• Improve Administrative facilities
at hospital level as well as for District
Health officers and Taluk Medical
officers.
• Strengthen referral.
• Additional staff.
• Project conceptually includes focus
on disadvantaged and women.
• Epidemic preparedness.
5. OPEC
• Focus on a disadvantaged
region of the state (but the choice
seems to have been by the donor).
____________ Weaknesses__________
• Only lip service for
Software components (Training,
referral, MIS, support services not
adequately addressed inspite of
availability of KHSDP support system).
• Slow fund release /
Utilization.
• Seems mostly brick and mortar
project.
• Decentralised utilisation of funds
without close monitoring led to
problems of leakage, poor quality
control, 'thoughtless payments'
(Dilemma of centralization Vs
decentralization)
• Foreign consultants (SANI Plan)
from Germany were not very effective in
their coordination with local consultants
hence inordinate delays.
Affected by Indo - German relations.
Scaled down after the nuclear bomb!
• Not a comprehensive
plan. Very focussed on just a hospital
and not need based.
• Inadequate local planning and
ownership.
• Delays and adhoc action.
• In the planning no clarity on how to
implement or actually go about running
the institution.
• No clarity on how govermnent will
raise minimum Rs. 10 crores per annum
to run the hospital (Now approaching
Private sector for partnership!)
• No clarity on how tertiary,
secondary input would, link or support
PHC through referral system.
• Presently the hospital has been
inaugurated and providing minimal OPD
services. Plans have been initiated to
find a private sector partner !
S.No/EAP
6. RCH
____________ Strengths___________
• Attempt to adopt Community
Needs Assessment approach (in
principle).
• Adolescent Health priority.
• Links with literacy campaign
• Financial envelope idea:
- Focus on disadvantaged.
- States free to choose intervention.
- Flexibility etc.
• Focus on Northern districts
- Gulbarga, Bidar, Raichur, Koppal,
Bijapur, Bagalkote.
• Bellary sub project which involved
NGOs.
• Partnerships with NGOs,
Professional bodies and medical
colleges initiated.
|>6c
____________ Weaknesses___________
• The work of UNICEF support in the
earlier phase of RCH not acknowledged.
Programme not learning from earlier
experience and strategies.
• Civil works preoccupation like
Other WB projects with delays and
cost over runs.
• Software components like IEC,
Training, moving very slowly or not
at all.
• Too much Family planning oriented
not integrated with health adequately
(Population agenda strong).
• Delays in basic training / delivery
kits etc.
• Focus on Secondary care more than
primary care - institutional services more
than field services.
• Top down Package deals oriented
rather than 'process' and local planning
and empowerment oriented.
• Overall progress of RCH project
which is high priority is very slow and
financial utilization seems quite
sluggish.
• Nutrition neglected in programme.
• Consultants not clear about actual
roles.
• Not adequately integrated at project
planning level (left to adhoc decisions).
• Too women oriented need to retain
balance and involve men as well.
• Sustainability not addressed
Community Needs Assessment on
paper.
S.No/EAP
7. UNICEF
_____________ Strengths___________ _____________ Weaknesses___________
• Complementarity of initiatives like • High vacancy rates of ANMs in
CSSM, RCH, and immunization.
disadvantaged Northern districts.
• Using fixed day session and
• Logistics of cold chain Drugs, kits
campaign approaches.
not adequately tackled delays etc.
• Pilot schemes tried out .in some
• Orientation / training of Programme
districts or towns and then expanded /
managers to deal with many departments
replicated in other areas.
network, sustain partnership is still not
adequately developed.
• Generation of training materials
and training programmes more local
• Complementary of UNICEF and
and relevant.
• RCH (WB) programmes not
• Involvement of Medical colleges,
adequately tackled due to project
research centres in MICES survey and
compartmentalization.
other projects.
Inspite of attempts to promote inter
sectorality UNICEF support programmes
• Learning from experience and
still get listed to one department or the
responding to local needs and demands
other.
good.
• Policies, guidelines manuals
evolved with local expertise.
• Policy to focus on Northern
Karnataka and districts with weakest
child development indicators.
8. RNTCP
Very important priority problem.
Hence selective strategy still required
and emphasized.
• Many DTC's do not still have
District TB officers (9)
• Laboratory technicians posts vacant.
• Abrupt transfer of trained personnel.
• Some DTC's have no building (9).
• Complex procurement procedures.
• Lack of cooperation from medical
colleges / major hospitals.
• Inadequate budgetary support at state
/ district level.
• RNTCP districts Vs short course
chemotherapy districts of SCC continuing ambiguity.
• Overall TB still low priority.
S.No/EAP
9. KSAPS
Phase I
___________ Strengths__________
• Zonal blood testing centres
established.
• Modernisation of Blood banks.
• Surveillance centres set up (8 + 5
new)
• NGO involvement good leading to
development of AIDS Forum
Karnataka - mostly Bangalore
(includes work with sex workers,
truckers and care and support for
PLWHA’s)
• Strengthening of STD clinics.
• IEC activities at many levels.
• Training activities on a regular
basis.
• State AIDS prevention society set
up-
___________ Weaknesses___________
• Supply of drugs delayed and
continuity of care and treatment (due to
complicated procurement procedures)
• Lab diagnostic facilities for voluntary
testing in all districts still inadequate.
• Lack of full or sustained partnership
with NGO’s in other parts of Karnataka.
• Lack of counseling facilities in
District and major Hospitals.
• Inadequate policy guidelines on HIV
testing.
3. Inadequate operational management capacity
Overall there were inordinate delays between launch of the projects and getting
operational strategies of the ground. These seemed to be lack of capacity at all
levels to convert ‘good project objectives’ into ground level strategies. While these
improved over time at the state level as seen in KHSDP, IPP IX, at the ground level
i.e., the District level; the PHC level and Panchayati Raj Institutions (PRI) level
these remained a weak chain in the link
4. Maintenance of Infrastructure not built in
Inspite of predominant infrastructure development, no planning or provision has
been made for future maintenance of the developed infrastructure. The state or ZP’s
capacity to maintain them adequately has also not been addressed.
5. IEC non starter
IEC was an overall weakness - with preparation of materials often overshadowing
actual efficient use in the field. Often materials did get printed / produced but
logistics of distribution were not adequately planned and operational use by health
workers and others at the field level were most inadequate with a few exceptions.
6.1HMIS, Monitoring and Evaluation weak
The monitoring and evaluation of the projects seemed weak inspite of efforts at
building up M and E strategies and lots of effort in some projects to evolve HMIS
systems. Most of the HMIS seemed to be used only by higher levels to help the
central planning process or monitor the programme. At the field level or base the
quality of HMIS data was often poor since the ‘collector of data’ did not see himself
or herself as a user of the data for their own planning purposes and was collecting it
disinterestedly for someone else at a higher level.
7. Sustaining innovative ideas was inadequate
Many innovative ideas were being tried out but their long term integration or
sustainability was not properly planned for. To begin with even their complete
documentation has been inadequate. Many schemes started but were discontinued
without proper evaluation; while many others were continued just for the sake of
continuity without monitoring evidence of value addition, if any.
Some other issues are included in the next chapter as policy imperatives.
An Innovative Scheme
“Under an innovative scheme the IPP IX project has provided funds to the
Vivekananda Trust to train girls from the tribal hamlets and post them as ANMs in
those hamlets. This training is a one-year course following the governmentapproved ANM curriculum with an added component of tribal medicine. The
training has not been recognized by the Nursing Council, and the trained tribal
ANMs are working through the NGOs working in these areas. Following
discussions with the MOHFW, the trained ANMs have been accepted as trainees in
the ANM training centers at the completion of which they will also be eligible for
employment in the non-tribal areas. An evaluation of the first batch of 40 tribal
girls trained as ANMs indicated a satisfactory knowledge of MCH, herbal medicine,
nutrition, and personal hygiene. However, their knowledge of the reproductive
system and human anatomy needed strengthening, and this will be rectified through
training in the government ANM training schools. This scheme ensures access to
MCH services in the remote and underserved tribal areas, and the presence of a
female service provider at the SCs. Another important benefit is the opening up of
job opportunities to tribal women within and outside of the tribal areas”.
Source : IPPIX World Bank Review Mission Aide Memoire
]
F. Lessons from Case studies
In spite of the time constraint the researchers felt that it would be a good idea to add
a few case studies of the situation on the ground vis a vis some operational aspects
of these EAP’s. Using two strategic opportunities - a quick assessment of Training’
opportunities experienced by a group of medical officers in a Northern district was
included as case study A and a surprise visit to an urban health centre covered by an
EAP was included as case study B. Both case studies focus on some learning
experiences from ground level realities and are not meant to be taken as any sort of
rigorous evaluation.
1. Lessons from case study - A
An interview of 6 doctors in a surprise visit to a Northern district showed the
quantity and quality of training inputs from a wide variety of EAP’s (around five
EAP’s) These are described in case study A. They show the following important
trends:
i.
ii.
iii.
iv.
v.
vi.
vii.
Five out of the 6 doctors had undergone some training or the other with three
of them having attended 5-6 training programmes. Most of these have been
in the past 5 years (1995 onwards) This has not been a uniform process with
some getting more opportunities than others.
The EAP’s supporting these training programme included IPP IX, RCH,
NACO, DAN-PCB AND CSSM (UNICEF)
The programmes ranged from 4 days to 18 days.
Most of them were in the Rural Health and Family welfare training centre
though one was at Hubli and other at Bangalore Medical college.
Most of them wanted CME’s atleast once or twice a year.
They suggested better skill orientation in training programmes and more
comprehensive induction training when they first join as PHC medical
officers.
Have suggested better resource persons and better centres than at present.
On the whole the case study shows that the EAP’s have managed to support training
of project mangers at field level even in the disadvantaged Northern districts which
is very creditable. However since these are done by different project administrations
there is overlap in themes and focus and the selection of courses do not fit in to any
available training schedule or CME of a local PHC. The selection and deputation
seems adhoc and opportunistic. Very often the MO gets transferred after a special
training programme so he is not able to add value after training to his ongoing work.
CASE STUDY - A :
Training Experience in Northern district
A few Doctors with Government service varying from 6 months to 20 years were interviewed
regarding their training under various projects / programmes. Some details about the training of
these doctors are given below:
1.
Dr. A with about 7 1/2 years of government service had undergone the following training
a.
MCH Training______
CSSM
1 week
1995
RHFWTC
b.
FP & MCH Training
RCH
1 week
1997
c.
FP Training_________
CSSM
2 weeks
1998
d.
Management Training
IPP IX
2 weeks
1999
e.
Administrator Training
1 week
Nauzad
MO
1999
Ahmed, Rural
Training
Development
Training
Centre_______
Inspite of all the regular training feels necessity for skill based training in MTP, tubectomy (learnt
tubectomy himself) and CME's (atleast twice a year). Also felt that quality of training at RFWTC
could be improved by getting trained resource persons from private / professional institutions.
2.
Dr. (Mrs.) B with about 5 1/2 years service underwent the following:
RHFWTC
a.
CSSM Training___________
CSSM
18 days
b.
Combined Medical Education
IPP IX
c.
DANPCB
Blindness Training_________
h
4 days
Leprosy Training__________
d.
4 days
At Hubli
e.
AIDS / STD Training_______
NACO
RHFWTC
RCH
5
days
RCH
Management
Training
f.
Had not been given any training in MTP or tubectomy. Felt that such skill based training would
enable to cater to the female population. Felt the need for CME's (1-2 per year).
Dr. C with 1 year service (excluding 4 years contract service). Very capable, efficient
young MO, underwent the following training:-_____________ ________________________
RHFWTC
2 weeks
1996
Reorientation Training
IPP IX
a.
b.
2 weeks
1997
MCH Training______
RCH
1 week
1998
c.
Leprosy Training
II
1 week
2000
d.
Management Training
2000
1 week
e.
STD / AIDS Training
NACO
Bangalore
2 weeks
2000
Medico-legal Training
f.
Medical College.
Is able to assist in tubectomy only. Feels the requirement of better training courses and skill based
training in MTP and tubectomy. Also feels that he could benefit from CME's.
3.
II
tf
4. Dr. D having 6 1/2 years service has underwent only Orientation training and Management
training under IPP IX. Has assisted in tubectomies. Feels the necessity for more comprehensive
induction training and training in Administration and Medico-legal aspects.
5. Dr. (Mrs) E also serving in the District with 5 months service has had no training whatsoever
(regular KHSDP appointment). Feels the requirement of rigorous training in all aspects to
effectively perform the job responsibilities of a PHC doctor.
6. Dr. F serving in the District with 5 years Government service underwent only 3 weeks continued
Medical Education Training under IPP IX on induction (1995 October) and no other training. Assists
in practical training of ANM's at the co-located ANM Training Centre. Feels the requirement of
regular training especially skill based and activity based training. Training needs identified include
MTP, tubectomy (including laprascopic), anesthesia and Medico-legal training (including post
mortem is a must), as he has performed 30-35 autopsies in his short service.
2. Lessons from Case Study - B:
A visit to an urban Family Welfare (Health centre) supported by an EAP showed
some interesting features described in the observations listed out in case study B.
The case study emphasizes that inspite of quite a good level of conceptual
framework generation and the evolution of a large number of guidelines the gaps
between concept and practice can be wide.
Various local adhoc, modifications of programmes: temporary or permanent short
cuts: lack of continuing education: supportive supervision and motivation of field
staff: poor logistical support to supplies: and lack of sustained efforts to maintain an
innovation can lead to discontinuation of innovations; closure of certain functions;
modifications of strategies which can be wasteful or counterproductive; or result in
glaring mismatches and distortions as exemplified by the observations.
While some functions go on fairly well and as per the objectives, some get distorted
or modified. The case study exemplifies the need for continuous monitoring and
evaluation; efficient supplies and logistic support; constant problem solving
supportive supervision; and good team work and continuing education to ensure the
quality of the implemented programme and to reduce what is often called in policy
circles ‘the implementation gap’.
< I
CASE STUDY B- An Urban Health Centre
SECTOR OF WORK
1. Family Planning Oriented
2. Referral Oriented
3. Laboratory services not available
4. Family Planning services
5. Drugs Inadequate
6. SHE clubs defunct
7. Link workers a strong asset
8. LHV / ANMs from corporation
9. Immunization
10. Health Education IEC activities
discontinued.
11. ISO 9002 Certification
12. Fall in activities / performance
OBSERVATIONS
No male patients seen;
No well baby clinic;
No well women clinic;
No screening for Breast Cancer or Cancer of the Cervix;
Only IUD insertion carried out, CCs and OPs distributed_________
No normal deliveries conducted even in day time.
All deliveries referred to Maternity Centres (MCs)
Referral card not well designed and common to all categories.
ANC card not given to the patient.
Laparoscopic Tubectomy or Tubectomy at MCs only.___________
Only Haemoglobinometer available cases usually referred to MCs,
long queue;
Tests sometimes done at UHC by visiting Lab technician's;
Lab tests -VDRL Hb, Blood group, Urine Albumin._____________
Only where LMO trained, only Menstrual Regulation
Conditional i.e., only if patient willing for tubectomy / IUD._______
Inadequate quantity to routinely treat OPD patients.
Very limited antibiotics.
No pediatric preparations/ syrups, no eye/ ear drops
(except chloroapplicaps) or skin ointments.
Definitely not Rs.50,000/- p.a. worth of drugs.
LMOs give prescriptions for purchase from outside._____________
Earlier vocational training - now discontinued.
Only serve as community feedback group._____________________
From community, dedicated.
Low honorarium so frequent turnover.
Bring ANC cases early as well as children immunization._________
Experienced, competent (could be corrupt)?___________________
Cold chain maintained.
Vaccines available.
Outreach immunization also.
Twice a week, so load less._________________________________
Do not put posters in slums as destroyed by children.
A-V van discontinued due to corruption.
Mainly printing - less lecture demos.__________________________
Purely technical assessment.
Based on parameters like cleanliness, record keeping, waste
disposal, sterilization of OT and equipment etc.
Would not significantly improve quality of care.
False sense of perfection.___________________________________
Since start of centre all activities have reduced significantly.
Assessment required of reasons for this.
Glossary IUD - Intrauterine devices
MC - Maternity Centres
OPD - Outpatients department
CC - Conventional contraceptive
(Condom)
LMO - Lady Medical officer
ANC - Antenatal card
UHC - Urban Health centre
OP - Oral Pills
G : Some Policy Imperatives Including Integration and Sustainability
The previous chapters provide an overall framework of the 10 EAP’s in Karnataka
and some of the quantifiable or qualitatively describable indicators and features of
these projects to help the project overview. As indicated in the project protocol this
exercise was primarily a critical policy review and not an evaluation exercise of
each of the EAP’s per se. Some of the finding in the previous chapters and tables
have addressed some of the questions that were included in our original list. In this
chapter we try to address those which have not been adequately covered by the
earlier one as well as provide some additional critical comments even on those that
have been covered, drawing primarily from the very candid and frank interactive
discussions we had with a wide variety of project directors. These policy issues and
imperatives are as follows:
1. Scope of Pro jects
All the projects focus on Health System Development with varying degrees of
emphasis on Primary Health care. While some focus on secondary level (e.g.
KHSDP) there is a built in assumption that the secondary care support is with a
view to support through efficient referral systems - the primary health care network.
While in practice the links may not be so well established the conceptual framework
is well directed to this issue. It is at the ‘Public Health’ context level however that
the projects show a general weakness inspite of the fact that unlike other states in
the country ‘public health expertise’ is available even among the senior leadership
of the state. One can only surmise that in the changing financial situation perhaps
financial management contingencies and bio-medically defined management
framework are inadvertently distorting public health concepts and priorities. The
focus on basic determinants of health is weak (nutrition, water supply, sanitation,
environment) both at content level, emphasis and linkages; key public health
components like surveillance and health promotion are inadequate; and the ‘new
public health’ emphasis on empowerment of the community and public at large in
health decision making is totally overshadowed by top down provision of specific
packages euphemistically called social marketing. This lacunae / weakness needs to
be seriously addressed.
2. Project Planning
In the absence of a strong Strategic Planning Cell in the Directorate (inspite of a
provision in KHSDP for this) problems of project flexibility, design, long lead times
and delays, in preparation, complications in procedures and various ongoing
management and operational problems, all of which have been experienced in one
EAP or another - are a symptom of lack of adequate attention to building in-house
capacity for more realistic project planning and management. This has led to
compartmentalized planning, inadequate collection of field based data or evidence,
and adhocism in decision making further compounding the problem. Lessons are
not learnt from positive and negative experiences of a particular EAP or its success
-I6S
30
F
at some form of system development so the ‘wheel is reinvented’ each time by each
project and the system is not enriched by the collective experience. E.g. Different
EAP’s have had different experiences of dealing with the ‘NGO sector’ or the
private sector - some positive; some not so positive; some even disastrous in terms
of unreliable partners or even ‘fly by night’ operators but the whole system does not
learn from this to evolve a Directorates policy for NGO or Private sector
partnership. This situation may change with the Task Force recommendation on
state policy directives but for the present this is a lacunae to be urgently addressed.
3. Who drives the projects?
This was a very difficult policy issue to address. On the face of it, the State
Government / State Health Directorate drives the project not the funding partners or
their external consultants and all sorts of mutual consultations / reviews are
organised. However two factors do affect the ‘driving’ of the project.
Absence of local homework
In the absence of rigorous ‘policy’ and evidence based homework on the
governments ! directorate side due to a lack of strategic planning capacity as
mentioned earlier, external consultants of funding partners are often able to drive
the decision by just providing more options, more evidence based on data
marshalled from experience elsewhere and the state policy makers are then more
easily influenced or ready to accept them. e.g. During the study period an external
funding agency resource person provided more data and perspective on private
sector in Karnataka, than could be marshalled by local expertise thus inadvertently
pushing the private sector agenda. The reliability of this data or whether it was
extrapolated from quite different sources could not be commented upon, adequately
without local homework.
Conditionalities of funding partners
World Bank loans more than other agencies are also usually supported by some
conditionalities that are clearly stated in their documents.
The need for economic reforms.
i.
ii.
The need to engage the private sector.
The need to promote user fees as a means of cost recovery.
iii.
The need to follow certain forms of ‘tender’ or ‘consultancy ‘laid down
iv.
by bank’ etc.
There does not seem to be adequate home work in-house on these and
implications especially long term options, before loan agreements are signed.
46?
their
1
Some World Bank conditions
“The Country Approach Strategy (CAS) recommends focussing Bank-group
financed investments on states that are undertaking economic restructuring
programmes and supporting sectoral policy reforms. Karnataka is one of the state
that has initiated important fiscal, sectoral and governance reforms. Further more it
supports the CAS objectives by strengthening institutional capacity
,
engaging the private sector
,
“Each project state
shall levy user charges in district and subdivisional
hospitals in accordance with a program and time schedule acceptable to the
Association(IDA)”.
“Goods and works shall be procured in accordance with provisions of section I of
the guidelines for procurement under IBRD loans and IDA credits” (International
competitive bidding, bid packages etc).
“Consultants services shall be procured under contracts awarded in accordance with
the provision of the Guidelines for the use of consultants by World Bank borrowers
and by the World Bank as executing agency - published by the Bank in August
1981”.
Source : Various reports of the Bank and Project Agreements
Both these factors lead to the continuing perception and the fact that indeed the
‘external agent’ does drive the project intentionally through general conditionalities
or ‘inadvertently through inadequate borrowers homework’. This needs to be
addressed urgently.
Even where conditionalities are inevitable, these should be closely monitored and
either reviewed if they have negative consequences or internalised into the system if
they have positive implications.
4. Are there areas of overlap / duplication ?
•
Compartmentalized projects by the very fact of being developed independently
as ‘stand alone’ projects and not as components of a larger wholistic integrated
project are bound to produce overlap and duplication.
•
Not surprisingly the chairperson of the Task Force during one of his recent
inspection visits found ‘three operation theatres in a PHC compound’ built by
different EAP’s with no evidence from the MIS of local needs that warranted
such investment. In HMIS, IEC, and Training there are many overlaps and
duplications .
So different projects produce manuals and teaching aids or audio visual
aids for Health Education which are quite similar in content;
Health functionaries are expected to maintain a wide variety of registers
that cater to the needs of different HMIS of different EAP’s ; and
Doctors go for different training programmes organised by a wide
variety of EAP’s that add to variety but not to a coordinated training plan
at district or PHC level (see case study A)
•
An overall integrated planning and training exercise is therefore urgently
required. At the directorate / state level there are efforts to prevent this
duplication of input and efforts but systematic change to streamline this process
and prevent even accidental or inadvertent duplication is required since the
health sector functions under a constant financial resource constraint and any
effort to ensure more efficient deployment of available resources is welcome. A
good example of adhoc integration is the utilization of KHSDP Resources for
KfW project needs.
5. Ownership and Leadership
•
In most projects the state level ownership is strong except perhaps in those
projects which are ‘package deals’ decided at the centre.
•
Because some of the EAP’s have established independent structural identities
e.g. KHSDP, IPP VIII, IPP IX, the links and feeling of shared ownership by the
parent directorate (in the case of KHSDP and IPP IX) and the parent Municipal
Corporation (in the case of IPP VIII) is weak. E.g. no serious consideration
regarding sustainability issues and integration challenges relevant to KHSDP or
IPP IX projects have been addressed at the directorate or Health secretariat. Nor
is the Municipal Corporation adequately concerned about the very same issues
vis a vis IPP VIII project.
•
Another significant lacunae seen in the EAP’s as they are presently structured, is
that ownership at District level - at the point of implementation is quite weak vis
a vis District Health Officers and PHC MOs; and perhaps non-existent vis a vis
PRI institutions. All these three groups are crucial to ensure the integration and
long term sustainability of all these projects. Ownership can be enhanced by
involving all of them from the very inception and conceptual planning stage of
such projects.
•
Leadership of the project directors has been good as long as there have not been
frequent changes of leadership or the burdening of project directors by multiple
and additional responsibilities.
•
However the leadership and ownership are particularly crucial if EAP’s have to
become more complementary or supplementary to each other and the whole
health care delivery system,
promotes linkages is crucial.
•
Leadership that coordinates, networks and
Public Health orientation and socio-epidemiological orientation of the leadership
- whether generalist administrator or medical / technical leadership is an
important necessity to prevent inadvertent distortions due to extraneous lobbies
or market forces. This will also enhance capacity to negotiate with external
consultants and others as well.
6. Intersectorality
While in many EAP’s the importance of this factor is mentioned, the intersectoral
coordination between departments and programme managers and decision makers
of different concerned ministries is still not given adequate priority. At the heart of
good ‘public health strategies’ is the emphasis on intersectoral coordination and
while EAP’s may have not seized the opportunity in this aspect so far, the evolving
Integrated Health, Nutrition and Population project (HNP) must focus on this aspect
urgently and significantly. Even at the grassroots level a better coordination
between PHC, ICDS centre, local schools, women credit cooperatives and
development workers would strongly strengthen programme performance and
outreach.
7. Integration
There is urgent need to integrate Health with Family welfare; public health , primary
health care and the population agenda with each other to avoid not only duplication
by compartmentalization but also to reach the community and tackle the health
problems of people especially the poor in a more integrated way. Much lip service
has been paid to the issue of integration but the stand alone EAP’s have not tackled
this issue adequately. In fact different EAP’s focussed on different problems even
further disintegrate the work of the directorate.
DHO’s and MO’s are constantly preoccupied or distracted at ground level by
frequent visits of consultants, review teams, project teams asking for this and that
data or feed back; the more EAP’s the more such distraction from the normal
planning and management routine.
At the directorate level different EAP’s require different protocols to be filled,
(different MIS mechanisms) so quite a bit of directorate staff time is spent in filling
up questionnaires, schedules enhancing paper work but not necessarily enhancing
efficiency of planning and management.
Consultants for each EAP provide their own framework of ideas and decision
making. These do not allow for any inter-EAP consultant communication. One
EAP may appoint a consultant that suggests one type of ideas, another EAP another
type and all these have to function at the same PHC level or the same district level
W-
or have to be operationalised by the same health functionary. This situation
necessarily leads to adhocism and anarchy especially in the absence of state policy
guidelines. Integration and coordinated communication is urgently required.
Another urgent area for integration to avoid wasteful duplication of time and
procedure is the need for integrating all the single project related district level and
state level societies into one Health society at both levels to receive and disburse the
funds. Serious policy reflection also needs to be done to ensure that the District
society’s work under the purview of the Zilla Parishad and PRI.
8. Equity
While overall the EAP’s do not have a well planned Equity focus some emphasis on
Northern disadvantaged districts and on women and SC/ST have been identified and
noted. HMIS of all EAP’s as well as the Directorate must begin to focus on Equity
in a more concerted way in the years to come. This ‘equity imperative’ must include
i.
ii.
iii.
iv.
Geographical - Within districts and between districts.
Gender - between male and female sections of the population and
especially focus on girl child.
Class / Caste - Between rich, middle class and poor or the so called
haves and have - nots or ‘landed’ and ‘landless’ etc.
Marginalisation - SC / ST or special groups such as child labour or rural
migrants to urban areas, street child, elderly, people with disabilities etc.
Unless the HMIS focusses on disaggregated data the equity principle cannot be
furthered by active policy or programmatic intervention. EAP’s could build this in
to their framework more concretely so that they go beyond policy rhetoric.
9. Partnerships
All EAP’s have built some form of partnerships with the voluntary sector, NGO’s,
private sector, academic institutions or research institutions. But these do not build
on a larger policy framework of the state since guidelines on such partnerships are
not available. They tend to be some what adhoc. The directorate should actively
move towards some form of Resource Directory; Accreditation system; or
reviewing and registering system for such partners so that EAP’s and different
health departments can draw from pooled experience and pooled resource lists. A
partnership cell in the Directorate like the erstwhile Society for Coordination of
Voluntary Agencies (SCOVA) idea could build such directories, framework of
guidelines and linkages, of use to all departments and projects.
10. Community Partnership and Empowerment
The resistance of the Health department to work with Panchayati Raj Institutions is
well known and though some of the reservations of the health leadership may be
-H3
very genuine and based on difficult or awkward situations of ‘interference’ or
extraneous push / pull factors in decision making - there is urgent need to review
this and get over the problem rather than ignore it. With increasing political
decentralization, PRIs will play an important part in local planning and
administration in the future and EAPs should promote this process and not distort it.
The district level societies which leave decision making in the hands of the
bureaucracy may be good for efficient disbursement of EAP funds but they
definitely mitigate against active community participation. EAP’s in particular must
begin to focus on human development more than infrastructure; and in this human
development component strengthening of community based organizations like PRI
institutions to contribute to local planning and ensure accountability and
transparency through capacity building will become as crucial as building health
teams to deliver the programmes efficiently and effectively.
11. Accountability / Transparency
EAP’s may develop their own monitoring system and evaluation systems, even
audit systems but they are not accountable to the people, the political system, the
legal system in the same way as the directorate and its regular programmes. While
bureaucrats and technocrats may be closely involved with the development of these
projects and the evolution of their frameworks of action there is still the danger of
creation of a parallel system of decision making and programme management which
may be seen as relevant in the short term but could become problematic in the long
term.
However it was noted that overall some of the guidelines and procedures of the
projects were able to immunize the project from the corruption and political
interference which affect the larger system all the time since it does prevent the
influence of extraneous ‘push’ and ‘pull’ factors due to clear cut guidelines that are
not easy to circumvent.
In the short term review we were not able to make clear cut judgement whether
extraneous interference’s were making any sort of affect on programme formulation
or implementation. The use of retired government personnel as consultants was
common (a sort of ‘old boy’ network) which affected the dynamics of the
programme and subsequently its performance in some cases but not necessarily to
integrity. On the whole it may be surmised that EAP’s are as subject to outside
interference as the rest of the system not necessarily more.
However in the matter of construction costs and delays and whether some
contractors were favoured rather than others - These areas were difficult to explore
in the time constraint. There was hearsay evidence of this type all the time
including architects inflating designs / and enhancing profit margins in other
ways, etc.
-1^
I
12. Sustainability
This was one area on which there was very little real focus or policy discussion or
planning in the projects at any level - project plans, project dialogue, project
implementation mechanisms and so on. It is important to emphasizes that
sustainability is often seen as being financial only. It is actually more than this and
includes staff and other policies as well.
The overall assumptions which ignored this imperative and the trends seen were as
follows:
i.
The projects were seen as filling lacunae in the existing system and not
creating additional structures or functions.
ii.
The parent unit or department like the BMP in the case of IPP VIII and
Health Directorate in the case of IPP IX, KHSDP etc were expected to take
over the project when the period of the project was over. There seemed to
be no contingency plans being evolved for this inevitable reality.
iii.
In some project documents there was mention of cost recovery usually
through user fees mechanism; or sustainability was to be made possible by
NGO - or private sector partnership or take over but this was not followed
up by serious operational guidelines or planning with the concerned parties.
iv.
Sustainability as an issue seemed to be considered in the last year of the
project as a knee-jerk reaction rather than as a serious plan evolved from the
very beginning.
v.
Unless the directorate estimates recurrent costs, running costs, maintenance
costs and other such definable entities seriously as the time for phasing out
of the project nears and unless these costs are budgeted for or recovery
planned in some sort of methodical way - Sustainability like cost recovery
will remain rhetorical and ultimately ignored or considered as someone
else’s problem at a later date.
vi.
In some cases there seemed to be a confidence that some project donor
would always step in to fill the lacunae if one donor phased out - so again
this complacency led to a fatalistic non-planning situation which was not at
all uncommon.
Sustainability of these relatively large EAP’s is a very serious policy issue that
needs urgent attention at the highest level and the active involvement of the finance
ministry as well.
H. Some Reflections on the Financial / Economic implications of EAP’s
Understanding the financial / economic implications of the increasing reliance on
EAP’s to support the health care delivery system in the state and the gradual shift
from grant giving funding partners to becoming ‘borrowers’ of loans, was not an
easy policy issue to review due to atleast two constraints.
• The financial management of the EAP’s are separate systems not easily listed to
the states own health budgeting / accounting system.
• The loan implications and the debt burden and debt servicing implications are
not easy to explore in a short time constraint under which the project functioned.
The reviewers studied some earlier analysis particularly the review document
(Analysis of Expenditure Medical and Public Health, Family welfare by
S.Subramanya) and the more recent study of Dr.Vinod Vyasulu and group and also
studied the credit agreements of various projects and the budget and account
statements as well as status of project tables from World Bank and other sources.
From a review of all these secondary sources of data the following conclusions and
policy concerns are listed out: (See also box items which are extracts from authentic
source and support our conclusions)
1. While the overall expenditure on health and family welfare is gradually
decreasing and hovering between 1.1 and 1.4 of net state domestic product
which is itself an overall low investment (ICSSR / ICMR recommend 8%), the
reliance on EAP’s is increasing which means Non-plan expenditure is coming
down and Plan allocations are increasing. This is not a very healthy trend.
2. Most of the expenditure in non-plan is now directed to salaries with less and less
available for programme / action components. EAP’s are tending to take over
more and more of this programme component - again not a healthy trend.
3. Considering that EAP’s are now more and more loans rather than grants or long
term soft loans this is a worrisome development. If these loans are not utilized
with efficiency then we have the double burden of continuing ill health and a
‘debt burden’.
4. Though all the projects talk about sustainability and cost recovery and user fees
mechanism is often mentioned as a long - term option there is no indication that
this mechanism is effective in reality. While some recovery has been
demonstrated; and some efforts to identify those who cannot pay etc is being
experimented; and the decision to let the amount / revenue collected be kept at
the institutional level for local use rather than transferred to the general account
or treasury - none of the mid-term reviews show that this could be a major
option for sustainability even though in the short term they may help to improve
quality by enhancing consumer participation. Researchers and programme
evaluators are not unjustified in their concern that ‘user fees’ may ultimately
S'*
Health Financing - An Analysis
1. “State Finances, Health Finances and Efficiency: Three key issues, with regard
to public sector finances at the state level need to be addressed. First the overall
fiscal situation in many states has deteriorated sharply since the early 1990s,
with a rise in the fiscal deficit, an increase in interest payments as a share of
total revenues, and an increase in debt outstanding as a share of state domestic
product. The deterioration in the overall financial situation faced by the states
has had a deleterious effect on the health sector. The share of health and family
welfare in the total state revenue budget has declined since the early 1990s
suggesting that past declining trends of health sector’s share in the budget has
been exacerbated, rather than reversed. The decline in the health sector’s share
occurred despite a rise in real per capita expenditures in all states up to 1991,
indicating that total government expenditures rose faster than health
expenditures. Total government spending is about USS 2-3 per capita for health
services and is inadequate to meet the government’s stated objectives. To
achieve the government’s objective of funding a basic package of health
services, substantially more resources for health care are required, but the
overall state finances noted above pose a serious problem. Second, within the
health sector in most states, resource allocation in the public sector is skewed in
favour of tertiary care services relative to needs at the primary and secondary
levels, particularly rural and community hospitals. Third, much of the resources
are absorbed by salary costs. The recurrent budget for operations and
maintenance is chronically under-funded and the programs are not fully
effective”.
2. “Alternative Methods of Health Care Financing : The resource constraints faced
in the health sector will required alternative methods of health care financing to
supplement budgetary allocations. Alternative methods of financing health care,
such as cost recovery, social and private insurance, and participatory schemes,
are limited. Reported revenue data indicate that cost recovery in the health
sector is about 3% on an average in India, although there are problems in
estimating the level. Some of the problems faced with cost recovery include:
a. Lack of an appropriate mechanism within the government to review user
charges;
b. Weak administrative mechanism for collecting user fees;
c. Difficulty in targeting the poor for exemption from user fees; and
d. Constraints to greater retention of funds generated through user charges at
the point of collection.
Based on international experience it should be noted, however, that a cost
recovery rate of 15-20% in the health sector is about the most that can be
expected in the public sector. In the long run, issues such as private insurance
and managed health care will need to be addressed, as the industrial and urban
sectors in India expand, and cost containment becomes increasingly important”.
Source : Analysis of Expenditure on Medical & Public Health, Family Welfare
State Health Finances
“Non Plan expenditure, which is met from resources raised internally by the state,
accounted for 63-69 percent of the total expenditure on health and family welfare
between 1990-91 and 1994-95; this came down to 57 percent in 1995-96.
Reduction in the proportion of non-Plan expenditure in 1995-96 is because of
increase in Plan allocations and capital outlays. One reason for this increase could
be the availability of funds from externally assisted population and health projects
and Central government aided projects such as the AIDS control programme”.
“With expenditure on health and family welfare accounting for only 1.21 percent of
the net State Domestic Product down to 1.14 percent in 1991-92, but up to 1.24
percent in 1992-93, decreasing again to 1.22 percent in 1993-94 before increasing to
1.37 percent in 1994-95. It is clear that fluctuations of this nature are undesirable
for the growth of the health sector as also that expenditure on health and family
welfare is, by any reckoning, inadequate. A study group on Health for All, set up
jointly by the Indian Council of Social Science Research and Indian Council of
Medical Research, recommended ‘a substantial increase in public expenditure on
health at about 8 or 9 percent per year (at constant prices) over the next 20 years”.
Source : Human Development in Karnataka - 1999
de-emphasize the need to focus on the marginalised. Other problems with this
mechanism are highlighted in the box items as well.
5. There is a danger that increasing reliance on EAP’s will ensure that programme
costs in the regular non-plan health budgets will be ignored with a long - term
distortion in budgeting creeping in. (This will perpetuate long standing
budgetary imbalances with long term implications for health budgets).
6. There seems also a tendency to be more extravagant with issues like
constructions, consultancies, equipment, vehicles, etc because EAP’s promote
unwittingly a more ‘private sector’ ethos so thrift, careful planning, basic
simplicity and other such values that would ensure ‘quality’ at low cost or a
more judicious use of resources so that more is available for grassroot needs is
being affected.
7. Finally it may be important to caution that reliance on EAP’s should only be a
short term plan. Ultimately health budgets like the investment on education and
welfare (social sector) should be increased as a long term investment in quality
human development. Enough economic analysis and theory - including the
more recent endorsement by the work of economists like Amartya Sen and
others show this direction as the way ahead. This needs political will and
commitment and some courageous state development policy planning. Let short
term solutions like EAP’s not come in the way of concerted, action for sustained
development and higher investment in health.
J. General Policy Concerns : Are we reinventing the wheel?
The key researcher for this study and some of his colleagues had reviewed the
World Bank activities in the Health Sector in India based on a case study on “The
World Bank’s role in the Health system in India” facilitated by the Sector and
Thematics Evaluation Group of the Operations Evaluation Department of World
Bank in August 1999.
That review had raised seven sets of questions / findings for a policy meeting
organised by the Bank with Planning Commission, Ministry of Health and Family
Welfare and others. The review of EAP’s in Karnataka was a good opportunity to
look at these propositions in a wider variety of project initiatives and with
partnerships beyond the one with the bank. Our findings suggest that many of these
concerns are very real ones even in the context of the current EAP’s in the state and
need to be given serious consideration by policy makers and project directors within
the state before these distortions and concerns become too systemic. They are
equally important for the funding partners. These concerns are enumerated as a set
of policy questions that project directors and partners should reflect upon as they
review their projects for long-term sustainability and integration within the larger
system.
1. Is Public Health not being adequately emphasised in problem analysis
project planning and formulation?
Is there a confusion in understanding public health?
Is economic or techno-managerial context taking precedence over socioepidemiological analysis?
Are the wider determinants of health like nutrition, water supply, sanitation,
and pollution not adequately addressed?
Is the focus on poor, indigent, marginalised not central?
Are regional diversities and differentials not central to decisions on focus of
programme?
2. Is Primary Health Care being given adequate emphasis and priority ?
Is there focus on selective ‘cost effective treatment strategies’ rather than
enabling / empowering processes?
Is there focus on first referral units rather than primary health centres,
subcentres and home based care?
Is community involvement in planning and organisation mostly
rhetorical with community capacity building made subservient to
exigencies of top down management systems.
Are Panchayati Raj institutions generally ignored and registered societies
promoted as an instrument of decentralization but under bureaucratic
control?
k3
3. Are these partnerships adequately transparent and accountable ?
Are the partners willing to share the costs of failure and distortions due
to poor programme design or planning which ultimately affects the poor?
Is long term sustainability or integration into existing health care system
being adequately addressed or followed up as an end of project after
thought?
Is there unhealthy competition between projects rather then collaboration
and sharing of expertise and experience?
Are accountability and transparency systems not clearly defined and
hence not actively monitored?
4. Some ethical issues and dilemmas ?
What is the ethics of promoting NGO-private sector partnership in the
absence of solid evidence that these are more efficient operational
options?
What is the ethics of taking credit when an initiative is successful and
yield positive results while pointing a finger to the directorate or ministry
when the initiative is problematic?
What is the ethics of expanding quality at the cost of or absence of
adequate and operational quality control?
What is the ethics of promoting infrastructure and ‘hardware’ at the cost
of ‘software ‘ that can more easily focus and reach the poor?
5. Some management issues and dilemmas?
In spite of marshalling lots of expertise both local and foreign is there a
tendency to:
Develop ‘hardware’ rather than ‘software’?
Expect ‘training’ to get over needs for serious management reforms?
Little thought to social accountability and transparency?
Inadequate attention to building ownership among different stake holders
particularly district level players?
Focussing on ‘user fees’ as the only primary fund enhancing option
rather than looking at diverse options?
Overall neglect of health human power issues like continuity, skill
development and promoting team concept?
6
Is the political economy adequately addressed?
Are the health projects adequately located in a broader, political, social,
institutional analysis and adequately based on evidence of how projects
run or do not run?
-Wc
Are issues such as political will; corruption and influence of lobbies
political interference; market economy; being given adequate emphasis
in the strategic planning exercises?
Without developing a strong ‘public health policy resource group’ within
the directorate is the free lancing, free floating, adhoc Consultancies and
commissioned studies not allowing the means of change to become
systemic?
7. Is cultural context being disregarded?
Inspite of a rich and diverse tradition of Indian and alternative systems of
medicine, including promotion and investment in health humanpower
development in these systems by government and private initiative; are
the EAP’s ignoring the local cultural context and these alternatives in
their formulation?
All these issues are relevant today and it was surprising to find that most of them
were applicable to all the EAPs in the state and not only for those supported by
World Bank. However it must be noted that the current health leadership both
bureaucratic and technocratic seemed much more alive to these policy issues. That
was a positive finding, symbolizing future potential. However as was brought out
again and again in the interactive discussions local holistic problem analysis and
policy homework was inadequate in all these aspects. Strengthening of
strategic policy analysis and development was an urgent action imperative.
Policy makers and project managers need urgent orientation to Public Health
aspects of decision making and socio-economic politico - cultural aspects of
health situation analysis. Any strategic planning exercise in the future for the
continuation of the existing projects or the evolution of newer one must take these
crucial questions into account so that the projects can be implemented more
effectively and in a more realistic context with reduction in the implementation
gaps.
L
J. Final Conclusion and Recommendations from a future Policy point of view.
The previous sections highlight the key findings and trends that emerged from the
review process. However taken as a whole set of project experiences the key issues
and conclusions that have emerged as significant for a concerted policy response are
the following
1. While the EAP’s do focus on a large number of health problems and health
sector development issues, addressing various lacunae in the existing Health
care delivery system in the state at both primary and secondary level, they do
evolve, exist and function in relatively compartmentalized ways without
fitting cogently into a comprehensive, integrated strategic larger state
health policy / plan evidenced by -
•
The absence of any state health policy document that includes serious reviews or
details of all of them.
•
Any coordinating mechanism at directorate level that addresses them in a
collective context.
•
Any consistent and rigorous strategic planning exercise / document that was
used by programme designers when these EAPs were evolved.
Some
congruence / complementarity between / across projects has evolved since the
members of the project committees overlap with senior policy makers common
to all, but this is ‘adhoc’ and not always intentional.
[Probably the HDR Report, Karnataka Task Force in Health and the recently
evolving HNP project are fore-runners for this much needed paradigm shift from
selective compartmentalized programme planning to more comprehensive
integrated Health sector planning processes].
2. On the other hand while compartmentalized evolution may have lead to some
problems of duplication and integration, especially in IEC and training, but also
sometimes
in infrastructure development, the very feature of
compartmentalization has also lead to a certain degree of project autonomy that
has lead to many interesting initiatives and innovations in structure, framework,
operational mechanisms, evaluation and monitoring, some of which have been
identified by this short-term review. These need to be rigorously documented,
objectively evaluated further and adopted / adapted by the whole system as the
projects phase out and get taken over and integrated by the ongoing larger
systems.
3. Overall the Directorate / EAP’s have shown
•
An ability to evolve laudable objectives for each EAP.
•
General lack of competence in the evidence based homework required to
translate objectives into implementable strategies leading to delays in starting up
times.
•
Diffidence in guidelines and systems development leading to operational and
execution delays.
•
While ability to handle the hardware (infrastructure construction - civil works,
equipment and transport) has been established, effective software development
(training, IEC and Quality Assurance) has remained a weak skill / capacity.
Also cost over runs have been many compounded with poor utilisation in other
areas showing in-different financial management capacity as well.
4. Like the general health care services development, the projects have not shown
any evidence-based focus on equity, gender, regional disparity or other
policy imperatives like impact assessment, community partnership and
ownership, partnership building and decentralization and hence though there
are some successes and some failures as well, in none of these areas can EAP’s
be shown to have used their own programme / project autonomy to enhance the
health sector experience in these areas. This is partly a reflection also that at
the Ministry level there are no clearly circulated policies or programme
guidelines on these policy imperatives and hence project managers have had to
explore these dimensions if at all with diffidence rather than confidence and
clarity. Similarly the issues of corruption, political interference, transparency
and accountability seem to effect them just as much as they affect the larger
public health system- no less, no more though perhaps in the tendering /
purchase policies sometimes as conditionalities of the funding agencies, there
seems to be an overall feeling among programme managers that outside or local
interference is less!
5. Lack of continuity of key personnel has been an important handicap and lack
of systems to monitor quality of care and responsiveness to local needs had
handicapped the establishing or the enhancement of effectiveness. In addition
selection of consultants and senior project consultant need to be critically
reviewed and made more competence based and transparent. Apart from an oldboy network phenomena selection is not always focussed on skills for the job.
6. While the general impression of the programme managers seemed to be that
these EAPs were not consciously donor driven and there was space and
opportunity for local technical opinion to evolve project formulation, the
impression of donor driven agenda was often attributed to lack of local
homework and evidence generation and hence a tendency to accept the
suggestions / frame work / ideas of working external consultants as an easy
option. This aspect again underlines the urgent need to develop and enhance the
strategic planning capacities of the Ministry / Directorate and making it multi
disciplinary as well [The KfW and OPEC experiences have however been good
examples of the need ‘to look at gift horses in the mouth’ seriously which could
have avoided all the problems that have followed. They have also shown the
absence of long term planning capacities especially in human resource
development for the hospitals being upgraded].
7. Integration as an issue does not seem to have been seriously considered by any
of the projects since many projects were seen as stand alone or focusing on
infrastructure not process. [The absence of clarity in development of a referral
system complex between primary and secondary care (for example: IPP VIII,
IPP IX and KHSDP) is a case in point. Similarly IPP VIII, IPP IX and RCH
could have been more complementary, etc.] This leads to wasteful duplication
at the ground - level.
8. Sustainability is another policy imperative that does not seem to have been
taken seriously by the whole system since in many ways this should be a long
term concern of the Directorate and not just of the EAPs. KfW project had some
serious options outlined in the project part which were not adequately
experimented with. [Efforts to evolve systems of user fees; efforts to identify
and hand-over (contract) out services to NGO’s and or private sector etc. are
being experimented with in KHSDP, IPP VIII, RCH but these experiments seem
adhoc and not within a clear-cut policy framework. Nor are they being
evaluated objectively to establish relevance or effectivity]. Overall the human
power development experience that is crucial for sustainability has often been
ignored or inadequately addressed.
9. Overall EAPs do not seem to be adequately drawing upon the Public Health /
Community Medicine capacities of the state in any concerted or formal way
nor for that matter on the phenomenal inter-disciplinary capacities of institutions
such as IIM, ISEC, NLSUI and other resource centers of health, social
development or strategic planning expertise- many of which are also available in
other districts and regions. In fact there seems to be an overall lack of public
health / sociological orientation in problem identification, situation analysis
or programme planning in the EAPs evidenced by a sense the researchers got
of the dominance of:
Infrastructure over human resource development.
Bio medicine over socio-epidemiology.
d
Secondary care over primary health care
public health).
:
(especially preventive
"
need
,0a)
enhance capacities all round/and integrate not disintegrat .
This canacitv should be multi-disciplinary, directorate-based and as
Svrde^bied Srin^trl tfeheahh progmmmesof the
state including EAPs.
b)
the starting point of such a mechanism].
Both
these mechanisms should draw on mu/tid^ipll^p
c)
Health Cell (an NGO) but this needs to be done with greater clan y
and flexibility.
c)
A more Md Mernal review and
evidence based long term strategic programme planning.
K. Limitations of the Review Exercise
.
The task of reviewing ten Externally aided projects in Health in the state m a
short term framework of 4-5 months was a very stupendous and exhaustive task
and perhaps quite unrealistic as well.
.
Hundreds of pages of reports, reviews and other documents had to be perused
and interactive interviews had to be arranged with a large number of very busy
government officials and project managers within this short term framework by
researchers who also had to work within a framework of complementary
demand and deadlines.
.
In two cases RNTCP and KSAPS interactive discussions with programme
directors could not be completed so we used reported information monthly both presentations at KTFH meetings and documents and one other programme
due to time constraint. NLEP (Leprosy control) was not included. Since this
review was trying to identify the broader policy issues relevant to Externally
aided projects in general all the nitty gritty’s of all the projects were not
focussed upon.
•
The study was also focussing on many issues that are neither easy to measure
nor always easy to elicit because qualitative judgements on qualitative issues
are often not easy to collect especially if the judgements are negative or cntica .
We must record however that most of the people interviewed showed a
phenomenal degree of openness, frankness and willingness to discuss even
‘sensitive’ areas and this candidness is really appreciated.
.
We have tried to do our best integrating the rich, response and feedback that was
received in the interactive discussions supported by background notes and
papers and our own reading and critical analysis of all the documents that we
were able to access. The effort has been made to make this review a learning
experience as a partner not as a critical external reviewer.
.
We hope we have been able to collate and highlight the salient features - both
strengths and weaknesses of EAP’s when taken collectively. Much more needs
to be done to address all the questions originally listed out, some have been
answered, others only just considered. More time would definitely have helped.
However the experience has shown that full justification can only be done it t is
review both
in-house and external becomes part of the ongoing Strategic
Planning Cell of the Directorate / Ministry. If our study has helped to get this
message across we would have felt fully complimented by our efforts.
So
L. Acknowledgements
To the Karnataka Task Force in Health for the opportunity to make an overview of
the externally aided Health projects of the state.
To all the project directors particularly Mr. Arvind Risbud (KHSDP, OPEC, KfW),
Mr. Krishna Rao (IPP VIII and IPP IX), Dr. G.V.Nagaraj (RCH) and Dr
Jayachandra Rao (IPP VIII) Dr. Shamanna (NPCB-K) and all their consultants and
supportive staff for the frankness and openness with which they participated in the
review and made available reports and other documents.
To Dr Thelma Narayan and Dr. C.M. Francis who shared insights as the Task Force
process continued; and all the CHC team members who encouraged and supported
the project framework.
riiian
iu ivu
1-1 cum Account Assistant) who typed the
Finally to
Mr. Anil Kumar (Secretarial
manuscript, Mr. M.Kumar (Administrative Officer) and the rest
helped with all the operational aspects of the short term
team, who particularly
}
project.
Dr. Ravi Narayan,
Community Health Adviser,
Community Health Cell,
Bangalore.
Dr. Sampath.K.Krishnan,
Policy Fellow &
Research Associate,
Community Health Cell,
Bangalore.
Dated: 28th March 2001.
5F
M. Bibliography
(This is a partial bibliography which includes the main document / reports. It doesn’t include all the
aLe Memoir^' review mission notes, newsletters, credit agreements, project partnership documents,
submissions by project directors and other formal and informal documents).
General:
Human Development in Karnataka, 1999. Planning Department
^SuTramanva
Analysis of Expenditure on Medical and Public Health, Family Welfare (Dr. S. Subramany ,
1.
2.
3.
4.
5.
6.
of world B.d< AoMios 1. .ho Ho.!,!, Soc.o, in Indi. M.y !W (Soe« .nd
Thematic Evaluations Group, Operations Evaluation Department, The World Bank)^
Comments on ‘Case study of World Bank Activities in the Health Sector m. India ^i hlarayan
et al in Health and Equity - Effecting change, HIVOS Technical Report senes 1.8 (2000y
A guide to sector - wide approaches for health development - concepts, issues and working
arrangements Andrew Cassels. (WHO, DANIDA, DFID, European Commission), WHO 997.
Towards Equity with Quality in Health (Karnataka), Interim Report of Task Force on Health and
Sth SgeH^rnmaka - Vinod Vyasulu ( a report presented to Task Force on Health and
7.
Sdbo^kofHeS^FLily Welfare - Sector investment programme Department of Family
8.
Welfare, GOI and EC Health and FW programme office, March 2000.
IPP VIII:
9. Family Welfare (Urban slums project) Brochure of IPP VIII, Bangalore
10. Staff Appraisal Report, India, Family Welfare (urban slums) project, May 1992, The World
Bank (India county operations department (10548-IN)
IPP IX:
11.
12.
13.
14. Ma: Family welfare project (Population IX) World Bank Review Mission Aide Memoire (May
i
2000).
15. IPP IX - Project implementation status, September 2000.
16 IPP IX World Bank Review Mission, Aide Memoire, September 2000.
7 Evaluation of ANM training for Tribal girls under India Population Project -IX - Innovat ve
scheme (P.J. Bhattacharjee and R. Venugopala Raju), Population Centre, Bangalore, March
1999.
KHSDP:
18.
Karnataka Health Systems Development, Project proposal Department of Health and Family
Welfare, GOK, May 1995.
19. KHSDP project proposal - January 1996.
Referral system manual, June 1999.
20. KHSDP
Staff Appraisal Report, February 1996, The World Bank, (State Health Systems Development
21.
project II).
. .
,,
,
j
Health Systems project (Karnataka, Punjab, and
22. Procurement Workshop Manual, Second State
West Bengal) September 1996.
<1
I
i
23. Status Report of Manpower position in Karnataka Hospitals, KHSDP, April 2000.
24. Overview of Training programmes under KHSDP and KfW project, KHSDP, June 1999.
25. Newsletters of the Strategic Planning Cell, KHSDP.
KfW:
26. Upgrading secondary level Health care facilities in the state of Karnataka, Final project proposal
for KfW, Germany, Department of Health and Family Welfare, GOK, July 1995.
27. KfW project - Progress Reports numbers 8 to 12.
OPEC:
28. Project Proposal for OPEC Assisted Hospital at Raichur, Department of Health and Family
Welfare, GOK, May 1996.
RCH:
29. Reproductive and Child Health services, Programme. District level Implementation Guidelines,
RCH project Bureau, April 1999.
30. A brief note on Reproductive and Child Health, GOK, November 2000.
31. Reproductive and Child Health Project - status report, sub project Bellary, October 2000.
UNICEF:
32. Approach paper for 2000 - Karnataka, Hyderabad Field office, UNICEF.
33. Border Cluster Districts Project, A strategy paper (Sanjiv Kumar)
34. Reproductive and Child Health - UNICEF Cooperation - Achievements, Impact, Constraints - a
hand out.
RNTCP:
35. Project Report for Revised National TB control programme, Department of Health and Family
Welfare, GOK, 1997.
36. RNTCP - Project implementation plan, DOHFW / GOK April 2000.
DANPCB / NPCB-K:
37. National Programme for control of Blindness, Karnataka State profile, August 2000, State
Ophthalmic Cell, GOK.
38. NPCB - Schemes for implementation during IX plan, 1997-2000 Ophthalmology / Blindness
control section, DGHS, MOHFW, GOI.
39. NPCB - Guidelines for District Blindness control society, GOI.
40. NPCB - Course material for training in District programme GOI.
41. NPCB - Schemes for participation of voluntary organizations GOI.
42. DANPCB - Eye care through Primary Health centres.
43. DANPCB - Creating awareness and demand generation for cataract surgery.
44. DANPCB - Rapid Assessment of cataract Blindness, February 1997.
NACO / KSAPS:
45. The Karnataka Strategy on Management of HIV / AIDS - The way forward, KSAPS, September
2000.
46. NACO, Scheme for prevention and control of AIDS - Phase II.
47. KSAPS Project implementation plan, - Phase II - December 1998.
ISA
TABLE ill
Externally Aided Projects in Health Service Delivery in Karnataka
COMPONENTS OF PROJECT PROGRAMMES AND ACTIVITIES FOCUS
(Review of Budget Headings)
si
No
Component
2
3
4
5
6
Construction_________
IPP-8 IPP-9 KHSDP
_x Land Purchase / prepn
Furniture / Equipment
Drugs and supplies
Vehicles_____________
Training (Local)______
Consultancy (Local)
Training (Foreign)
Consultancy (Foreign)
Books / Training Mtrls
Innovative schemes
_8
9
10
11
12 Additional staff-salaries
13 I EC Materials prodn
14~ Revolving Fund_______
KfW OPEC RCH KSAPS RNTCP NPCB-K Score
+
+
+
+
+
+
+
_6
2^
_1_
+
2^
2
5
J_
16 Training Material______
17~ Evaluation studies
18~ Kits__________________
20
21
22
23
24
25
26
Surveillance
J_
J
+
+
___
32 Adolescent Health
33_ Remunerations________
34 School Health
5^
2
2
2
+
Video / Media________
Waste Handling_______
Safety Net for Disadvan
Improving women health
MIS__________________
Design and Engineering
Project Management
Sustainability__________
28_ Contingencies_________
29_ NGO support_________
30 Blood safety_________
31__ Voluntary testing_______
£
+
is' Maint Vehicles & Eqpt
19’
2
7
9
6
5
2
1
+
+
+
+
4
1
4
x
6
5_
1
1
1_
x
1
15a
APPENDIX -1
Project Proposal
Review of externally Aided Projects
in the context of their integration into the
Health Services Delivery in
Karnataka.
I
i
i
J
Content List
1. Introduction
2. Objectives
3. Methodology
4. Budget
5. Project Outcome
6. References
7. Appendices
Submitted by
Dr. Ravi Narayan, M.D. (AIIMS), D.T.P.H, (London), D.LH. (U.K.)
Community Health Adviser
Community Health Cell
367, 'Srinivasa Nilaya', Jakkasandra 1st Main,
Koramangala 1st Block, Bangalore - 560 034.
Tel / Fax: 5525372
Email: sochara@vsnl.com
If
iqi
1 Introduction
Since mid 1990's, Karnataka Government has negotiated and received grants / loans from
International Funding Agencies for an increasing number of Health related projects.
These have included IPP - 8, IPP-9, KHSDP, KFW, RCH, Prevention of Blindness,
RNTCP and other projects. These externally aided projects have their particular focus
and framework and operational strategies to support and enhance both quantitatively and
qualitatively different aspects of the Health Sector development. Each of them has had
various mid term and concurrent reviews and some of them are currently reaching the end
of specific phases. The Karnataka Task Force in Health while reviewing these projects
informally in their discussions and deliberations have raised some important questions for
review.
i. "What are the learning points from each of these projects"
ii. How can they be integrated into the health system incorporating beneficial
points and avoiding distortions?
iii. What are the issues for consideration of sustainability, accountability and
transparency" (1)
This project proposal is a short-term initiative to explore some of these issues
qualitatively as a preliminary to perhaps a larger study at a later date.
Community Health Cell is a technical Community Health and Public Health oriented
policy research and training group that has reviewed external aided projects in the past.
Four policy initiatives are relevant to this study.
1) Review of health projects in India supported by Misereor / Germany. (7)
(6)
2) Review of Health Partnership of Memisa in Netherlands.
3) Review of partnership in Health (Cebemor Netherlands Government) (5)
4) Policy reflections on World Bank Activities in India - (see references) (3)
2. Objectives of Study
1. The study will review all the externally aided projects not just individually but in their
collective context and relation to the Primary Health Care and Public Health system
development in the state using a SWOT approach.
More specifically it will look at
a. The Strengths of each project and the positive learning experiences.
b. The Weaknesses or difficulties encountered in each project.
c. The Opportunities that have been created or exist to enhance primary and
public health care system development in the state.
d. The Threats or distortions that may have been inadvertently caused by the
project assistance to the health sector or that may be caused during the process
of integration.
Some specific questions are in Appendix one, though a more structured approach will
emerge after the literature, review.
3. Methodology
The time frame work of three months is too short to evolve a rigorous data based,
quantitative approach to project design and therefore a more qualitative approach that
will focus on a participation, interactive process is being suggested rather than an expert
external review the method suggested will try to make it a collective learning experience
for all concerned. Each project will be requested to allot atleast one project staff to be
part of an evidence collecting, evidence sifting; and evidence collecting exercise.
The steps of the process will be
A. Phase one 15th September - 15th October 2000
i.
ii.
Literature Review of all project proposals and mid term/ concurrent reviews and
aide memoirs.
Informal discussions with all project leaders and support team to clarify the
nature and process of review and seek required support and participation (As a
half day interactive workshop together, tentative date 10th October 2000.)
B. Phase Two - 15th October - 30th November 2000
Qualitative interviews with Directors and staff of each of these projects and with
a small representative sample of other stake holders including medical officers
and other staff. (Some visits outside Bangalore will be required)
ii. Interactive participation workshop with representatives of all the projects to
address the issues of sustainability accountability etc. and all those issues, which
are common to all projects and derive from phase one review, (atleast two, to be
discussed at A. ii)
iii. A questionnaire survey of some key aspects relevant to the study to be filled up
by each project as 'evidence contribution' to the review.
i.
C. Phase Three - 15th November - 15th December 2000
Integration of all the data/evidence from phase one and phase two processes into
a project analysis document.
ii. Circulation of this document to all concerned with a weeks time framework for
replies.
iii. Incorporation of all comments / suggestions and final editing of a document to be
submitted to KTFH hopefully not later than 15th October 2000.
i.
W3
■t
4. Budget
A budget proposal to support the study and including costs of Researchers, other
assistance, office support including photocopying, computer facilities, postage,
stationery, travel of research assistant and co-ordinator of study and some supportive
costs for three interactive workshops is included in Appendix Two.
The study will be undertaken by Dr. Ravi Narayan of CHC supported by a full time
research associate for 3 months and drawing upon short-term research assistance from
some other members of CHC team on a flexi-time basis.
Some elements of the study / review are complementary to the project proposals of
Mr. Vinod Vyasulu of Centre for Budget and Policy Studies, Dr. Ramesh Kanbargi of
ISEC; Mr. As. Mohamed of SJMC and Dr. Pankaj Mehta of Manipal Hospital and so
their involvement in some aspects of the study will be operationalised through informal
interaction at no additional cost.
Finally to make the short term process more cost effective and efficient under the
circumstances - close co-ordination with the project leaders will be established so that
some aspects of the study including the interactive aspects can be linked to any ongoing
schedule of meeting/training programmes or midterm/concurrent reviews so that
opportunity costs are enhanced.
5. Project Outcome
A project report highlighting a SWOT review of the External Aided Projects and Policy
guidelines for integration, sustainability and future projects of this type.
6. References
1. Topics for Action Research Studies identified by Task Force ( a KTFH handout)
2. Comprehensive Health, Nutrition and Population services development initiative in
Karnataka (An idea draft from CHC)
3. Comments on Case Study of World Bank Activities in the Health Sector in India (A
CHC policy reflection)
4. A Guide to sector-wide approaches for Health development - concepts, issues and
working arrangements (Andrew Cassels) A WHO/DANIDA/DFID publication.
5. Programme Evaluation-Basic Health Services India (cebemo / icco/DGIS), October
1994. (CHC)
6. Partners in Health - Challenges for the next decade: A process renew of the Indian
Partnership of Memisa - 1989-1994, (October 1994. CHC)
7. Promoting Health in India: A process review of the Indian Partnership of Misereor,
December 1994. (CHC)
APPENDIX - II
Integration of Externally Aided Projects in Health Services Delivery
(Karnataka)
Some Issues and Questions to be addressed in the Review Project by
Literature Review and Interactive discussions.
A Check List
1. Descriptions of each project including year of starting, period, focus, objectives,
components, programmes, budgets, reviews, etc.
2. Was the ‘problem analysis’ and the ‘problem solution’ comprehensive or selective?
If selective then factors used for prioritization? or selection of strategies?
3. How does the project support,
a) Health System Development ?
b) Primary Health Care?
c) Public Health?
4. How is the project funded?
a) Direct or indirect
b) Loan agreement/conditionality
c) Repayment
d) Budget components etc.
5. What has been the experience of
a) financial management
b) disbursement
c) expenditure
d) delays
e) shortfalls, etc.
6. Is the project funding leading to distortions in spending priorities?
7. Are a reliance on projects perpetuating long-standing budgetary imbalances;
implications on existing state health budget etc.?
8. Are there diversities in accounting/auditing procedures?
9. Strengths, Weaknesses, Opportunities, Threats of each project including those
identified by mid-term reviews.
10. Are there problems of
a) Project flexibility
b) Overdesigned
c) unnecessary long lead time, preparation delays
d) Slow rates of disbursement
e) Complicated procedures
f) Any other managerial/operational problems.
11. Are there areas of overlap / duplication with othri ornjects?
a) HMIS
b) IEC
c) Training
d) Staffing
e) Others
12. Are projects creating islands of excellence in an otherwise under funded sector?
13. Who drives the project?
a) State Health Directorate
b) Funding partners
c) External consultants
d) Others
14. Are there problems of:
Ownership
i)
Leadership
ii)
iii)
Intersectorality
iv)
Implementation
v)
Monitoring and Evaluation
Any other areas
vi)
15. How do the projects perform in the context of some policy imperatives:
a) Equity
b) Gender sensitivity
c) Regional disparties
d) Partnerships
i.
NGOs
ii.
Private sector
iii.
Academics-Research
iv.
Others
e) Accountability including corruption and political interference
f) Community involvement and partnership
g) Decentralization and Panchayatiraj
16. Do multiple projects make it difficult for the government to develop and implement a
coherent health policy for the health sector as a whole?
17. What has the project done in the context of sustainability?
18. Any other cross cutting themes that emerge in the discussion between researchers and
the project leaderships.
I
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