TOWARDS EQUITY, INTEGRITY AND QUALITY IN HEALT
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TOWARDS EQUITY, INTEGRITY AND QUALITY
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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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REVIEW OF EXISTING TRAINING PROGRAMMES FOR HEALTH
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PERSONNEL IN KARNATAKA
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Dr. Pankaj Mehta
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Dr. C. Shivaram
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Dr. Ramesh Kanbargi
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?x,sMn3lra,.n,P9 programmes for health personnel
The Department of Hearth and Family Welfare employs more than 60,000 personnel working in
various cadres and in various institutions including the hospitals. The department has health
administrators who look into the policies of the Government to improve service delivery through
Public Health system. There are service providers like Medical Officers, Staff Nurses and
paramedical staff working in the hospital to implement the programmes of the department. In the
selection process, educational qualification is the key factor. However, provision of health
services require many additional skills in addition to technical knowledge and skills like
administrative and management skills. These are not adequately emphasized in basic education
and at the time of entry to the hearth department, selected individuals greatly lack these skills so
necessary for their effective functioning. It is also an established principle that professionals or
administrators do require a sort of refresher course at periodical intervals in order to update the
professional skills and managerial skills. Limited training programmes are being conducted by the
Department of Hearth and Family Welfare and these have now widened under the Karnataka
Hearth Systems Development Project, IPPIX, etc., However, the department does not carry out
routine
nd planned training activities which are important and key factors in human resource
development and management. Therefore, there is a need to review the activities of the training
department and to develop suitable strategies
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at all levels for upgrading the knowledge and
skills of the staff of the Department of Hearth and Family Welfare. This review was undertaken
with the above mandate.
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There are two components of this study. The Hearth Worker (Female)/Auxiliary Nurse Midwives
and Hearth Assistant/Lady Hearth Visitor being such an important human resource in hearth care
delivery it was felt that their training component should be studied and evaluated as a complete
separate entity. SECTION A deals with all categories of hearth care providers except hearth
worker (female) and Hearth Assistant (female) and SECTION B gives details on the hearth worker
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(female) and Health Assistant (female).
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EVALUATION OF TRAINING PROGRAMMES FOR GOVERNMENT HEALTH CARE
PERSONNEL IN KARNATAKA
EXCLUDING HEALTH WORKERS (FEMALE) AND HEALTH ASSISTANT (FEMALE)
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EXECUTIVE SUMMARY
The Department of Health and Family Welfare employs more than 60,000 personnel working in
various cadres and in various institutions including the hospitals. Limited training programmes are
being conducted by the Department of Health and Family Welfare and have now widened under
the Karnataka Health Systems Development Project, IPPIX, etc.. There is thus a need to look into
this field and to develop suitable strategies to establish a continuous activity at all levels for
upgrading the knowledge and skills of the staff of the Department of Health and Family Welfare.
Hence, this review of "existing training programmes for health personnel in Karnataka" was
initiated under the mandate of the Task Force on Health and Family Welfare.
There are two components of this study. SECTION A deals with all categories of health care
providers except Health Worker (female) and Health Assistant (female) and SECTION B gives
details on the Health Worker (female) and Health Assistant (female).
Section A of the report summarises the present status of training as a component of Human
Resource Development in the Department of Health and Family Welfare and based on the
interviews, opinions, observations and analysis identifies me lacunae and the changes required. It
also gives details of an “ideal” training scenario for the future.
The OBJECTIVES of the study included studying a representative sample of the existing training
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systems and training programmes of various types of health personnel in the Department of
Health and Family Welfare, classifying and determining details of various training programmes,
identifying the methods used in training processes, evaluating the staff appropriateness and
fitness of the venue, study of the training manuals and usage of teaching aids.
The METHODOLOGY adopted was
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1.
Key Informant Interviews and Discussions.
2.
Primary Data Collection through Self Administered Questionnaire and
Discussions (Individual and Groups).
3.
Desk Review.
4.
Obtaining a very comprehensive training status and felt needs of the State health
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personnel by obtaining information from staff at the 1675 Primary Health Centres and 473
Primary Health Units of the State through a Kannada questionnaire prepared for data
collection.
5.
Review of as many training manuals as possible.
6.
Utilising the valuable data recorded in the investigators logbook.
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OBSERVATIONS
The review of the Training programme for the government health care personnel gave an unique
opportunity and insight to the investigators to understand the existing machinery and mechanics
of the training programmes in the Department of Health. The interaction and discussions with the
implementing staff was not merely a methodology but also a sensitisation and motivation session.
The investigators found themselves with mixed feelings: frustration, indignation, hopelessness in
some areas and rays of hope, happiness and satisfaction where few successful endeavours were
being undertaken even in difficult circumstances. In general, there was a sense of apathy and a
casual approach towards training. The enthusiasm was muted, existing as an exception.
Training was expressed as an activity that “one had to go through”: the unwritten expression
being that training programmes were not always necessary and that a pre-induction training in
administration and medico-legal matters was all that was required. Also, it was felt that factors
outside the immediate purview of the training programme most often determined its successful
outcome.
A visit to the training institutions re-inforced the disappointment. The once premier training
institute at Ramanagaram was found to be in a derelict and dilapidated condition - a result of
neglect and abandonment of purpose.
The Heads of the Institutions clearly lacked the will and vision to take the issues forward and one
wondered at the rationale of their occupying such an important post. Whether it was because of
past actions of their predecessors or an inadequate support from the State level officials, it
seemed they were “resigned to their fate” and had accepted “reality” and “non-action” as the best
recourse. Obviously if the top level was not concerned, it is not surprising then to find the rest of
the staff lacking any motivation or interest even to undertake their routine training activities let
alone innovation.
During the skills development training courses, due to various reasons, hands on experience was
either insufficient, inappropriate or inadequate. In essence - “going through the motions’' was the
general feeling amongst both the investigators and the “trained” personnel. Often, adequate and
appropriate infrastructure was not made available to the trainees after the training course.
Regional requirements for training were not considered and factored while framing the curriculum
or even during its implementation. Standardised syllabus had replaced the earlier freedom to
innovate.
-5The Training section has not received its due in the directorate except in the recent past, a
major reason being the lack of realisation of its importance in improving the quality of
health care delivery services.
Another major reason was the lack of a forceful personality in leadership role - an individual who
could demand and obtain the necessary support and finances for carrying out training
programmes on a regular basis successfully. This led to a situation where the training section
had hardly any funds and work to carry out. Even "induction training" - so important for a proper
orientation and grounding of new staff was not being carried out.
With the projects and programmes setting their own training agendas and funding training
programmes, routine training activities of the department took a back seat - leading to a lot of
frustration and a sense of resignation and hopelessness amongst the senior staff of the training
section in the directorate.
The limited time frame projects have demonstrated the need for training and given it the due
importance. Of course, once the project funding is over, training will need to be financed from
routine funding mechanisms of the department. There is therefore a genuine need to streamline
the training section in the department so that it always receives its necessary importance, priority
and support.
At present the department has training institutes (State, Regional and District and ANM training
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centres) where all State level training is carried out. In addition, institutes like the National
Tuberculosis Institute also carry out training activities for the state health employees. The State
and District level institutes have only recently been set up (in some districts - are still being set up
under I PRIX).
The training staff in the directorate not having any budget for training purposes and the World
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Bank funded projects being able to fund many training activities in these institutes has created a
dichotomy of interests in the department. The training department staff posted in the directorate
feel completely bypassed and frustrated at these developments and their lack of information on
training facilities and activities was indeed surprising but not completely unexpected under the
circumstances.
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There is also an absolute lack of coordination of training activities - training being ad hoc and
project driven with no need based appraisals (including geographical distribution) being carried
out. Being project driven, their regular maintenance once the project period is over will be
necessitated from the funds allocated for training. Whether the budget at that stage will be able
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to absorb these additional costs needs to be seen specially since in the past the funds allocated
for training activities were so meager and the priority given to training so low.
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-6It is unlikely that training activities as envisaged and needed can be carried out unless an
estimated Rs.5 crores (only around 1% of the proposed health budget) are annually allocated to
training section (this amount excludes salaries to employees).
With the projects showing the way and giving training activities the necessary fillip and
importance for improving the quality of health services being delivered by the department,
allocating funds for training (to this amount at least) from the health budget should be done
without any compromises in the future.
To streamline training activities of the department - a restructuring of the department staffing and
line of reporting is required.
RECOMMENDATIONS
IDEAL (Desirable) TRAINING SCENARIO for Department of Health, Government_Qf
Karnataka
A] THE STATE INSTITUTE OF HEALTH AND FAMILY WELFARE
1.
The State Institute of Health and Family Welfare becomes the apex trarmg institute as
well as an institute of excellence.
2.
The State Institute will be completely autonomous and the funds for its activities and
maintenance are to be allocated from the State Health and Family Welfare Department
Budget directly.
3.
The Institute will have a Director at the helm and this post will be a selection post with all
the perks and privileges that are offered to a person of this level. Its tenure will be for a
period of 5 years. He will report to the Health Secretary directly (Figure 1). The person
occupying this chair should have a medical degree and should also have training and
experience in medical education and training of trainers. Ideally, the individual should have
spent some years working at various levels in the department in the field.
* 4.
A Deputy Director will assist the Director with various administrative and technical matters.
The post of the Deputy Director should be a selection post with requirements similar to the
Director’s post and should have a tenure of 5 years.
5. The institute should have a full complement of training, administrative and supportive staff
with appropriate qualifications.
6.
Considering the importance of social sciences and communication skills, the institute
should have either full time or part time staff for these departments or engage the services
of experts as and when required during training sessions.
7. The institute should have all necessary training equipment and facilities including teaching
space and identified field training centres.
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-7B] THE REGIONAL HEALTH AND FAMILY WELFARE TRAINING CENTRES AND THE
DISTRICT TRAINING CENTRES
1. The Regional Health and Family Welfare Training Centres (RHFWTC) and the District
Training Centres(DTCs) would administratively be under the State Institute.
2. Their budget will be released by the State Institute.
3. Their activities to be based on local needs and practices and to be planned and coordinated
by the State institute.
4. At present there are 2 Regional Institutes in the Northern (West and East) and 2 in the
Southern part of the State (Figure2). There are none in the Central part of the state. This
anomaly needs to be rectified. Also, not all 27 districts have a DTC. Since the activities of a
DTC are different from the RHFWTCs each district needs to have its own DTC or the
RHFWTC should also undertake the activities of the DTCs without compromising on quality in
districts where RHFWTCs exist but where there are no DTCs. However, the State needs to
keep in mind the recurrent expenditure of so many institutes and based on needs appraisal if
it is determined that 2 districts can share one DTC, for practical reasons and long term
effective functioning, recourse to this may need to be taken and the plan of having so many
DTCs reconsidered.
5. With the formation of the DI Cs, many of the training activities can now be done at this level.
This will require careful coordination and supervision to ensure quantity and quality of
training.
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6. The DTCs based on Needs Assessment will identify the training requirements of the district
and forward this to the state institute for necessary plan of action. The DTCs will also directly
oversee the functioning of the ANM training centres in their districts and provide all the
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necessary support.
7. As in the state Institute, all necessary facilities and equipment need to be provided to the
RHFWTCs and DTCs at the earliest for their effective functioning. At present, many of them
lack basic teaching aids and educational materials.
8. The effectiveness of these institutes will depend to a large extent on its human resources.
The training institutes should be allotted staff based on qualifications or appropriateness and
not on personal needs, contacts and political influence and the ability to take care of
extraneous criteria (read favours). Merit and appropriateness should be the only criteria.
Abundant precautions should be taken to ensure that these training institutes do not continue
to be the islands of inefficiency they have been for so many years.
9. The Principals of these training centres should be selected with great care and should be
given the right administrative and technical training themselves at the State Institute prior to
their taking up these posts. This is important, as besides having adequate administrative
duties, very often, they will be directly involved in training activities themselves.
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10. Regular upgradation of knowledge and training skills, revision courses, as and when
programmatic changes are introduced should be mandatory for all staff of all training
institutes.
C] PLANNING the TRAINING PROGRAMMES
1. A committee consisting of the Director - State Institute and all Additional Directors of the
Health Department will identify the training needs, prioritise activities and prepare the budget
for training activities.
2. The Director of the State Institute will be the Secretary of this committee and will be assisted
by the Deputy Director in formulating and drawing out the master plan of operations (based
on the needs identified by the committee).
3. Approval for the formulated plans will be put forward during the committee meeting where the
Health Commisioner/ Director General of Health Services are also invited.
4. Approved budgetary funds will be sought from the State and handed over to the State
Institute for implementing the training activities.
5. To carry out the planned training activities funds as required will be made available in
addition to the funds earmarked for training purposes in different programmes (e.g. Malaria,
RCH, Tb. etc.).
6. The training needs of the different funding programmes will be respected and honored.
However, to enhance effectiveness of training, avoid duplication and to cut down on
unnecessary expenditure on travel, DA, etc., wherever feasible multiple training will be
carried out in one training programme.
7. Rigorous district and person wise data of all training undergone will be maintained and
computerised. This is to avoid wastage of resources and to ensure that everybody undergoes
training and not just a favored few (as is the custom very often now - same people going for
different training programmes whereas many others never obtaining a chance to enhance
their knowledge and skills).
8. This Information system on training will be maintained District wise at the District level, the
State Institute and Directorate. When a staff member moves out of one district to another
district, necessary changes will be made and the data base will be continuously and
constantly updated.
9. Since the committee now decides on training, there will not be any need to have a separate
training section in the Directorate - its functions being taken over by the State Institute, its
Director and the Training Committee of the Department. Adequate support from all necessary
sectors in this scenario should be feasible unlike the present situation where funds are never
or meagerty, miserly provided.
10. It will be advantageous to build up the State’s own training resources and training institutes
and depute Health staff for training in such institutes rather than at places outside the state.
At present, because of lack of training facilities many of the State staff are deputed out of the
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state for training purposes. If the training is done within the state we will strengthen and build
up our own systems, strengthen our own resources, and provide training in our environment
using case material which is similar to what the trainees will ultimately see.
11. As far as possible all training should be done within the state or at the most in some training
institutes within the country. There is an unnecessary clamor for foreign training postings.
Today, our country offers almost all training and skills required for the effective training of its
staff or for the provision of quality health services. No carrots in the form of foreign training
sessions are called for. With the money spent on such training a lot more can be achieved
and many more people trained. Very often staff are posted for short term observation
training. When the conditions and environment are so different and where training is MNOT
SKILL BASED ACQUIRING OR HANDS ON", SUCH TRAINING OUTINGS BECOME ONLY
OUTINGS RATHER THEN KNOWLEDGE/SKILLS ENHANCERS.
In all fairness, good
training opportunities with full scholarships are offered by international agencies like -WHO,
Commonwealth organization, etc.. It is a shame to see such useful training opportunities
being wasted because of non-recommendation of names on time or processing of papers on
time or staff being released on time. Full use should be made of such opportunities for
professional enrichment.
The State Institute should have information of all such
scholarships/grants availability and should decide on the staff for deputation for such training
courses.
12. A major advantage in having the training programmes within the State is that the training can
be done in Kannada using Kannada speaking patients and families which makes it much
more easier for the participants to understand and absorb. Less financial resources will be
required for such state conducted training and the resources saved could be utilised for
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further strengthening of our institutes.
13. Wherever the training is "technical" or the observation invite for technical matters - "technical"
people (and not non-medical - non-technical administrators) are to be sent/deputed for such
courses. There is merit in this recommendation. Our administrators are made to change
departments quite frequently. Sending them for such sessions then is absolutely non
productive to the department as the technical training in the health sector (presuming that
they are capable of absorbing the technical nuances involved) is not going to be of use to
them in another department like Sericulture or WAKF. However, if the training is for
strengthening administration related skills, the administrative staff should make full use of
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such scholarships.
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14. There is an immediate identified need of training for about 470 Block Health Educators.
Instead of deputing them in small batches to Gandhigram (and take years to complete the
training for all of them), one of the Regional training institutes could be strengthened and
provided the necessary infrastructure and human resources to carry out this training. All
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further induction training for BHEs could subsequently be carried out in this centre. Such
judicious distribution of training activities is very necessary for optimal utilisation of limited
resources.
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15. Distance education methodology is a grossly underutilised training mechanism in our state.
Today, such education facilities from reputed organizations like IGNOU, Jamia Millia,
Manipal, is available in many health areas. They are well planned and so structured that they
are practically useful to the trainees. The government should encourage such training and as
an incentive offer one time payment of a lumpsum amount (one month’s salary?) for every
distance education course of 6 or more months duration completed successfully by the staff
to a maximum of two such courses. In fact, once these universities offer more and more
health related administrative, managerial and technical courses, the Government should
make the successful completion of such a course a mandatory condition for promotion to a
higher grade after a certain level of promotion.
16. If trainers for a particular training area are not available, for effective training to be conducted
it may be necessary to tap the services of an outside expert. This is a must where institute
staff lack the necessary knowledge/skills. It is therefore highly desirable to identify the right
"consultants" and have a resource base of such individuals. Care must be taken to see that
such consultants have the necessary field experience, as very often such "experts" tend to be
very theoretical or out of tune with field based reality. However, having said that, care must
also be taken to ensure that all such expert consultants are not retired staff from the
Department. They do not necessarily make the best experts and the "buddy system" may not
be the best way to utilise the limited resources of *he training section.
17. Strengthening Public Health training is the need of the hour. The well planned and useful
DPH course - post MBBS, had very few takers as it was not advantageous career wise to do
such courses and over a period of time the number of seats available for such training
decreased. That DPH was no longer a necessary criteria for promotion to higher categories
in the Department gave it a final blow. It is only recently that the Government has once
again realised the need for such training for its staff. At present, the medical colleges do
offer a few seats. The Department should plan for the future and provide DPH training at the
State Institute itself. The modalities need to be worked out with Rajeev Gandhi University of
Health Sciences and necessary support for the infrastructure and resources sought so as to
start these courses by 2005 at least. Simultaneously, the colleges providing these courses
should be encouraged, infrastructure made available to them and Government Health staff
deputed.
Long term planning is the need of the hour for better and effective future
functioning.
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- ii SUGGESTED VISION, GOALS AND OBJECTIVES FOR TRAINING ACTIVITY for the
Department of Health and Family Welfare, Government of Karnataka
VISION
To provide technically competent, socially relevant, appropriate health services to
the fullest satisfaction of the people of Karnataka.
GOALS
- By 2002 January, every health care personnel who joins the government health service will
receive induction training.
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By 2005, every health care personnel will receive the identified and necessary refresher
training and skills up-gradation.
By 2010, systems are in place for the conduct of regular, ongoing, continuous refresher and
induction training with adequate provision of resources.
OBJECTIVES
1.
Preparing the individual’s competence by enhancing communication skills and learning
capabilities that are necessary for managing the day-to-day activities of the health
centre and for delivery of quality health care in accordance with the existing health
programmes and local health situation.
2.
To nurture and enrich the organisation culture which supports and enhances team
effort, harmonious interpersonal relationship, pursuit of excellence, spirit of enquiry and
innovation as a way of work life and to create an organisation environment where each
can share and contribute towards achieving the shared goals.
3.
To create sensitivity to the needs of the society, discharge the multiple roles and
responsibilities and fulfill the obligations as a health care provider.
4.
To help and support each individual to develop their potential to realise their self-goals
while contributing fully to the success of the organisation.
5.
To achieve synchronisation of the goals and aspirations of the individual, organisation
and society.
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Enhancing preparedness for willing participation in development activities which have a
bearing on health of the community.
7.
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Facilitate building a strong character of integrity, honesty and leadership.
-12INTRODUCTION
Human Resources development is a serious business. A business, which, requires specific
knowledge and skills to make it run successfully. It is resource and labour intensive. The ultimate
aim is to make a difference — to bring about the desired change amongst the participants and
enhancement of knowledge and skills so as to function more effectively.
Training as a subsystem of the health care system has the objective of optimising the health
resources input to the health care system through strengthening of knowledge, skills and attitudes
of health care personnel. The knowledge, skills and attitude that enable health staff to contribute
to the realisation of the goals of the health care system are usually derived from their basic
education obtained before joining the service and from the experience obtained by working in the
health care system. Proper training therefore plays a very important role in the effective
functioning of the health system.
Changes in health care delivery interventions happen frequently. New technologies are regularly
introduced and call for new skills for their use. The field personnel specially and other personnel
too may become outdated in a short period of time in terms of their knolwedge and skills. This
prevents their optimum utilisation and to their providing outmoded, less effective services. Skills if
not used for a long time get attenuated. Continuous education will assist and motivate staff in
improving their skills. The personnel enjoy the challenge of learning new skills or taking on a new
responsibility or improving their existing skills.
TRAINING AND RETRAINING IS LIKE CHARGING A BATTERY. Training or continuous
education has to be accorded high importance in human resource development and is crucial to
the planning and implementation of any project.
Training as a signal component of HRD is best understood as a learning experience. A training
programme is a learning experience for both the trainer and the trainee. It is also a learning
experience for the system, which commissioned it. A training programme is said to be successful
as long as it is a learning experience. The emphasis on learning and not just on training is
important for it also includes the follow-up of the training as an integral component.
The broader agenda of HRD includes dimensions of undergraduate degree / diploma / certificate
courses; the existing / creating environment in which the training / learning is facilitated; the
media and methods adopted to assess / evaluate; organisation structure and job responsibilities.
Hence to be more appropriate to this line of thinking this report should be titled Human Resources
-13Development for Health Care Delivery in the Public Health Sector. However due to the mandate
given in the terms of reference and the time duration, the original title is retained.
This section of the report summarises the present status of training as a component of HRD in
the department of Health and Family Welfare and based on the interviews, opinions, observations
and analysis identifies the lacunae and the changes required. It also gives details of an “ideal”
training scenario for the future.
The Objectives of the study were as follows:
1. Studying a representative sample of the existing training systems and training programmes of
various types of health personnel in the department of health and family welfare.
2. Classifying the training programme into pre-induction, in-service, refresher courses, skills
enhancement, additional qualification.
3. Determining details of training programmes like duration, selection process, eligibility,
geographical distribution, their appropriateness and adequacy based on job description of
health personnel.
4. Identifying the methods used in training process.
5. Evaluating the course content for their appropriateness, adequacy and effectiveness.
6. Evaluating the staff appropriateness and fitness of the venue for the various training
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programmes.
7. Study of the training manuals.
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8. Availability, usefulness, appropriateness and frequency of usage of teaching aids in the
training programmes.
METHODOLOGY
The following methodology was adopted for this section:
1.
Desk Review: The existing organization infrastructure, the available past review
reports and related literature were reviewed.
2.
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Key Informant Interviews and discussions: The key administrative personnel
responsible for the training programmes for the Government Health Care Personnel at
the level of the Directorate of Health Services, State Institute of Health and Family
Welfare, Regional Health and Family Welfare Training Centres and District Training
Centres were interviewed and their opinions, thoughts, concerns and suggestions were
documented. In addition efforts were made to meet as many senior and retired
Government officials as well as NGO representatives as possible for obtaining their
inputs for the endeavour. Discussions were held with the Chairman and Members of
the Task Force on Health and Family Welfare.
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3.
Primary Data Collection through
a. Self Administered Questionnaire
i. Focus Discussions
- Individual
- Groups
b.
Three sets of questionnaires were drafted, field-tested, finalised and used for
data collection. The first set of questionnaire was meant for the Training
Institutions. The second (English) and third (Kannada) sets were used to
collect data from individual health staff - both medical and paramedical.
(Annex’!). The interactions with various key individuals commenced from 1“
November 2000.
c.
Field data collection was undertaken during the period 12* November 2000 to
30* December 2000. The Four divisions and the respective Regional Health
and Family Welfare Training Centres including selected District Training
Centres were personally visited. In addition, one district other than the
Divisional Headquarters district was also visited. In these regions as many
Taluka Health Centres, Community Health Centres and Primary Health
Centres as possible were visited during the survey period.
d.
Focus discussions were held with individuals and groups from these Health
Institutions. Contents included: the need for training programmes, need,
duration and contents of the Induction and continued training programmes,
methodology and the location of the training programmes to be undertaken,
staff to be involved, training of trainers and related issues.
e.
All the 1675 Primary Health Centres and 473 Primary Health Units of the State
were posted three copies of the Kannada questionnaire for obtaining a very
comprehensive training status and felt needs of the State health personnel.
f.
The data collected was processed using the MS Office Excel Worksheets and
analysed using the WHO Freeware EPIInfo6 package.
4.
As many training modules as possible were collected and reviewed.
5. The investigators logbook formed an important and valuable source of data for analysis
and report preparation.
6.
The names of Institutions and Individuals who participated in the study are given in
Annex 2.
OBSERVATIONS
The following paragraphs document the findings of the researchers of the training endeavour and
activities in the Department of Health and Family Welfare. The presentation includes three parts:
1.
Summary tables of the information given by the Health Care Personnel in the structured
format.
-152.
The information obtained during the focus discussions with the Health Care Personnel by the
investigators.
3.
The information processed from personal discussions and as a result of the documents made
available.
[1] SUMMARY TABLES OF THE INFORMATION GIVEN
BY THE
HEALTH
CARE
Median
Mode
52
52
50
29
PERSONNEL IN THE STRUCTURED FORMAT (English)
The average age (in years) of the study population
Tablet:
Mean
Range
Number studied
Category
52
25 to 58
87______
_____ Medial
47
28 to 58
93______
Paramedical
48
25
to
57
43_____
Non Medical
47
28
to
55
7
Not mentioned
51
50
50
50
Since the Department does not have similar data on all its employees, the representativeness of
this group could not be ascertained. However, all groups had persons with wide age ranges.
Sex distribution of the study population
Table 2:
Male
Number studied
Category
55 (63%)
087
Medial
31 (33%)
093
Paramedical
36 (84%)
043
Non Medical
06 (86%)
007
Not mentioned
128
(56%)
230
Total
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Female
29 (33%)
62 (67%)
07 (16%)
01 (14%)
99 (43%)
Not mentioned
03(04%)
00 (00%)
00 (00%)
00 (00%)
03 (1%)
The lower female representation is partly because of their being studied in details separately, the
findings of which are presented in the second part of this study.
Average period of service (in years) of the study population
Table 3:
Median
Mean
Range (years)
Number studied
Category
20
19
1
month
to
36
87
______
_____ Medial
27
25
1
month
to
37
93______
Paramedical
25
22
1
month
to
36
43______
Non Medical
16
17
1 month to 33
7
Not mentioned
Mode
2
30
27
Again, a wide range helped give greater opportunity for representation of staff having had varying
induction and in-service training opportunities.
L
Qualification of the medical personnel
Number (%)
Qualification
25 (29%)
MBBS___________________________________
24 (28%)
Post graduate Diploma____________________
33 (38%)
Post Graduate Degree_____________________
01 (01%)
Post doctoral____________________________
04 (04%)
Not mentioned___________________________
Note: The specialist areas are given in Annex 3
Table 4:
r
r
r
FT
rr
-16Desire of the study population for administrative knowledge
Table 5:
Not stated
Para Medical Non Medical
Medical
Required
04 (57%)
11(27%)
25(27%)
52 (61%)
Yes
01 (14%)
04
(09%)
15(16%)
15(17%)
No
02 (29%)
28 (64%)
53 (57%)
20 (22%)
Not mentioned
Total
92 (40%)
35 (15%)
102 (45%)
The Medical staff are responsible for administrative supervision unlike the paramedical staff The
finding that 61% of them desired greater administrative knowledge is indicative of their interest,
inadequacies in the basic training content and is a very positive sign to improve their
administrative functioning.
Desire of the study population for Technical knowledge
Table 6:
Not stated
Non Medical
Para
Medical
Required
Medical
04 (57%)
07 (16%)
29 (31%)
37 (43%)
Yes
01 (14%)
09 (21%)
10(11%)
29 (34%)
No
02 (29%)
27 (63%)
54 (53%)
21 (23%)
Not mentioned
Total
77 (34%)
49 (21%)
103 (45%)
Only 31% paramedical and 43% medical staff desired greater technical knowledge These low
percentages need to be further investigated, specially for the paramedical staff who do not have .
too many training opportunities.
Desire of the study population for evaluation and supervision knowledge
Table?:
Total
Not stated
Para Medical Non Medical
Required ______ Medical
74
(32%)
03
(43
zo)
03 (7%)
32(34%)
36 (42%)
______ Yes
51
(22%)
01 (14%)
13 (30%)
07(8%)
30 (35%)
______ No
104
(46%)
03 (43%)
27 (63%)
54 (52%)
21 (19%)
Not mentioned
Supervision and evaluation activities are important activities of health care personnel specially of
the medical category. Greater focus needs to be given to enhancing these knowledge and skills.
Desire of the study population for administrative skills
Table 8:
Not stated
Para Medical Non Medical
Medical
Required
01 (14%)
08
(19%)
22
(24%)
32 (37%)
______ Yes
03 (43%)
08
(19%)
18(19%)
35 (41%)
No
03 (43%)
27
(63%)
53
(57%)
20 (22%)
Not mentioned
Desire of the study population for technical skills
Table 9:
Para Medical Non Medical
Medical
Required
Yes
No
Not mentioned
20 (23%)
45 (52%)
22 (25%)
26 (28%)
12 (13%)
55 (59%)
05 (12%)
11 (26%)
27 (63%)
Total
63 (28%)
64 (28%)
102 (46%)
Not stated
Total
03 (43%)
01 (14%)
03 (43%)
54 (24%)
69 (30%)
106(46%)
Desire of the study population for evaluation and supervision
skills
Not stated
Para Medical Non Medical
Medical
Required
03 (43%)
03 (7%)
29 (31%)
23 (27%)
Yes
01 (14%)
13 (30%)
10(11%)
42 (49%)
No
03 (43%)
27(63%)
54
(58%)
22
(25%)
Not mentioned
Table 10:
Total
58 (25%)
66 (29%)
105 (46%)
The large number of non-responses in skills enhancement section was rather unfortunate and
prevents coming to any definite conclusions about them.
-17Table 11:
Category
Number of train ng programmes attended
Number
Training
programmes
studied
Induction
documented
10 (4%)
280
87
Medial
6 (5%)
155
Paramedical
93
1 (2%)
65
Non Medical
43
17 (3%)
500
223
Total
Note: The List of training programmes is given in Annex 4
Course type
In service
266 (95%)
98 (63%)
45 (69%)
409 (82%)
Not
mentioned
04(1%)
51 (32%)
19 (29%)
74 (15%)
Duration of training programmes evaluated
Table 12:
Duration (in days)
Training
Category
Number of
personnel
programmes
Range
Median
Mean
documented
_______ studied
10
19
280
1 to 90
Medial
87
14
2 to 365
49
155
ParamedicalI_________ 93
21
65
3 to 90
37
Non MedicalI
43
Table 13:_____ Type of training programmes
Nature of the Programme
Medical
(n= 280)
Lecture demonstration
231 (83%)
91 (33%)
Workshop
_______
160 (57%)
Participatory________
Role play___________
67 (24%)
64 (23%)
Hands on Training
52 (19%)
Modular
Paramedical
(n = 155)
83 (54%)
31 (20%)
78 (50%)
60 (39%)
32 (21%)
21 (14%)
Non Medical
(n= 65)
36 (56%)
07(11%)
17 (26%)
10(15%)
08 (13%)
04 (06%)
Mode
03
30
90
Total
(n=500)
350 (70%)
129 (26%)
255 (51%)
137 (27%)
104(21%)
077 (15%)
a
In this group, there were only 23% amongst the medical group and 21% amongst paramedical
who received hands on training.
.17
Table 14a:
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Trainees comments on the training programmes
Paramedical
Non Medical
Medical
Training Programme
(n= 280)
(n= 65)
(n = 155)
217 (78%)
97 (63%)
42 (65%)
Highly useful_______
Adequate__________
212 (76%)
82 (53%)
29 (45%)
Content adequate
197 (70%)
76 (49%)
31 (48%)
211 (65%)
Content relevant
83 (54%)
35 (54%)
Helped acquire
212 (76%)
83 (54%)
40 (62%)
knowledge_________
Helped acquire skills
195 (70%)
82 (53%)
35 (54%)
Total
(n=500)
356 (71%)
323 (65%)
304 (61%)
329 (66%)
335 (67%)
312 (62%)
Table 14b:
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Trainees comments on the training programmes
Medical
Paramedical
Non Medical
Training Programme
(n= 280)
(n = 155)
(n= 65)
ADDITIONAL KNOWLEDGE
Useful in every day
206 (74%)
84 (54%)
32 (49%)
activity_________________
Used once in way
32(11%)
11 (7%)
06 (9%)
Occasionally____________ 18(6%)
02 (1%)
05 (8%)
Not applicable
11 (4%)
0 (0%)
0 (0%)
Total
(n=500)
322 (64%)
49 (10%)
25 (5%)
11 (2%)
-18ADDITIONAL SKILLS
Useful in every day
activity____________
Used once in way
Occasionally_______
Not applicable_____
191 (69%)
82 (53%)
29 (45%)
302 (61%)
31 (11%)
23 (8%)
14 (5%)
12 (8%)
03 (2%)
0 (0%)
10(15%)
04(6%)
0 (0%)
53(11%)
30 (6%)
14 (3 %)
The above table clearly depicts the benefits of training programmes to this group.
Reasons for non-application of the knowledge and skills
Non Medical
Paramedical
Medical
Reason
(n= 65)
(n
=
155)
(n= 280)
KNOWLEDGE_______
6 (9%)
7 (5%)
20 (7%)
No opportunity______
0 (0%)
0 (0%)
0 (0%)
No interest__________
0 (3%)
2(1%)
6 (2%)
No freedom to act
2 (3%)
4 (3%)
35 (13%)
Lack of technical
support____________
0 (0%)
3 (2%)
29 (10%)
Inadequate equipment
4 (6%)
14
(5%)
No encouragement
1 (1%)
Table 15:
SKILLS_____________
No opportunity_______
[ .o interest__________
No freedom to act
Lack of technical
support_____________
In adequate equipment
No encouragement
Total
(n=500)
4 (1%)
0 (0%)
14 (3%)
41 (8%)
32 (6%)
19 (4%)
15 (5%)
0 (0%)
5 (2%)
19 (7%)
5 (3%)
0 (0%)
2(1%)
4 (3%)
5 (8%)
0 (0%)
0 (0%)
2 (3%)
25 (5%)
0 (0%)
7 (1%)
25 (5%)
27 (10%)
6 (2%)
3 (2%)
0 (0%)
4 (6%)
30 (6%)
1 (1%)
11 (2%)
About a quarter of the participants were not able to utilise the knowledge and skills given in the
training programmes - the major reasons being inadequate equipment and lack of technical
support.
Trainers ability as perceived by the trainee
Paramedical
Medical
Particular
(n = 155)
(n= 280)
Impart knowledge 94 (65%)
223 (80%)
good____________
91 (59%)
204 (73%)
Impart skills ■ good
Communication 85 (55%)
204 (73%)
good
Table 16:
Non Medical
(n=65)
Total
(n=500)
34 (52%)
351 (70%)
24 (38%)
319 (64%)
24 (38%)
313 (63%)
The training ability of paramedical and non-medical trainers obtained quite low ratings. Since
they are a very important component of health care delivery services, the trainers’ abilities for
these groups needs to be enhanced.
INFORMATION OBTAINED DURING FOCUS DISCUSSIONS WITH THE HEALTH
[2]
CARE PERSONNEL BY THE INVESTIGATORS
The following issues were raised during the open ended discussions:
-193)
(Health Personnel) Learnt PHC administration mostly through self-learning and
through the guidance from non-medical and para-medical staff, perusal of records
and scrutiny of the government circulars.
b) Many difficulties faced while managing the financial aspects, in the initial stages.
c) INDUCTION TRAINING
Induction Training should be a must.
•
Lack of induction training resulted in lack of self-confidence and competence
to manage the administration of the PHC at the initial posting.
•
Induction Training should be conducted before the selected candidates are
posted to the respective PHCs.
•
The duration should preferably be three (15 days to six months) months.
•
Of these one month should be in theoretical aspects of administration and
finance. In the remaining two months the selected candidates should be
exposed to practical training including training at sub-centre and PHC levels
rather than being trained only at the divisional level.
•
The Training pattern should be 1/3 field-work, 1/3 discussion, 1/3 lectures.
•
Induction training should commence from sub-centre level.
•
Current Induction Training emphasized more on clinical aspects rather than
office procedures.
i1
•
posted first to PHC for one or two months and then drawn for induction
training. By doing so, they would be more focussed on their training
:i
requirements.
d)
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An opinion was also expressed that the newly recruited staff should be
Topics suggested for inclusion in the Induction training for Medical Officers were:
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Administration
Supervision
Management (Finance, Vehicle, Materials, Stress and Personnel)
Human relations
Inter-sectoral co-ordination
Job responsibilities
Office procedures
Medico-legal aspects including Law and Medicine
Inter-personal relationship with staff and general public
Human Resources Development
How to deal with Non Governmental Organisations?
Counselling for adjustment to rural areas.
Use of computers
Disciplinary powers
Preventive ) & S(ocial) M(edicine)
MTP
Tubectomy
-20•
Leadership qualities
e) PARA-MEDICAL TRAINING:
•
Need for induction training for the Nursing staff.
•
Pre-induction training for Para-medical staff to be between 2 to 3 weeks.
•
Pre-induction Training for Lab technicians is a must. The present LT training is of
poor standards.
•
ANM training should be under DHO and not under District surgeon. Since they
would be working under the supervision of the Programme Officers and the DHO.
•
ANM Training to be 24 months rather than 18 months. Of these 6 months should
be "internship” training in association with experienced ANMs.
•
Minimum qualifications for ANM training should be PUCII year pass / graduation.
•
The trainers should possess Diploma in Public Health Nursing.
•
The ANM training centres to be l der the supervision of the District Training
Centre Principal and the staff of these institutions to be associated with ANM
training.
f)
IN-SERVICE TRAINING
• In-service Training should be need based rather than based on
hierarchy. The training and postings at present are not need based.
•
The training programmes are many a times repititous.
•
The TA/ DA payment is delayed and inadequate.
• Ideal duration of the training programme should not be too long or too
short. The best period is 3-5 days.
•
Training schedules should not hamper regular and routine service
delivery (problem of single medical officer).
• Need for better accommodation facilities and incentives for the
trainees was mentioned by many.
• Many Medical Officers of Health are not attending TOT. There is
confusion in deputation to training programmes. Late intimation
precludes from attending the training programmes. Training not being
mandatory / compulsory is a common reasons for poor attendance.
There was divided opinion regarding private practice being a reason
for poor attendance during the training sessions.
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In-service training of ANMs being promoted to LHV cadre for 6
months duration is insufficient.
g) TRAINING PROGRAMME
•
Training groups to be Homogenous as heterogenous groups will
result in loss of interest in training, the training being multilevel and
more time-consuming.
•
Training and other resource materials should reach the trainees well
in time.
•
Training in AIDS and Tuberculosis at Foreign institutes (I! sic).
• No incentive should be given for undergoing the training programme.
•
Training should be on the lines of IAS / KAS.
•
There are lacunae in training but certificates are issued.
• Equal importance should be given for training in all National Health
Programmes.
• It was surprising to hear one of the trainee mentioning that Training in
Communicable diseases is practically nil.
• ATI training for administrative Officers is a must from middle level
onwards.
a
• Administrative re-inforcement training should be conducted once in
three to five years.
• Health management training should be given at all levels.
A
•
•
There should be periodical short course training in supervisory skills.
Contract Doctors are not Administrative heads; so management
training to them is a waste.
i.
• Learning should be participatory rather than lecture based; skill based
rather than theoretical; the theory practical ratio to be 10 to 20 to 40:
L
60 to 80 to 90; unlike at present - 60% theory and 40% practical (just
r
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the reverse).
• Practical sessions to have discussions, demonstrations and problem
solving exercises and not just reading and by-hearting of notes.
• Hands-on training and workshops are better.
h) POST TRAINING SCENARIO
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Following training the Medical Officers do not practice what they
have learnt.
•
The required infrastructure is not a vailable or provided.
-22•
The
trainees
do
not
have
confidence
following
(especially
laproscopy) training.
•
Feed back from the trainees is a must. Monitoring and follow up
evaluation should also be undertaken. The present system of pre
test and post-test assessment needs a change.
•
The trainees must be accountable to the official superior and to the
general public. The responsibility for each trainee after the training
should be decided prior to training.
•
There should be periodical feed back from every cadre regarding the
training undergone. This also should include their ability to apply the
learning from the training in their day-to-day work.
•
Inspectorate team should be formed to monitor and supervise
training activities on the spot. Independent evaluation of training
process by external agency should be provided for.
i)
CME should be introduced for all categories of health personnel. For Medical Officers
CME / refresher courses should be held at the district level and at Divisional level
once in 6 months to three years. There should be re-inforcement training for taluka
level and CHC level doctors for 7 working days and 2 weeks for DHO level. Training
should include updates on National Health Programmes.
J)
PROMOTIONAL TRAINING:
•
Promotion should be need-based.
•
Promotional training is very much required particularly in the areas of
administration, finance and supervision at all levels.
•
The topics should include administration, rules and regulations,
finance, planning, supervision and personnel management.
•
However a few expressed that promotional training was not required
since the topics would have been covered during the induction
training.
k)
There should be more and more interaction between faculty of teaching institutions
and health personnel.
I)
Exposure to General or Family Practice during internship (is desirable).
m) All Circulars from the Directorate should be marked to the Principals of the Training
Centres also.
n) Upgrade the post of the Principal, RHFWTC to the DJD level
o) Faculty at the training center require TOT re-orientation once in two to three years or
whenever new programmes are introduced. A major training need identified was
-23training in advanced and recent communication technology. Faculty at RFWTC
should be screened for teaching competency before appointment.
p) Changes in health and programme interventions are fast and frequent - so planning
is not possible. (- in response to the preparation of the Annual Training Plan). There
must be political will for allocating resources for undertaking training.
q)
It is preferable to have Karnataka Health Administrative Services, KHAS like KAS.
3]
INFORMATION PROCESSED FROM THE DOCUMENTS
(A)
The following paragraphs summarise the information collected from the
training institutions:
State Institute of Health and Family Welfare, I51 Cross, Magadi Road, Bangalo - 23
This institute has been set up right next to the RHFWTC, Bangalore. The Total filled up Positions
is 68%. (28 / 42). TEN Deputy Director Posts are sanctioned apart from those of office staff. A
total of 06 are reported to be vacant including that of 02 Deputy Director posts. A Deputy Director
and an Accounts officer are working part-time.
The facilities cover an area of 4200 Sq ft with 12 rooms for faculty, 9 rooms for other staff, 5
classrooms and 1 Seminar room.
The functional equipment are 1 OHP, 1 Slide projector, 1 Computer with Printer, 1 photocopying
machine, 1 binder, 3 Audio cassette players, 3 VCPs, 4 TV monitors.
i. 1
The two Transport vehicles (Jeep and an Ambassador car) are on road.
The Library with 563 books occupies an area of 400 Sq FT and there is No separate staff. There
are plans for subscribing to Journals.
The Hostel has 16 rooms for trainees, 1 staff room, 1 dining hall, a kitchen and a recreation hall
with a TV.
'i A
The sanctioned budget was released on time and was adequate. Seventy seven percent of the
amount was utilised and Rs. 10,04,123 was surrendered, (reasons being non filling up of staff
and non conduction of some training courses)
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The training conducted at this center was RCH orientation training for faculty of ANMTC/LHVTC
under the Government of India.
The Centre has NO PUBLICATIONS to its credit.
The Instructional materials available are 20 Modules / Manuals, 02 models, one set of 36 slides
and 10 video films.
Regional Health & Family Welfare Training Center, Magadi Road, Bangalore- 23
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Filled up posts 83 % (12 Teaching faculty, that include 03 Doctors) Vacancies of Health
Education Instructor 01, Management Instructor 01, Artist cum photographer 01 and 02 Group ‘D’
staff.
-24An Urban Family Welfare Centre is also attached to the center with an additional staff of 05 out of
the sanctioned 06. All the above staff are employed on a full time basis.
The facilities cover a floor area of 4000 SqFt for faculty and other staff including 01 classroom, 01
Seminar room, Audio Video room and a Library.
04, auoio
Audio
The equipment available consists of an overhead projector 01, Slide projectors U4,
cassette players 02, video cassette players 02, still camera 01 and TV monitors 02. Of these 03
Slide projectors and 01 Audio cassette player are Non-operable but can be repaired.
Transport consists of 01 Tempo, which is on road while the Mahindra Jeep 01, Mini Bus 01 are
under repair. An Ambassador car is to be condemned. 25% Vehicles are on road:
There is no library staff. The library, contains 1095 Text Books including reference books and 04
subscriptions for periodicals.
The Hostel comprises of 02 buildings (old and new) with a total of 19. Each has its own dining hall
and kitchen. Neither of the buildings have recreation facilities.
The Budget release for 1999 - 2000 was delayed. The center incurred an excess expenditure of
Rs.4, 55,453/-
02 Training programmes were conducted:
Generation Awareness Twining Course (Composite group 2) in 1999-2000
and a Course on Management for Medical Officers of Health in the current year.
The Teaching staff’s time during Non-training was spent as below:
60 % in preparing instructional materials,
10 % in staff interaction,
20 % in professional enrichment, and
10 % in Translation work and attending work assigned by DH&FWS and State Institute.
The 704 instructional materials include 300 Slides, 85 video films, 250 models and manuals.
Remaining (69 - 9.8%) consist of charts, models, flip charts/books, flash cards, information kits,
pamphlets, folders and posters.
Teaching materials prepared by the institute and used fortraining include the following:
1. Sukhee Kutumba (folder by the Faculty, HFWTC, Bangalore)
2. WHO day- April 7,2000 (folder) [translated by the center into Kannada }
3. CHETANA.... Training modules for
• Block Health Educators.
• Senior Health Assistants (M&F)
• Junior Health Assistants (M&F)
The last two are English training modules translated into Kannada.
The other two publications to the credit of this institution are:
2. Nimma Arogya Kapadikolli by the Faculty, HFWTC, Bangalore
3. Surakshita Laingikate, by the Faculty, HFWTC, Bangalore
Regional Health & Family Welfare Training Centre, Metagally, Mysore 16
Positions filled up 87% (7 of 8). The faculty includes 02 Doctors. The one vacancy is
that of Health Education Instructor.
f
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-25The center has a building with 14 rooms (13 for the faculty and 1 for the other staff). In
addition there are 02 classrooms and one each of the following, Seminar room,
Demonstration room and a Recreation hall. The total floor space covered is
approximately 350 SqMts.
The equipment available at the center consists of 02 OHP's, one each of Slide projector,
Audio cassette player and 16mm projector. Two each of Video Cassette player and TV
Monitors. Of this equipment one Video Cassette Player is in need of repair while the
Radio needs to be condemned.
Transportation is in the form of two vehicles - One a Swaraj Mazda Canter which is in
service while the other is a Standard -20 which needs to be condemned.
The Library has 57.7 SqMts of floor area and has 927 books. However, no Journals or
Periodicals are being subscribed to. A lending facility as well as a photocopier and
computer are in the library. Working hours are 10 AM to 5 PM.
A hostel is also provided and it consists of 10 rooms for students and 15 for the staff and
a dining hall, kitchen, and a recreation hall with a TV .
The Budget for the previous financial year was sanctioned and released on time. The
amount utilised was Rs. 26,14,331. The amount released Rs. 27,55,860 was found to be
adequate.
.1
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The training undertaken last year was an In-service training for Medical Officers and
another for Zilla Parishadh members, BEO, NGO’s CDPO and Taluka Panchayat
members.
No publications have been made from this center.
The teaching staff’s Non-training time usage was as follows:
10% in course planning,
15% in lesson planning,
20% in preparing instructional materials,
10% in field follow up
20% in staff interaction
25% in professional enrichment
The Instructional materials available at the center for teaching include 36 Charts, 160
Modules and Manuals, 3 Models, 120 Slides and 18 Video films.
No teaching materials have been prepared by the center.
Regional Health and Family Welfare Training Centre, KIMS Campus, Hubli 580 022.
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Positions filled up: 76% (41 / 54) The 13 vacancies are for Office Supdt (01), Driver (01),
Typist (01), Class D (02), Sanitation officer (01), Skilled Mechanics (05).
The faculty at the centre include apart from the Principal and 02 (Doctors) Chief
Assistant Medical, Social Science, Health Education, Public Health Nurse Instructors,
-26Management Instructors, Health Supervisors, Communication Officers, Assistants,
Office staff and Motor vehicle related positions.
The center covers a total floor space of approx 520 sq mts and includes 07 rooms for
faculty, 02 for staff and one for the Projectionist apart from 04 classrooms as
instructional areas. There are no Seminar Room, Demonstration room or Lab Facilities.
The Hostel facilities comprise of 16 rooms for the trainees, a dining hall and kitchen.
There is no recreational room but a few games, TV and radio are made available at the
hostel.
The offices of Sample Survey and Assessment unit, the Taluka Health Office and Urban
FW center are accommodated in the 118 sq mts area of the centre.
Functional equipment at the center include 1 Over head projector, 4 slide projectors, 3
video cassette players, 1 TV monitor, 1 each 16mm and 8mm slide projector and 1
Microscope.
The OHP (1), slide projector (1), audio cassette player (1), TV Monitor (1), and the PA
System need to be repaired. Both the 8mm and 16mm projectors are to be condemned.
Of the 5 vehicles for Transport facilities the two mini vans are to be condemned. Three
vehicles are on road, including a Jeep.
The Library with a floor area of 44.2 SqMts has 1323 Text Books and Reference books
with a subscription to 11 Journals and Periodicals. There is photocopying facilities, but
NO LIBRARIAN has been sanctioned.
A budget of Rs. 66,68,440 was sanctioned on time and was found to be adequate. An
amount of Rs. 8,35,095 (12.5%) was surrendered for various reasons.
The training courses conducted were:
In-Service training for Medical Officers in STD surveillance
- STD surveillance for Sr. Health Assts / Staff Nurses (13 batches)
- Awareness generation training under ROH for Medical Officers with NGOs (06
batches)
- ROH workshop for District Programme Officers (1 batch)
- Community Health Training for one batch of Ayurvedic Students.
RCH training for two batches of SOSVA Personnel.
Community Health for one batch of Staff Nurse students.
- Population Education training for four batches of ITI students.
- RCH training for NGO’s.
- MLEC programme for In-service personnel.
The studies undertaken from the center are:
- A report on the evaluation of trained personnel under IPP IX.
- A report on the evaluation of Pulse-Polio Immunization coverage in Hubli-Dharward.
- KAP study report on Diarrhoea at Yaraguppi village.
- A Sample study on Birth-Death Report at Sulla and Kiresur villages.
- Knowledge study on ANC care and Breast feeding at Yellapur town.
f
-27The Teaching staff spend their time during the Non-training period as follows:
05% in lesson planning,
05% in preparing instructional materials,
05% in measuring learning,
20% in field follow-up,
05% in record keeping,
10% in staff interaction,
10% in professional enrichment.
The other 40% is taken up by other activities like Talk shows on AIR, School Health,
etc.,.
The center has Charts (on health & FW programmes), 2 Modules and manuals, 1 Model
Skeleton 1 FW programme Model, 82 video films and 16 strip films as Instructional
material
The following Teaching materials has been prepared by the institute:
1) Kannada version of the Chetna training module for BHE’s
2) Video-cassette for Ayurvedic practioners and FW in the field.
3) Folk literature , including songs, drama and Harikatha were developed for IEC
Bangalore.
Regional Health & Family Welfare Training Centre, Old Hospital Premises,
Gulbarga.
The filled up positions is 84% (16/19) with 7 Part Time faculty. Many of the faculty of the centre
have a Diploma degree in Health Education.
In the floor area of about 3470 Sq ft, there are 7 rooms for the faculty, 04 for the staff, 2
classrooms, 1 Seminar room, 1 Dark room and an AV room. There is no Laboratory or
Demonstration room.
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The functional equipment include 1 OHP, 1 Audio cassette player, 1 Video camera, 3 TV
monitors and 1 Video cassette player. The Still Camera is to be condemned and the 02 OHPs, 1
Side projector, 1 VCP and the Photocopying machine are in need of repair.
A total of two vehicles - a mini bus and a matador are on road. A Jeep is to be condemned.
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The Library with an area of 300 Sq ft has 701 books. No Periodicals or Journals are being
subscribed. There is no computer or photocopying facility.
The Hostel with a floor area of 1800 sq ft has 15 rooms including a room for the warden, a Dining
hall, kitchen and a recreation hall.
Of the Budget released for the previous financial year 32% was utilised. Rs.2,48,082 was
surrendered since no deputation was made for the RCH awareness programme resulting in non
conduct of these courses.
The Training programmes conducted were as follows:
- In-service RCH awareness programme for Medical Officers.
SOSVA Field workers training under RCH.
District level workshop on RCH.
No separate publications have been made from this center.
The Teaching Staff‘s Non-training time activities were as follows:
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21.4% in course planning,
21.4% in lesson planning,
10.7% in preparing instructional materials,
14.28% in Field training,
28.6% in record keeping, and,
03.6% in Professional enrichment.
The instructional materials available at the center are 6 Charts, 4 Modules / Manuals, 2 Models,
23 Slides and 32 videocassettes.
The teaching materials prepared at the center are:
- Module for BHE category “ Chetana Module “
- CME training teaching lessons.
(B)
ASSISTED/ FUNDED PROJECTS AND TRAINING PROGRAMMES
International and Multilateral and Multinational Agencies
The international and multi lateral and multinational agencies including the World Bank have been
assisting the Government of Karnataka and the Department of Health and Family Welfare directly
or indirectly through Government of India. The assistance has been in terms of both soft credits
and grants to undertake the health and disease related endeavours and training is an important
component in these projects.
This has even got a historical context. The first public sector Family Planning clinic was started in
Ramanagaram with assistance from the Rockfeller Foundation. The Induction training
programmes was started in this centre during the pre-independence days.
The India Population Projects I and III though specifically concentrated on the development of
infrastructure also undertook training endeavours. Programme specific training got a major boost
both in terms of both methodology and content
(MODULAR training programmes) with the
Universal Immunisation Programme.
The Child Survival and Safe Motherhood Programme implemented in phases since 1992 by the
Government of India with assistance from the World Bank attempted at "rationalising the
(fragmented) services with a package". The well thought out situation analysis as a methodology
of training which was a major component in the CSSM training programmes did not seem to be
implemented with the spirit which it was intended to.
The current ongoing projects are India Population Project VIII (for Urban slums in Banglore
Cities and recently extended to eleven other cities in the State), India Population Project IX (for
upgrading the Primary Health care Infrastructure in select districts of the state with a major
component of training - establishing the State Institute of Health and Family Welfare and the
District Training Centres) and Karnataka Secondary Health Systems Development Project
(for upgrading the network of Referral services at the secondary level care). The Reproductive
-29and Child Health Programme though a World Bank funded programme is being implemented
through the Government of India. The World Bank is assisting the Government of India in the
National AIDS Control endeavours by supporting the formation and sustenance of the Karnataka
Sate AIDS Prevention Society (a major component is training in HIV / AIDS including
management of Sexually Transmitted diseases). Two other programmes on similar lines are the
District Blindness Control Programme and the Revised National Tuberculosis Control
Programme. A comprehensive Health, Nutrition, Population Project is in the offing and is
slated for the middle of 2002.
The following paragraphs highlight both the general and the programme specific review of training
programmes in these projects.
1.
Unfortunately, the Disease specific or programme related training programme was
promoted at the cost of generic training programme. This lead to many health staff not
receiving this very necessary and important entry level enabling capacity for
appropriate functioning. It may be noted that the current very senior level functionaries
who are about to retire are the only ones who have received the generic or induction
training programmes exception being the new recruits over tue last two years.
However, the General Law and Accounts exam, which the health care personnel have
to pass to obtain their increments was the only saving grace in this situation.
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2.
Overall training needs assessment of the system gave way to programme requirement
training. The pros and the cons of such an approach cannot be dismissed as academic
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discussions. We have in the system today, people who have not been trained for their
keeping in mind their job responsibilities and have learnt the trick of the trade of
managing by trial and error (see vide supra - Focus discussion). This unfortunately is a
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highly undesirable method of learning.
3.
A major positve feature of the Externally funded projects have been the
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systematic independent Mid Term Reviews that have been undertaken. The strict
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monitoring of the progress of the planned activities has indeed resulted in the
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desirable mid course corrections.
4.
Efforts are now on to integrate the systems and sub-systems more so with regards to
training - creation of the State Institute of Health and Family Welfare and the District
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Training Centres through India Population Project IX and the re-introduction of the
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Induction Training through the Karnataka Health Systems Development Project being
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examples.
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A question still remains unanswered. Do the time bound (5 years) project mode of
these endeavours end up in merely 'having new buildings' without adequate,
appropriate skilled human resources? This needs to be seen beyond the rhetorical
question for there is a distinct possibility that there would be the double burden of new
buildings with inadequate trained staff and inappropriately trained health care
providers. Unless this question is addressed as an immediate priority, there will be
precious little to even think let alone talk about the Public Health and Primary Health
Care for the future generations of the residents of the State.
The review of the IPP VIII, IPP IX and the KHSDP training programmes revealed the recent
conduct of independent in-depth studies (Mid Term Reviews). One of the MTRs (for KHSDP
Skills training evaluation) is being concluded. It is too very early to expect to asses the impact of
the changes being brought in. There have been certain process shortfalls indicated in these
MTRs. Given below is our finding on the progress made subsequent to the MTR based on our
discussion with the concerned officials. Pending the submission of the final report of the Skills
evaluation review for KHSDP, the gist of the informal personal interaction with the evaluator is
documented below.
It was evident that training was now getting a relatively higher priority than earlier. The IPPVIII
(Bangalore City component) is far ahead in terms of the training for its health care personnel in
particular the new category of LINK WORKERS. The IPP IX demonstrated that despite the
shortfall in the targets that were to be achieved both in terms of infrastructure and training
programmes, there has been considerable progress documented. The KHSDP has re-introduced
the Induction Training programme for the new recruits and also initiated the Clinical Skills
upgradation programme. The HIV/AIDS training programme has introduced the participatory
learning methods in the training sessions. The new training programme for RCH has taken the
integration forward with administrative training, communication skills and supervision skills.
(c)
TRAINING MANUALS
Multiple training manuals are being used for training purposes by various training institutions.
Quite a few of these are manuals used in other states for training purposes or manuals
recommended by Central Government (NIHFW, Manuals used in Andhra Pradesh, CHETNA
manuals, etc.,.) Some of the above manuals have been translated into Kannada for the training of
para-medical staff. A review of these manuals indicate a need for updating of information. Many
of these were prepared for training purposes for earlier programmes and changes have
happened since (for example - CSSM and the current RCH programme). By far and large, the
manuals do not present knowledge in a training format. They read more like textbooks or guide
-31 books. Training exercises, presentation of knowledge in a format which would be easy for the
trainees to absorb, newer methods of training methodology, lack of learning objectives as well as
essential knowledge, non-interactive format were some of the flaws noted (exceptions being the
NIHFW manuals which are being used under IPPIX at DTCs, and a few others like the RCH,
etc.,.). The contents in these manuals seemed to be more theoretical and lacked the focus and
emphasis on the field situation and ground realities. A change in focus of the concerned
programme very often necessitates the training institute to commission a new training manual.
Change is inevitable and programmes are constantly evolving. However, the change sometimes
is rapid and frequent often leading to repeated trainings with very few new learning additions.
Because it is a new programme the manuals also get redone with slight modifications.
(□)
OTHER SPECIAC ISSUES INCLUDE
1. All the heads of the Training institutions at the State and Regional level do not have the
requisite experience and capability required for the posts. This necessarily has a bearing
on the various endeavours of the institutes. Where the top is shaky, non-confident, not
capable how much can one expect from the team.
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2.
The antecedents of the post of the Medical Lecturer Cum Demonstrator (MLCD) could
not be ascertained.
3.
Only Sixty percent of the personnel interviewed were able to understand the questions
asked and give appropriate response.
4.
Those who had cleared the Accounts Higher and General Law Part-I mentioned that it
gave them greater confidence and competency to handle
day-to-day PHC
A
administration.
5.
POL issue: POL was earmarked as per trainee per day. When the number of trainees
was 30 this amount would be sufficient. But when the number of trainees was less which
was usually the case the amount would be inadequate. This was more so, when the
number of trainees were 10 or 15.
6.
A finding which was disturbing was the "fees" paid to the staff of the training institutes for
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taking training sessions. Often about half the fees of an expert external consultant, the
need to pay these "internal" department/training institute staff is hard to justrfy/explain
considering that they have been employed to do training(’) and conducting/giving training
is their job! So if they are required to be paid additionally for conducting training sessions
of the various projects in their state or regional institutes then what is their salary being
paid to them for? This matter obviously calls for some justification.
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DISCUSSION AND CONCLUSION
a) The review of the Training programme for the government health care personnel gave an
unique opportunity and insight to the investigators to understand the existing machinery and
mechanics of the training programmes in the Department of Health. The interaction and
discussions with the implementing staff was not merely a methodology but also a
sensitisation and motivation session.
b) The
investigators found
themselves
with
mixed
feelings:
frustration,
indignation,
hopelessness in some areas and rays of hope, happiness and satisfaction where few
successful endeavours were being undertaken even in difficult circumstances. In general,
there was a sense of apathy and a casual approach towards training. The enthusiasm was
muted, existing as an exception. Training was expressed as an activity that “one had to go
through”: the unwritten expression being that training programmes were not always
necessary and that a pre-induction training in administration and medico-legal matters would
suffice. This outlook decreased the effectiveness of the training programmes. Participants
often looked at training as an “opportunity for change”, “to go out” - rather than a learning
and growing session. These naturally lead to enormous wastage of resources.
c)
Factors outside the immediate purview of the Training programme most often determined its
successful outcome - timely intimation, deputation and relieving of the personnel; the
payment of adequate TA/DA on time; the training facility (infrastructure / staff / equipment
including vehicle) available. A very critical determinant of success was the feeling of the
usefulness of the training programme by the trainee. In the absence of strict monitoring and
evaluation in general administration and with a relaxed disciplinary effort, training
programmes depended on the individuals perception rather than systems requirement. In this
regard, the Tubectomy and MTP training programmes were the main casualty.
d)
Most of the trainees were at the fag end of their careers or they would be unable to put their
training into practice.
e) A visit to the training institutions re-inforced the disappointment; the once premier training
institute at Ramanagaram was found to be in a derelict and dilapidated condition - a result of
neglect and abandonment of purpose. The available infrastructure at some of the regional
Institutes was also found to be inadequate and this could be one reason for their gross
underutilisation. The number of training days never exceeded 30 days in the previous
calendar year in all the training centers visited. Amazingly, the Heads of the Institutions
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-33clearly lacked the will and vision to take the issues forward and one wondered at the rationale
of their occupying such an important post. Whether it was because of past actions of their
predecessors or an inadequate support from the State level officials, it seemed they were
“resigned to their fate” and had accepted “reality” and “non-action” as the best recourse.
Obviously if the top level was not concerned, it is not surprising then to find the rest of the
staff lacking any motivation or interest even to undertake their routine training activities let
alone innovation.
f)
Often, Adequate and appropriate infrastructure was not made available after training. During
the skill development due to various reasons, hands on experience was either insufficient,
inappropriate or inadequate. In essence - “fooling ourselves” was the general feeling
amongst both the investigators and the “trained” personnel.
g)
Regional requirements for training were not considered and factored while framing the
curriculum or even during its implementation. Standardised syllabus had replaced the earlier
freedom to innovate.
h) The Training section has not received its due in the directorate except in the recent past, a
major reason being the lack of realisation of its importance in improving the quality of health
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care delivery services.
Another major reason was the lack of a forceful personality in
leadership role - an individual who could demand and obtain the necessary support and
finances for carrying out training programmes on a regular basis successfully. This led to a
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situation where the training section had hardly any funds and work to carry out. Even
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’’induction training" - so important for a proper orientation and grounding of new staff was not
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being carried out.
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With the World Bank financed projects setting its own training agendas and funding training
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programmes, routine training activities of the department took a back seat - leading to a lot of
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frustration and a sense of resignation and hopelessness amongst the senior staff of the
training section in the directorate.
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The limited time frame projects have demonstrated the need for training and given it the due
importance. Of course, once the project funding is over, training will need to be financed
from routine funding mechanisms of the department. There is therefore a genuine need to
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streamline the training section in the department so that it always receives its necessary
importance, priority and support.
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k)
At present the department has training institutes (State, Regional and District and ANM
training centres) where all State level training is carried out. In addition, institutes like the
National Tuberculosis Institute also cany out training activities for the state health employees.
The State and District level institutes have only recently been set up (in some districts - are
still being set up). The funding for this came from IPP IX / KHSDP. The training staff in the
directorate not having any budget for training purposes and the World Bank funded projects
being able to fund many training activities in these institutes has created a dichotomy of
interests in the department.
The training department staff posted in the directorate feel
completely bypassed and frustrated at these developments and their lack of information on
training facilities and activities was indeed surprising but not completely unexpected under
the circumstances.
I)
There is also an absolute lack of coordination of training activities - training being ad hoc and
project driven with no need based appraisals (including geographical distribution) being
carried out.
Und^r these circumstances - the setting up of new District training centres adds
an altogether new dimension in training funding and activities.
Being project driven, their
regular maintenance once the project period is over will be necessitated from the funds
allocated for training. Whether the budget at that stage will be able to absorb these additional
costs needs to be seen specially since in the past the funds allocated for training activities
were so meager and the priority given to training so low.
m) It is unlikely that training activities as envisaged and needed can be carried out unless an
estimated Rs.5 crores (only around 1% of the proposed health budget) are annually allocated
to training section (this amount excludes salaries to employees). With the projects showing
the way and giving training activities the necessary fillip and importance for improving the
quality of health services being delivered by the department, allocating funds for training (to
this amount at least) from the health budget should be done without any compromises in the
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future.
n) To streamline training activities of the department - a restructuring of the department staffing
and line of reporting is required.
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INFERENCES AND CONCLUSIONS
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TRAINING POLICY / FINANCING / PLANNING / ADMINISTRATION
1.1
There has been an absolute neglect of the training component in the department.
The approach of the directorate has been casual and not systematic.
1.2
There is an absolute paucity of “routine funds" with the training section in the
Directorate. This has lead to a lack of interest, hopelessness and frustration
amongst the training staff of the department specially in the Directorate
1.3
The externally funded projects have been able to give training a much needed
focus and importance. They have assisted in setting up of new training
institutions and provided the older ones with work and some "training funds".
1.4
The Training activity in the Department of Health and Family Welfare is "project
driven". At the stage of the development of the different Project Proposals there
has been noted a coherence of thoughts and activities for the Human Resource
Development for the Government Health Care Sector.
1.5
Transforming of the thinking into action has been delayed or has not been
achieved.
1.6
There exists no mechanism for centralised planning of training nor any needs
based inputs from the field.
1.7
There is no database of the training undergone by the government health staff.
1.8
The different programmes and projects independently conduct some degree of
needs assessment and plan the training activities. This leads to considerable
a
wastage of resources. (Same individual obtaining a repeat training in the same or
very similar area).
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1.9
very unfortunate that these institutions for excellence have been considered as
“accomodative posting centres” or “rehabilitation centres”.
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2.0
TRAINING INSTITUTIONS / ORGANISATION / EQUIPMENT
2.1
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There exists a network of training organisations right down to district level with a
great potential.
2.2
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There has been noted an indifference with regards to proper administration of the
training institutions. The Posting of the heads of these institutions seems to have
been undertaken without regard to the requirements of the training centre. It is
There exists human resources in the health sector who with adequate motivation
and training could convert these institutions into centers of excellence. What is
urgently needed is to match the needs with requirements and putting the right
person in the right position.
2.3
The postings at the training institutions are sought more for convenience and
selections are based more on “personal needs, ability to influence, etc.,“ than on
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abilrty to train. For many others, training institution postings meant "loss of
practice" and therefore was undesirable.
2.4
The training institutions are grossly underutilised. The SIHFW and the DTC are
new institutions and are yet to become totally functional. The RHFWTC continue
to be neglected.
2.5
The attention given to maintenance of the institutions is highly inadequate /
insufficient.
2.6
3.0
Key vacancies remain unfilled / gets filled with wrong personnel.
TRAINING NEEDS ASSESSMENT
3.1
There is no systematic comprehensive Training needs assessment undertaken at
any point of time and no training database exists.
3.2
The TNA when undertaken has not been correlated to the performance /
achievement of the individual health care personnel (even as evidenced by the
confidential reports of the department)
3.3
There is a need to delineate, specify and inform the personnel about the job
responsibilites.
3.4
TNA should also incorporate the infrastructure that would be necessary for the
trained personnel to effectively undertake specified endeavours.
4.0
FACULTY/TRAINERS
4.1
The Faculty in the training institution are demotivated and consider themselves
unfit either because they are not adequately qualified or prepared for the post
they are occupying or their training potential remains unutilised / grossly under
utilised.
4.2
A great felt need is the approapriate Training of Trainers in all the training
institutes. The JIPMER Model used for RCH ToT is an example of success.
5.0
TRAINING MANUALS
5.1
Multiple training manuals are being used for training purposes by various training
institutions.
5.2
These manuals need updating of information. By far and large, the manuals do
not present knowledge in a training format. Some of the flaws noted include lack
of training exercises, underutilization of newer methods of training methodology,
lack of learning objectives and non-interactive format.
5.3
There is a dire need to have a very thorough and detailed analysis of the various
manuals that are presently being used for training purposes. They need to be
made more user-friendly, have a greater self-learning component and more
-37practical and field based exercises. The NIHFW has recently come out with the
updated versions of many of their training manuals incorporating the latest
programmatic changes. The training institutes have already been provided with
copies.
5.4
The contents in these manuals seemed to be more theoretical and lack focus
and emphasis on the field situation and ground realities.
5.5
With a change in focus of the concerned programme the training institutes
commissioned new training manuals. With programmes constantly evolving,
frequent changes lead to repeated trainings with very few new learning additions.
However, the manuals get redone with slight modifications for almost all new
training courses.
6.0
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7.0
TRAINEES
6.1
There is a demand for Induction Training and Promotional Training by most
health care personnel - both medical and paramedical.
6.2
There is also an expressed desire for regular periodic Continuing Education
programmes.
6.3
There is a need for improving the facilities given to the trainees including TA/DA,
Resource materials, quality of hostel accommodation, food, etc.,
FEEDBACK / FOLLOW UP / MONITORING
7.1
The existing system of monitoring and feedback is limited to Post-Test
assessment related to the subject matter. No long-term or application of skills
monitoring is carried out at present.
7.2
There exists no monitoring of the Training programmes and activities of the
training department save for the budget spent.
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RECOMMENDATIONS
The RECOMMENDATIONS have been made based on the following:
a) Observations made by the investigators during their personal visits
b) Discussions with the concerned health care personnel.
c)
Information from the analysis of the Self-Administered Questionnaire.
d)
Records and documents that were shared by the concerned officials with the investigators.
IDEAL (Desirable) TRAINING SCENARIO for Department of Health, Government Qi
Karnataka
A] THE STATE INSTITUTE OF HEALTH AND FAMILY WELFARE
1. The State Institute of Health and Family Welfare becomes the apex training institute as well
as an institute of excellence.
2. It is completely autonomous and the funds for its activities and maintenance are to be
allocated from the Health and Family Welfare Department Budget directly.
3. The Institute will have a Director at the helm and this post will be a selection post with all
the perks and privileges that are offered to a person of this level. Its tenure will be for a
period of 5 years. He will report to the Health Secretary directly. The person occupying
this chair should have a medical degree and should also have training and experience in
medical education and training of trainers. Ideally, the individual should have spent some
years working at various levels in the department in the field.
4. A Deputy Director will assist the Director with various administrative and technical matters.
The post of the Deputy Director should be a selection post with requirements similar to the
Director's post and should have a tenure of 5 years.
5. The institute should have a full complement of training, administrative and supportive staff
with appropriate qualifications.
6. Considering the importance of social sciences and communication skills, the institute
should have either full time or part time staff for these departments or engage the services
of experts as and when required during training sessions.
7. The institute should have all necessary training equipment and facilities including teaching
space and identified field training centres.
B] THE REGIONAL HEALTH AND FAMILY WELFARE TRAINING CENTRES AND THE
DISTRICT TRAINING CENTRES
1.
The Regional Health and Family Welfare Training Centres and the District Training
Centres would administratively be under the State Institute.
2.
Their budget will be released by the State Institute.
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3.
Their activities to be based on local needs and practices and to be planned and
coordinated by the State institute.
4. At present there are 2 Regional Institutes in the Northern (West and East) and 2 in the
Southern part of the State.
There are none in the Central part of the state. This
anomaly needs to be rectified. Also, not all 27 districts have a DTC. Since the activities
of a DTC are different from the RHFWTCs each district needs to have its own DTC or the
RHFWTC should also undertake the activities of the DTCs without compromising on
quality in districts where RHFWTCs exist but where there are no DTCs. However, the
State needs to keep in mind the recurrent expenditure of so many institutes and based on
neeeds appraisal if it is determined that 2 districts can share one DTC, for practical
reasons and long term effective functioning, recourse to this may need to be taken and
the plan of having so many DTCs reconsidered.
5.
The DTCs based on Needs Assessment will identify the training requirements of the
district and forward this to the state institute for necessary plan of action. The DTCs will
also directly oversee the functioning of the ANM training centres in their districts and
provide all the necessary support.
6.
As in the state Institute, all necessary facilities and equipment need to be provided to
these institutes at the earliest for their effective functioning. At present, many of them
lack basic teaching aids and educational materials.
The effectiveness of these institutes will depend to a large extent on its human resources.
The training institutes should be allotted staff based on qualifications or appropriateness
and not on personal needs, contacts and political influence and the ability to take care of
extraneous criteria (read favours). Merit and appropriateness should be the only criteria.
Abundant precautions to be taken to ensure that these training institutes will not become
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the islands of inefficiency they have been for so many years.
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8. With the formation of the DTCs, many of the training activities can now be done at this
level. This will require careful coordination and supervision to ensure quality of training.
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9. The Principals of these training centres should be selected with great care and should be
given the right administrative and technical training themselves at the State Institute prior
to their taking up these posts. This is important as very often they will be directly involved
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in training activities besides having adequate administrative duties.
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10. Regular upgradation of knowledge and training skills, revision courses, as and when
programmatic changes are introduced should be mandatory for all staff of all training
institutes.
C] PLANNING THE TRAINING PROGRAMMES
1.
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A committee consisting of the Director - State Institute and all Additional Directors of the
Health Department will identify the training needs, prioritise activities and prepare the
budget for training activities.
-402.
The Director of the State Institute will be the Secretary of this committee and will be
assisted by the Deputy Director in formulating and drawing out the master plan of
operations (based on the needs identified by the committee).
3. Approval for the formulated plans will be put forward during the committee meeting where
the Health Commisioner/ Director General of Health Services are also invited.
4.
Approved budgetary funds will be sought from the State and handed over to the State
Institute for implementing the training activities.
5.
To carry out the planned training activities funds as required will be made available in
addition to the funds earmarked for training purposes in different programmes (e.g.
Malaria, RCH, Tb. etc.).
6.
The training needs of the different funding programmes will be respected and honored.
However, to enhance effectiveness of training, avoid duplication and to cut down on
unnecessary expenditure on travel, DA, etc., wherever feasible multiple training will be
carried out in one training programme.
7.
Rigorous district and person wise data of all training undergone will be maintained and
computerised. This is to avoid wastage of resources and to ensure that everybody
undergoes training and not just a favoured few (as is the custom very often now - same
people going for different training programmes whereas many others never obtain a
chance to enhance their skills).
8. This Information system on training will be maintained District wise at the District level
and at the State Institute and Directorate. When a staff member moves out of the district
to another district, necessary changes will be made and constantly updated.
9. The committee now decides on training, This therefore means that there is no need to
have a separate training section in the Directorate - its functions being taken over by the
State Institute, its Director and the Training Committee of the Department. Adequate
support from all necessary sectors in this scenario should be feasible. Unlike the present
situation where funds are never or meagerly, miserly provided.
10. It will be advantageous to build up our training resources and institutes and depute staff
for training in such places. At present, because of lack of training facilities many of our
staff are deputed out of the state for training purposes. If the training is done within the
state we will strengthen and build up our own systems, strengthen our resources, and
provide training in our environment using case material which is similar to what they will
ultimately see.
11. As far as possible all training should be done within the state or at the most in some
training institutes within the country. There is an unnecessary clamor for foreign training
postings. Today, our country offers almost all training and skills required for the effective
training of its staff or for the provision of quality health services. No carrots in the form of
foreign training sessions are called for. With the money spent on such training a lot more
can be achieved and many more people trained. Very often staff are posted for short
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-41term observation training. When the conditions and environment are so different and
where training is “NOT SKILL BASED ACQUIRING OR HANDS ON", SUCH TRAINING
OUTINGS BECOME ONLY OUTINGS RATHER THEN KNOWLEDGE/SKILLS
ENHANCERS. In all fairness, good training opportunities with full scholarships are
offered by international agencies like -WHO, Commonwealth organization, etc.. It is a
shame to see such useful training opportunities being wasted because of non
recommendation of names on time or processing of papers on time or staff being
released on time. Full use should be made of such opportunities for professional
enrichment. The State institute should have information of all such scholarships
availability and should decide the staff for deputation for such training courses.
12. A major advantage in having the training programmes within the State is that the training
can be done in Kannada using Kannada speaking patients and families which makes it
much more easier for the participants to understand and absorb.
Less financial
resources will be required for such state conducted training and the resources saved
could be utilised for further strengthening of our institutes.
13. Wherever the training is “technical" or the observation invite for technical matters "technical" people (and not non-medical - non-technical administrators) are to be
sent/deputed for such courses.
There is merit in this recommendation.
Our
administrators are made to change departments quite frequently. Sending them for such
sessions then is absolutely non-productive to the department as the technical training in
the health sector (presuming that they are capable of absorbing the technical nuances
involved) is not going to be of use to them in another department like sericulture or
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WAKF. However, if the training is for strengthening administrative related skills the
administrative staff should make full use of such scholarships.
14. There is an immediate identified need of training for about 470 Block Health Educators.
Instead of deputing them in small batches to Gandhigram (and take years to complete
the training for all of them), one of the Regional training institute could be strengthened
and provided the necessary infrastructure and human resources to carry out this training.
All further induction training for BHEs could subsequently be carried out in this centre.
Such judicious distribution of training activities is very necessary for optimal utilisation of
limited resources.
15. Distance education methodology is a grossly underutilised training facility in our state.
Today such education facilities from reputed organizations like IGNOU, Jamia Millia,
Manipal, is available in many health areas. They are well planned and so structured that
they are practically useful to the trainees. The government should encourage such
training and as an incentive offer one time payment of a lumpsum amount (one month’s
salary?) for every distance education course of 6 or more months duration completed
successfully by the staff to a maximum of two such courses. In fact, once these
universities offer more and more health related administrative, managerial and technical
courses, the Government should make this a mandatory condition for promotion to a
higher grade after a certain level of promotion.
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-4216. For effective training to be done it may be necessary to tap the services of an outside
expert. This is a must where institute staff lack the necessary knowledge/skills. It is
therefore highly desirable to identify the right "consultants" and have a resource base of
such individuals. Care must be taken to see that such consultants have the necessary
field experience, as very often such “experts" tend to be very theoretical or out of tune
with field based reality. However, having said that, care must also be taken to ensure
that all such expert consultants are not retired staff from the Department. They do not
necessarily make the best experts and the "buddy system" may not be the best way to
utilise the limited resources of the training section.
17. Strengthening Public Health training is the need of the hour. The well planned and useful
DPH course - post MBBS, had very few takers as it was not advantageous career wise
to do such courses and over a period of time the number of seats available for such
training decreased. That DPH was no longer a necessary criteria for promotion to higher
categories gave it a final blow. It is only recently that the Government has once again
realised the need for such training for its staff. At present the medical colleges do offer a
few seats. The Department should plan for the future and provide this training at the
State Institute. The modalities need to be worked out with Rajeev Gandhi University and
necessary support for the infrastructure and resources sought so as to start these
courses by 2005 at least.
There are many advantages to the above suggestions. Not only will less staff be required
but there will be less friction as now only one agency - the Training Institutes and its staff
are involved in training activities. The Director - State Institute with a lot more independent
charge will have no hindrance from Directorate training staff as there are none envisaged
in the above proposal. Even though there is no representation of training staff based in
the Directorate, the Training Committee is formed with representatives of all sectors who
are based in the Directorate. This committee advises the Director State Institute on
training activities and approves the required budget. This hopefully should be more
effective, less competitive, frictitious and threatening. The above proposal though radical
and quite different from the present scenario is being recommended so as to provide a
more long term commitment, sustainability and effectiveness to the training programmes
in the Department. Training is best left to trainers. True. But what is also very necessary
for training to succeed is to have a coherent and not divergent/competitive viewpoints as
very often happens under the present structure because of fragmentary funding and
training activities as well as multiple implementing sectors.
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1. TRAINING POLICY / PLANNING / FINANCING / ADMINISTRATION
a. The Department of Health and the Directorate of Health and Family Welfare need
to spell out their Vision, Policy, Goal and Objectives for a comprehensive Human
Resource Development particularly for training its personnel.
b.
The Department of Health and Family Welfare needs to set up a functional, co
ordinated, central mechansim to assess the systems training requirements and
its monitoring.
2.
c.
There is a need to set up mechanisms to undertake both internal and external
evaluation of its training programmes.
d.
There is a need to streamline the administration and functioning of the training
activities sub-centre upwards.
e.
For achieving the planned training activities, an exclusive financial support to the
extent of 0.5 to 1% of the total budget of the health department should be made
available.
TRAINING INSTITUTIONS / ORGANISATION / EQUIPMENT
a. The SIHFW should be mad., functional as an apex, nodal centre and an
institution of excellence. All the existing Training Institutions to be administratively
and functionally linked up to perform as an effective organization under the
leadership of SIHFW.
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b.
a
The existing RHFWTCs should be strengthened and steps taken to ensure their
adequate utilization.
c. The existing DTCs need to be made functional at the earliest.
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d.
Prioritisation of allocation of limited resources would very much be required so as
to achieve its efficient and effective utilization, specially since the number of
training institutions have now increased.
e.
There is an urgent need to address the release of funds for repairs and
maintenance of the institutions including non-functional but repairable equipment
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in the existing centres.
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3.
A uniform standard of personnel and equipment need to be specified for the
training institutions across the State.
TRAINING NEEDS ASSESSMENT
a.
The TNA should be taken up systematically for all levels and should be co
ordinated with the Individual Performance assessment of the health care
personnel.
H
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b.
Health Management Information Systems HMIS) need to be put in place on a
priority basis for the training needs and training undergone of all health care
personnel. This has to be generated from the district level upwards and the
information base and accession should also be made available district level
upwards.
4.
FACULTY/TRAINERS
a. Only individuals with relevant and appropriate qualifications and experience
should be posted to these centres.
b.
All the faculty including the heads of the institutions should undergo a pre-posting
training in Educational Technology before taking charge of their posts.
c. The Trainers should be given a periodic refresher course to upgrade their
knowledge and skills.
d.
More models like the JIPMER model need to be immediately formulated and
implemented. This is all the more necessary considering the spurt of training
activities planned for in the coming months and recruitment of staff for the newly
established DTCs.
e.
Consultants should be empanelled for key support areas of training like
Communication, Social Sciences, Statistics, etc., at each training institute. These
consultants are to be chosen on their merits and experience in training. They
need not necessarily be selected from retired or functioning government officials.
f.
The Training activities of all trainers including consultants should be evaluated for
each session not only by the trainees but also by institute staff and feed back for
making the necessary changes provided.
5. TRAINING MANUALS
a. There is a dire need to have a thorough and detailed analysis of the various
manuals that are presently being used for training purposes. They need to be
made user-friendly with a greater emphasis on self-learning and more practical
and field based exercises. The manuals need to present knowledge in a training
format and not as textbooks or guide books. Training exercises, presentation of
knowledge in a format which would be easy for the trainees to absorb, newer
methods of training methodology, stating of learning objectives and essential
knowledge and use of interactive format are required.
b.
A set of essential training manuals should be provided to all training and health
care institutions including PHCs. Appropriate mechanisms for their storage and
safety at these institutions need to be worked out.
c. A process needs to be evolved that would make it feasible to update the manuals
with the additional inputs / changes rather than completely redoing them with
!
-45changes happening in the programmes. This would result in saving of precious
resources.
d.
Whereever feasible, the training manuals instead of being freshly written should
be adopted / adapted from existing manuals on the same or similar subjects.
6.
TRAINEES
a.
Trainees should be released on time, and they should report at the beginning of
the training course. Very often the introductory sessions are the most important
sessions in the training programmes and missing these sessions greatly
weakens the effectiveness of the rest of the training programme. Also the
trainees should be present through out the training course. Mechanisms to make
this feasible should be developed and instituted (for example linking the monthly
emoluments to the successful completion of the course as per defined
parameters).
b.
Induction Training and Promotional Training to be made mandatory for all
categories of Health Care Personnel.
c. Follow-up mechanisms should be instituted to assess the post-training
performance of the individual trainees periodically.
7.
7
FEEDBACK / FOLLOW UP / MONITORING
a. A system of immediate Post-training assessment regarding the training
d
TF
programme needs to be carried out. This should look into subject matter,
methodology of the training and effectiveness of the faculty. A system needs to
be instituted for the reporting of feedback to the concerned faculty and action
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taken on the post-test assessment.
b.
a
A periodic (once in three years) review / evaluation of all the existing training
programmes for the health care personnel should be undertaken. Evaluation
also needs to be carried out whenever any new component is added to the on
going training programmes.
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c.
The performance appraisal (Confidential Reports, etc.,) of the individual staff
should include the training undergone and identify further training needs.
An effort has been made to define the vision, goals and objectives
for the department. This needs to be adopted with appropriate
modifications by the department so as to increase the commitment
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towards training. Also given below is the outline of a proposed
pilot endeavour for training activity in one division.
-46VISION, GOALS AND OBJECTIVES FOR TRAINING ACTIVITY FOR THE
Department of Health and Family Welfare, Government of Karnataka
VISION
To provide technically competent, socially relevant, appropriate health services to the
fullest satisfaction of the people of Karnataka.
GOALS
By 2002, January every health care personnel who joins the government health service will
receive induction training.
By 2005, every health care personnel will receive the identified and necessary refresher
training and skills up-gradation.
By 2010, systems are in place for the conduct of regular, ongoing, continuous refresher and
induction training with adequate provision of resources.
OBJECTIVES
1. Preparing the individual’s competence by enhancing communication skills and learning
capabilities that are necessary for managing the day-to-day t. Jtivities of the health centre
and for delivery of quality health care in accordance with the existing health programmes
and local health situation.
2.
To nurture and enrich the organisation culture which supports and enhances team effort,
harmonious interpersonal relationship, pursuit of excellence, spirit of enquiry and
innovation as a way of work life and to create an organisation environment where each
can share and contribute towards achieving the shared goals.
3.
To create sensitivity to the needs of the society, discharge the multiple roles and
responsibilities and fulfill the obligations as a health care provider.
4.
To help and support each individual to develop their potential to realise their self-goals
while contributing fully to the success of the organisation.
5.
To achieve synchronisation of the goals and aspirations of the individual, organisation
and society.
6.
Enhancing preparedness for willing participation in development activities which have a
bearing on health of the community.
7.
Facilitate building a strong character of integrity, honesty and leadership.
PILOT ACTIVITY
It is absolute necessary that any radical surgery is attempted a pilot endeavour be
planned in a smaller sub system which provides for opportunity and facilitates for an
adequate and in-depth learning of the crisis management in the system. Additionally,
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-47this approach accomplishes the much-needed involvement of a larger select group of
the system who, are the stakeholders for change.
The following needs have been considered while formulating the Pilot Activity of the Team of
Excellence in Training (TOEIT).
a)
There is a need for co-ordinated decentralised planning for the endeavours
towards Training. This includes Training Needs Assessement, framing of the curricula
and identifying the resources at each level of training before implementing the activity.
b)
The State Institute of Health Family Welfare to be recognized as the apex and
premier Institution for training in the state. The RHFWTC and the DTCs to be identified as
the regional and peripheral wings of the apex institute.
c)
The existing organisation structure of the Training “wing” of the department
needs to be restructured. There should be a similar staffing pattern at the three levels District, Division / Region and State. There should be a well laid out and comprehensible
hierarchy with specified responsibilities. The lines of authority with their attendant network
linkages to be identified..
d)
The system also needs to factor the future training requirements of the state with
regards to the health sector.
The following points delineate the components of the proposed Pilot endeavour for Training
activity. The final Plan of Action may be arrived at after further consultations.
1. Gulbarga division to be the focus of the endeavour.
.1
2. The Divisional Joint Director, Gulbarga to be the team leader for the activities. Twenty
to twenty five members selected from amongst the existing staff / faculty / officials in
the Division would constitute the TOEIT.
3. Necessary support could be drawn from the District Training Centres, the Regional
Health and Family Welfare Training Centre and the State Institute of Health and
Family Welfare.
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4. The current research team would be the key facilitators for the endeavour.
5. The Task Force on Health and Family Welfare and the team involved in the preparation
of HNP Policy for the Department of Health and Family Welfare to facilitate and also
provide the required technical inputs.
6. The TOEIT would undertake a systematic training needs assessment in the division
keeping in mind the existing realities of service delivery, the proposed activities of the
department and the future requirement of the system.
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7. The TOEIT would then involve themselves in the preparation of the curriculum,
methodology (including identification of resource persons, resource materials and
training environment) and schedule for the training for the next three years. They
would also prepare the required annual and total budget for the endeavour.
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8. The Pilot Activity would be monitored on a regular and pre-identified intevals and will
be based on suitable indicators (both qualitative and quantitative).
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B
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EVALUATION OF TRAINING PROGRAMMES FOR GOVERNMENT HEALTH CARE
PERSONNEL IN KARNATAKA
HEALTH WORKERS (FEMALE) AND HEALTH ASSISTANT (FEMALE)
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INTRODUCTION
Health status of people in India has shown remarkable improvements during the last two
decades. The Crude Death Rate (CDR), Infant Mortality Rate (IMR) and Crude Birth Rate (CBR)
have shown sharp fall and key health indicator 'Life Expectation at Birth’ which was about 42 in
early Fifties has crossed 60 years in the early Nineties. Wide differentials across states in India,
however, have persisted throughout suggesting the need to take corrective measures to bring in
much desired equity in health to reach the goal 'Health For All by 2000’ India has committed at
Alma-Ata in 1978 (See Table 1 for differentials).
The data presented in Table 1 clearly brings out the fact that Southern States - Kerala, Tamil
Nadu, Karnataka and Andhra Pradesh have shown relatively better performance as compared to
Hindi speaking BIMARU States - Bihar, Madhya Pradesh, Rajasthan, Uttar Pradesh and Orissa.
Wide differentials within state by rural-urban residence, gender and social class exist across the
Districts. The Human Development Report 1999 - Karnataka provides CDR, CBR and Life
expectancy at Birth for all the districts that reveal the differentials. IMR another sensitive health
indicator shows that Dakshina Kannada reported the lowest IMR (27) in the state while Gulbarga,
Bijapur, Bellary had IMR about 3 times higher than Dakshina Kannada district. There is other
strong evidence to support the IMR estimates - institutional deliveries in Dakshina Kannada
accounted for 77 percent while in Gulbarga it was only about 27.9 percent suggesting the strong
negative association between IMR and institutional deliveries - safer deliveries.
TABLE 1 : HEALTH SITUATION IN INDIA AND SELECTED STATES
d
State
Maternal
mortality
ratio 1986
CDR1996
IMR 1996
s
1
l
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CBR
1996
R
U
T
R
U
T
India
77
46
72
9.7
6.5
9.0
580
| 927
| 27.5
AP________
Karnataka
Kerala______
Tamil Nadu
Uttar Pradesh
Rajasthan
MP________
Bihar_______
Orissa
73
63
13
60
88
90
102
73
99
38
25
16
39
67
60
61
54
65
65
53
14
53
85
85
97
71
96
9.2
8.6
6.3
8.7
10.7
9.6
11.8
10.6
11.2
5.9
5.4
6.0
6.6
8.2
7.1
7.6
6.9
7.5
8.4
7.6
6.2
8.0
10.3
9.1
11.1
10.2
10.8
394
439
247
372
920
627
507
813
844
972
960
1036
974
879
910
931
911
971
22.8
23.0
18.0
19.5
34.0
32.4
32.3
32.1
27.0
934
934
23.4
25.7
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Sex
Ratio
1991
7.4
439
48 8.7
5.4
58
31
Maharashtra
373
7.6
6.2
8.3
68
46
61
Gujarat_____________________________________________
Source: 1) Family Welfare Programme in India, 1996-97, Government of India.
2) Mari Bhat P.N., 1995.
The latest data-set (1998-1999) collected in National Family Health Survey and Reproductive
and Child Health Survey (NFHS II and RCH) provide valuable insights for effective policy
-50interventions to reduce the disparities across districts by rural-urban residence, social class and
gender Findings from both the surveys suggest that the out reach services of maternal and
child health hold the key to bridge the differentials and these services are to be delivered by
Female Health Workers popularly known as Auxiliary Nurse Midwives (ANMs) and Lady Health
Visitors (LHVs).
The Present Study
The present study is an attempt to examine the role of these grass root level female health
workers and adequacy of their training to discharge their responsibilities satisfactorily that can
help to reduce considerably the disparities observed across districts.
Objectives
Taking into consideration the major midwifery responsibilities assigned to the ANMs and LHVs
after a rigorous foundation training of 18 months the study proposes to achieve the following
objectives.
To examine the knowledge of ANMs regarding the Ante-Natal care service and its
•
delivery to pregnant woman.
.
To assess their knowledge of identifying the high-risk pregnancies and ensuring safe
delivery that will help to reduce maternal mortality.
•
To examine the knowledge of supplementary nutrition to be advised and supplied to all
pregnant women to reduce malnutrition.
•
To examine their knowledge of identifying high risk infants and measures to be taken to
ensure their survival to reduce IMR further.
•
To identify inadequacies in the training of ANMs/LHVs if any, and suggest corrective
measures.
The Sample
The study was conducted in three districts of Karnataka that differ widely in indicators relevant to
reduce IMR and MMR. These indicators were drawn from the RCH Survey (First Phase Kanbargi et.al., 1998). They are :
•
Percent women who received full Ante-natal care package (At least 3 ANC visits + 2TT
injections and 100 IFA Tablets)
•
Percent institutional deliveries.
•
Percent children in 12-23 months age who did not receive any immunization.
•
Percent women who had knowledge of all modern contraceptive method.
Based on these criteria following three districts were selected.
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District /
Full ANC
Institutional
State
(percent)
deliveries
(percent)
1
£
3
Children not
immunised
(percent)
Family
Planning
knowledge
of
all
modem methods
Percent________
Udupi (DK)
78.9
76.6
0.5
70.7 ___________
Tumkur
0.5
68.7
48.4
40.8 ___________
Gulbarga
21.2
27.9
31.1
27.2___________
State_________________________________________________________
_
52.2
52.4
8.3
46.1
Source: Rapid Household Survey RCH, 1998, Kanbargi el Al.
The three Districts selected differed maximally in several other variables also. For example the
percent girls marrying before 18 years - legally approved age was highest in Gulbarga about 59
percent, 29 percent in Tumkur and only 5 per cent in Udupi (which was part of Dakshina
Kannada then. We selected Udupi District based on the data of Dakshina Kannada district as
data for Udupi are yet to be made available. The observed early marriage and its impact on
CBR is clearly reflected in these districts (Gulbarga 32, Tumkur 24.7 and 21.4 in Udupi).
The three selected districts - one highly advanced - Udupi, one with medium progress - Tumkur
and one backward - Gulbarga in terms of demography and health would be able to provide
insights sought in the functioning of the ANMs and LHVs in the state. For data collection 8
Taluks 22 PHCs and 87 sub-centres were selected randomly. The following table provides these
details.
TABLE 3 : THE STUDY AREA
District
Taluks
f
Udupi
Tumkur
Gulbarga
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Total
Udupi
Kundapur
i) Gubbi
ii) Madhugiri
iii) Kunigal
i) Afzalpur
ii) Gulbarga
iii) Chitapur
8 Taluks
PHCs
SC (ANMs)
8
26
6
41
8
20
22 PHCs
87 ANMs
Methodology
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The relevant data was collected from all ANMs available in the selected PHC/Sub-Centres by
employing survey methodology. A standardised questionnaire was constructed for administering
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to each ANM/LHV in the selected PHC/Sub-centre. The administering of the questionnaire was
preceded by a brief introduction about the survey and assurance that the information collected
will be kept confidential and used only for research purpose. In PHC we met the medical officer
(MO) and other staff present and briefed them about the study. We assured all that they will not
be harassed by Health Department or any authorities for sharing their honest views on the
functioning of the Health Care Services.
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-52There were focus group discussions to get insights in the functioning of the Institutions that
provided valuable information.
This information is exploited to supplement the hard data
collected in the survey.
Each questionnaire administered to ANMs/LHVs took over an hour. The interviews were
abrupted often when many ANMs broke down who were to be consoled to start the interview
again. The respondents reported that it is first time in their entire service someone is enquiring
about their problems and welfare. When they were asked whether they would be happy if their
daughter (those having one) was offered ANMs job, it was revealing that most of them reported
that they do not mind if their daughter goes for agricultural labour but they don’t want them to
become an ANM like their mother. It indicated harsh working environment they are situated in,
their frustration and helplessness.
Data and Analysis
The brief profile presented in Table 4 suggest that most of the Female Health Workers are
currently married, have at least 10 years of schooling and in their middle ages with tong
experience. As there are limited opportunities of advancement in the career they feel dejected
struck with the same work for years. Those who were on the verge of retirement were eagerly
looking forward for the day to free themselves and lead a relaxed life.
TABLE 4: FEMALE HEALTH WORKERS IN THE STUDY AREA :
A PROFILE (87 ANMs and LHVs)
1
Below 40
49
41
58
50
2
Per cent
33
23
35.6
37.9
26.4
04
77
06
4.6
88.5
6.9
11
17
13.3
20.5
41
14
49.4
31
Marital Status
Single
Currently Married
Widowed/Divorced
3
Frequency
_______ Variable
Age (years)
No.of living children
0
1
2
3+
16.9
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-53TABLE 4: FEMALE HEALTH WORKERS IN THE STUDY AREA :
A PROFILE (87 ANMs and LHVs) (continued)
4
_______Variable
Education
Below SSLC
SSLC Pass
PUC
PUC +
5
Frequency
Per cent
18
54
11
04
20.7
62.1
9
22
39
17
10.3
25.3
44.8
19.5
12.6
4.6
Length of Service
(in years)
Less than 5
- 14
- 29
30 +
One of the major problems faced by the respondents was shortage of housing - only 40 percent
of them had housing facility provided by the Government, whereas 23 per cent of ANMs were
residing in rented houses in the sub-centre villages. Another 23 percent were in a rented house
in the sub-centre village and the rest 37 percent were commuting to their place of work that
required about an hour. Udupi had an excellent net work of public transport with very good road
that was found to be a very important factor to improve accessibility to health care services
whereas Gulbarga had bad roads or no roads and poor public transport that badly affected easy
accessibility. Tumkur can be placed in between these two districts with some area with good
roads - Kunigal section whereas Madhugiri was having serious problem of roads and public
transport. It would be of interest to mention here that during our visit to observe an ANC camp at
a sub-centre village in Gulbarga we had to leave our car at a point and hire a Land Rover jeep to
reach the Sub-Centre as the road was full of boulders and ditches which only jeep could
negotiate with great difficulty. To cover a distance of 15 kilometers it took an hour at high cost.
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Lady Health Visitors have to supervise the work of ANMs. In the study area we could get only 10
LHVs who had to cover on an average 40 villages in addition to their administrative work of
compiling service statistics from each ANM on maternity, immunisation, etc. The fact as reported
by both LHVs and ANMs is that supervisiorVwork monitoring in the villages has almost ceased to
exist. Many senior ANMs recalled that when they joined service they had to cover larger areas population but they used to enjoy the work. There was a team spirit, co-operation and guidance
from M.O and DHO. Work was taken very seriously. The Medical Officers provided home visits
to sterilised cases for follow-up services. Deliveries were supervised and post natal care then
was good. Now hardly anybody bothers about supervision and monitoring. ANMs feel lonely
and helpless in the job as there is neither any help nor guidance and no supervision but if
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anything goes wrong they will be held responsible. The information collected from ANMs show
that exceptionally large number of villages 11 to 18 villages were to be covered by 13 ANMs in
Tumkur. Whereas in Udupi and Gulbarga despite vacancies that add burden to ANMs work they
were found to be covering about 3-4 villages as size of population is large. As over half of the
-54ANMs were natives of the same district they were quite familiar with sociology and culture of the
area. While more villages add only to travelling time, size of the population, average number of
couples to be served in RCH seem to be well within manageable limits of ANMs with very few
exceptions.
The Foundation Course
The female health workers have to complete the foundation course specially designed for them
to be eligible for consideration for the job. But some had 2 years training while over 80 percent
had completed 18 months course at different District Head Quarters. Surprisingly it was found
that there was a long time gap before they got the job. About 20 percent had joined after 3 - 4
years of their completion of the course and they took considerable time to refresh their training
skills they had almost forgotten. Indeed, 6 ANMs had joined service after 5 years gap. In
addition to the foundation course LHVs have to undergo another 6 months training to become
LHV.
They were asked to assess the quality of their foundation training course in terms of (a)
Curriculum (b) Duration (c) Regularity of Faculty (d) Quality of training (e) Practical training in
hospital and (f) Practical training in the field. Their response was classified in 3 categories. The
distribution of r ^ponses are reported below.
TABLE 5 : ASSESSMENT OF THE FOUNDATION TRAINING BY
THE TRAINEES (PERCENT)
_______
Poor
Fair
Good
1
2^
2
£
6
Curriculum________
Duration__________
Regularity of Faculty
Quality of training
Practicals in hospital
Practical in field
78.2
34.5
70.0
24.1
19.5
25.3
15.0
63.2
25.3
64.4
57.5
59.8
2.3
2.3
8.0
19.5
11.5
Can’t say
4.5
2.3
2.3
3.4
3.4
3.4
It is to be noted that 18 months duration is divided as 12 months theory and 6 months practicals
in hospital and field. The majority of ANMs (63.2 percent) considered that duration was too short
as they had to complete 10 theory papers. It is also reflected in the assessment of practicals in
hospital as 57.5 percent reported that on job training was too short to master the art of good
midwifery. Almost 60 percent felt that the field training that forms the most important component
of their job was inadequate.
Majority of the ANMs opined that the curriculum is good but heavily biased towards theory
whereas most important for their job is field work where they have to manage themselves with
midwifery that put heavy responsibility. Communication skills which they need most in their field
work was found to be lacking. It seems there is an assumption, that all ANMs have that skill.
During discussion with ANMs we asked how confident they were when they conducted the first
delivery of their career. Majority response was they were very shaky. Few were fortunate to
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-55have a LHV who was good to instill confidence in them giving guidance in the conduct of delivery
that went a long way in building their confidence. But many were not that fortunate but could
manage the situation without any serious problem.
How the training received several years back is relevant now? Several respondents mentioned
that except midwifery hardly anything is relevant. AIDS, RCH, Target free approach are all new
and are relevant now.
More skills are required for day to day work and to recorded them
properly in the registers provided.
SECTION I
In this section we have tried to review the training programmes that respondents have completed
and how they perceived their utility in their day to day work. The major programme in this regard
was the Child Survival and Safe Motherhood training followed by several other short term skill
knowledge enhancing programmes.
Child Survival and Safe Motherhood (CSSM) Training
Reduction in maternal and child mortality was highlighted in the National Health Policy 1983.
The sustained high levels of immunisation programme that increased contacts of female health
workers with women and children demonstrated that about 2million children were saved durin~
1984-92 (the difference in child mortality rates of 1984-92 which was monitored). It was followed
by Universal Immunisation Programme that envisaged that every child would be protected by all
the preventable killer diseases of children.
j
In order to accelerate the declining trends observed in child mortality 'Child Survival and Safe
Motherhood’ programme was launched in August 1992. It was fine tuning of the earlier
programme with emphasis on quality and outreach. It is very relevant for this study to consider
the objectives of CSSM programme and examine the ANM/LHV training impact on their
performance.
The CSSM had set the following goals:
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1. By 1995
a) Eliminate neonatal tetanus.
b) Reduction in Measles by 90 percent, deaths by 95 percent.
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2. By 2000
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a)
Elimination of Poliomyelitis.
b)
Reduction in diarrhoea deaths by 70 percent.
c)
Reduction in ARI deaths by 40 percent.
d)
Reduction in maternal mortality to 2 per 1000 deliveries.
e)
Reduction in IMR to 60 or less per 1000 live births.
f)
Reduction in under 5 mortality to 10 per 1000 children under 5 years of age.
g)
Reduction of perinatal mortality to 35 per 1000 births.
-56In order to equip the Female Health Workers for the huge programme massive training
programmes were launched in the states began. An earlier study conducted in Karnataka that
covered Channapatna and Hoskote Taluks (all PHCs and Sub centres) found that CSSM training
given to ANMs/LHVs had significantly improved their midwifery skills and improved immunisation
in the area resulting in reduction in IMR (Kanbargi, 1997).
In the study area only 60 percent of the respondents had undergone CSSM training.
The
duration of training varied between 3 days to 21 days at different locations where the training
was imparted. It was not possible for us to verify the wide ranging duration and the reasons for
it.
However, most of the respondents expressed their appreciation for providing training that
refreshed their memory. There is hardly any continuing education programme for them. An
important fact that came out during the study was how CSSM changed some age old practices
that were routinely followed. For instance, babies were given bath soon after birth that often led
to complications. The CSSM training has changed it. Now baby is kept warm for a day before
giving bath. This practice may reduce considerably the incidence of diseases peculiar to
childhood. The training also, as reported by all those trained, enhanced their knowledge on
ANC, PNC and midwifery skills many of whom had learnt 20-25 years back. The five cleans or
Pancha Shuchitwa was very much valuable learning. Some of the respondents expressed their
happiness that CSSM training not only improved their skills but was accompanied by a booklet
and a Disposable Dai Kit (DDK). The booklet which should be given to every ANM/LHV as they
reported it has proved invaluable for them for all time. (Unfortunately the Research Team could
not see the booklet).
The respondents were asked about other skill based short term special training programmes that
are imparted. There does not seem to be any systematic approach in organising these training
programmes nor there seem to be any compulsion that say those who have put in 20 years of
service should have some minimum number of training programmes. As one ANM (very senior)
told us that often they do not know that their colleague from other sub-centre had gone for a
training programme about which MO had not even informed others. It was only after her return
they learnt.
We had listed 10 important programmes to check how many of them were attended by the
respondents. They were training programme pertaining to Malaria, Cataract, Tuberculosis,
Family Planning Target Free Approach, RCH, Leprosy, AIDS, IUD, MPW, MTP and an open
ended 'others’. The response and ratings recorded are presented below:
TABLE 6 : TRAINING PROGRAMMES AND THEIR ASSESSMENT
Rating
Percent
No.of ANMs
Training
Some what
Very good
trained
useful
60.0
_______
26.6
17.2
15
Malaria
41.7
_______
25.0
69.0
60
Cataract
65.2
_______
17.4
26.5
23
TB______
59.3
_______
16.9
67.8
59
Target free
54.1
_______
32.4
42.5
37
RCH
55.2
19.4
77.0
67
Leprosy
Not
useful
13.3
33.3
17.4
23.8
13.5
25.4
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AIDS
39
44.8
41.0
35.9
18
61.0
IUD
20.7
33,3
MPW
23.0
50.0
20
45.0
MTP
04
4.6
100.0
Others
45
46.7
51.0
48.9
23.1
5.6
5.0
4.4
The rating and percent trained for different health programmes reveal some interesting facets.
Even during our discussion the findings in the table were repeated. Short term programmes
particularly one-day training was disliked by most of the respondents. It was reported in all sub
centres that the faculty would arrive, generally, late and by the time the programme starts it is
time for lunch and post lunch session - after heavy lunch is not very conducive for learning. The
administration might have to confront with several problems in encouraging training courses
lasting for at least a week. Given the large number of vacancies in the sub-centres, withdrawing
ANMs for training for a week will certainly disrupt the skeletal services that reach the community.
Arranging right resource person for the programme, communicating with the trainees etc. do
pose hurdles in efficient organisation. However, given the rating of the trainees and assessment
of the utility of these programmes it may be more productive to enhance the duration and enforce
discipline of the resource persons.
There is also the problem of the size of the trainees. An elderly ANM reported that she was one
of the 30 trainees in a programme and was sitting in the back row, hardly could hear what was
lectured and instrument to be used was only one which she could not see at all. By the end of
the day she thought she would not have missed anything by not attending it.
I
A shocking observation which the earlier study (Kanbargi 1996) had found was substantiated
here that only one in five ANMs knows how to insert an IUD. It is widely acknowledged now that
Indian Family Planning Programme is synonym with massive female sterlisation as they account
for 80 - 90 percent of all acceptors. The programme managers argue that if women prefer only
sterilisation what can be done? This argument is hollow as the eligible women who need
contracepting method are not even fully aware of the choice they have. The district level
information provided in Table 2 makes it very clear. It is only female sterilisation which is
universally known in rural areas. Spacing methods ignored in the family welfare programme
need urgent redressal.
&
SECTION II
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Review of Training Impact: Insights from the Field
This section has tried to review the impact of training programmes on day-to-day practice of the
respondents. It is classified as (I) Antenatal care, (ii) Identification of high risk pregnancies -
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(during Ante-natal care), (iii) Midwifery services and (iv) child care. These are all part of safe
motherhood and child survival programme which is being implemented in the state for few years
now. As it was revealed that only 60 percent of respondents have undergone CSSM training but
interaction among trained and not trained possibly will improve overall performance of all
respondents.
-58Antenatal Care
The antenatal period is of great importance in determining future course of events for an
expectant mother. During pregnancy traditional practices are followed despite some modern
knowledge. It surely influences the health care seeking behaviour of women and their health
status that will have a great bearing on outcome of the pregnancy. One of the most important
fact that affect pregnant women’s health is the suggested strict diet regime - severe restrictions
on food - what to eat and what not to eat. The strong dietary taboos can further adversely affect
the nutritional status of women most of whom are already malnourished. But there are also
traditional norms that put restriction on activities that may have some beneficial impact.
The knowledge about conception is widely known to all - pregnancy is recognised by the
absence of periods or nausea. If the ANMs are regular in their beat and meet all the potential
women they are likely to know that a particular woman has missed her period and if she had a
fairly regular cycle guess that she is pregnant. The care should start from registering such
women.
The recently completed RCH survey (Kanbargi et.al. 1998) considered at least 3 ANC visits to
each pregnant woman during her pregnancy, 2 anti tetanus injection and supplementing nutrition
by providing folic-acid tablets for 100 days as minimum package to be ensured to each pregnant
woman. The survey found wide variations across districts ranging between 78 percent in
Dakshina Kannada - Coorg districts to only 21 percent in Gulbarga. There could be a variety of
reasons to be explored. Many researchers have questioned the efficacy of this approach in
reducing maternal mortality in the states e.g. a study conducted in Kanakpura rural areas found
“ante natal care provided by the government was only “contact service” and are often routine that
leaves much to be desired. Weight of most of the women was not recorded, not haemoglobin
estimated nor urine test done. This is in marked contrast to services provided by private
practioners.
Apart from providing tetanus toxoid and iron folic acid very little is done in
government health care” (Jayashree Ramakrishnan et.al., 1999).
The findings from the present study fully agree with the above observations. The questionnaire
had a check list of 14 items like (I) Registering a pregnant woman which should be the beginning
of the service and when is it done? When a woman informs about pregnancy or during 3-5
months of pregnancy? It was assumed that ANM is supposed to visit the households routinely
and during her visit a woman may report that her periods are post-poned or missed. However,
the respondents could not distinguish the nuance and the objective behind splitting the question
in two parts and it was of not much use in over 50 percent of respondents, (ii) When they start
supplying IFA Tablets, (iii) When the Tetanus Toxide injections are given, (iv) When is the blood
pressure measured, (v) When urine test is done, (vi) when is the blood test done, (vii) when is
the taken, (viii) when is the abdominal examination done, (xi) when is the vaginal examination is
done, (x) Whether diet advise is given (xi) Whether advice on breast feeding given (xi) Whether
the woman is informed about possible complications in pregnancy (xii) Whether contraceptive
advice is given to either post-pone next pregnancy or avoid it and lastly whether need for post
natal check-up is explained? The following chart provides the responses of ANMs/LHVs to these
questions.
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TABLE 7 : ANTENATAL CARE KNOWLEDGE : PERCENT
Checklist
SI
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Registration__________________
I FA tablets___________________
TT injection__________________
BP_________________________
Urine test____________________
Blood test____________________
Weight test___________________
Weight taken_________________
Abdominal check______________
Diet advised__________________
Breast feeding advise__________
Pregnancy complications explained
Contraception advised__________
Post-natal check advised
Frequency
Yes
No
Q—
100.0
100.0 ________ 0
98.5 _________ 1.5
92.0 _________ 8.0
96.6 _________ 3.4
93.1 ________ 6.9
96.5 _________ 3.5
100.0 ________ 0
74.7 ________ 2S3
100.0
100.0 _______ o
83.9 ________ 16.1
94.3 _______ 57_
14.0
86.0
2_____ o
Most of the ANMs were aware of what is ANC and its importance. But they had problems with
discharging these responsibilities because of lack of instruments required like BP instruments
and stethoscope, chemicals needed for testing urine etc. In addition many ANMs were not sure
what is high BP that need attention? Weighing machines were provided to only 10 percent of
ANMs. Only one ANM in a sub-centre (Gulbarga) showed me two weighing machines - one for
just born babies and other for adults. She had another weighing machine for babies who can be
placed in the panel weighing. But this was an exception, checking haemoglobin content and RH
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It was clear that the knowledge of ANMs is not fully exploited in providing quality care during
pregnancy. To explore further we visited two ANC camps in Gulbarga district —one held in a
sub-centre and another at a CMC. The Registers maintained revealed that in CMC about 20
percent of women were examined for blood pressure and taken their weight. It was reported that
large crowd about 100- 150 women makes it impossible to provide the text book - prescribed
services to all pregnant women.
The sub-centre clinic was held in a school - an opology for the absence of quality service. There
was one table and a chair courtesy the school and the room was partitioned by a thin dirty bed
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sheet for examining women. Hardly there was any privacy. There was a crowd of 50 - 60
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women at noon still waiting for their turn to be examined. The Lady Medical Officer was tired but
committed to do her best to the pregnant women who had walked long distances to come here.
They had very little choice as the ANM staying in the sub-centre village was hardly equipped with
her needs. She had hired a room at the back of the school, she had to collect water from a well
and go to field for her natural calls. Her husband was staying in Gulbarga.
We observed that because ANMs have not been provided with required facilities they request the
pregnant women to come to a ANC camp held once in a week or once in two weeks. The Sub
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Centre we observed held ANC camps every week and serves about 10 near by village women.
The camp naturally gets crowded making it difficult to do all required tests for each one. A
seasoned medical practioner will take the blood pressure if she has reason to doubt otherwise in
-60-
such situation no. Maintaining record of blood pressure, weight gain chart that immensely help in
identifying high risk pregnancies/babies and planning safe deliveries is not possible. If the ANMs
who are trained for ANC and used only for distributing I FA tablets and abdominal check-up it is
gross under utilisation of their talents and putting more pressure on limited resources at the Sub
Centre causing great inconvenience to women clients.
The ANC section has two very important questions that are generally ignored. One was whether
the expecting mother knows when she is expecting a baby - probable date of delivery. The
ANM should be able to suggest the same. We observed 82 out of 87 were aware how to
estimate the date of delivery. Another crucial factor is where it will take place? It is crucial
because during ANC period there will be clear indication regarding the type of delivery - whether
it will be normal or complicated. Depending on the need ANM can suggest the place. If it is
going to be a normal delivery certainly can take place at home. If not, the family has to arrange
for a hospital delivery including the resources. But surprisingly only two in three ANMs reported
that they often suggest to women where they should go for the delivery. But the rest said it is to
be decided by the family based on their economic situation. Our broad impression was, as
mentioned early, the ANC means 3 visits to pregnant woman, 2TT injections and I FA supply of 3
months. Though it may be considered as minimum needed, much more has to be done to do
justice to CSSM programme and improve the situation of women and children.
Identification of High Risk Pregnancies
Identification of high-risk pregnancies is the first and single most important step to be followed by
going to a referral hospital fully equipped to provide efficient services to ensure safe delivary.
The responsibilities of the ANMs and LHVs listed in the Training Manual prepared by State
Department of Health and Family Welfare under India Population Project (IPP IX) include urine
test and blood test of all pregnant women for albumin, sugar and hemoglobin contents during
their home visits. It also mentions that at least 50 percent of the deliveries are to be conducted
by ANMs and the rest conducted by Trained Dais are to be monitored or supervised by ANMs.
The questionnaire has prepared an exhaustive list of symptoms that indicate high- risk
pregnancies. Each ANM was asked whether they know what constitute risk to pregnant woman.
The list prepared included risks related to last pregnancy termination, history of systemic illness,
reported complaints during pregnancy in addition to the generally known factors like first birth or
higher order births, height of the woman, status of blood pressure, etc.
The knowledge reported in the following tables is based on combined responses - some
spontaneous and others received after a little probing. The responses are presented in two
formats for the convenience and understanding of the reader.
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SI
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Symptoms
No
1_
2
3
£
5
Not
aware
percent
11.5
25.3
37.9
18.4
47.1
Aware
(percent)
Age less than 18 and over 35 years__________________
1st or 4th and higher order births_____________________
Current pregnancy within two years of previous
Height less than 4’. 10”____________________________
Abnormal wieght gain - over 10 kg. Weight gained during
pregnancy
____________ ___________________
Sustained high blood pressure over 140/90_____________
Poor weight gain 5 - 6 kg only______________________
Mai presentation of foetus
______________________
Weak or no movement of foetus_________________
Convulsions in pregnancy_______________________
88.5
74.7
62.1
81.6
52.9
49.4
50.6
6
51.7
48.3
7
22.0
78.0
8
46.0
54.0
9
30.0
70.0
10
It may be mentioned here that many ANMs in Tumkur District reported that for this interview they
had spent two sleepless nights to go through their notes/books of training period to refresh their
memory like they used to prepare for their theory examination. However, the information
provided in Table 8 and 9 is disappointing picture. It was the respondents in 50+ age who had
more problems in responding as they frequently said “we have forgotten many things taught long
back”. There were two respondents who were deaf and posed problems for communicating
effectively.
4
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It may be noted here that most of the respondents knew that short women constitute high risk
during their pregnancy but they could not define what is short? Similarly they knew that
sustained high blood pressure during pregnancy carry high risks but did not know exactly what is
high blood pressure. As mentioned earlier most ANMs do not possess the instrument and those
few who had it, was not in working condition.
TABLE 9 : IDENTIFICATION OF HIGH RISK PREGNANCIES
History of last pregnancy
SI.
No.
i) Last pregnancy terminated as
1
t
Abortion
Still birth
Premature birth
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Retained placenta
Sepsis
In neonatal death
Systemic illness
Heart disease
(ii) Diabetics
(iii) TB
(iv) Hypertension
u
Not Aware
Percent
64.4
57.5
55.1
35.6
42.5
44.9
55.1
60.9
16.1
44.9
39.1
71.3
71.3
77.0
57.0
83.0
28.7
23.0
43.0
17.0
ii) In complicated delivery with
prolonged labour ended with
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Percent
-62TABL E 9 : IDENTIFICATION OF HIGH RISK PREGNANCIES (continued)
Woman complains of
3
32.2
44.8
48.3
35.6
62.1
52.9
36.8
18.4
Breathlessness
Excessive tiredness
Palpation
Puffiness of face
Tightening of ring/bangles/chappals
Vaginal bleeding
Pain in abdomen
Fevers
67.8
55.2
51.7
64.4
37.9
46.9
63.2
81.6
___
The responses presented in tables 8 and 9 reveal inadequate knowledge about identification of
high risk pregnancies among the ANMs. The focus group discussion clearly brought out the
problem of ensuring safe delivaries even in cases of identified high risk pregnancies as the
required facilities were not available even at Community Health Centres supposed to be first
referral centres.
An example of a maternal death reported in one PHC area would explain the situation on ground
level. The woman who delivered a baby with the help of a trained Dai and developed
complications on third day. She was bleeding. The PHC kept her for a day with medication.
The bleeding did not stop and she was advised to go to District hospital in the night. The amily
could not arrange transport and resources. Instead they took her home and she died next day.
Some enquiry was conducted and the case was hushed up.
The data collected on ANC services and ability to identify high-risk pregnancies reveal that there
is a long way to go to achieve effective reduction in maternal mortality and infant mortality. As
noted earlier ANC means three visits to pregnant woman, 2TT injections and 100 IFA tablets.
Even this minimum package of services have made considerable impact in bringing down IMR in
the state, further decline depends upon improving the services of ANMs, infrastructures of PHCs
and CHCs to reach the goal of IMR 30 mentioned in the policy statement of 2000.
Institutional Births
Institutional deliveries are meant to provide safe motherhood and the resultant significant
reduction in maternal deaths. Wide variations were observed in them in the selected districts from about 79 percent in Dakshina Kannada to only 21 percent in Gulbarga. ANMs in Udupi
reported that many of them have not conducted a single delivery during last five years because
women prefer to go to maternity homes or Government hospitals at District level. The private
sector health services in Udupi - particularly the Manipal Hospital have expanded their maternity
services to rural areas that has almost ensured safe delivery to any woman - poor or rich. Our
visit to a remote place in Udupi where we had to cross a river to reach the village revealed that
just a telephone call to the Manipal Hospitals maternity home situated at a distance of 14
kilometers will provide them not only free delivery but also free ambulance service to transport
the pregnant woman to the hospital. The public-private co-operation observed in the district is
really remarkable to try in other poor districts like Gulbarga or Bellary that can improve
accessibility to good care and go a long way in ameliorating the sufferings of poor women.
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As a contrast to Udupi ANMs who have not conducted a single home delivery during last five
years, committed ANM in Gulbarga where there is hardly any choice for most rural women
reported that she conducted 120 deliveries this year of which 20 were high risk whom she
referred to CHC and ensured safe births. Another ANM reported to have conducted 94 out of 99
births in her areas this year - 5 being conducted by a trained dai. These two ANMs stay in the
sub-centre quarter and a visit there will convince that they were model sub-centres. The two
ANMs were residents there, available any time for service, had BP instrument, weighing
machines for babies and adults, providing good ANC by testing urine, keeping records of weight
to know the gain, recording BP of all women and ensuring the pregnant woman at least one
check-up by a lady medical officer to confirm that every thing is OK with all her clients. The sub
centre that as conceptualised at the starting of out reach programme, perhaps was like this. The
outreach programme might have conceptualised such sub-centres as modesl. But they are
exceptions now as ANMs having no housing facilities stay in a place where she can get a house
on rent and naturally night deliveries can not be attended by her.
Identification of High Risk Babies (Who weighed less than 2500 gms at the time of Birth)
. 1
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The data collected in Reproductive and child Health (RCH Phase 1) survey in the selected three
districts revealed that only about 7 percent of babies born in rural areas in Gulbarga district were
weighed after birth and 58.3 percent of them were under weight (less than 2500 gms). On the
other hand in Udupi (Dakshina Kannada) 62 percent babies bom were weighed and only 13
percent of them were under weight and in Tumkur about 28 percent of babies’ weight was
recorded and 20 percent of them were reported weighing less than 2500 gms. These findings
present a grim picture for Gulbarga and also to some extent Tumkur that certainly fare better
than Gulbarga for underweight babies who carry high risk of death. Though one of the simple
measure to reduce this incidence of low weight babies is to improve the nutritional level of the
mother by supplementing her diet and providing I FA tablets. The ANMs have knowledge of the
under nourished mother and the need to supply I FA tablets to them in their area
The RCH survey reports that in Gulbarga where the proportion of low birth weight babies is
highest in the study area only 48 percent of pregnant women had received IFA tablets, it was 87
percent in Tumkur and 92.3 percent in Udupi (Dakshina Kannada). It is difficult to understand
why this simple low cost remedy available is not taken seriously in Gulbarga where it is
absolutely essential.
It would be interesting to note here our observations and the community perceptions about how
these essential services are delivered by ANMs.
Our interaction with community leaders and women in particular provided surprising data. We
met a Lady Panchayat Chairman in Gulbarga who was in her late forties, literate and was having
concern for women’s issues including their health. She said that the ANM stays in the village
(only village she is to serve as it is quite large with 3500+ population), has a telephone at home
and also keep some essential drugs for emergency. She conducts most of the deliveries in the
village by charging anywhere between Rs.300 - 1000 depending upon the economic status of
the family. But she never visits any home for providing services. People have to call her on
phone or meet her personally if they require any service - of course at a price. The Lady
-64Panchayat Chairperson did not know that ANM is supposed to visit all families in her jurisdiction
to enquire the welfare of women, their pregnancies, children health etc. Even her husband and
many others who gathered there during our focus group discussion reported ignorance and said
the panchayat will issue a letter to the Medical Officer in this regard soon to ensure her services
to all homes in the village. It would not be surprising in such situation that poor and scheduled
caste women may not be able to avail her services free.
This was not an exceptional example in Gulbarga. In three more sub-centre areas we observed
similar things. Absence of good roads and transport facility may be important hurdles to AN Ms in
addition to inadequate housing facilities. But administration both in the health department and at
Zilla Parishad should try to improve the situation to ensure accessibility to health care for all.
Rarely, except in ones we could see a chart showing ANMs travel programme for the week
usually displayed in all PHCs. It was also surprising that many ANMs/LHVs in Gulbarga were
not found earing uniform white saree during working hours. But in Tumkur and Udupi we did not
see any ANM/LHV not in the uniforms.
However an effort was made to know respondents abilities to identify high risk new born babies
(who weigh less than 2500 gms) if check listing some symptoms.
TABLE 10: IDENTIFYING HIGH RISK NEW BORN BABIES (WEIGHING <2500 gms)
Aware (percent)
________ Symptoms
78.2 ____________ __
Refusal of feed____
56.3 ______________
Increased drowsiness
75.0
Difficult breathing
55.0_________ __
Cold to touch_______
62.0______________
Yellow staining of skin
26.4 ______________
Convulsions________
14.9 ___________
Others___________
The data presented in Table 10 reveal that there is much to be desired. However, some ANMs
were aware that if the baby is cold, they would keep it under 200 watt electric bulb to improve the
body temperature of the baby.
Acute Respiratory Infection (ARI)
Only about half (52 percent) of the ANMs were aware about Acute Respiratory disease and 85
percent of them had knowledge of at least one symptom of ARI and also were aware that it is an
important reason for high I MR.
Pneumonia
Most of the ANMs, (91 percent) were aware about pneumonia and more than half of them knew
one or more symptoms of pneumonia like excessive drowsiness, respiratory grunting, convulsion
and inability to drink.
Diarrhoea and Dysentry
Diarrhoea, a major killer of infants and its symptoms like passage of watery stools 3-4 times a
day was known to 92 percent of ANMs. However, there was confusion among many in
distinguishing diarrhoea from dysentry which has symptoms like blood in faces, abdominal
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-65cramps, fever and weight loss. Only one in five respondents were aware that diarrhoea/dysentry
is a major killer of infants. All respondents were aware (100 pr cent) of dehydration that follows
dysentry/diarrhoea and could mention all the symptoms like restlessness, decreased skin tugor,
dry mouth-tongue, sunken eyes and lethargic appearance of the baby. Management of
dehydration through measures such as giving ORS or home made syrup of sugar and salt,
plenty of gluids, and continue to breast feeching was known to all respondents.
The strong emphasis given to the child immunisation was reflected in every respondent knowing
what immunisation is to be given when. Liquid I FA, however, to be given to malnourished babies
was known to only one in four perhaps it is not supplied in the state. It was reported that children
are given small I FA tablets.
Knowledge about Cold Chain
While immunisation coverage has shown remarkable improvement over time, quality of
immunisation has remained a question to be answered. Is cold chain maintained to ensure the
required vaccine potency? We wanted to test whether personnel who play a key role in
immunising children know about cold chain?
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It was revealing experience for the research team which visited a Primary Health Centre in
Gulbarga district. It seems a diary is to be maintained and the temperature shown on the
thermometer of the new type refrigerator in the PHC where vaccine is stored is to be recorde ' by
the Medical Officer. We were surprised the recording in the diary was up to date with recorded
temperature, date and signature of the Medical officer but the thermometer that indicates
temperature was not working for several days and not repaired. It was also clear from the
observation of the diary that all the entries for the month were made the previous day. Neither
the staff nor the clients who receive were aware of the importance of maintaining cold chain to
ensure effective immunisation.
Compare this with what was reported by almost all respondents in Udupi. They said that the
immunisation day for them will become a nightmare if power in the area was shutdown even for
half an hour as mothers would object for immunising their children as there was power shut down
yesterday as such what guarantee is there of the vaccine potency? With all the explanation by
the ANMs about the advantages of new freezers that they have, some mothers would still prefer
to go to private practitioners for immunisation. These observations, though accidental, reveal the
casual approach adopted by qualified responsible authority whom the illiterate and ignorant
community trusts and it deserves serious consideration in the department to ensure that there is
responsible approach how immunisation under the circumstances it was not surprising that about
40 percent of respondents expressed their ignorance about the required temperature to maintain
the vaccine potency.
Infant Feeding
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There was a question to check the respondents’ knowledge on exclusive breast-feeding. What
does it mean? How long a baby should be exclusively breast-fed? Response of all the
respondents was that babies should be breast-fed for 3 months. They also knew the advantages
that exclusive breast-feeding provides more nutrition (90 percent), protects against infections (87
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percent) but only 46 percent knew about its contraceptive effect. The RCH survey 1998 found
that in Gulbarga babies being breast fed within two hours of birth accounted for only 9.5 percent
while it was 36 percent in Tumkur and 47 percent in Dakshina Kannada District. Continuously
repeated advantages of cholestrum milk that provides effective immunisation to babies is almost
denied in Gulbarga. The general opinion of ANMs was their advice during ANC and delivery
does not make much sense against the strong traditional beliefs that still govern the community
behaviour.
Weaning
We also enquired whether the respondents are aware about weaning? And when to start it?
Each ANM reported that breast milk will be inadequate to babies growth after three months and
babies will have to be introduced to some other semi solid foods like 'Ragi Sari’, 'Rice Ganji’,
'Bele kattu or liqufied pulses’ etc. which can be prepared at home with locally available food.
Few of them reported that they also suggest to mothers to go for baby food available in the
market. More than 70 per cetn of ANMs in Udupi reported that weaning food also can be
purchased from market.
While the latest WHO recommendation is that exclusive breast milk should continue for 6 months
and only afterwards weaning foods be introduced, all available evidence in Karnataka show that
there is need to improve the understanding of mothers in rural areas about the advantages of
cholostrum milk and exclusive breast feeding. Surveys have reported wide spread practice of
squeezing cholostrum milk and feeding just born babies with variety of liquids like sugar and
syrup castoroil with enormus, health hazards. The respondents reported that during mothers
club meetings as well as during ANC they explain all the advantages of breast-feeding including
cholestrum milk however the outcomes are poor. In this regard there is need to consider for
vigorous campaign and improved I EC programme. Several babies we saw in ANC camps in
Gulbarga and Tumkur convinced about the poor health status of surviving children. They were
looking thin with sunken eyes. It is possible that under-nourished mothers even though supplied
I FA tablets were not regularly consuming them to derive the benefits.
General Knowledge
We perceived ANMs/LHVs as backbone of rural health delivery system. They are the link
between the vast rural illiterate women and modern health care providing PHCs. They are
expected to visit every household in their area and are familiar with each of the household that
make them not only a health worker but a friend, philosopher and guide to those women. During
their visit they may conduct mothers meeting to provide them important information on their own
or have to answer some questions raised by their clients. Therefore their knowledge and advice
carries great impact as such this study attempted to assess how familiar they are with the
population problem — particularly whether they knew that India’s population has crossed 100
crore mark. We asked what is India’s population and gave three hints - 50 crore, 150 crore and
100 crore. Only 46 percent of them could say it is 100 crore.
It was noted earlier about the low age at marriage of females and its consequences on IMR,
MMR and also fertility levels. Marriages before a girl attains 18 years of age are legally
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prohibited. But its impact is negligible on the marriage age. Only 79 percent of respondents
were aware of legally approved age at marriage of boys and girls. One in five respondents were
not aware themselves and they may not have discussed about it is the meetings of mothers. If
female age at marriage continues to rise as slowly as is observed despite all efforts than what
are the options left to policy makers to reduce its consequences? Or should this area be left as
nothing can be done as it is parents of the bride and groom who decide the marriage who and
are not bothered about the age? Marriage is certainly a complex social and economic issue.
Good harvests see more marriages in any village and droughts few or no marriage and difficult to
bring interventions to drastically change the pattern.
In this situation female health workers can play a very important role of motivating the young
married couples to postpone the first birth by a couple of years or till the young woman attains 20
years. The focus group discussion revealed that talk about contraception will begin only after the
couple has one or two children and intensive efforts begin only after 2 children. It is obvious that
if sterilisation is considered as the only suitable method for the couple by the ANM, there is no
alternative. But can they not advise them to use condoms or safe period or even least harmful
orals that are available in the market? They are not trained to motivate couples for adopting
spacing methods.
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The focus group discussions also brought out some interesting problems ANMs face in the field.
It was reporter that the distribution of IFA tablets to pregnant woman generally starts in fifth
month of pregnancy. If given soon after registration of pregnancy of the woman and the
pregnancy is terminated in abortion women hold the ANM responsible for it. Because it is she
who supplied IFA tablets saying that her health will improve and on the contrary she had
abortion. Such news spread very fast In villages the whole village may turn out hostile and ask
her not to give those tablets to any pregnant woman in their village. Similarly motivating for
contraception is confronted with the problem of child survival. If the only son among the two the
couple has dies, ANM will not be forgiven for motivating them to accept sterilisation. So to play
safe they said it is better a couple should have two sons and a daughter before undergoing
tubectomy. It is not surprising that NFHS II found 90 percent of sterilised women had not
adopted any other contraceptive method before. Distribution of Bill and condom through public
sector, therefore, constitute insignificant proportion in rural Karnataka.
This background is aptly reflected in the responses of ANMs/LHVs as 18 percent of them could
not say what is safe period and explain it correctly. But 95 percent could explain what tubectomy
is and how it is performed because they reported that they explain it to all potential acceptors.
Medical Termination of Pregnancy
Abortions were legalised in India in early 1970s and the number of legal abortions have
increased significantly over the time as also approved places for conducting abortions. But rural
women are deprived of this facility as most of the PHCs in the study area do not have the
equipment or person / approved by the government to provide abortion facility to women. None
of the ANMs are trained to conduct MTP and when we asked them when will they recommend
MTP to women? It was disappointing that none of them had suggested any woman to go for an
abortion. Looking at the clandestine abortions reported and observed by the hospital records
-68-
showing sepsis/infections caused by quacks while aborting and admitted to hospitals in serious
conditions, there is need to examine what ANMs can do in rural areas. While ANMs took a moral
stand and their response was very firm in reporting that they neither perform nor recommend
MTP to any woman that does not reflect reality.
The job responsibilities listed by the Department of Health and Family Welfare 1999 clearly has
mentioned that ANMs should identify women in need of MTP and inform them the nearest
approved place for MTP to obtain an MTP. We think there is an urgent need debate on the issue
of providing this facility to rural needy women.
The Eligible Couple Register
Eligible Couple Register the Female Health Workers are supposed to maintain and keep it up to
date with all relevant information. It is a valuable document that guides in her work. It has all
information she needs - how many currently married women are there by contracepting status
and number of children, helps in identifying children is need of immunisation, and women in need
of advice on nutrition, etc. A general complaint emerged in all our meetings was the shortage of
EC Registers - some places not supplied for 7 - 8 years and ANMs have to purchase a Note pad
and record the information to the best of their abilities. Non-supply or irregular supply certainly
creates serious problem in compiling service statistics from Sub-Centre.
We wanted to learn from ANMs whether still they feel EC Register serves an important purpose
and help them. There was a unanimous response that it is important and they should be
supplied EC Register so that they will be able to improve their performance.
Mothers Meeting
The respondents also informed that they routinely conduct mothers’ meetings and discuss
different health issues and about nutrition. They think that these meetings will become more
effective if the ANMs are provided with educational materials for use during the meeting to make
the meetings more productive.
Advise to Adolescents
The needs of the adolescent girls that were ignored for long is getting attention now. There are
special programmes designed for their benefit. To improve their knowledge about personal
hygiene and health. There were few reports of providing Tetanus Toxide injection to these
adolescent girls. What was interesting to learn from many ANMs was that often in mothers
meeting some adolescent girls also participate and when the topic of contraception / pregnancy
is to be discussed they are asked to go out as they need not learn about contraception because
educating these unmarried girls in Family Planning methods because of the fear of using them
before marriage. Given the sea change that is being realised through recent research on
changing sexuality in the society and the AIDS threat becoming more and more serious there is
need to think about what should be the policy for these girls, Most of whom are illiterate and
ignorant of many vital issues concerned with their own person,
If they are educated about
contraception will that enchance its use after they get married?
The Working Environment
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-69We examined the training programmes that the ANMs/LHVs have undergone so far and the
extent they are utilising the skills - knowledge that they were able to retain from them. The focus
of the study however was confined to issues concerned with the health and survival of women
and children who still constitute a major component in the crude-death rate.
It was mentioned that the grass root female health workers are considered as backbone of our
rural health delivery system in Karnataka and with several drawbacks in the system considerable
progress has been made during the last two decades. The widely differing indicators of
achievements among different districts and by gender and social class within each district is a
cause for concern and further improvements will be faster if backward districts, deprived sections
within backward districts get relatively more attention. As it is, there is uniform policy and
strategies in the state. We did not come across any special efforts to improve health care
delivery services in Gulbarga or Tumkur.
The three districts selected for this brief intensive study present three unique settings. Udupi
has very high female literacy, high age at marriage, wider knowledge of contraceptive methods
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Box 1
PHC 1 - Gulbarga
The Research Team reached here by 10 AM. There was only an Aitender and no responsible staff
member. The Attender - the only person in the PHC was not aware of our visit nor about reasons for
the absence of the l/c MO and other staff. The PHC had conducted Tubectomy Camp two days earlier
and there were six women (who had come from different villages). One of them had developed
complications and was advised to go to Gulbarga for consultations by Head Quarters ANM. Who had
undergone Tubectomy operation.
The Head Quarter ANM who is supposed to provide care to the sterilised women had gone on
leave as her husband seriously took ill and she admitted him in a hospital in Sholapur. The MO had
not come to the PHC for a week without any reason nor informed any authority - like Taluk Medical
Officer and resides at Gulbarga situated at a distance of about 45 kms. Journey takes about 2 hours
because of bad road conditions.
We contacted the DHO and reported the situation who in turn telephoned taluk Medical Officer who
rushed to our place. He reported his helplessness as he had warned the MO a couple of times. We
also learnt that the local MLA also had warned him to be punctual but of no consequence. In-charge
MO was not able to improve his functioning. The Taluk Medical Officer who looked committed and
honest also expressed his helplessness regarding the verification of drugs in the PHU as the
pharamacist never met him nor showed the tock during his last three visits.
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while it is a contrast in Gulbarga - a district perhaps politically very influential as 6 ministers hail
from that district in the contemporary political scene with two of them may be considered as very
heavy weight politicians in every sense. Things could have been better with their interventions in
the district. But unfortunately health, sector, perhaps, does not command much attention. To
make things worse any disciplinary action against an erring official in health sector-from an ANM
to Medical officer is extremely difficult as there will be instructions from top that he or she is our
person and nothing should be done to him/her and there ends the matter. This benevolent
attitude of powerful personalities of the district has almost demoralised the health department in
the district. The crucial services are casually taken. The Box 1, 2 and 3 present the contrasting
picture to high light the issues in three different settings.
The three senarios presented depict differing consequences on the people of the area.
Gulbarga Pulic Health Care service is a single most important provider of services to the people
Box 2
Contrast:
A PHC in Udipi District
We arrived at this PHC, without prior intimation, at 9.30 A.M. We were surprised that the PHC was busy
functioning - MO, Lab Technician and other staff were attending the patients. On an average there are 50-60
patients a day. The young MO here is appointed on a contract basis but is very regular to his work and fully
committed.
The PHC building, though old is very clean. The MO’s chamber had privacy for patients. It had a clean wash
basin, running water, soap and a clean towel. The toilet was also clean. All the records were UR^-darte and
well maintained. The PHC had displayed prominently at the entrance that if any visttor to the PHC had any
complaint on its functioning they can get a free post card to write the complaint which they can mail to the
concerned authorities whose addresses were mentioned In bold letters.
The MO reported that the drugs supplied to him are of very good quality and adequate. The drugs that pnvate
sector hospitals provide to their patients is certainly not of better quality than that of PHCs. Therefore the
visitors to the PHC are happy that the centre works not only very efficiently but also supplies quality drugs. He
had only one complaint - that the patients who visit his PHC have simple ailments while he was
in
attending to chronic/serious cases also and improve his abilities. For this he goes to a Private Hospital in the
night - not for earning more money but to Improve his understanding.
with negligible presence of private sector even in the District Town. If the Public Health Services
are inaccessible to people, will have serious health consequences.
Udupi on the other hand strong presence of private sector which has social commitment as seen
by the free delivery services with free transport just with a Telephone Call. The Public health
BOX 3
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We reached this PHC in Tumkur by 9.30 am. All the staff including ANMs/LHVs were waiting for us. The
Medical Officer was a young man with 3 years of experience in PHC. He was in a neatly pressed white
coat and any visitor would recognise him as a Doctor.
The PHC was crowded with patients. But lacked many facilities. There was no running water. Toilets
were there but not clean. The PHC did not have a compound wall and in the evening cattle, drunkerds
squatted in the compound creating scare among inmates (Delivery cases).
All the feamle health workers complained that they are not supplied registers to record for several years
cholirination of wells, DDT spraying has been stopped since three years. The ointment, paracetemol
supplied to them is inadequate - does not last even for 4 months but people.
It was surprising with all the problems the PHC was still serviving people as seen by the large crowd of
outpatients. There are 70 - 80 patients on an average visiting the PHC for consultation and treatment.
We contacted the DHO and reported the situation who in turn telephoned taluk Medical Officer who rushed
to our place. He reported his helplessness as he had warned the MO a couple of times. We also I63™*
that the local MLA also had warned him to be punctual but of no consequence. In-charge MO was not
able to improve his functioning. The Taluk Medical Officer who looked committed and honest also
expressed his helplessness regarding the verification of drugs in the PHU as the pharamacist never met
him nor showed the stock during his last three visits.
care services are equally efficient and competant but suffers from inadequate infrastructure and
equipment. The end result is that the educated population can make a reasonable choice and
there is choice for the rich and also for the poor. Poor are assured of good health care at Public
Health Institutions. PHCs function efficiently - maintain working hours, ensure presence of
Doctor and supply of drugs of as good as quality that of private sector quality. It is not surprising
that health indicators, health seeking behaviour indicators are most impressive. Tumkur district
on the other hand is certainly better than Gulbarga in several ways. The PHCs work regularly
though there were complaints of shortage of drugs, quality of drugs etc. General public, though
heavily depend on Public health Institutions, there are large number of quacks having presence
in every village having a population of 4 — 5000. Shivashakti Clinic, Unani Davakhana and a hot
of other clinic try to provide some relief to needy poor. We did not come across any untoward
-71incident occuring because of quacks as we were informed that if the 'Quack' realise that he can
not handle the case, he will advise them to go to Tumkur District hospital and will not take any
risk.
In this background it may be noted that increasing number of Institutional deliveries affect work
burden of female health workers as it has happened in Udupi. Our information collected from
ANMs report that only 6 percent of deliveries are conducted by them and the rest occurred at the
Institutions. In Gulbarga about 40 kilometers away a PHC reported that during April 2000 December 2000 had 627 births about 200 at PHC and the rest 427 by 8 ANMs in the PHC.
There were 7 still births. 27 infant deaths reported.
Not a single birth had taken place in private nursing homes. The Medical Officer of the PHC
stays in the quarter and is always accessible to the needy. His wife is a lady Medical Officer
whose services are also easily availed any time. As they stay in PHC they have full control over
other staff who also show concern and commitment to the health concerns of the public. But
such PHCs are exception in the District. The general rule in Gulbarga is that either Medical
Officer's post is vacant, if it is filled the person is erratic in discharging his responsibilities as the
authorities are hesitant to discipline them because of political interference. While the situation is
continuing like this the social costs are too high even to measure or community suffers
enormously. The case of Kunchoor illustrates this. Kunchoor or Kunchavaram is a village
situated at the border of Karnataka —Andhra Pradesh in Gulbarga. The village has a PHC and
for last five months there is no medical officer (vacant). Lady Medical Officer’s post is filled but
she never turns up. The Chairman of the Taluk Panchayat died three days ago (when we were
enquiring) without any medical assistance, 2 children died during the week and causes for these
deaths are not known. The member of the Zilla Parishat, a resident of this village has tried his
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best to get a ’couple’ husband-wife’ team to this PHC but without any success. In such a
situation expecting ANMs/LHVs to be committed in discharging their responsibilities in futile. The
Kunchoor PHC area is dominated by a Scheduled Tribe-Lambadies.
SUMMARY AND CONCLUSIONS
a
The short term intensive study was carried out in three districts of Karnataka State that widely
differ in health and demographic indicators. The main objective of the study was to assess the
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various training programmes the grass root level female health workers (ANMs/LHVs) have
undergone, extent of their utilisation by them in their day to day work. The study went beyond
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the stated main objectives to examine whether providing training per se will improve health care
services as its effective exploitation Is related with a host of other factors like infrastructure,
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equipment and team spirit at PHC level from where these services are organised, supervised
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and monitored.
The focus of the study was confined to those training programmes that were designed to improve
the health status of women and children - more specifically in reducing further IMR and MMR.
For this intensive study 3 districts - Udupi, Tumkur and Gulbarga were selected. From these
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All Female Health
Workers (ANMs/LHVs) at these centres were administered a standard questionnaire that was
specially constructed to check their skills required in their work.
The 87 respondents were
covering a population of 2, 61,155.
All respondents had successfully completed the foundation course - 18 months and few had 2
years training programme. The gap between the completion of course and joining the service for
many was as large as 4 - 5 years in few exceptional cases.
The general impression of the respondents regarding their training that some had completed 30
years back was that there was inadequate attention to practical hospital training and training in
field work. An indication of this was the reported shaking of hands’ during the first delivery
conducted by most of them. There were one-or-two exception to this general observation. An
ANM in Gulbarga mentioned she had the best opportunity of conducting 24 deliveries during her
training period under the able supervision and guidance of a gynecologist. It was suggested that
training programmes should be need-based and practical in real life situation and not just
lecturing with lot of information.
There was long gap between Foundation course and the next most important training
programme related to maternal and child health viz. CSSM training. The findings show that still
40 percent of ANMs have to undergo this programme that has great relevance to reduce further
IMR and MMR.
It was shocking to find that most of the ANMs are not trained to insert IUD. Policy studies have
repeatedly highlighted the urgent need to enhance use of spacing methods particularly among
rural women as it will have directly impact on the health of women and children. This needs
serious attention.
Similarly ANMs/LHVs need to be more sympathetic to women’s need for Abortion. Whether they
can be trained to perform medical termination of pregnancies is a technical question to be
decided by experts, we strongly recommend that at least MTP service be made available at PHC
level and ANMs/LHVs should be trained in the legal aspect of MTP and when they can
recommend it to needy women.
In addition to CSSM, a host of training programmes have been conducted for the respondents.
A general observation is that the short term training programmes of one or two days have been
rated as not very satisfactory by the respondents.
There was a strong suggestion of all
respondents in Tumkur and Gulbarga that Continuing Education programme for a week should
be a regular feature to update their skills and knowledge of maternity and child health. This
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programme should be holistic and may cover other relevant contemporary health problems in the
state / district.
Identifying high risk Pregnancies
The findings suggest that there is a need to have as suggested above, one week Continuing
Education programme to enhance the knowledge and skills of ANMs/LHVs of pregnancy
management.
Except in Udupi/Dakshina Kannada and Kodagu districts where Institutional
deliveries have become a rule in all other districts where domiciliary deliveries dominate, the
improvement of the knowledge of ANMs with intensive training should be given serious attention.
ANMs/LHVs must have knowledge of measuring blood pressure, testing urine for albumin and
sugar and keeping these records for all pregnant women (at least I readings for a woman).
These services should be provided in the yield to women by ANMs apart from. TT injections, IFA
tablets. It should be followed by blood test of each woman for haemoglobin content at least at
PHC level.
It may be noted that we had trained Field Investigators of NFHS II Survey to
measure haemoglobin of all women in the sample at their home in each village. It was possible
because very simple to use technology was made available from USAID. It should not be
difficult to obtain this technology by the state government for use of ANMs/LHVs. The time taken
for the test is very little-just 1 minute per woman at their door step. Unless minimum package of
services are provided to all pregnant women and each high risk pregnancy is identified and taken
to nearest referal unit for safe delivery, MMR will continue to be very high.
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Identifying high risk babies needs serious attention. Knowledge of Acute Respiratory Injection is
very poor among the respondents. NFHS II reports that about 34 percent of children were
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suffering
from ARI in Karnataka indicating the serious nature of the illness and its
consequences. The present study found that ANMs were confused when asked to distinguish
between the symptoms of diarrhea and dysentery. As 15 per cent of children in the state were
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found to be suffering from these illness improving the knowledge of ANMs and LriVs in
identification of these illness and ARI is to be given immediate attention.
It was, however,
satisfying that Oral Rehydration Therapy (ORT) is universally known not only to ANMs but also to
mothers.
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Immunisation coverage in the state has shown gradual improvement as seen by the service
statistics. We came across a report in Gulbarga that a baby afflicted by polio in a village was
living next door to the sub-centre. But looking at the crowd in immunisation Centres with several
agencies participating, a child might have missed immunising. ANMs were found to be well
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IS
(*
versed with immunisation process and were confident that all children in their area are protected.
-74While in Udupi Rotary, Lions, Womens Organisations, College Students and many enlightened
women participated in pulse polio in a big way even in rural areas such support in Tumkur and
Gulbarga was more concentrated in District towns.
Respondents knowledge about benefits of exclusive breast feeding and weaning was
appreciably good and needs periodic updating. Their understanding of India’s population and
legally approved age at marriage for males and females was found poor that needs to be up
dated.
The most glaring lacunae reported by ANMs and LHVs in their training is lack of communication
skills and inadequate attention to it in any of their training. Simple observation is that to combat
with strong traditional practices having serious adverse impact on women and children like
squeezing of colostrum milk needs intensive campaign. It would be effective only when ANMs
can play an important important role. Similarly introduction of spacing methods to young married
couples would be facilitated greatly if ANMs are properly trained to convince the young village
couple of its advantages.
Most cruc!al issue to be considered here is that training, upgrading skills and information
becomes inevitable to improve overall health status measured in several ways. The goals set in
the health sector can be achieved when such relevant training programmes bring in qualitative
changes in the services provided to clients. If all that is told in training programme is difficult to
put in practice because of lack or absence of infrastructure, equipment and other supplies the
purpose of training cannot be served.
It was observed that vast expansion of health care services - personnel during the decade is not
followed by adequate care and required resources. The quick expansion perhaps created a
problem of finding professionally trained personnel. A look at the staff position at district level is
surprising if not shocking. If health care service delivery is ensured with or without these large
number of vacancies, it is in itself an indicator of quality care.
At policy level, it is desirable to think of a district or a group of districts for intervention.
For
example in Gulbarga and Tumkur and such districts there is need for greater attention to improve
the management of pregnancies and their outcomes which may need more resources like
improving PHC/Sub-Centre infrastructure, equipment to ANMs such as BP instrument, chemicals
to test urine, haemoglobin/blood test etc. Where as in Udupi, Dakshina Kannada, Coorg with
good adequate support from private sector this problem is not there. But AIDS is looming large
in these districts with large out migration of males and females.
We heard reports of AIDS
deaths caused in every village we visited with documentary evidence.
All the deaths had
occurred to the return migrants and it seemed as if they all came home only to die.
t
I
-75At state level there is a uniform policy of resource allocation for health sector. If some districts
perform poor as indicated by several indicators it would be necessary to ensure that
administration in these districts are pulled up. The poor perception of people regarding the
public health care system in health poor districts needs serious attention.
Precious public
resources deserve more productive use. The backward nature of some districts is known for
long for over four decades and these districts have remained at the bottom even now. Unless
some fundamental change is brought in the administration for improvement they will continue to
be at the bottom.
I
1
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^^00000000000000000000000000^1^0/^00000^^^00
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■ S
GOVERNMENT OF KARNATAKA
0
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TASK FORCE ON HEALTH AND FAMILY WELFARE
0
- 0
0
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A
Commissioned
Research
Study
0
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r
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FEMALE HEALTH WORKERS IN KARNATAKA:
0
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AN ASSESSMENT OF THEIR TRAINING
r 0
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By
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Dr. Ramesh Kanbargi
■ s
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CENTRE FOR SOCIAL DEVELOPMENT
No. 8, Shantishree, Nagarabhavi Post
Bangalore - 560 072.
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FEMALE HEALTH WORKERS IN KARNATAKA ;
AN ASSESSMENT OF THEIR TRAINING
By
Ramesh Kanbargi
Centre for Social Development
Introduction
©
©
Health status of people in India has shown remarkable improvements
©
dunng the last two decades. The Crude Death Rate (CDR). infant Mortal,ty Rate
s
o
(IMR) and Crude Birth Rate (CBR) have shown sharp tall and key health
■ndtcator Ute Expectation at Birth' which was about 42 in early Fifties has
crossed 60 years in the early Nineties Wide differentials across states tn India
•3
J
however, have persisted throughout suggesting the need to take corrective
measures to bnng ,n much desired equity in health to reach the goal Health For
All by 2000' India has committed at Alma-Ata in 1978 (See Table 1 for
differentials).
The data presented in Table 1 clearly brings out the fact that Southern
States - Kerala, Tamil Nadu. Karnataka and Andhra Pradesh have shown
relatively better performance as compared to Hindi speaking BIMARU States -
r13
Bihar, Madhya Pradesh, Rajasthan. Uttpr Pradesh and Orissa.
Wide differentials within state by rural-urban residence, gender and social
class exist across the districts.
The Human Development Report 1999 -
J»
Karnataka provides CDR. CBR and Life expectancy al Birth for a« the districts
r
that reveal the differentials. IMR another sensitive health Indicator shows that
Dakshina Kannada reported the lowest IMR (27) tn the state while Gulbarga
J3
3®
Bijapur, Bellary had IMR about 3 times higher than Dakshma Kannada district
There ,s other strong evidence t„ support the IMR estimates - inSlitutionat
deliveries ,n Dakshina Kannada accounted for 77 percent while ,n Gulbarga ,1
was only about 27.9 percent suggesting the strong negative association between
IMR and institutional deliveries - safer deliveries.
j®
J
2
>7
TABLE 1 : HEALTH SITUATION IN INDIA AND SELECTED STATES
State
1MR 1996
CDR 1996
Maternal
mortality
ratio 1986
Sex
Ratio
1991
CBR
1996
927 ,
27.5
R
U
T
R
U
T
India
77
46
72 •
9.7
6.5
9.0
580
AP_______
Karnataka
Kerala
Tamil Nadu
73
63
13
60
38
25
16
39
65
53
14
53
9.2
8.6
6.3
8.7
5.9
5.4
6.0
6.6
8.4
7.6
6.2
8.0
394
439
247
372
972
960
1036
974
22.8
23.0
18.0
19.5
Uttar Pradesh
Rajasthan
MP________
Bihar______
Orissa
88
90
102
73
99
67
60
61
54
65
85
85
97
7j
96~
10.7
9.6
11.8
H3_6
11.2
8.2
7.1
6.9
7.5
10.3
9.1
111
10.2
10.8
920
627
507
813
844
879
910
931
911
971
34.0
32.4
32.3
32.1
27.0
Maharashtra
Gujarat
58
68
31
46
48
61
8.7
8.3
5.4
6-2
7.4
7.6
439
373
934
934
23.4
25.7
1
nJ
©
a
©
Source: 1) Family Welfare Programme in India, 1996-97, Government of India.
2) Mari Bhat P.N., 1995.
The latest data-set (1998-1999) collected in National Family Health
Survey and Reproductive and Child Health Survey (NFHS II and RCH) provides
valuable insights for effective policy inferventions to reduce the disparities across
©
districts by rural-urban residence, social class and gender. • Findings from both
the surveys suggest that the out reach services of maternal and child health hold
a
3
the key to .bridgeJhe^differentials and these services are to be delivered by
Female Health
popularly known as Auxiliary Nurse Midwives (ANMs)
and Lady Health Visitors (LHVs).
The Present Study
The present study is an attempt to examine the role of these grass root
level female health workers and adequacy of their training to discharge their
f
o
I
■'A‘3
I
‘3
3
O
responsibilities satisfactorily that can help to reduce considerably the disparities
observed across districts
Objectives
Taking into consideration the major midwifery responsibilities assigned to
the ANMs and LHVs after a rigorous foundation training of 18 months the study
□
proposes to achieve the following objectives.
'al
1. To examine the knowledge of ANMs regarding the Ante-Natal
e
care service
and its delivery to pregnant woman.
2. To assess their knowledge of identifying the high-risk pregnancies and
ensuring safe delivery that will help to reduce maternal mortality.
3. To examine the knowledge of supplementary nutrition to be advised and
supplied to all pregnant women to reduce malnutrition.
4. To examine their knowledge of identifying high risk infants
and measures to
be taken to ensure their survival to reduce IMR further
5. To identify inadequacies in the training of ANMs/LHVs if any, and suggest
corrective measures.
c
c
The Sample
The study was conducted in three districts of Karnataka that differ widely
m indicators relevant to reduce IMR and MMR.
These indicators were drawn
from the ROH Survey (First Phase - Kanbargi et.al., 1998). They are
1)
Percent women who received full Ante-natal care package (At least 3 ANC
>
visits + 2TT injections and 100 IFA Tablets)
i
t
2)
Percent institutional deliveries.
3)
Percent children in 12-23 months
age who did not receive any
immunization.
4)
Percent women who had knowledge o( all modern contraceptive method
Based on these criteria following three districts were selected.
i r
1 b
4
-■>
TABLE 2 SEI.ECTION OF THE SAMPLI. DISTRICTS
F District/State Full ANC j Institutional ri Children not
(percent) i
|
deliveries
(percent)
!
I
Family Planning
knowledge of all
modern methods
Percent
immunised
(percent)
i
2 Udupi (DK)
'5
2 Tumkur
78.9
68.7
766
48_4
_()_5
05
7~().'7
40 8
3 Gulbarga
21.2
27.9
31 I
State
52.2 52,4
8.3"
_______
Source. Rapid Household Survey RCH, 1998, Kanbargi'7t?aT
____ ?7 r_
46.1
3
The three Districts selected differed maximally in several other variables
also. For example the percent girls marrying before 18 years - legally approved
age was highest in Gulbarga about 59 percent, 29 percent in Tumkur and only 5
per cent in Udupi (which was part of Dakshina Kannada then. We selected Udupi
3
District based on the data of Dakshina Kannada district as data for Udupi are yet
3
to be made available). The observed early marriage and its impact on GBR is
clearly reflected in these districts (Gulbarga 32. Tumkur 24.7 and 21 4 in Udupi).
The three selected districts - one highly advanced - Udupi, one with
3
O
©
medium progress - Tumkur and one backward - Gulbarga in terms of
demography and health would be able to provide insights sought in the
functioning of the ANMs and LHVs in the state
For data collection 8 Taluks 22
PHCs and 87 sub-centres were selected randomly
The following table provides
these details.
I
a
TABLE 3 : THE STUDY AREA
District
Udupi
1
Tumkur
Gulbarga
Total
3
Taluks
1) Udupi
2) Kundapur
i) Gubbi
ii) Madhugiri
iii) Kunigal
i) Afzalpur
ii) Gulbarga
jii) Chitapur
8 Taluks
PHCs
l
SC (ANMs)
8
26
6
41
8
20
22 PHCs
87 ANMs
I
[
r
3
1
s
Methodology
The relevant data was collected from all ANMs available in the selected
PHC/Sub-Centres
by
employing
survey
A
methodology.
standardised
questionnaire was constructed for administering to each ANM/LHV
in the
selected PHC/Sub-centre. The administering of the questionnaire was preceded
by a brief introduction about the survey and assurance that the information
collected will be kept confidential and used only for research purpose
3
In PHC
we met the medical officer (MO) and other staff present and briefed them about
the study. We assured all that they w.ll not be harassed by Health Department or
any authorities for sharing their honest views on the functioning of the Health
©
■I)
Care Services.
There were focus group discussions to get insights in the functioning of
the Institutions that provided valuable information.
This information is exploited
to supplement the hard data collected in the survey
£
Each questionnaire administered to ANMs/LHVs took over an hour. The
interviews were abrupted often when many ANMs broke down who were to be
consoled to start the interview again
The respondents reported that it is first
a
time in their entire serv.ee someone is enquiring about their problems and
3
welfare. When they were asked whether they would be happy if their daughter
3
(those having one) was offered ANMs job, it was revealing that most of them
b
reported that they do not mind if the.r daughter goes for agricultural labour but
they don’t want them to become an /\NM like their mother.
*3
It indicated harsh
working environment they are situated in, their frustration and.helplessness.
Data and Analysis
i3
r
The brief profile presented in Table 4 suggest that most of the Female
Health Workers are currently married, have at least 10 years of schooling and in
their middle ages with long experience.
As there are limited opportunities of
advancement in the career they feel dejected struck with the
years. Those who were on the verge of retirement were
a
'b
I
for the day to free themselves and lead a relaxed life
same work for
eagerly looking forward
(>
□
□
TABLE 4: FEMALE HEALTH WORKERS IN THE STUDY AREA
A PROFILE (87 ANMs and LHVs)
Variable
1
I -requencv
Per cent
31
35 6
37.9
Age (years)
i
Below 40
40 - 49
50 - 58
2
9
3
3
04
77
88.5
06
6.9
1I
.17
41
14
13.3
20.5
49.4
Below SSLC
SSLC Pass
IS
54
PUC
PUC -
1I
04
20.7
62.1
12.6
4.6
No.of living children
0
I
2
34~4
264
Marital Status
Single
Currently Married
Widowed/Divorced
0
3
33
23
I
I
i
I
16.9
Education
i1
©
5
46
Length of Service
(in years)
I
J
3
Less than 5
5 - 14
15 - 29
30 +
9
22
39
17
1Q.3
25.3
44.8
19.5
■s>
J
■&
a
One of the major problems faced by the respondents was shortage of
housing - only 40 percent of them had housing facility provided by the
Government, whereas 23 per cent of ANMs were residing in rented houses in the
sub-centre villages. Another 23 percent were in a rented house in the sub-centre
village and the rest 37 percent were commuting to their place of work that
r
3
i
J
-y
3
required about an hour Udupi had an excellent net work of public transport with
very good road that was found to be a very important factor to improve
accessibility to health care services whereas Gulbarga had bad roads or no
roads and poor public transport that badly affected easy accessibility. Tumkur
can be placed in between these two districts with some area with good roads Kunigal section whereas Madhugiri was having serious problem of roads and
3
3
public transport. It would be of interest to mention here that during our visit to
observe an ANC camp at a sub-centre village in Gulbarga we had to leave our
car at a point and hire a Land Rover jeep to reach the Sub-Centre as the road
o
was full of boulders and ditches which only jeep could negotiate with great
■3
difficulty. To cover a distance of 15 kilometers it took an hour at high cost.
3
Lady Health Visitors have to supervise the work of ANMs.
3
In the study
area we could get only 10 LHVs who had to cover on an average 40 villages in
addition to their administrative work of compiling service statistics from each
3
ANM on maternity, immunisation, etc. The fact as reported by both LHVs and
ANMs is that supervision/work monitoring in the villages has almost ceased to
exist.
Many senior ANMs recalled that when they joined serv.ce they had to
cover larger areas - population but they used to enjoy the work
r|3
team spirit, co-operation and guidance from M O and DHO.
There was a
Work was taken
very seriously. The Med.cal Officers prov.ded home visits to sterilised cases for
i&
'f
follow-up services.
Deliveries were supervised and post natal care then was
good. Now hardly anybody bothers about supervision and monitoring. ANMs
feel lonely and helpless in the job as there is neither any help nor guidance and
no supervision but if anything goes wrong they will be held responsible
F3
L
r
The
information collected from ANMs show that exceptionally large number of villages
11 to 18 villages were to be covered by 13 ANMs in Tumkur. Whereas in Udupi
and Gulbarga despite vacancies that add burden to ANMs work they were found
to be covering about 3 - 4 villages as size of population is large. As over half of
the ANMs were natives.of the same district they were quite familiar with
sociology and culture of the area. While more villages add only to travelling time,
size of the population, average number of couples to be served in RCH seem to
rJ>
rf
>
'»
be well within manageable limits of ANMs with very few exceptions
X
The Foundation Course
The female health workers have to complete the foundation course
■
specially designed for them to be eligible for consideration for the job
But some
had 2 years training while over 80 percent had completed 18 months course at
■9
different District Head Quarters. Surprisingly it was found that there was a long
time gap before they got the job. About 20 percent had joined after 3-4 years of
their completion of the course and they took considerable time to refresh their
training skills they had almost forgotten. Indeed, 6 ANMs had joined service after
5 years gap. In addition to the foundation course LHVs have to undergo another
6 months training to become LHV.
They were asked to assess the quality of their foundation-training course
Q
in terms of (a) Curriculum (b) Duration (c) Regularity of Faculty (d) Quality of
training (e) Practical training in hospital and (f) Practical training in the field.
Their response was classified in 3 categories. The distribution of responses are
0
reported below.
0
TABLE 5 : ASSESSMENT OF THE FOUNDATION TRAINING BY
THE TRAINEES (PERCENT)
©
2
2
Duration_________
0
y
Regularity of Faculty
Quality of training
Practicals in hospital
Practical in field
0
a
4
2
6
Curriculum
Good
lair
78.2
34.5
J5_0
63.2
25.3
64.4
57.5
59.8
7001
24.1
19.5
25.3
Poor
2,3___ '
8.0
19.5
11.5
Can't sav '
d
21
2.3
34
14
3.4
r
0
3
It is to be noted that 18 months duration is divided as 12 months theory
and 6 months practicals in hospital and field.
The majority of ANMs (63.2
0
percent) cpnsidered that duration was too short as they had to complete 10
0
theory papers. It is also reflected in the assessment of practicals in hospital as
57.5 percent reported that on job training was too short to master the art of good
©
midwifery.
r
f
Almost 60 percent felt that the field training that forms the most
important component of their job was inadequate.
©
f
0
1
■ >' ♦
'J
Majority of the ANMs opined that the curriculum is good but heavily biased
towards theory whereas most important for their job is field work where they have
to
manage
themselves
with
midwifery
that
put
heavy
responsibility.
Communication skills which they need most in their field work was found to be
lacking. It seems there is an assumption, that all ANMs have that skill.
□
During discussion with ANMs we asked how confident they were when
they conducted the first delivery of their career. Majority response was they were
©
very shaky.
Few were fortunate to have a LHV who was good to instill
confidence in them giving guidance in the conduct of delivery that went a long
way in building their confidence.
But many were not that fortunate but could
manage the situation without any serious problem
o
How the training received several years back is relevant now? Several
3
respondents mentioned that except midwifery hardly anything is relevant. AIDS.
RCH, Target free approach are all new and are relevant now. More skills are
required for day-to-day work and in recording them properly in the registers
r
provided.
Section I
Io
In this section we have tried to review the training programmes that
©
respondents have completed and how they perceived their utility in their day-to-
.1©
day work. The major programme in this regard was the Child Survival and Safe
<- w©
Motherhood training followed by seyeral other short term skill knowledge
-I
enhancing programmes. ■
>
Child Survival and Safe Motherhood (CSSM) Training
Reduction in maternal and child mortality was highlighted in the National
Health Pohcy 1983. The sustained high levels of immunisation programme that
r
increased contacts of female health workers with women and children
demonstrated that about 2million children were saved during 1984-92 (the
difference in child mortality rates of 1984-92 which was monitored). It was
^3
‘ 3
.75
J
H)
followed by Universal Immunisation Programme that envisaged that every child
would be protected by all the preventable killer diseases of children
75
In order to accelerate the declining trends observed in child mortality
'Child Survival and Safe Motherhood’ programme was launched in August 1992.
1)
It was fine tuning of the earlier programme with emphasis on quality and
outreach.
It is very relevant for this study to consider the objectives of CSSM
programme and examine the ANM/LHV training impact on their performance.
The CSSM had set the following goals:
1. By 1995
a) Eliminate neonatal tetanus.
□
b) Reduction in Measles by 90 percent, deaths by 95 percent.
2.
By 2000
a) Elimination of Poliomyelitis.
b) Reduction in diarrhoea deaths by 70 percent.
■a
c) Reduction in ARI deaths by 40 percent.
a
d) Reduction in maternal mortality to 2 per 1000 deliveries.
e) Reduction in IMR to 60 or less per 1000 live births.
a
f) Reduction in under 5 mortality to 10 per 1000 children under 5
years of age.
g) Reduction of perinatal mortality to 35 per 1000 births.
»
a
a
In order to equip the Female Health Workers for the huge programme
massive training programmes were launched in the states.
An earlier study
conducted in Karnataka that covered Channapatna and Hoskote Taluks (all
a
&
PHCs and Sub centres) found that CSSM training given to ANMs/LHVs had
significantly improved their midwifery skills and improved immunisation in the
i
area resulting in reduction in IMR (Kanbargi, 1997)
In the study area only 60 percent of the respondents had undergone
CSSM training. The duration of training varied between 3 days to 21 days at
r
different locations where the training was imparted. It was not possible for us to
verify the wide ranging duration and the reasons for it
However, most of the
f
I
0
0
II
A’’*!
respondents expressed their appreciation for
providing training that refreshed
There is hardly any continuing education
programme for them
An importan, fact that came out dunng the stud, was how CSSM changed some
their memory.
0
■
0
age old practices that were rout,net, Mowed
•fA
For .nstance, babies were given
bath soon after birth that often ted to compticat.ons
The CSSM training has
changed it. Now bab, Is kept warm for a da, before giving bath. This practice
o
ma, reduce considerabl, the incidence of diseases peculiar to childhood
3
raining also, as reported by all those trained, enhanced their knowledge on ANC
0
The
PNC and midwifery skills many of whom had learnt 20-25 years back The five
Cleans or Pancha Shuchitwa was very much valuable learning
Some of the
respondents expressed their happiness that CSSM training not only improved
3
their skills but was accompanied by a booklet and a Disposable Da, Kit (DDK)
•3
The booklet which should be given to every ANM/LHV as the, reported it has
proved invaluable for them for all time (Unfortunately the Research Team could
not see the booklet).
The respondents were asked
asked about
about other
other skill
based short term special
skill based
.3
raining programmes that are imparted
There does
does not seem to be any
There
systematic approach ,n organising these training programmes nor there seem to
’P
be an, compuision that say those who have put
20 years of service shou.d
have some minimum number of training programmes As one ANM (ver, sen,or)
o
us that often they do not know that their colleague from other sub-centre had
gone for a tra.nmg programme about which MO had not even informed others It
r
was only after her return they team,. This aspect. „ is hoped. ,s covered b, other
study by Dr Mehta and Dr Shivram.
We had listed to Important training programmes to check how many of
hem were attended b, the respondents.
They were training programme
pertaining to Maiana, Cataract. Tuberculosis. Fami.y Planning Target Free
A preach RCH. Leprosy. AtOS. W. MPW. MTP and an open ended others
Others category rnciuded ,PP and continuing education programmes that were of
F
p ned th Mb" dUraS°n Were aP~ by ,hS
rI
response and ratings recorded are presented below:
$
o
')
pned
the programmes were broad based and more practice,
ANMs
The
v15
12
TABLE 6
Training
3
1-- -J
o
No.of ANMs I
trained
Percent
J5
17.2
69.0
26.5
67 8
42.5
77.0
44.8
20.7
23.0
4.6
51.0
Malaria
Cataract
TB
Target free
RCH
Leprosy
AIDS
IUD
MPW
MTP
3
TRAINING PROGRAMMES AND THEIR ASSESSMENT
Others
60
23
59
37
67
39
18
20
04
45
Very good
-i—
T
t
t
26.6
J5_0_
JT4
J^Q'
32.4"
19.4
41.0
61.0
500
100.0
46.7
JRating
Some what
_ USCM _
60.0 '
41.7
65.2
593
54 1
55.2
35.9
__ 33.3
45.0
48.9
Not
useful
132
33 3 ~
17.4
23.8
13.5
25.4
23 L
5.6
5.0
4.4
O
The rating and percent trained for different health programmes reveal
some interesting facets.
Even during our discussion the findings in the table
3
were repeated.
$
disliked by most of the respondents. It was reported in all sub-centres that the
Short term programmes particularly one-day training was
O
faculty would arrive, generally, late and by the time the programme starts it is
a
a
time for lunch and post lunch session - after heavy lunch is not very conducive
for learning. The administration might have to confront with several problems in
encouraging training courses lasting for at least a week. Given the large number
of vacancies in the sub-centres, withdrawing ANMs for training for a week will
a
a
a
certainly disrupt the skeletal services that reach the community. Arranging right
resource person for the programme, communicating with the trainees etc. do
pose hurdles in efficient organisation. However, given the rating of the trainees
and assessment of the utility of these programmes it may be more productive to
>
a
enhance the duration and enforce discipline of the resource persons.
r
There is also the problem of the size of the trainees.
a
An elderly ANM
i
reported that she was one of the 30 trainees in a programme and was sitting in
the back row, hardly could hear what was lectured and instrument to be used
3
f
a
a
I
B
3
was only one which she could not see at all
By the end of the day she thought
she would not have missed anything by not attending it.
A shocking observation which the earlier study (Kanbargi, 1996) had found
was substantiated here that only one in five ANMs knows how to insert an IUD.
It is widely acknowledged now that Indian Family Planning Programme is
‘•3
synonym with massive female sterlisation as they account for 80-90 percent of all
acceptors.
The programme managers argue that if women prefer only
sterilisation what can be done? This argument is hollow as the eligible women
I
who need contracepting method are not even fully aware of the choice they have.
The district level information provided in Table 2 makes it very clear. It is only
female sterilisation which is universally known in rural areas. Spacing methods
□
a
ignored in the family welfare programme need urgent redressal.
Section II
Review of Training Impact: Insights from the Field
This section has tried to review the impact of training programmes on day-
to-day practice of the respondents.
It is classified as (I) Antenatal care, (ii)
Identification of high risk pregnancies - (during Ante-natal care), (iii) Midwifery
services and (iv) child care. These are all part of safe motherhood and child
survival programme which is being implemented in the state for few years now.
As it was revealed that only 60 percent of respondents have undergone CSSM
training but interaction among trained and not trained possibly will improve
*3
overall performance of all respondents.
>
Antenatal Care
i
The antenatal period is of great importance in determining future course of
events for an expectant mother.
During pregnancy traditional practices are
r
followed despite some modern knowledge. It surely influences the health care
'3
seeking behaviour of women and their health status that will have a great bearing
on outcome of the pregnancy.
a
1F
--$
r3
One of the most important fact that affect
pregnant women’s health is the suggested strict d.et reg.me - severe restrictions
on food - what to eat and what not to eat. The strong dietary taboos can further
'J?
14
adversely affect the nutritional status of women most oi whom are already
'•^
malnourished.
But there are also traditional norms that put restriction on
activities that may have some beneficial impact.
7$
The knowledge about conception is widely known to all - pregnancy is
recognised by the absence of periods or nausea. If the ANMs are regular in their
beat and meet all the potential women they are likely to know that a particular
■’3
'3
■3
woman has missed her period and if she had a fairly regular cycle guess that she
is pregnant. The care should start from registering such women.
The recently completed RCH survey (Kanbargi et.al., 1998) considered at
least 3 ANC visits to each pregnant woman during her pregnancy, 2 anti tetanus
a
injection and supplementing nutrition by providing folic-acid tablets for 100 days
as minimum package to be ensured to each pregnant woman. The survey found
wide variations across districts ranging between 78 percent in Dakshina Kannada
■a
- Coorg districts to only 21 percent in Gulbarga.
a
reasons to be explored. Many researchers have questioned the efficacy of this
>
3
There could be a variety of
approach in reducing maternal mortality in the states e g. a study conducted in
Kanakpura rural areas found “ante natal care provided by the government was
only “contact service” and are often routine that leaves much to be desired.
Weight of most of the women was not recorded, not haemoglobin estimated nor
3
urine test done.
O
practioners. Apart from providing tetanus toxide and iron folic acid very little is
e
done in government health care” (Jayashree Ramakrishnan et.al., 1999).
3
This is in marked contrast to services provided by private
The findings from the present study fully agree with the above
observations. The questionnaire had a check list of 14 items like (I) Registering
a pregnant woman which should be the beginning of the service and when is it
done? When a woman informs about pregnancy or during 3 - 5 months of
pregnancy?
It was assumed that ANM is supposed to visit the households
3
routinely and during her visit a woman may report that her periods are post
3
3
poned or missed. However, the respondents could not distinguish the nuance
•S
use in over 50 percent of respondents, (ii) When they start supplying IFA Tablets,
3
3
r
and the objective behind splitting the question in two parts and it was of not much
(iii) When the Tetanus Toxide injections are given, (iv) When is the blood
f
f
9
i
7*
15
'3
pressure measured, (v) When urine test is done, (vi) when is the blood test done,
(vii) when is the weight taken, (viii) when is the abdominal examination done, (xi)
when is the vaginal examination is done, (x) Whether diet advise is given (xi)
Whether advice on breast feeding given (xi) Whether the woman is informed
about possible complications in pregnancy (xii) Whether contraceptive advice is
:o
given to either post-pone next pregnancy or avoid it and lastly whether need for
post-natal check-up is explained? The following chart provides the responses of
ANMs/LKVs to these questions.
TABLE 7 : ANTENATAL CARE KNOWLEDGE : PERCENT
■eg
1®
SI
No
Check list
j2
2
Registration__________
1FA tablets__
4
5
TT injection
BP_____________
Urine test______
x
6
7
8
9
10
•3
11
12
13
14
~
Blood test
Weight test________
Weight taken
Abdominal check
Diet advised______
Breast feeding advise
Pregnancy complications expjajned
Contraception advised______
Post-natal check advised
i
~
Frequency
Yes
No
WOO
0
100.0
0_
98. <
1.5
92.0
8.0
96,6
3.4
93.1
6.9
96.5
W0.0_
74,7
100.0 ~o~'
1000 _0_
83.9
16 r
94.3
5.7
86.0
14.0
Most of the ANMs were aware of what is ANC and its importance.
But
they had problems with discharging these responsibilities because of lack of
instruments required like BP instruments and stethoscope, chemicals needed for
testing urine etc.
In addition many ANMs were not sure what is high BP that
need attention? Weighing machines were provided to only 10 percent of ANMs.
Only one ANM in a sub-centre (Gulbarga) showed me two weighing machines -
one for just born babies and other for adults. She had another weighing machine
for babies who can be placed in the panel for weighing.
&
But this was an
’Vp^
exception, checking haemoglobin content and RH - ve was not possible even in
Community Health Centres and PHCs.
It was clear that the knowledge of ANMs is not fully exploited in providing
quality care during pregnancy. To explore further we visited two ANC camps in
ST
Gulbarga district - one held in a sub-centre and another at a CHC. The Registers
'3
maintained revealed that in CHC about 20 percent of women were examined for
3
blood pressure and taken their weight. It was reported that large crowd about
3
100-150 women makes it impossible to provide the text book - prescribed
services to all pregnant women.
The sub-centre clinic was held in a school - an apology for quality service.
•9
There was one table and a chair courtesy the school and the room was
3
3
partitioned by a thin dirty bed sheet for examining women. Hardly there was any
a
be examined. The Lady Medical Officer was tired but committed to do her best
3
privacy. There was a crowd of 50 - 60 women at noon still waiting for their turn to
to the pregnant women who had walked long distances to come here. They had
very little choice as the ANM staying in the sub-centre village was hardly
equipped with her needs. She had hired a room at the back of the school, she
3
had to collect water from a well and go to field for her natural calls. Her husband
*3
was staying in Gulbarga.
3
We observed that because ANMs have not been provided with required
e
a
facilities they request the pregnant women to come to a ANC camp held once in
a week or once in two weeks. The Sub-Centre we observed held ANC camps
every week and serves about 10 near by village women. The camp naturally
gets crowded making it difficult to do all required tests for each one A seasoned
I
medical practioner will take the blood pressure if she has reason to doubt
J
otherwise in such situation no. Maintaining record of blood pressure, weight gain
>
chart that immensely help in identifying high risk pregnancies/babies and
3
planning safe deliveries is not possible.
3
3
3
If the ANMs who are trained for ANC
f
and used only for distributing IFA tablets and abdominal check-up it is gross
under utilisation of their talents and putting more pressure on limited resources at
f
the Sub-Centre causing great inconvenience to women clients.
r
3
a
r
3
3
i
17
The ANC section has two very important questions that are generally
ignored. One was whether the expecting mother knows when she is expecting a
baby - probable date of delivery. The ANM should be able to suggest the same.
We observed 82 out of 87 were aware how to estimate the date of delivery
a
■J
Another crucial factor is where it will take place? It is crucial because during
ANC period there will be clear indication regarding the type of delivery - whether
it will be normal or complicated. Depending on the need ANM can suggest the
©
place. If it is going to be a normal delivery certainly can take place at home. If
Q
not, the family has to arrange for a hospital delivery including the resources. But
surprisingly only two in three ANMs reported that they often suggest to women
where they should go for the delivery. But the rest said it is to be decided by the
family based on their economic situation.
Our broad impression was, as
mentioned early, the ANC means 3 visits to pregnant woman, 2TT injections and
IFA supply of 3 months.
Though it may be considered as minimum needed,
much more has to be done to do justice to CSSM programme and improve the
■0
situation of women and children.
■‘a
'I®
Identification of High Risk Pregnancies
Identification of high-risk pregnancies is the first and single most important
step to be followed by going to a referral hospital fully equipped to provide
L
'I®
efficient services to ensure safe delivery.
The responsibilities of the ANMs and LHVs listed in the Training Manual
prepared by State Department of Health and Family Welfare under India
Population Project (IPP IX) include urine test and blood test of all pregnant
]•
women for albumin, sugar and hemoglobin contents during their home visits. It
la
also mentions that at least 50 percent of the deliveries are to be conducted by
i*a
ANMs and the rest conducted by Trained Dais are to be monitored or supervised
by ANMs.
e
!J®
The questionnaire has prepared an exhaustive list of symptoms that
indicate high- risk pregnancies. Each ANM was asked whether they know what
constitute risk to pregnant woman. The list prepared included risks related to last
pregnancy termination, history of systemic illness, reported complaints during
Q
IX
$
0
pregnancy in addition to the generally known factors like first birth or higher order
births, height of the woman, status of blood pressure, etc.
The knowledge reported in the following tables is based on combined
responses - some spontaneous and others received after a little probing
The
responses are presented in two formats for the convenience and understanding
o
of the reader.
©
TABLE 8 : IDENTIFICATION OF HIGH RISK PREGNANCIES
<9
0
SI
No
Symptoms
Aware
(percent)
1
Age less than 18 and over 35 years__________
1st or 4n and higher order births____________
Current pregnancy within two years of previous
Height less than 4\ 10"
Abnormal weight gain - over 10 kg. Weight gained
during pregnancy_______
Sustained high blood pressure over 140/90
Poor weight gain 5 - 6 kg only_________
Mai presentation of foetus__________
88 5
74,7
2
■3
~3
<3
4
5
3
6
©
7
8
9
10
Weak or no movement of foetus
Convulsions in pregnancy
62.1
Not
aware
percent
11.5
25.3
37.9
8J_6
52 9
'
4_
“47. f
50.6
48.3
;
?
49 4
51.7
21°...
. 'T. ?_?A
54.’<r” ' 46.0 _]
70.0
30 0
It may be mentioned here that many ANMs in Tumkur District reported
©
that for this interview they had spent two sleepless nights to go through their
©
notes/books of training period to refresh their memory like they used to prepare
3
for their theory examination. However, the information provided in Table 8 and 9
□
is disappointing picture.
&
problems in responding as they frequently said “we have forgotten many things
taught long back”.
&
It was the respondents in 50+ age who had more
There were two respondents who were deaf and posed
problems for communicating effectively.
r
It may be noted here that most of the respondents knew that short women
constitute high risk during their pregnancy but they could not define what is
?
©
short? Similarly they knew that sustained high blood pressure during pregnancy
©
carry high risks but did not know exactly what is high blood pressure.
As
I
©
©
f
©
©
I
3
3
19
3
3
mentioned earlier most ANMs do not possess the instrument and those few who
had it, was not in working condition.
3
3
I ABI.I-. 9
O
SI.
IDENTIFICATION OF HIGH RISK PREGNANCIES
History of last pregnancy
Aware
No.
<3
©
1
i) Last pregnancy terminated as
a) Abortion
b) Still birth
c) Premature birth
3
2
7©
a) Retained placenta
b) Sepsis
c) In neonatal death
Systemic illness
(i) Heart disease
(ii) Diabetics
(iii) TB
(iv) Hypertension
i
Not Aware
Percent
64 4
57.5
55.1
35.6
42.5
44 9
55.1
60.9
16.1
44 9
39 1
71 3
71 3
77 0
57.0
83 0
28 7
23 0
430
17 0
32.2
44.8
48.3
35.6
62.1
52.9
368
18.4
67.8
55.2
51.7
64.4
37.9
46.9
63.2
81 6
i
ii) In complicated delivery with
prolonged labour ended with
0
Percent
3
3
’I
r
©
1b
Woman complains of
(i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(viii)
Breathlessness
I
Excessive tiredness
Palpation
Puffiness of face
Tightening of ring/bangles/chappals
Vaginal bleeding
Pain in abdomen
Fevers
1
’0
The responses presented in tables 8 and 9 reveal inadequate knowledge
about identification of high risk pregnancies among the ANMs. The focus group
discussion clearly brought out the problem of ensuring safe deliveries even in
!T
cases of identified high risk pregnancies as the required facilities were not
20
available even at Community Health Centres supposed to be first referral
centres.
An example of a maternal death reported in one PHC area would explain
the situation on ground level. The woman who delivered a baby with the help of
a trained Dai and developed complications on third day. She was bleeding. The
PHC kept her for a day with medication. The bleeding did not stop and she was
advised to go to District hospital in the night.
'S)
transport and resources.
The family could not arrange
Instead they took her home and she died next day.
Some enquiry was conducted and the case was hushed up.
The data collected on ANC services and ability to identify high-risk
pregnancies reveal that there is a long way to go to achieve effective reduction in
□
maternal mortality and infant mortality. As noted earlier ANC means three visits
to pregnant woman, 2TT injections and 100 IFA tablets.
Even this minimum
package of services have made considerable impact in bringing down IMP in the
3
state,
further
decline
depends
upon
improving
the
services of ANMs,
infrastructures of PHCs and CHCs to reach the goal of IMP 30 mentioned in the
policy statement of 2000.
Institutional Births
©
Institutional deliveries are meant to provide safe motherhood and the
resultant significant reduction in maternal deaths. Wide variations were observed
©
3
in them in the selected districts - from gbout 79 percent in Dakshina Kannada to
only 21 percent in Gulbarga. ANMs in Udupi reported that mapy of them have not
conducted a single delivery during last five years because women prefer to go to
3
maternity homes or Government hospitals at District level.
The private sector
3
health services in Udupi - particularly the Manipal Hospital have expanded their
3
maternity services to rural areas that has almost ensured safe delivery to any
3
woman - poor or rich. Our visit to a remote place in Udupi where we had to cross
a
a river to reach the village revealed that just a telephone call to the Manipal
Hospitals maternity home situated at a distance of 14 kilometers will provide
i
them not only free delivery but also free ambulance service to transport the
pregnant woman to the hospital
The public-private co-operation observed in the
!
©
□
f
3
9
i
21
G
district is really remarkable to try in other poor districts like Gulbarga or Bellary
that can improve accessibility to good care and go a long way in ameliorating the
sufferings of poor women.
As a contrast to Udupi ANMs who have not conducted a single home
delivery during last five years, committed ANM in Gulbarga where there is hardly
.'Vt
any choice for most rural women reported that she conducted 120 deliveries this
year of which 20 were high risk whom she referred to CHC and ensured safe
births. Another ANM reported to have conducted 94 out of 99 births in her areas
this year - 5 being conducted by a trained dai. These two ANMs stay in the sub
centre quarter and a visit there will convince that they were model sub-centres.
The two ANMs were residents tpere, available any time for service, had BP
instrument, weighing machines for babies and adults, providing good ANC by
testing urine, keeping records of weight to know the gain, recording BP of all
women and ensuring the pregnant woman at least one check-up by a lady
r?
medical officer to confirm that every thing is OK with all her clients. The outreach
programme might have conceptualised such sub-centres as models. But they
are exceptions now as ANMs having no housing facilities stay in a place where
she can get a house on rent and naturally night deliveries can not be attended by
her.
Identification of High Risk Babies (Who weighed less than 2500 gms at the time
r
of Birth).
The data collected in Reproductive and Child Health (RCH Phase 1)
survey in the selected three districts revealed that only about 7 percent of babies
born in rural areas in Gulbarga district were weighed after birth and 58.3 percent
•■H
of them were under weight (less than 2500 gms). On the other hand in Udupi
(Dakshina Kannada) 62 percent babies born were weighed and only 13 percent
of them were under weight and in Tumkur about 28 percent of babies’ weight
’i
was recorded and 20 percent of them were reported weighing less than 2500
gms. These findings present a grim picture for Gulbarga and also to some extent
<F
Tumkur that certainly fare better than Gulbarga for underweight babies who carry
high risk of death. Though one of the simple measure to reduce this incidence of
rT
J
ir
4
22
3
low weight babies is to improve the nutritional level of the mother by
supplementing her diet and providing IFA tablets, the ANMs should have
knowledge of the under nourished mother and the need to supply IFA tablets to
3
them in their area.
The RCH survey reports that in Gulbarga where the proportion of low birth
weight babies is highest in the study area only 48 percent of pregnant women
a
had received IFA tablets, it was 87 percent in Tumkur and 92.3 percent in Udupi
©
(Dakshma Kannada). It is difficult to understand why this simple low cost remedy
available is not taken seriously in Gulbarga where it is absolutely essential.
It would be interesting to note here our observations and-the community
perceptions about how these essential services are delivered by ANMs.
:S
a
a
a
Our interaction with community leaders and women in particular provided
surprising data. We met a Lady Panchayat Chairman in Gulbarga who was in
her late forties, literate and was having concern for women's issues including
their health.
She said that the ANM stays in the village (only village she is to
serve as it is quite large with 3500+ population), has a telephone at home and
o
also keep some essential drugs for emergency.
She conducts most of the
deliveries in the village by charging anywhere between Rs.300 - 1000 depending
upon the economic status of the family.
But she never visits any home for
providing services. People have to call her on phone or meet her personally if
a
they require any service - of course at a price. The Lady Panchayat Chairperson
>
did not know that ANM is supposed to visit all families in- her jurisdiction to
enquire the welfare of women, their pregnancies, children health etc. Even her
husband and many others who gathered there during our focus group discussion
reported ignorance and said the panchayat will issue a letter to the Medical
Officer in this regard soon to ensure her services to all homes in the village. It
would not be surprising in such situation that poor and scheduled caste women
a
a
©
a
may not be able to avail her services free.
This was not an exceptional example in Gulbarga.
In three more sub
r
centre areas we observed similar things. Absence of good roads and transport
facility may be important hurdles to ANMs in addition to inadequate housing
f
e
■Q
2^
facilities. But administration both in the health department and at Zilla Parishad
should try to improve the situation to ensure accessibility to health care for all.
Rarely, except in one we could see a chart showing ANMs’ travel programme for
the week usually displayed in all PHCs.
0
0
It was also surprising that many
ANMs/LHVs in Gulbarga were not found wearing uniform white saree during
working hours. But in Tumkur and Udupi we did not see any ANM/LHV not in the
uniforms.
However, an effort was made to know respondents’ abilities to identify
high risk new born babies (who weigh less than 2500 gms) by check-listing some
symptoms.
a
TABLE 10 : IDENTIFYING HIGH RISK NEW BORN BABIES
(WEIGHING LESS THAN 2500 gms)
&
_______ Symptoms
Refusal of feed______
Increased drowsiness
Difficult breathing
Cold to touch_______
Yellow staining of skin
Convulsions________
Others
Aware (percent)
____ _________
56.3___
____ 75,0 ‘
____ 55.0_” _
62 0 ~ J
26,4
14.9
The data presented in Table 1Q reveal that there is much to be desired.
However, some ANMs were aware that if the baby is cold, they would keep it
under 200 watt electric bulb to improve the body temperature of the baby.
%
Acute Respiratory Infection (ARI)
Only about half (52 percent) of the ANMs were aware about Acute
Respiratory disease and 85 percent of them had knowledge of at least one
symptom of ARI and also were aware that it is an important reason for high IMR.
1a
24
Pneumonia
Most of the ANMs (91 percent) were aware about pneumonia and more
than half of them knew one or more symptoms of pneumonia like excessive
drowsiness, respiratory grunting, convulsion and inability to drink.
:>
e
Diarrhoea and Dysentry
Diarrhoea, a major killer of infants and its symptoms like passage of
watery stools 3-4 times a day was known to 92 percent of ANMs
However,
there was confusion among many in distinguishing diarrhoea from dysentry
which has symptoms like blood in faeces, abdominal cramps, fever and weight
loss. Only one in five respondents were aware that diarrhoea/dysentry is a major
killer of infants. All respondents were aware (100 pr cent) of dehydration that
Q
follows dysentry/diarrhoea and could mention all the symptoms like restlessness,
decreased skin turgor, dry mouth-tongue, sunken eyes and lethargic appearance
of the baby. Management of dehydration through measures such as giving ORS
£
or home made syrup of sugar and salt, plenty of fluids, and continue breast
feeding was known to all respondents.
The strong emphasis given to the child immunisation was reflected in
Q
every respondent knowing what immunisation is to be given when
Liquid IFA,
however, to be given to malnourished babies was known to only one in four,
It was reported that children are given
perhaps it is not supplied in the state.
a
small IFA tablets.
»
'3
3
Knowledge about Cold Chain
While immunisation coverage has shown remarkable improvement over
time, quality of immunisation has remained a question to be answered. Is cold
chain maintained to ensure the required vaccine potency? We wanted to test
&
a
whether personnel who play a key role in immunising children know about cold
chain?
I
It was revealing experience for the research team which visited a Primary
©
Health Centre in Gulbarga district. It seems a diary is to be maintained and the
temperature shown on the thermometer of the new type refrigerator in the PHC
r
a
i
J
25
where vaccine is stored is to be recorded by the Medical Officer
•3
We were
surprised the recording in the diary was up to date with recorded temperature,
date and signature of the Med.cal officer but the thermometer that indicates
temperature was not working for several days and not repaired. It was also clear
"A
from the observation of the diary that all the entries for the month were made the
previous day. Neither the staff nor the clients who receive were aware of the
importance of maintaining cold chain to ensure effective immunisation.
□
©
Compare this with what was reported by almost all respondents in Udupi
They said that the immunisation day for them will become a nightmare if power in
the area was shutdown even for half an hour as mothers would object for
a
immunising their children as there was power shut down yesterday as such what
Q
guarantee is there of the vaccine potency? With all the explanation by the ANMs
O
about the advantages of new freezers that they have, some mothers would still
prefer to go to private practitioners for immunisation. These observations, though
accidental, reveal the casual approach adopted by qualified responsible authority
whom the illiterate and ignorant community trusts and it deserves serious
consideration in the department to ensure that there is responsible approach to
immunisation.
Under the circumstances it was not surprising that about 40
expressed
their ignorance
I. 1
percent of respondents
ro
temperature to maintain the vaccine potency.
about the
required
J©
Infant Feeding
(
There was a question to check the respondents’ knowledge on exclusive
breast-feeding. What does it mean? How long a baby should be exclusively
breast-fed? Response of all the respondents was that babies should be breast
fed for 3 months. They also knew the advantages that exclusive breast-feeding
provides more nutrition (90 percent), protects against infections (87 percent) but
only 46 percent knew about its contraceptive effect. The RCH survey 1998 found
that in Gulbarga babies being breast fed within two hours of birth accounted for
>
e
r^3
>
only 9.5 percent while it was 36 percent in Tumkur and 47 percent in Dakshina
Kannada District.
Continuously repeated advantages of cholostrum milk that
provides effective immunisation to babies is almost demed in Gulbarga.
The
□
26
general opinion of ANMs was their advice during ANC and delivery does not
make much sense against the strong traditional beliefs that still govern the
community behaviour.
'1
Weaning
3
We also enquired whether the respondents are aware about weaning?
And when to start it? Each ANM reported that breast milk will be inadequate to
3
©
babies growth after three months and babies will have to be introduced to some
other semi solid foods like Ragi Sari, Rice Ganji’, ’Bele kattu or liqufied pulses’
etc. which can be prepared at home with locally available food.
Few of them
reported that they also suggest to mothers to go for baby food -available in the
market. More than 70 percent of ANMs in Udupi reported that weaning food also
a
can be purchased from market.
While the latest WHO recommendation is that exclusive breast milk should
a
continue for 6 months and only afterwards weaning foods be introduced, all
available evidence in Karnataka show that there is need to improve the
understanding of mothers in rural areas about the advantages of cholostrum milk
&
and exclusive breast feeding.
©
Surveys have reported wide spread practice of
squeezing cholostrum milk and feeding just born babies with variety of liquids like
sugar syrup and castor oil with enormous health hazards.
The respondents
reported that during Mother’s Club meetings as well as during ANC they explain
0
all the advantages of breast-feeding -including cholostrum milk however, the
outcomes are poor.
3
r
In this regard there is need to consider for vigorous
campaign and improved IEC programme.
Several babies, we saw in ANC
camps in Gulbarga and Tumkur convinced about the poor health status of
surviving children. They were looking thin with sunken eyes.
It is possible that
under-nourished mothers even though supplied IFA tablets were not regularly
0
consuming them to derive the benefits.
r
O
General Knowledge
I
We perceived ANMs/LHVs as backbone of rural health delivery system.
They are the link between the vast rural illiterate women and modern health care
!
r
i
~4
27
.3
providing PHCs. They are expected to visit every household in their area and
are familiar with each of the household that make th4m not only a health worker
but a friend, philosopher and guide to those women
During their visit they may
3
conduct mothers' meeting to provide them important information on their own or
3
have to answer some questions raised by their clients.
3
knowledge and advice carries great impact as such this study attempted to
Therefore their
assess how familiar they are with the population problem - particularly whether
•3
they knew that India's population has crossed 100 crore mark. We asked what is
a
India's population and gave three hints - 50 crore. 150 crore and 100 crore.
Only 46 percent of them could say it is 100 crore.
It was noted earlier about the low age at marriage of females and its
consequences on IMR, MMR and also fertility levels.
Marriages before a girl
attains 18 years of age are legally prohibited. But its impact is negligible on the
&
marriage age. Only 79 percent of respondents were aware of legally approved
age at marriage of boys and girls.
One in five respondents were not aware
themselves and they may not have discussed about it in the meetings of
mothers. If female age at marriage continues to rise as slowly as is observed
despite all efforts then what are the options left to policy makers to reduce its
consequences? Or should this area be left as nothing can be done as it is
L*
3
parents of the bride and groom who decide the marriage and who are not
Li©
bothered about the age? Marriage is certainly a complex social and economic
q®
issue. Good harvests see more marriages in any village and droughts few or no
marriage and difficult to bring interventions to drastically change the pattern.
>
In'this situation female health workers can play a very important role of
motivating the young married couples to postpone the first birth by a couple of
9
■•»
years or till the young woman attains 20 years.
The focus group discussion
revealed that talk about contraception will begin only after the couple has one or
rj>
two children and intensive efforts begin only after 2 children. It is obvious that if
©
sterilisation is considered as the only suitable method for the couple by the ANM,
>
there is no alternative. But can they not advise them to use condoms or safe
period or even least harmful orals that are available in the market? They are not
1
r’®
' »
trained to motivate couples for adopting spacing methods.
3
3
2X
vZ
3
The focus group discussions also brought out some interesting problems
ANMs face in the field.
It was reported that the distribution of IFA tablets to
pregnant woman generally starts in fifth month of pregnancy. If given soon after
registration of pregnancy of the woman and the pregnancy is terminated in
abortion women hold the ANM responsible for it. Because it is she who supplied
IFA tablets saying that her health will improve and on the contrary she had
abortion. Such news spread very fast in villages the whole village may turn out
□
3
9
hostile and ask her not to give those tablets to any pregnant woman in their
village. Similarly motivating for contraception is confronted with the problem of
child survival. If the only son among the two the couple has, dies, ANM will not
be forgiven for motivating them to accept sterilisation. So to play-safe they said it
is better a couple should have two sons and a daughter before undergoing
tubectomy. It is not surprising that NFHS II found 90 percent of sterilised women
had not adopted any other contraceptive method before. Distribution of Pill and
Condom through public sector, therefore, constitute insignificant proportion in
3
&
rural Karnataka.
This background is aptly reflected in the responses of ANMs/LHVs as 18
percent of them could not say what is safe period and explain it correctly. But 95
©
-i
percent could explain what tubectomy is and how it is performed because they
reported that they explain it to all potential acceptors.
Medical Termination of Pregnancy
a
»
Abortions were legalised in India in early 1970s and ttie number of legal
abortions have increased significantly over the time as also approved places for
conducting abortions. But rural women are deprived of this facility as most of the
>3
PHCs in the study area do not have the equipment or person/approved by the
>
government to provide abortion facility to women. None of the ANMs are trained
3
to conduct MTP and when we asked them when would they recommend MTP to
i
women? It was disappointing that none of them had suggested any woman to go
for an abortion. Looking at the clandestine abortions reported and observed by
the hospital records showing sepsis/infections caused by quacks while aborting
and admitted to hospitals in serious conditions, there is need to examine what
i
3
5
29
■>
ANMs can do in rural areas While ANMs took a moral sland and lheir response
was very firm in reporting that they neither pertorm nor recommend MTP to any
woman that does not reflect reality.
The job responsibilities listed by the Department of Health and Family
□
Welfare 1999 clearly has mentioned that ANMs should identify women in need of
MTP and inform them the nearest approved place for MTP to obtain an MTP. We
think there is an urgent need for a debate on the issue of prov.ding this facility to
rural needy women.
3
The Eligible Couple Register
Eligible Couple Register the Female Health Workers are supposed to
maintain and keep it up to date with all relevant information.
It is a valuable
document that guides in her work. It has all information she needs - how many
currently married women are there by contracepting status and number of
children, helps in identifying children is need of immunisation, and women in
A general complaint emerged
in all our
- [>
need of advice on nutrition, etc.
th
meetings was the shortage of EC Registers - some places not supplied for 7 - 8
I©
years and ANMs have to purchase a Note pad and record the information to the
3
io
<1©
best of their abilities.
Non-supply or irregular supply certainly creates serious
problem in compiling service statistics from Sub-Centre.
We wanted to learn from ANMs whether still they feel EC Register serves
an important purpose and help them. There was a unantmous response that it is
important and they should be supplied EC Register so that they will be able to
>
improve their performance.
t
Mothers Meeting
The respondents also informed that they routinely conduct mothers'
meetings and discuss different health issues and about nutrition. They think that
&
these meetings will become more effective if the ANMs are provided with
>
educational materials for use during the meeting to make the meetings more
e
']»
productive.
q®
'•
30
0
Advise to Adolescents
*)
The needs of the adolescent girls that were ignored for long is getting
attention now.
There are special programmes designed for their benefit to
improve their knowledge about personal hygiene and health.
There were few
reports of providing Tetanus Toxide injection to these adolescent girls. What was
J
interesting to learn from many ANMs was that often in mothers meeting some
adolescent girls also participate and when the topic of contraception / pregnancy
>
3
is to be discussed they are asked to go out as they need not learn about
contraception because educating these unmarried girls in Family Planning
methods because of the fear of using them before marriage.
Given the sea
change that is being realised through recent research on changing sexuality in
the society and the AIDS threat becoming more and more serious there is need
to think about what should be the policy for these girls.
Most of whom are
illiterate and ignorant of many vital issues concerned with their own person.
>
4a
If
they are educated about contraception will that enchance its use after they get
married?
Summary and Conclusions
The short term intensive study was carried out in three districts of
&
Karnataka State that widely differ in health and demographic indicators.
The
main objective of the study was to assess the various training programmes the
©
grass root level female health workers {ANMs/LHVs) have undergone, extent of
their utilisation by them in their day-to-day work. The study went beyond the
5
stated main objectives to examine whether providing training per se will improve
health care services as its effective exploitation is related with a host of other
1
factors like infrastructure, equipment and team spirit at PHC level from where
1
these services are organised, supervised and monitored.
>
The focus of the study was confined to those training programmes that
r
were designed to improve the health status of women and children - more
specifically in reducing further IMR and MMR. For this intensive study selected 3
f
districts - Udupi, Tumkur and Gulbarga. From these three districts 8 Taluks and
22 Primary Health Centres were selected.
All Female Health Workers
!
f
I
3
31
A
(ANMs/LHVs) numbering 87 of these centres were administered a standard
questionnaire that was specially constructed to check their skills required in their
work. The 87 respondents were covering a population of 2 61 155
3
1
All respondents had successfully completed the foundation course - 18
months and few had 2 years training programme. The gap between the
completion of course and joining the service for many was
large and few
exceptional cases it was 4-5 years.
The general impression of the irespondents regarding their training that
3
some had completed 30 years back was that
therej was inadequate attention to
---------
a
a
practical hospital training and training in field work. An indication of this
reported shaking of hands' during the first delivery conducted by
most of them.
There were one-or-two exception to this general observation.
a
r
1®
Gulbarga mentioned she had the best
was the
An ANM in
opportunity of conducting 24 deliveries
during her training period under the able supervision and guidance of a
gynecologist. It was suggested that training programmes should be need-based
and practical in real life situation and not just lecturing with lot of information.
There was long gap between Foundation course and the next most
important training programme related to maternal and child health viz. CSSM
training. The findings show that still 40 percent of ANMs have to undergo this
programme that has great relevance to reduce further IMR and MMR
It was shocking to find that most of the ANMs are not trained to insert IUD.
Policy studies have repeatedly highlighted the urgent need to enhance use of
spacing methods particularly among rural women, as it will have direct good
impact on the health of women and children. This needs serious attention.
f
r F»
3
>
Similarly ANMs/LHVs need to be more sympathetic to women’s need for
Abortion.
Whether they can be trained to perform medical termination of
pregnancies is a technical question to be decided by experts, we strongly
recommend that at least MTP service be made available at PHC level and
ANMs/LHVs should be trained in the legal aspect of MTP and when they can
recommend it to needy women.
In addition to CSSM, a host of training programmes have been conducted
for the respondents.
r?>
fF
A general observation is that the short term training
3
3
12
T
programmes of one or two days have been rated as not very satisfactory by the
j
respondents. There was a strong suggestion of all respondents in Tumkur and
Gulbarga that Continuing Education programme for a week should be a regular
feature to update their skills and knowledge of maternity and child health. This
programme should be holistic and may cover other relevant contemporary health
problems in the state / district.
Identifying high risk Pregnancies
3
The findings suggest that there is a need to have as suggested above,
3
one week Continuing Education programme to enhance the knowledge and skills
S>
3
&
of ANMs/LHVs of pregnancy management. Except in Udupi/Dakshina Kannada
and Kodagu districts where Institutional deliveries have become a rule in all other
districts where domiciliary deliveries dominate, the improvement of the
knowledge of ANMs with intensive training should be given serious attention.
ANMs/LHVs must have knowledge of measuring blood pressure, testing urine for
%
albumin and sugar and keeping these records for all pregnant women. These
3
services should be provided to women in their homes by ANMs in addition to TT
Ol
injections and IFA tablets. It should be followed by blood test of each woman for
a
e
haemoglobin content at PHC level.
It may be noted that we had trained Field
Investigators of NFHS II Survey to measure haemoglobin of all women in the
sample at their home in each village. It was possible because very simple to use
technology was made available from USAID. It should not be difficult to obtain
3
this technology by the state government for use of ANMs/LHVs. The time taken
3
for the test is very little-just 1 minute per woman at their door step. Unless
3
3
minimum package of services are ensured to all pregnant women and each high
risk pregnancy is identified and taken to nearest referal unit for safe delivery,
MMR will continue to be very high.
3
Identifying high risk babies also needs serious attention.
3
Acute Respiratory Infection is very poor among the respondents.
3
reports that about 34 percent of children were suffering from ARI in Karnataka
S
indicating the serious nature of the illness and its consequences. The present
3
study found that ANMs were confused when asked to distinguish between the
3
i
Knowledge of
r
NFHS II
r
!
f
3
I
5
5
31
3
symptoms of diarrhea and dysentery. As 15 per cent of children in the state were
found to be suffering from these illness rmproving the knowledge of ANMs and
LHVs in identification of these illness and ARI is to be given immediate attention
3
It was, however, satisfying that Oral Rehydration Therapy (ORT) is universally
5
known not only to ANMs but also to mothers.
Immunisation coverage in the state has shown gradual improvement as
revealed in the service statistics. We came across a report in Gulbarga that a
baby afflicted by polio in a village was living next door to the sub-centre. Looking
a
at the crowd in Immunisation Centres with several agenc.es participating, a child
may miss immunisation. ANMs were found to be well versed with immunisation
>
process and were confident that ail children in their area are protected. While m
3
Udupi Rotary, Lions, Womens Organisations, College Students and many
3
enlightened women participated in pulse polio in a big way even in rural areas
3
such support in Tumkur and Gulbarga was more concentrated only in District
3
towns.
3
Respondent’s knowledge about benefits of exclusive breast feeding and
weaning was appreciably good and needs periodic updating. Their understanding
of India’s population and legally approved age at marriage for males and females
J®
3
[b
was found poor that needs to be up-dated.
The most glaring lacunae reported by ANMs and LHVs
in their training is
lack of communication skills and inadequate attention to it in any of their training.
Simple observation is that to combat with strong traditional practices having
serious adverse impact on women and children like squeezing of cholostrum milk
needs intensive campaign. It would be effective only when ANMs can play an
c
I -a
I?
important important role.
Similarly introduction of spacing methods to young
married couples would be facilitated greatly if ANMs are properly trained to
convince the young village couple of its advantages.
Most crucial issue to be considered here is that training, upgrading skills
and information becomes inevitable to improve overall health status measured in
several ways. The goals set in the health sector can be achieved when such
relevant training programmes bring in qualitative changes in the services
’I
>
provided to clients.
If all that is told in framing programme is difficult to put in
5
34
1
practice because of lack or absence of infrastructure, equipment and other
3
supplies the purpose of training cannot be served.
It was observed that vast expansion of health care services - personnel
during the decade is not followed by adequate ■ care and required
resources.
The quick expansion perhaps created a problem of finding professionally trained
□
personnel. A look at the staff position at district level is surprising if not shocking.
If health care service delivery is ensured with or without these large number of
vacancies, it is in itself an indicator of quality care.
At policy level, it is desirable to think of a district or a group of districts for
intervention. For example in Gulbarga and Tumkur and such other districts there
is need for greater attention to improve the management of pregnancies and their
3
outcomes which may need more resources like improving PHC/Sub-Centre
3
infrastructure, equipment to ANMs such as BP instrument, chemicals to test
urine, haemoglobin/blood test etc.
3
3
Where as in Udupi. Dakshina Kannada,
Coorg with good adequate support from private sector this problem is not there.
But AIDS is looming large in these districts with large out migration of males and
females. We heard reports of AIDS deaths caused in every village we visited
3
with documentary evidence. All the deaths had occurred to the return migrants
a
and it seemed as if they all came home only to die.
3
At state level there is a uniform policy of resource allocation for health
3
sector. If some districts perform poor as indicated by several indicators it would
>
be necessary to ensure that administration in these districts are pulled up. The
a
f
poor perception of people regarding the public health care system in health poor
districts needs serious attention.
Precious public resources deserve more
3
productive use. The backward nature of some districts is known for long for over
3
four decades and these districts have remained at the bottom even now. Unless
some fundamental change is brought in the administration for improvement they
3
will continue to be at the bottom.
I
a
a
3
&
3
i
i
9
3
-3
Y)
□
Nayak Committee recommended that PRIs should have
3
group ‘C and D’ employees, the State government is
powers of transferring
yet to accept it.
The Present Study
In this background of one step forward and two steps backward policies
•^i
persued dunng the last two decades the present study has attempted to examine
3
©
©
the working of Public Health Care System under the contemporary Panchayat
Raj System in Karnataka.
Objectives
The main objectives of the study are :
1)
To identify areas of confrontation/friction between elected representatives
and the officials of health departments at district level and below and
3
a
©
identify the underlying causes as attitudinal, legal, procedural and others
2)
effective functioning of PR|S and health functionaries.
3)
r©
:i®
3
I
J©
c
5>
To examine the legal procedural factors that need modification for smooth
To study the disparities in health indicators across the districts and across
social class within the districts and how PRIs intervention can reduce
them.
4)
To study the delivery of public health care services, identify best practices
followed that can be replicated in the state to improve the outreach
services.
Data and Methodology
1
Considering the limited time and resources it was' decided that the study
would confine t0 three districts of the state. The required data was coliected from
various etected representatives at district, taluk and gram panchayat levels, from
heakh staff working at various tevels Hke District Heakh Officer. Taluk Medtcal
Officer Medical Officer al PHCs. PHUs. CHCs. Para medica, staff, staff dealing
f
with administrative work and most ImportanUy the generat pubtic from 31 vkiages
randomly selected
It was focus group discussion on various issues that
provided valuable insights for the study
©
r©
e
The general public, however was
H-
administered a questionnaire to understand the extent of their participation in
PRIs and their understanding of quality of health care services delivered
At the outset we met the members of the Karnataka Government Medical
Officers Association - a strong body of over 500 medical officers as its members.
The discussion revolved around various issues confronting them in general like
the reported corruption in the department - particularly charges against the
medical officers, their perception of decentralised governance and its pros-cons
on their functioning and the contemporary service conditions.
Emerging Issues : Confrontation
The prolonged discussion with the office bearers at the state brought out
□
3
the issue of working under decentralised system of governance and their strong
resistance to it. It was also revealed that in the current situation all the medical
officers would not aspire for the post of District Health Officer as compared to the
earlier days when there was a rush to hold the coveted post that carry not only
3
enormous responsibilities but also a high status — equivalent to any other district
level high officials like Deputy Commissioner. Today he is at the receiving end
only - ZP will hold him responsible for every thing that may go wrong like a
cholera cases, malaria cases detection in his area which rightly cannot be
considered as his responsibility only. It is concerned with water supply or supply
of DDT for spraying that cuts across the departments.
The health department officials also are harassed by the elected
representatives as revealed by the Association of office bearers. It was told that
DHO has left with little time to attend to his enormous responsibilities because of
several meetings he has to attend during a month (at least 6 statutory) and there
i
are visits from Ministers that need DHOs presence and there is hardly any time '
left for his work that results in poor supervision and monitoring the health
3
programmes in the district.
In addition, the elected representatives who are
drawn from different socio-economic background and new to their work do not
O
know how to conduct themselves with the bureaucrats who expect respect -
a
regard from every one. The Association expressed strong reservation about the
G
i
t
r
Q
3
r
i
1
I i
. '"J
way Medical Officers are treated by the elected representatives and reported that
2
it was most inappropriate.
In addition to the above mentioned confrontations the Association was
J
'5
more disturbed with the way promotions were given, how a very junior medical
officer became his senior boss because he possessed a Diploma / Degree in
Public Health. Their view was that public health and its intricacies can be learnt
by any medical officer through his experience and he may perform better than a
■$
person who possesses the degree/diploma in public health.
$
It is not very
relevant for this study to deal with this issue in detail as the ZPs or TPs are not
authorised to deal with such issues which lies with the State government. It was
clear from the above discussion that the strong resistance to work under PRI by
the Karnataka Government Medical Officers Association was not on any
3
ideological or legal - structural issue but based more on their stray - scattered
experience with some elected representatives
The meeting, however, provided
valuable insights for conducting the study.
The Study Area
The study was to be confined to three districts but another district was
added to it based on the reported problems of confrontation between health
—r,
©
bureaucracy and ZP there.
The three districts were selected on the
achievements in health sector. Udupi - a newly carved district is much ahead of
most of the districts in the state in terms of education particularly female
education, health and also other development indicators. Tumkur is situated in
the middle level and Gulbarga district is still a backward district (Table 1).
Table 1 provides valuable insights in the existing disparities in the selected
d.stncts m terms of health and education. Udupi is an advanced district, whereas
A
Gulbarga has retained its backward status during last five decades of
reorganisation of States.
Tumkur has performed better than Gulbarga but is
poorer compared to Udupi. Thus the findings from this study would present
representative picture of the state.
©
»
a
K
.J
Table 1
Development Indicators in the Selected Districts
; District/
Crude
Birth Rate
1999
Percent
safe
deliveries
Crude
Death
Rates
1990-91
Percent
females
literates
1996
Udupi
19.7
2
63.7
3
91.5
4
7.0
5
78.5
Percent
children
aged 12-36
months
immunised
fully
6
86.0
Tumkur
24.1
61.3
63.5
8.2
51.1
88.0
2047
Gulbarga
30.1
39.2
47.7
10.7
30.9
25.3
2431
State
22.5
58.1
68.2
8.5
52.7
70.5
2558
■ State
I
3
Percent
women
contracepting
r
Per capita
income
1995-96
(Rs.)
7
2632
Source: 1,2,3 and 6. RCH Survey 1998 (Phase 1)
4,5 & 7. Human Development Report (Karnataka) 1999, p.78, 255, 212.
3
The presentation of the report will be in four sections. The first section
would present the health status of people and highlight the observed disparities
by social class and caste.
The second part would discuss, given these
disparities, what the PRIs can do to improve the situation and the third part would
present the findings of the data collected from the PR I visits followed by
summary of the findings and recommendations.
Section I
©
Health status of a population is determined by several factors including
health care services.
It is closely associated with genetic, social, economic,
cultural and political factors.
Although interaction among these factors is
multidirectional and complex, it is increasingly being realised that an integrated
approach to development would minimise conflicts and undesirable side effects
3
of sectoral approach. But what should be the critical mix of these interventions to
obtain the desired results is not very clear and planning in most of the countries
and at states within the country is still dominated by sectoral approach.
!
The
significance of health care services is that they can reduce pain, sufferings and
deaths many of which could have been minimised by an integrated approach to
r
a
r
■0
I '>
development.
The health care services have to ensure quality at an affordable
cost to the population. There are differentials in access to health care services in
■
India and also in the State of Karnataka by urban / rural residence Good health
care services are concentrated in urban areas and do provide a choice to people
- either avail public health care services - which are also relatively better in
urban areas as compared to rural, or and also avail private health care services
'’5
that are more concentrated .in urban areas.
Residents in rural areas have to
increasingly depend on public health care services particularly deprived sections
like Scheduled Caste and Scheduled Tribe population or those living in remote
inaccessible areas where either private services are not existing or scarcely
a
available.
□
more adverse impact on rural poor particularly the SC/ST population.
3
If public health care services are not easily accessible it will have
In order to improve the accessibility to public health care services the
Central and State governments have been trying to expand these services
hoping that all sections in rural areas are benefited from them. As a result it is
3
observed that during 1960-61 on an average a Primary Health Centre (PHC)
■>
served 81,000 population whereas at present (1996-97) a PHC serves only about
21,500 persons. Similarly a female health worker (ANM) was serving about 8000
persons during 1980-81 while in 1996-97 she is serving only about half of that
population.
These public health care services are supposed to be free and
therefore the poorer sections who may find private health care relatively
expensive may use them more than the affluent rural population. Particularly the
t
women belonging to SC/ST may'benefit
may 'benefit from the free care provided by the
But intensive research studies i
carried out in the state present a
different picture which is very disturbing.
government.
It would be in order to note how the
L
p
3
L
public health care services are
delivared before presenting the observed disparities
reported in the research
studies. Looking at the disproportionately high mortality
and morbidity among
women and children at national and state level delivery of services are
concentrated on women and children. The grassroot female health worker
popularly known as ANM provides these basic services. In order to make child
14
births safe she is trained to provide antenatal care at the home of the pregnant
women in her area that has about 4000 population. On an average there are 165
- 170 eligible couples per WOO population.
>-
women some of whom need this service.
She has about 500 - 600 eligible
The ANC package includes a list of
services that she is supposed to provide to every pregnant woman to ensure safe
1
delivery, survival of woman and her baby.
The following table provides some
insights into how these services widely differ among the community by caste,
economic status, education of the woman and by rural/urban residence in 10
districts of Karnataka.
■&
Table 2 :
3
D
Access to Antenatal Care by Social and Economic Background of
Women in 10 Districts of Karnataka 1998
Type of service
Residence
Caste
Education
Type of H i
Rural
Urban
SC/ST
Others
SSLC + Kuchha Pu
No ANC
^6
12.9
17~0
81
18.9
oTe
221
3
2)
First ANC visit during
$
SI
No
3
3
3)
a) First Trimester
b) Second Trimester
c) Third Trimester
52.6
28.9
5.6
72.0
20.1
2.3
48.5
29.4
5.1
62.0
25.1
4.0
42.7
31.7
6.8
84.1
14.5
0.8
37.9
32.4
7.1
r
All 3+ ANC visits
74.0
88.0
68.7
81.0
65.3
95.9
58.9
£
1b.I
1 '
f
Percent women
$
4)
Whose
taken
weight
was
41.7
77.5
37.1
56.1
32.9
58.7
23.5
8u.<
5)
Whose
B/P
recorded
was
57.2
86.3
49.8
70.3
46.3
78.0
39.7
9
r
i
3
3
3
3
6)
Who were given IFA
tablets
72.5
72.5
66.9
75.2
65.9
77.7
61.1
7)
Who were given 2TT
injections
65.0
78.7
58.9
72.3
56.5
75.0
49.0
8)
Whose
abdominal
check-up was done
72.2
91.9
74.4
84.2
69.7
97.4
65.3
Total No.of women
2222
896
772
1811
1571
692
685
7
F
The data clearly brings out the differential access to the public health care
9
J
services in the State. It is the Scheduled Caste women, illiterate and those who
io
$
3
3
r
i
15
■J
live in kuchha house, in other words ‘poor’ are relatively more deprived of these
i
essential services. Though we do not have data on infant mortality and maternal
>:
mortality the NFHS II reports very high IMR in rural Karnataka areas for SC/St
5^
and illiterate women.
The information on place of delivery also reveal differentials by caste.
While for the state as a whole RCH First Phase reported 52.4 percent
institutional deliveries it was only 42.4 percent in rural areas while it was 77.3
percent in urban areas. Among Scheduled Caste women only one in 3 deliveries
were in an institution whereas it was 57 percent among others. Out of those who
lived in kuchha houses only 29.6 percent were able to go for delivery to a health
facility while those better of 81.7 percent delivered in a health facility. It is worth
noting that the home deliveries of SC women mainly were attended by
neighbours/relatives or untrained dai (74 percent).
In other words, even those
who give birth at home are deprived of ANMs’ or trained dais’ services that
increase the risks associated with child-birth among the poorer sections.
The new bom babies are protected against killer diseases by vaccinations.
i
The data provided by the RCH Survey reveal wide disparities in its utilisation and
poor accessibility.
Table 3 :
Accessibility to Immunisation Services in Karnataka by Social —
Economic Background of Children Bom During 1.1.1995
to 10.6.1997 (percent not received)
■ T
Type of
Service
1) O Polio
ri
Residence
Gender
Caste
Urban
M
F
SC/ST
Others
lllit-
10 yrs+
Kuchha
Pucca
61.8
30.8
53.0
53.0
69.7
50.0
72.6
22.9
75.5
22.9
13.7
18.2
27.6
11.5
26.6
1.3
34.6
4.7
12.6
26.7
1.1
32.6
5.2
I 2)
BCG
18.5
9.4
3)
DPT
18.3
11.3
14.7
18.1
26.6
*
T
Housing
Rural
I
f J
Education
!
I
!
4)
Polio
11.6
8.2
9.0
12.3
17.3
8.2
17.8
1.4
21.7
5)
Vitamin A
52.8
49.2
49.8
53.9
59.1
48.0
61.2
35.6
66.1
3.7
:
39.7
|
i
l(>
The differentials observed at state level hide the regional differentials
1
which are more pronounced. The following table provides these differentials in
the selected districts.
0
Table 4 :
Access to Antenatal Care in the Study Area by Socio-Economic
Background of Women 1998 (per cent not received)
District
Residence
Caste
Education
Housing
Rural
Urban
SC/ST
Others
lllit.
10 years
Kuchha
Pucca
Udupi
2.0
00
5.2
00
4.7
00
2.2
00
Tumkur
4.8
2.4
5.9
3.8
8.5
00
4.8
00
Gulbarga
34.0
14.8
28.5
26.8
35.5
3.1
32.1
27.2
©
3
The tables 4 and 5 are self explanatory and in this background it was not
□
surprising that the RCH survey reports maximum number of infant deaths in
3
Gulbarga district (17) during the reference period and all in rural area whereas
3
Tumkur reported 9 deaths - 8 in rural areas whereas Udupi reported only 3 infant
•3
deaths all in rural areas.
?)
Table 5 :
District
Access to Immunisation of Children Bom During 1.1.1995
to 30.6.1997 (per cent not received)
Residence
©
Sex
Caste
Education
Housing
i
Rural
Urban
M
F
SC/ST
Others
lllit.
10 yrs+
Kuchha
Pucc
■3
Udupi
15.0
8.0
17.0
10.0
20.0
13.0
17.0
4.4
15.0
14.1
□
Tumkur
13.0
6.0
11.4
12.8
16.0
11.5
13.7
3.00
20.0
4.5
3
Gulbarga
80.0
53.6
76.0
73.3
78.9
73.8
83.4
25.0
72.3
45.;
3
The information for 10 districts of Karnataka and the 3 districts in the study
area bring out clearly that delivary of public health care services do not reach all
r
those who need them because of various factors. Given the skewed distribution
[
r
■J
I"
?>
3
of basic health care services related with maternity and child survival it is not
surprising that health outcomes differ widely among districts - regions and also
social class in the state.
Reasons for such poor delivery of public health services in Gulbarga as
compared to other districts were not difficult to understand.
The Research
Teams visit to Community Health Centres. Primary Health Centres and SubCentres revealed that many of. these health centres do not function regularly.
*>
B
Infact, the day of our visit to selected health institutions in Gulbarga they were
locked and we learnt from the villagers that medical officers are very irregular in
attending to their work. Similarly the ANMs instead of visiting the households in
©
the sub-centre jurisdiction expect that women or children with problems should
come to them. No PHC had displayed the scheduled travel programme of ANMs
3
as is done in other districts. It is not, therefore, surprising that old women in the
neighbourhood or village ‘Soolagitti’ (village untrained dai) conduct most of the
deliveries in rural areas (every 3 of 4).
0
r
The problem is more complicated by the large number of vacancies
particularly of ANMs which is crucial in ensuring delivary of health care services.
When the vacancies of ANMs by taluks and PHCs within taluks were obtained
from the DHO's office and examined we were in for several surprises.
S3
k
In the
district of Gulbarga about 28 per cent - more than one in four positions were
vacant for ANMs (see table 6) and the LHVs.
Supervision of their work and
monitoring the performance has stopped for several years. The result of such an
apathy is very clearly reflected in several indicators reported earlier. One of the
‘0
major cause for poor performance reported by the staff at PHC/CHC was the
existing poverty in the rural parts of the district where traditional practices still
0
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■t
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'B
dominate and the department cannot be blamed for all the ills in health sector.
IX
Table 6 :
Vacancies of Female Health Workers (ANMs and LHVs) in
Gulbarga District by Taluks
District/Taluk
SI.
No.
Per cent Vacant
P-V
ANMs
LHVs
i Per cent
484/134
58/00
39/2
57/18
40/11
41/10
57/15
35/13
48/17
56/18
53/20
27.7
0.0
30.8
31.6
27.5
24.4
26.3
37.1
35.4
32.1
37.7
83/40
6/0
10/2
6/4
9/7
8/1
10/5
7/2
7/5
10/7
10/7
48.2
00
20.0
66.7
77.8
12.5
50.0
28.6
71.4
70.0
70.0
-.si
I Gulbarga Dist.
Gulbarga Taluk
2)
Jevargi
3)
Aland
4)
5) : Afzalpur
Chincholi
6)
Chitapur
7)
Sedam
8)
Shahpur
9)
10) Surpur
11) Yadagir
1)
Note: P
Total Positions: V - Vacant Positions.
•3
£
But the traditional practices have to continue because the modern health
O
services provided by the public services have miserably failed to entrench in the
society.
It was repeatedly emphasised that rural people prefer to conduct
deliveries at home and ANMs are helpless.
But when there are so many
uncertainties in the services — medical officer may not be there, drugs may be in
short supply and ANMs posts are vacant and naturally people stick to their
traditional practices. The positions of specialists in the district showed that 37
a
'9
3
3
per cent positions were vacant.
In Udupi district also about 30 per cent of ANMs positions were vacant but
easy accessibility to quality care in Private Sector Hospitals either free or at an
affordable cost has not made any adverse impact on the health of women and
children.
Most of the births about 92 percent take place in institutions that has
i
sharply reduced Infant Mortality Rate in the district (lowest in the State).
The
ANMs working in sub-centre reported that most of them have not conducted a
single delivery during last 5-6 years as there are maternity homes run by
0
t
(
o
r
□
1'2
missionaries, Manipal group and other private trusts that provide a choice to
everyone irrespective of their economic position. The public make an informed
choice of public and private services and have benefited to a large extent as
revealed by several indicators.
Tumkur district placed in between these two extremes provide different
problems. The public health care providing institutions generally work regularly
Our visits to several PHCs. CHCs and Sub-Centres convinced us that there is
regularity m attendance ot the staff to a large extent except in a few pockets
5
But
accessibility to the services Is severely restricted to the poorer sections because
of corrupt practices in these institutions
The Medical Officer in a PHC working
for more than 15 years, people reported, has ensured that the Lady Medical
□
3
3
Officer's post remains vacant A child birth conducted in this PHC will cost about
Rs 1000/-
If there is a LMO this income will be reduced to a large extent
In
another PHC it was found that LMO frowns at ANMs if they conduct home
deliveries and insists that they should bring delivery cases to the PHCs and
$
charges a minimum of Rs 500/- per delivery.
£
complained of harassments by the MOs and LMOs. With Malaria incidence still
Efficient and competent ANMs
high rn some pockets spraying of DDT has been stopped for 3 years and water
'[o
- ©
i®
r
. fj^
'; a
k
(p
lA
rp
'B
*3
' ’J
sources Irke wells have not received chlorinatron Io make them safe for drinking.
The public health measures have affected badly.
The vacant positions in the department has its
own adverse impact but is
not .severe as there were only 15 percent ANMs’ and
about 20 percent LHVs’
positions were vacant for varying 'periods some for 4-5
years that has
compounded the problem of outreach
services in the district’. Even then there is
some semblance of service in the district The buildings and other infrastructure
are in poor shape and are begging for
some action to improve but not received
any attention from authorities.
What the Panchayat Raj Institutions Can Do?
The decentralisation of governance in Karnataka in its first 'avatara' came
with the perception of Tower to the People’. The 1983 Act was based on the
•-J
2()
•1^’
principles enunciated in the Ashok Mehta Committee Report. The objectives of
the Act were to give highest priority to rural development, increase agricultural
development, eradicate poverty and bring in overall development.
To attain
these objectives the Act provided maximum degree of decentralisation both in
Planning and implementation.
•'-i
But there were unresolved issues, with the planning structure at the
national level and state level is it feasible to have district planning with the
consent of people and their participation? If not how the PRIs would participate -
0
only implementation of the plans that come from the State with resources? Who
Q
would ensure ‘good governance’ at lower levels? And How? are not cleared yet.
But the State government that provides resources to PRIs - resources that have
reached four to five fold increase during the decade believes that there has to be
.'j
O
greater transparency, social justice and accountability in PRIs to achieve the twin
goals of development and
social justice.
decentralised
sub-state
The
writings
on
concerned
with
voluminous
■>
governance
at
level
are
more
reservations, elections, provisions of rules, rights and procedures to be followed
than assessing what positive changes the new system has achieved and how to
improve it further, which can reduce the ‘politics only’ attitude observed at PRIs.
Despite our serious efforts to find some special studies that have examined
functions of the health sectors under decentralised system we could not trace a
e
single except the evaluation report submitted in 1989 that praised PRIs
eloquently for the good changes they had observed.
3
We conceptualise a very simpld mechanism that exists in PRI system to a
3
large extent useful in streamlining the functioning of health-care service delivery
3
system and bring in much needed discipline in the sector. The importance given
□
to ‘holding gramasabhas’ of village voters who are ultimately the masters can be
exploited. Already in six districts “Citizens Initiatives in Elementary Education” an
3
NGO initiative to activate Grama Sabhas to improve primary education is going
3
on. People who are not happy with the delivary of services, can bring it in the
3
meeting which will be passed on to Gram Panchayat that in turn can reach Taluk
and Zilla Parishad for action. The ZP based on the resolutions passed by the
■3
r
t
f
f
-3
r
□
J
Gram Sabhas can keep themselves abreast of
developments in health sector
and plan for its improvements.
The Zilla Panshad also has a statutory Committee called “Standing
Committee on Health and Education” that includes elected ZP members and also
some experts co-opted. They have to meet once a month and transact business
pertaining to health.
However, the role of Zilla Parishad in decentralised
governance and planning is one of a facilitator and co-ordinator.
3
Integrating
plans submitted by Taluk Panchayats, approving employment generating action
plans, allocation of resources to development programmes and monitoring
functioning of Taluk and Gram Panchayats. The President and Chief Executive
it}
3
Officer (CEO) have been endowed with powers to supervise and inspection
However, CEO has upper hand (section 180) to ask any record from TPs and
GPs pertaining to property, recovering arrears of land revenue, and superv.se
and control the execution of ZP works.
3
Gram
Panchayats are entrusted with
regulatory,
licence
- giving,
prohibitory, supervisory and sanctioning powers,
3
They have powers for taxation
and acquire movable and immovable properties,
Providing civic amenities,
promoting health and educational
services are other responsibilities entrusted
with Gram Panchayats.
The Taluk Panchayat have controlling and supervisory powers over Gram
Panchayats. They are perceived as highly resourceful and powerful intermediary
level institutions. They approve employment generating action plans they give
concurrence to action plans pertaining to education, health and famify welfare
etc. The executive officer can supervise in functioning of PHCs, Sub-centres and
report to DHO for action. He does not enjoy powers to take disciplinary action on
health staff.
There IS a mechanism to receive the public grievances regarding health
care services through the powerful Grama Sabhas for further action to improve
the equ.ty and accessibility - both if there is a desire.
In addition the Taluk
Medical Officer has supervisory powers to report for action to DHO.
if
I
1^
'3
head of the department and is responsible officer at district level.
DHO is
In addition
there is Executive Officer at Taluk Panchayat with supervisory powers and report
his findings to DHO. It is very clear from the above that there are enough ways
and means to improve the health care services directly through PRIs, through the
live of control existing in the departments and also more importantly through the
Grama Sabhas.
Given the situation described in the study area it would be in
order to examine how they work.
■5
r?
The Grama Sabha
The Gram Sabha is a statutory requirement that provides a unique
opportunity to village residents to vent their grievances which will reach the
concerned authority for redressal. It also provides an opportunity to the voters to
□
3
make their elected representatives accountable to them.
One of the main
architects of decentralisation in Karnataka considered Gram Sabha as a “more
powerful weapon created for the sake of accountability is Grama Sabha which
will not be elected nor has it vested with any executive power. But it is going to
3
play a crucial role in real politics because of their voting power and all elected
members are accountable to Grama Sabha”. It is mandatory on the part of PRIs
to explain their activities within the jurisdiction of the village. It also leads to right
3
$
to information.
Section II
How the Grama Sabhas are conducted if at all they are conducted?
a
Whether people bring their grievance^ to the forum?
3
conducted in the study area enquired from the randomly selected 82 heads of the
£
households whether the Gram Panchayat, Taluk Panchayat or Zilla Parishad of
The Household Survey
their area are taking any interest for the improvement of the local PHC?
Not
surprisingly in Tumkur and Gulbarga districts the response was an emphatic ‘No’
from each head of the household (100 percent in negative). They were very firm
&
about their view.
3
3
improve further the services in PHC (Table 7).
-3
3
3
But in Udupi district one in four felt that they are trying to
The selected heaas of the households were also asked whether there was
any discussion in the Grama Sabha meeting held recently on the functioning of
the ANM. LHV, PHC doctor and PHC.
The findings of these are presented
below.
0
Table 7 :
Peoples Assessment of PRIs interest in Public Health
SI
No :
Activity
1)
Districts
Udupi
’ Yes
No
; PRIs try to improve the 23.0 77.0
; PHC
Tumkur
^fes I No
00 | 100.0
Gulbarga
Yes
No
00
100.0
___ Total
Yes
11.0
No I
89.0
I
0
2)
□
□
a
I
Gram Sabha Discussed ■
about the Functioning
i)
ii)
I i»)
Of ANMs
8.6
Of LHVs
8 .6
Of MO in PHC and : 8 6
PHC
I
91.4
91.4
91.4
13.0
13.0
13.0
87.0
87.0
87.0
12.5
12.5
12.5
87.5
87.5
87.5
11.0
T1.0
11.0
89.0
89.0
89.0
-3
3
It is clear from the data that public view of PRIs interest in improving
health care service delivery of PHC level or about the functioning of crucial
personnel like ANM, LHV or MO of PHC is extremely poor. An important route to
©
bring critical assessment of health services for improvement was found to be
9
very insignificant.
.,3
The Bureaucracy
*3
i
There are multiple authorities who are supposed to supervise functioning
of their subordinates, monitor the performance and enforce discipline in the
health department. They are Taluk Medical officers, Executive Officers at Taluk
J
Panchayats, Chief Executive Officer, President at ZP and also DHO the Head of
*3
the department of health at district. In addition to all these levels of supervision,
f
there is another Deputy Secretary 1 in ZP who is entrusted with supervisory
powers who will report to the CEO.
With so many authorities entrusted with powers to ensure free flow of
services it was surprising that Public Health Care Services are of so poor quality
it ®
'b
rr-9
24
1
in the two districts of the study area viz. Gulbarga and Tumkur. Our discussion
.^4
with the young and energetic CEO in Gulbarga was surprising. He was unaware
of the way PHCs are functioning in the district. On the contrary he said often he
receives representations from people to retain some Medical officers in their
place and cancel the transfer order issued that gave him an impression that the
MO must be good and therefore people want to retain him. We met the Deputy
3
Commissioner of Gulbarga also and briefed him about our observation. Both the
CEO and DC asked for a copy of our findings for initiating action against erring
officials in the health department.
Similarly we discussed with the Deputy
Secretary (Dy S 1) and briefed him of our observations and he was non-
©
commital.
Our discussion with the Secretary ZP Council, Gulbarga was little
revealing. He reported that the meetings of the Standing Committees on Health
□
and Education mainly deal with approval of plans, proposals and programmes.
There is hardly any scope to discuss about the services their quality or its out
reach to all sections of the society.
How well the DHO is informed about the
□
happenings in his department? Does he also think that everything is fine with the
3
functioning of PHCs, CHCs and Sub-Centres in his district? Our discussion with
him was frank and free. He is aware about the irregular attendance of Medical
officers and has initiated disciplinary action against one or two.
disciplinary action takes a very long time.
But taking
There are interference from higher
authorities, elected representatives to thwart these initiatives because the
©
authorities take a benevolent view of such things and consider it on humanitarian
grounds — the person accused is marrited and have children why punish him/her?
J
The whole work culture in the district reflects that even for a petty issue there is
9
interference from the highest authority.
□
upward and use it to save himself from any punitive action.
3
Every one in public service has links
Tumkur district was slightly better as the Executive Officers at Taluk level
also visit some PHCs and reported that if the MO is absent on the day it will be
reported to DHO for treating it as leave without pay. But whether DHO acts on
3
L
r
that report or not was not clear. DHO Tumkur is aware about corruption that is
making public health care services inaccessible to the poor in the district but
3
•>
3
f
"J
25
reported like Executive Officer at Taluk level that they have not received a single
complaint from people in this regard and hence cannot act without evidence
It was in Udupi that the in-built mechanism of monitoring and supervision
was working. Even the MOs appointed on contract basis are regular in their work
and provide service to the people.
If there is regularity in the functioning of
health institutions that itself satisfies the clients who arrive there for relief.
$
Our
visit to PHCs, CHCs and some remote-placed Sub-Centres was very satisfying.
Perhaps if one wants to see what is equity and accessibility to health care
services should visit this part for getting acquainted with. The results are visible.
ZP Presidents
The Executive Head of the district is the President and certainly they can
make considerable impact on the quality services provided and their accessibility
3
%
to people. The Presidents of the ZPs in the study area were very enlightening.
In addition to 3 ZP presidents of Udupi, Gulbarga, and Tumkur, we met ZP
President of Kolar. They were all young, educated and enthusiastic about their
office that they were holding only for few months.
The women presidents of
Tumkur and Udupi were keen to improve health services. One of them was very
young, just married with no experience of either politics or holding a public office.
fJ
But her father was a leader and was holding a public office by getting elected.
0
The other was having some experience at Gram Panchayat.
Tumkur ZP
President was keen to learn the ropes of administration to act and improve. She
had visited some PHCs and believed that women still prefer to give births at
home as it is more convenient. She was aware that some-MOs and ANMs are
not regular and was planning lo discuss with the administration for possible
T
action.
3
h
f
The Gulbarga ZP president was very open and said that “MOs not only
are irregular but also sell the medicines in the open market. For days they do not
r
□
he would set things right in two weeks if he had powers. He was sorry that the
|3
State Government that belongs to his party is not receptive to their views
&
11
r^
' '!£
visit PHCs. But I do not have powers to set things right”. The President said that
2d
The ZP President of Kolar was more dynamic and when we met he had
visited a PHC (where he had gone for attending a public function) on the request
of the public who complained that the MO is very irregular.
Indeed MO was
absent when the ZP president visited the PHC. He called DHO to know how they
can take action against such officials.
He reported that he is new (like other 3
<7;
presidents) to the intricacies of the administration and though he attended some
training programmes organised for ZP presidents he has a long way to go to
master the art. He had kept a Rule Book prepared by the state government and
would refer to it often when he had some confusion. He was also of the opinion
0
that ZP has little scope to bring in discipline among the staff working in the district
on deputation. He often requests the DHO to be stricband wants to support him
in improving the health services for the benefit of the people.
J
3
The Vice Presidents
The Vice Presidents also echoed the views of their Presidents. ZP cannot
•3
take any action. They have to write to the Government for action and there are
3
long delays or no action. Vacant positions in the Health Department is reported
:3
routinely to the Government for filling but nothing is heard from them. The CEO
position was vacant for 2 months and during that time DC was incharge CEO.
One can imagine how things will move. It was clear that transfers, recruitments
or suspension of any health staff is not vested with ZP. Under the circumstances
poor accessibility and inequity in health care services become the order of the
day and both elected representatives Snd the bureaucracy become used to it.
3
It is to be noted here that none of top leadership in ZP-— elected members,
members of the Standing Committee on Health and Education, CEOs and DCs
were totally aware of the disparities that exist in the health status of people in
different districts, by gender, caste and economic status within the districts. The
r
next line of authority Deputy Secretary 1 were also equally ignorant of health
outcomes, indicators and job responsibilities of various categories of staff
a
The
f
Administration at Taluk and Districts were busy with construction of new
structures, equipments or drugs more than their use for public good. There was
i
r
©
3
i
a unanimous demand in Tumkur, Kolar and Gulbarga that there is need for
training to make them more informed and effective.
Why the DHO does not
provide them the insights of the Department? He has no time as all his time is
spent in the meetings.
The DHO also has several constraints.
Since he has
hardly any time his visits to Primary health Centres have reached minimum.
It is
only when a dignitary like District-in-charge Minister (another authority over all
'3
the happenings in the district) has a public function he may visit a PHC. The staff
at PHC could recall the past practice of frequent visits of DHO for supervision. It
was not only to their PHC but even to a nearby PHC would keep them alert with
a chance visit' to their PHC on the way back.
This practice has almost
disappeared now.
This brief description provides how the in-built mechanisms to ensure
5
3
accessibility to health care services have become ineffective. It is not surprising
that the health status of people in health poor districts continue to be poor even
though public resources - more valuable looking at the scarcity, become less
and less productive. One of the important reasons for the observed delay could
,3
be the faster expansion without consideration to the enormous resources needed
*3
for it. Earlier the quality of services, as reported by senior staff was much better.
Now even though the scarcity of equipment, maintenance of assets etc. is
reported to the authority may not be heard that leads to the weakening of the
authority because of the inability to solve it quickly. The only positive change is
? T
the improved drug supply after decentralisation.
Rest every thing is highly
unsatisfactory in health poor districts. '
Section III
Areas of Conflicts
k
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Given the situation described so far where lies the conflict between the
health bureaucracy and ZP or PRls? The focus group discussion often led to
mudslinging exercise.
That PRls arrival have lead to more corruption and
J
harassment of personnel. To start with, the bottom line ANMs complained that
is
elected representatives demand service on priority basis, call the ANMs to their
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2s
1
residence even for headache and stomach ache and demand medicines free and
often ANMs have to bear the costs. As most of them (elected representatives)
are not educated their behaviour is curt and without etiquettes and manners that
hurts ANMs. The MOs at PNC complained similarly in addition they reported that
4
the elected representatives question them if an ANM is not posted in a sub
centre which is not under his powers.
The DHOs office complained of
interference in day to day administration by the Elected Representatives.
>
A Taluk Medical Officer complained that there was out break of cholera
because of the contaminated water supply by the Taluk Panchayat. When he
reported that water supply has to be improved by taking some measures like
a
□
chlorination, he was abused for dereliction of his duties. When they send a
proposal to repair a collapsing building to DHO with a copy to -ZP the CEO just
does not bother.
Medicines are not supplied regularly.
They dump several
useless drugs which are of no use. PHO and MOs indent is often ignored.
The Quarters of ANM built by the PRI are of extremely poor quality. An
a
ANM was in tears to report how she has to cover the roof with polythene sheet to
protect her from leakage and to re-do the electrification to save from the shocks
spent Rs.3,700 from her pocket. Complaints made to DHO, ZP and TPs were of
no use.
She was told that she has to stay there the Quarter on which lot of
money is spent to make it according to the specification given.
A meeting with all medical officers of a Taluk brought out their vent against
elected representatives.
©
A LMO reported that new PHC was built but the
quarters for staff are not. The PHC is in the outskirts of a village and no body
dare to stay there in the night not even a watchman.
3
If they had constructed
housing along with the PHC it would have facilitated.
Another LMO who
commutes to PHC every day from Gulbarga complained that the people and
elected representatives harass her to stay in the PHC quarter which she has not
•3
occupied because there is no water, electricity and building is 25 year old needs
repairs. They are not keen to do anything to facilitate the services. Most of the
3
f
drugs that ZP supplies are about to expire and become useless.
I
a
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a
i
5
2'7
*5
i he months Feb-March are two months when ZP administration is too
busy to approve medical reimbursals of staff of Health Department and they not
even consult the DHO. Registers required to compile statistics are not supplied
for over a decade. All files move only if currency notes are enclosed with them.
ROH building fund of Rs. 10 lakhs is lying for over an year but even the plan is yet
3
3
to be made and approved. Nothing moves.
3
for any action. Taluk Medical officers can not even sanction Travelling bills of his
3
subordinate staff and those who approve it may not know whether the travel was
3
made to those places. ZP sanctions all such TA bills with a cut of 10-20 percent.
Taluk Medical Officer has to write to DHO who in turn has to forward to ZP
Even the DHO’s office in Gulbarga has several stories of delays. Power
3
connection to his office is not done though they have spent Rs.37,000 for it about
19 months back but ZP is still silent. The list is endless.
3
What ultimately emerges is that the conflict arise from multiple points of
3
authority with not a single source taking any interest in improving things.
3
question that arise is who should set things right with quick decision to solve the
■ 3
■3
problem.
The
It is only CEO who is authorised to act after waiting for instructions
from the Government on any of the complaints made. We did not come across
any such action except issuing a memo or deducting a days salary in some one
or two complaints against ANMs. But suspension orders can be issued only by
the Government.
Generally when there is such a serious complaint against a
MO or other officials. ZP elected members or a Minister interfere and nullifies all
efforts.
b
Some ZP Presidents had oomplained against unclean PHCs and a
couple of staff coming late when they had visited.
The PRI elected members have many stories against the health staff.
Irregularity, showing unconcern and asking money were very common.
3
L
surprising a lady member of the Standing Committee on Health and Education
whose husband (aged 44 years) died on Jan 4th 2001 because of the neglect of
MO in treating him.
He died of massive heart attack and MO had given him
treatment for acidity the previous day to his death.
>
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It was
He did not check his blood
pressure nor examined him. But she did not complain as he is well connected.
But the elected members of such statutory high power committees also are
ignorant as reported by many about the health situation - no idea about death
rate, infant deaths or maternal mortality which are very high in their area and
there was a strong demand to enlighten them on health issues to strengthen
them and to improve the situation.
In addition the bureaucrats at ZP believe that Medical Officers at PHC
CHC and district office lack badly administrative skills and management skills to
work in a team. The lack or absence of such skills go on accumulating and turn
into major issues. We also believe that managing the staff is an art that many
medical graduates who join the service as MO at PHC may not have and already
a
o
some programmes to train them as managers of PHC is on.
The proceedings of the Standing Committee on Health and Education of
Tumkur District however reflects what we noted about the district.
It says “
administration in health department has collapsed and DHO has no control over
3
his department” (page 4 of 24/10/2000).
3
suggestion that priority should be given to patients in rural areas by the Medical
3
Officers.
0
0
It also questions about MOs saying that there is no medicines in the
PHCs and prescribing drugs to be purchased by the patients in the market.
The proceedings of Udupi ZP’s Standing Committee that meets every
month regularly reveal that there is evidence of some efforts to improve the
services further.
o
It also notes the ZP Presidents
PHCs in Udupi display boldly that if the visitors to PHC have
any complaint to make about the functioning of the PHC they are provided a post
card free and they can mail it to the concerned authority for action.
9
3
such complaints the Committee resolved to examine such complaints and
recommend action to be taken (either terminate the services of contract MOs or
transfer them).
3
Based on
It also instructed the DHO to recruit group ‘D; employees on
temporary basis in place where there is need to ensure cleanliness of health
3
institutions.
a
unauthorised absence of a Taluk Medical Officer to consider his absence as
0
3
O
It notes of disciplinary action by issuing show cause notice to
r
leave without pay. These resolutions certainly indicate the efficient mechanism
!
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31
of receiving complaints and quick action within the limitations of ZP which are
worth emulating by other ZPs in the State.
The proceedings of Gulbarga ZP is silent on the situation in health service
delivary system in the district but emphasise more on building model Primary
Health Centre,
resource mobilisation, etc. that shows there is no in-built
mechanism of receiving public grievances or they are ignored.
Section IV
Summary of the Findings and Recommendations
The intensive study carried out with time constraint has been able to
effectively explore a complicated area ignored so far in academic circles. The
policy statement issued recently on population by the Government of India has
given the prominence to PRIs that they deserve.
It is brought out by the study
that multiple power centres and poor co-ordination among them for effective
decision making is hampering the smooth functioning of ZP and Health
Department at district level.
Appointment, transfer, suspension are the crucial
areas where ZP acts only as a Post Office.
Unless the State Government
approves they cannot act. The key post of DHO has been weakened because of
interference of elected representatives.
©
Even simple act like posting a
Laboratory Technician from a place where there is no serious demand for his
services to a place where there is an out break of an epidemic is resisted by
highest authority. Infact instructions come to him if he acts in his way he will be
in trouble.
'a
Such instances have ddmoralised him.
another place has become just impossible.
Transferring an ANM to
Time constraint is imposed by
several meetings he has to attend. This was the view of all high officials also in
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Bangalore that they find little time to work in their office.
The Grama Sabha - a most powerful instrument the people have to air
their grievances for redressal and which is given lot of importance
in
decentralised system of governance is almost non-functional as found in the
household survey responses.
People complained in Gulbarga and Tumkur
districts that meeting is not announced by Tam-Tam (drum beating) and contrary
i.-
it is held when most of the residents go for work and only few whom they want
attend it and non complaints are entertained.
The Udupi District that is in the
forefront in health sector has developed a good system of receiving public
grievances directly by the authorities concerned and redressal is quick. In other
two districts complaints are unheard and neglected on the ground that there are
-5
no written complaints.
Decentralisation is still in infancy in the state and suffers from several
constraints to be effective government at district level.
How to monitor the
functioning of the system of health care services delivery? Is not known to even
top officials like CEO, Dy. Secretary 1 and other officers at Taluk levels. Official
©
inspections are more ceremonial and unproductive even though such inspections
by different categories of authority are rare and routine.
There is no effort to
understand the problems and solve to improve the performance is not seen any
3
■3
where except in Udupi. Therefore there was a strong demand to enlighten them
with one day programme at ZP for all concerned officers. The officers in health
department were not even aware of research finding that should guide them in
their work.
The guiding principle of any public health care service delivery is equity
o
0
©
and universal accessibility. The state has a very very long way to go to achieve
it. Even then equity and universal accessibility will not be an automatic fall back
from expanding services or bringing in a semblance of quality in care. It can be
achieved by monitoring crucial services like basic primary care which is
absolutely missing at ZP level. Therd is need to intensify the efforts, if already
a
there are, to reach the goal of equity. For this there is need-to equip PRI elected
members, general public about the importance of health and its effective
utilisation.
The elected representatives have to develop responsibility towards
their activities. They come from diverse socio-economic and cultural background
r
and over the years grow as leaders. They have started asking questions about
services which is in the right direction.
Health personnel who were used to
departmental control are perturbed over the authority of representatives.
I
They
a
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will have to realise that their services are for them and they are the real masters
in a democratic system. There is nothing to worry.
But till the PRIs become more effective in their functions the department
has the crucial role to play. Efficiency and quality care and ensuring its outreach
1
of services have to be managed by them which will go a long way in building of
credibility of the department which is at a very low ebb now. PRIs will be happy
and stop interfering if they are convinced about good services to all.
The main questions that still remains to be answered is how decentralised
the state is really? Can ZPs be considered as Local Self Government? A short
term study such as this would not try to explain the extent of decentralisation in
the state today.
3
3
It seems there is a make-believe effort to show we are
decentralised while all the powers are centralised with the state (because of
several reasons stated and believed). One of the important factor for the mess in
health department is the multiple power centre without any direction - pulling the
cart in different direction.
The lost aura of DHOs and reluctance of efficient
Medical Officers to occupy this role reflects very clearly the situation. If health
care services are to be improved his position has to be strengthened.
Such
L^>
studies ideally need at least an year but an effort is made here to bring out
p
several complex issues that a longitudinal study should explore in the future.
&
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Recommendation
1)
There is an urgent need to nfake ZPs to consider health sector as an
important input in development and to educate officials ranging from Chief
Executive officer to Executive Officer at Taluk level on monitoring health
P
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services and on health indicators that reflect it.
T1
There is unbelievable
ignorance in the administration and also in the health department who are
major health care providers in rural areas on the status of health of their
people.
2)
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The Elected Representatives from Gram Panchayat to ZP level also need
to be educated about importance of health and their role in monitoring
{
34
health outcomes. Only ensuring presence of doctor or supply of drugs is
not adequate to achieve equity.
Monitoring plays a crucial role and it is
totally absent at all levels.
3)
The Health Department should be made responsible in improving health
care services in the districts and they should be ensured the support of
ZP, TP and GP in carrying out their responsibilities efficiently
there is need to build-up the credibility that is lost.
For this
The health services
would be considered good if the indicators of health improve and become
comparable with the best in the state to start with.
4)
There is an urgent need to establish fool proof mechanism to receive
public grievances for redressal as is effectively done in Udupi District.
Strengthening Grama Sabhas would play an important role if they are
□
conducted properly. PHCs in health poor district should provide free post
3
cards to public who should mail it to responsible authority for redressal
&
and quick action on the complaints will strengthen this mechanism in due
a
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course of time.
5)
Whether ZP Presidents should be fully empowered for taking any action or
not is a wider question we would avoid answering here. But they can play
an important role within the powers they enjoy now. Just calling an erring
officer and reprimanding him in public will do the trick. Even an indication
a
that they are serious will go a long way than proceeding on legal terms.
6)
The ZP and health bureaucracy at district level should learn to respect
3
each other and the need to uncterstand their complimentary role. Health is
3
a technical subject best known to health staff and they need all the
3
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support, encouragement and appreciation when they do a good job.
I
Health staff should realise that elected members to PRI though may not
a
be educated represent peoples views and respect them for that. There is
3
need to meet informally for achieving this by both.
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000000000000000000000000000000000000000000
GOVERNMENT
OF KARNATAKA
0
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TASK FORCE ON HEALTH AND FAMILY WELFARE
0
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A Commissioned Research Study
0
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0
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0
0
0
0
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0
0
0
0
0
0
0
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0
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0
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0
DISPARITIES IN HEALTH AND HEALTH CARE SERVICES
0
0
0
(Draft Report)
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1 0
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By
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Mr. As Mohammed
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St.
John's Medical College
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Bangalore
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STUDY ON DISPARITIES IN HEALTH
AND HEALTH CARE SERVICES
KARNATAKA
* BIDAR
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SPTTAR kannad
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Karnataka
BAN
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STUDY ON DISPARITIES IN HEALTH AND HEALTH CARE SERVICES:
Karnataka State with 27 Administrative P
Districts has an estimated population of
540.27 * lakhs as per the estimates for 2001.
-.. The state of Karnataka ranks 1310 on
Human development index scale at Global levelI u.._
and has 33.16% of the population
below poverty level. It has been observed-----that------therej exists disparities in health and
health care facilities in between:
♦
Regions:- North & South Karnataka
♦
Districts : 27 Districts
♦
Disadvantaged:- Lower class and Caste
♦
Vulnerable groups: Age and sex.
This is unnecessary and unjust. Such issues should no longer be curiosities for mere
speculation but demand close attention at the earliest for policy review and
implementation.
y
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^ea!thJS
f1?6. subJect- and
is the responsibility of Government to ensure an
equitable distribution of minimum and adequate health care that is accessible to the
0 e P°PU a^onConsidering the inadequacies in terms of infrastructure and
J®13 ^ely P°or hea|th indicators, there is a need to understand the disparities in the
health and health care services in the state.
J
OBJECTIVES:
The goal of this study is to highlight the extent of disparities that exist in health and
health care facilities between districts in the state and within the districts and to
suggest steps to be taken to reduce these disparities.
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L.
The objectives of the study therefore include:
1. To determine the disparities in Health determinants.
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2. To determine the disparities in Health status
3. To determine the disparities in Health Care resources allocation.
4. To determine the disparities in Health Care utilization.
5.
‘
To determine
the most disadvantaged districts in Karnataka to evolve and initiate
more focussed projects in these districts.
~
Revised National Tuberculosis Control Program: Action Plan, Govt, of Karnataka,
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Human Development Report - Karnataka State, 1999.
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METHODOLOGY
Given the constraints of time available only quantitative data that is available from the
following secondary sources on various characteristics was collected.
1.
2. 3.
4.
5.
6.
7.
Multi Indicator Cluster Survey - 1998 - UNICEF
Rapid Household survey under RCH project, Karnataka State - 1999
Human Development Report, Karnataka State - 1999
Directorate of Health and Family Welfare Services, Govt, of Karnataka
Sept.2000
ICDS - Women and Child Development Department Report - Nov. 2000
Census of India 1991, Karnataka State District Profile 1991.
Rural Development Panchayati Raj Department, Statement on Delow Poverty
Line Families, Govt, of Karnataka
Data was checked’for its quality and quantity and regional disparities were assessed
on the basis of available data on indicators in following essential categories:
(Annexure— I)
>
>
>
>
>
Health Determinants
Health Status
Health Resource Allocation
Health Care Utilization indicators and
Over all indicators
Each indicator in the above-mentioned categories was standardized and algebraically
added for each district. The total was re-standardized and a composite index as
Standardized “Z” Score was obtained for each district, which gives the relative position
of the districts on the scale in Karnataka State.
It has been observed in many studies that lower class and caste suffer with
disproportionate burden of diseases and mortality. Different types of morbidity and
mortality have different patterns with respect to the age, sex and social class. So to
assess the equity with respect to these characteristics, it is necessary to get the
primary data in disaggregated form at various levels right from taluk to state level.
However, disparities in health on the basis of class, caste, age, sex and the religion
could not be assessed, as data does not exist in disaggregated form for districts of
Karnataka.
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FINDINGS - A
disparities in health DETERMINANTS OF OiSTRiCTS IN KARNATAKA STATE
districts
Edn15+
HHP
Cwater
Bangalore Urban
.fangalore
Rural
______
__ 41
8
73.3
82.7
38.4
97.2
98..
____
46.8
46.1
37.5
41.5
70.6
35.8
45.1
32.8
36.9
30.1
ELC98 ACCIatrin ABPL TOTAL
INDE*
7Q a
79 4
96-3
85
66
90
26.4
2 80
0 55
-.«wj
.
.
Chamrajnagar
”
Chitradurga
Chikkamagalur
Davengere
Dakshina Kannada
pharwad
rT
Hassan
!"
Haveri
Kodagu
Kolar
Mvsnm
^Mysore
Shimoga
Tumkur
Uttar Kannada
Udupi
49.8
55.3
49
71
53.5
™
sTi
53.5
64.4
43.2
..X
41.5
^2a
56.2
47.2
62.2
71
90 3
29-1
96
' 96.8
88
98.6
98.6
99.9
60.5
67.1
72.5
74.4
69.6
69
75.4
12.3
20
30
40.5
36.3
73.4
39
60•
64
59
72
66
78
61
-0.30^
-0.29
0.14
0.37
0.24
1.35
0.26
192
29.1
36-3
86.8
99
84.5
84.5
78 3
75.4
56.5
14
16
44
35.2
79
69
82
61^
-0.02
0.19
0.47
0.37
415
35.8
95-5
95.9
85.9
67.1
19
44
70
69
0.12
35.6
45.3
34.1
30.1
94.8
99
97.1
98
78.9
77.5
79.4
69
31.8
19
38
60
68
69
70
79
0.48
0.39
0.78
1.20
J
Most of North Karnataka Districts are
n
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3
poor in health determinants.
0.30
Disparities in Health Determinants have been assessed on:
Edn15+
: Percentage of Literate in 15+ age group.
HPP
: Percentage of Houses in which both wall and roof are made of
permanent Materials
Cwater
: Percentage of households with access of clean water
Elc98
: Percentage of households with Electricity
ACCIatrin
: Percentage of households with Latrine
ABPL
: Percentage of families above poverty line - as per BPL census for
9th Plan
It is an established fact that environment has direct impact on those living in it. Good
housing, availability of safe water and sanitation facilities have positive fact on health
which has been measured in the present study by HPP, Cwater, Elc98 and ACCIatrin.
Studies have also indicated that education to some extent compensates the effect of
poverty on health irrespective of availability of health facilities and in this study the
education has been assessed by Edn15+.
Economic status determines the purchasing power, standard of living, quality of life and
the pattern of disease in the community. This aspect has been assessed by ABPL i.e.,
families above the poverty line as per the BPL census for 9th Plan.
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FINDINGS - B
DISPARITIES IN HEALTH STATUS OF DISTRICTS IN KARNATAKA STATE
DISTRICTS
U5 MR
Bangalore Urban
67
%Normal
under 5
45.34
Bangalore Rural
Bagalkot
67
88
44.83
34.56
__
API
Malaria
0.21
1.06
- 33
7’7“
Belgaum
Bijapur
69
88
40.37
36.41
1.09
4.95
Chamrajnagar
Pt. Prev
TB
1.88
Incident TOTAL
DIARR INDEX
5.8
0.05
1.88
1.37
10.1
7.1
0.26
-0.53
1.67
1.37
9.4
-0.19
~—-—--9 °-52
Chikkamagalur
Davengere
Dakshina Kannada
Dharwad
Gadag
75
104
46
95
95
Haveri"
I™1
Kodagu
p®
95
66
47/11
34.61
51.59
41.21
0-41
0.12
2.58
0.28
T6
1.52
1.34
1.19
U?
0.15
01
I5?
35.42
54 61
40.68
6 55
0 64
1.68
1.66
Tl4.1TlWo^68
8.5
-0.18
55
_
-0.34
0.12
1.62
0.13
0.56
1.03
1.17
0.86
1.34
13.1
10.9
11.9
1.1
egg
-0.27
1.16
-0.05
153
11
4.3
20.9
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L
Mandya
-~KS°re ,... „
84
89
Shimoga
Tumkur
Uttar Kannada
Udupi
88
102
69
46
•
lJ
____
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47.37
45.22
55.41
°j4
14.5
16
0.07
2.11
0.77
-0.11
1.68
2.76
U5MR which is available only for 1991 has been
extra po/ated for newly formed
distnets as they have been part of old districts.
9 fonnTtn’h.3
t
39.25
1.19
0.00
poor H °aim sretus
UK' Udupi' DK'
Bangalore Urban was
m°St °f 'he NOrth H^^nalaka rag.on districts has
Disparities in Health Status have been assessed on
U5MR
: Under five Mortality Rate - probability of dying in between birth and age
5, expressed as number of deaths among children under the age of five
per 1000 live births.
%Normal
: Percentage under five children whose nutritional status is within normal
limits based on weight for age.
API MALARIA: Annual Parasite Incidence of malaria, which is number of confirmed
cases of malaria per 1000 population under surveillance.
Pt.Prv.TB
: Point Prevalence of Tuberculosis includes pulmonary and extra
pulmonary tuberculosis caies per1! 000 population.
Incident diarrhoea: Percentage of children below the age of five reporting current
diarrhoea or diarrhoea during the last two weeks.
As no single indicator can adequately describe the situation it is desirable to
concentrate on limited number of specific indicators. Child health indicators are more
sensitive to Socio-economic differentials, and investment in child health has long term
impact on equity.
Therefore under-five mortality, incidence of diarrhoea and
percentage of normal children have been used for assessing the health status. These
indicators also reflect the nutritional health and health knowledge of mother, availability
of maternal and child services including prenatal care, income and food availability in
the family, the availability of clean water and safe sanitation and overall safety of the
child’s environment. These measures are also sensitive measures of gap in health
status that are generally judged to be avoidable, unnecessary and unfair.
Other indicators of health status included are API malaria and point prevalence rate of
tuberculosis including extra pulmonary TB which are the leading causes of deaths
among communicable diseases.
c
i1
FINDINGS -C
DISPARITIES IN GOVT. PRIMARY HEALTH CARE FACILITIES IN DISTRICTS OF
KARNATAKA STATE
DISTRICTS
PHC/LAKH
MOW/LAKH PARA/10,000
•^M^TJ9.^POPyi^TipN POPULATION
B^^lor^UrbanXil
Bangalore Rural
6.62
■f
L
’ I
1
Li '
i,
7
J
TOTAL
INDEX
Bijapur
Bidar
Chamrajnagar
Chitradurga
Chikkamagalur
Davengere
Dakshina Kannada
n«n
3.80
3.78
4.60
5.58
7.69
5.44
3.72
5.11
6.80
<5.86
7.84
10.62
6.02
4.95
3.51
3.61
2.85
4.81
4.89
2.71
3.62
Gadag
Gulbarga
Hassan
Haven
Kodagu
Knlar
3.61
4.34
7.29
4.77
5.90
4.63
5.16
5.72
9.09
5.68
10.55
6.14
3.25
Mandya
Mysore
559
5 79
8.41
8.28
3.46
4.46
0.60
0.95
Shimoga
Tumkur
Uttar Kannada
Udupj_______
S^SO
7.64
6.88
8.40
5.24
4.27
3.33
5.20
3.02
0.65
0.17
1.15
-0.06
©
5.14
5.57
5.71
3.23
3.95
3.28
7.60
____ 3,34
^|g|2«7^
-q--0.12
-0.30
0.93
2.01
-0.09
-0.45
-0.56
-0.27
1.34
-0.15
2.38
-0.09
Kodabu. Chikkamagalur, Hassan, UK, Mysore Chitradurga and Shimoga had
good Primary Health Care Facilities
onimoga had
Many North Karnataka districts and even Bangalore Urban lack in Primary
Health Care facilities.
iI
Disparities in Health Care Facilities have been assessed on
PHC
: Number of Primary Health Care Centres per lakh population
MOW : Medical Officers working per lakh population
Para : Para Medical (Staff Nurse, BHE, Lab. Techn., ANM and Male workers) working
per 10,000 population
These indicators refer to how resources actually are allocated. Primary health care
provided by network cf PHC and sub-centres with community participation is first level
of contact between the individual and health system. Majority of prevailing health
complaints and problems can be satisfactorily dealt with at this level.
These indicators reflect the distribution of Government health care resources in
different districts of state and of the provision of health care. The purpose of health
sen/ices to improve the health status of people.
11
FINDINGS: D
• vHKiMA I AKA
IN UTlL,ZATI0N pattern of health services in districts of
DISTRICTS
Bangalore Urban
Bangalore Rural
T
J
Immunization ANC3
77.7
83 7
t
r
Safe DEL.
CFPU
86.9
80.7
85.8
85.9
92.9
77.6
60.1
63
TOTAL
INDEX
0.75
0.56
94
S3 9
60.4
47.1
-035
-0.31
0.82
1.38
0.32
1.08
0.23
-0.27
Chitradurga
Chikkamagalur
Davengere
Dakshina Kannada
Dharwad
Gadag
88.4
83.5
88.4
86.0
74.8
74.8
70.3
94.9
91.6
92.2
89.1
72
66.5
43.4
75.1
93.4
75.9
94.5
80.1
78.3
57.8
90.7
97.5
61.3
91.5
80.4
56 2
Hassan
Haveri
Kodagu
Kolar
92.8
74.8
94.8
90.6
75.1
80.5
83.6
56.1
38.3
84.2
85.6
94.3
75
60.6
85.4
78.2
65.4
59.9
71.4
59.9
63.7
61.2
61 2
^39^2:
75.1
61.2
70.6
57.1
“88
92.7
80.2
83.3
37.6
83,3
73.3
77.5
71.7
65.4
0.13
0.74
92.9
88
. 89.9
86
90.9
67.6
81.2
85.9
72.3
92.1
84.9
93.9
83.9
77.8
88.6
89.5
69.3
61.3
66
63.7
0.92
0.45
0.89
0.99
3®P£aS
4
TT 2
Mandya
Mysore
Shimoga
Tumkur
Uttar Kannada
Udupi
0.24
0.10
1.07
0.22
^1
Most of North Karnataka Districts haive poor utilization pattern of existing Health
services
9
11
Disparities in Utilization of Health Services have been assessed on
Immunization
: Percentage of 12-23 months children completely immunized with
BCG, DPT-3/OP\/-3 and Measles
ANC3
: Percentage of pregnant women who have received 3 or more
ANC visits received during recent pregnancy
TT2
: Percentage of ANC received TT2/Booster during recent
pregnancy
Safe Del.
: Percentage of deliveries conducted by Trained Health personnel
• during recent delivery.
CFPU
: Percentage of current users of any Family Planning methods
<
i
Utilization of Primary Health Services included the utilization of Public and Private
health services.
Utilization of services is expressed as the proportion of people in need of a service who
actually receive it in given period. A relationship exists between utilization of health
care services and health needs and status. Health care utilization is also affected by
factors such as availability and accessibility of health services and the attitude of an
individual towards his health and the health care system.
Utilization of public health services is often inequitable with the higher quality, more
expensive services disproportionately used by more privileged segments of society.
ic
!
iI
1
FINDINGS - E
raSTRIBUTON OF OISTRiCTS ON THE BAS1S OF VAR.OUS CHARACTERISTICS
OF KARNATAKA STATE:
DISTRICTS
Bangalore Urban
Bangalore Rural
HEALTH
DET.
2.80
-
° a5
HEALTH HEALTH HEALTH
UTILIZ. FACILITY STATUS
0.75
-1.55
0.05
0.56
0.16
0.26
-0.23
-0.72
jjgpgr—Belgaum
TOTAL
0.92
0.54
---- ---
-0.57
§0 7Q
Chamrajnagar
Chitradurga
Chikkamagalur
Davengere
Dakshina Kannada
Dharwad
Gadag
1
J
Hassan
Haveri
Kodagu
Kolar
-0.29
0.14
0.37
0.24
1.35
-0.31
0.82
1.38
0.32
1.08
0.23
-0.27
-0.30
0.93
2.01
-0.09
-0.45
-1.68
-0.56
0.52
-1.00
0.09
-0.27
1.16
-0.05
-0.43
0.31
1.20
0.13
1.06
-0.20
-0.71
0.24
0.10
1.07
0.22
1.34
-0.15
2.38
-0.09
0.00
0.07
2.11
-1.05
0.45
0.13
1.80
-0.07
0 12
°12
n ~7A
0-74
n nc
0.95
-0.18
-0.34
0.27
0.43
0.48
0.39
0.78
1.20
0.92
0.45
0.89
0.99
0.65
0.17
1.15
-0.06
0.77
-0.11
1.68
2.76
0.93
0.35
1.41
1.15
0.26
-TOS
-0.02
0.19
0.47
0.37
L
____
d
■u
Shimoga
Tumkur
Uttar Kannada
Udupi
■J
E?
il
iig
iI
Complete Hyderabad-Karnataka region including districts of Bidar, Gulbarga,
Raichur, Koppal, Bellary, Bijapur and Bagalkot lack in Health Determinants,
Health Status and Health Utilization including availability of Government Primary
Health Care services.
Districts like Belgaum, Gadag also have negative indices but at low level.
Chamaraja nagar district has negative value of indices except on health status.
This may be due to few indicators on health status have been taken from
Mysore.
®
Dharwad and Bangalore Urban were also lacking in Government Primary Health
Care services.
•
<
©
Kodagu, UK, Chikkamagalur, Udupi, DK, Shimoga and Bangalore Urban districts
have good Health Determinants, Health Status, and Health Utilization of existing
Health Services.
I
1
d
]
12
11
LAST 7 DISTRICTS ON THE BASIS OF VARIOUS INDICES
OVERALL
HEALTH DET.
Koppal (95)
Koppal(96)
HEALTH
STATUS
Bellary(97)
Gulbarga (94)
Raichur (96)
Kolar (85)
Koppal (97)
Bangalore (U)
(94)
Raichur (94)
Gulbarga (89)
Bagalkot (93)
Bagalkot (90)
Bellary (94)
Bellary (89)
Chitradurga
(84)
Bidar (81)
Raichur (92)
Raichur (85)
Bagalkot (94)
Bijapur (87)
Gulbaga (77)
Bellary (85)
Bellary (81)
Bidar (79)
Bagalkot (87)
Raichur (76)
Bidar (84)
Belgaum (78)
Bijapur (79)
Gadag (85)
Koppal (75)
Belgaum (76)
Koppal (73)
HEALTH
UTILIZATION
Gulbarga (99)
GOVT.HEALTH
PRIMARY
Dharwad (95)
_
Figure in brackets indicates the position on 100 point scale
J
TOP 7 DISTRICTS ON THE BASIS OF VARIOUS INDICES
1
OVERALL
Kodagu (4)
Uttar Kannada (8)
Chikkamagalur
(12
Udupi (13)
L
HEALTH DET.
HEALTH
STATUS
Bangalore (U)(1) Udupi (1)
HEALTH
UTILIZATION
Chikkamagalur (8)
GOVT.HEALTH
PRIMARY
Kodagu (1)
Dakshina
Kannada (9)
Udupi (12)
Dakshina Kannada
(14)
Kodagu (14)
Chikkamagalur (2)
Hassan (9)
Udupi (16)
Uttar Kannada (13)
Shimoga (18)
Mysore (17)
Uttar Kannada (19)
Chitradurga (18)
Bangalore U (23)
Shimoga (26)
Uttara
Kannada (22)
Bangalore (R)
29)_________
Dakshina
Kannada(15)
Shimoga (18)
j Shimoga (32)
Bangalore-U(18)
'Kodagu (32)
Kodagu (2)
Uttar Kannada
(5)
Dakshina
Kannada (12)
Shimoga (22)
Chamrajnagar
(30)
Bangalore-R
(40)
Figure in brackets indicates the position on 100 point scale
However, disparities in health on class, caste, age, sex and the religion could
not be assessed, as data does not exist in disintegrated form for districts of
•\amataKa.
ir
ii
Relationship in between Health Status and Health Determinants among the
Districts of Karnataka State:
HEALTH
STATUS
LOW
HEALTH DETERMIN ANTS
MODERATE
HIGH
LOW
BELLARY
GULBARGA
KOPPAL
RAICHUR
CHITRADURGA
KOLAR
BIDAR
MODERATE
BAGALKOT
BIJAPUR
GADAG
DAVANGERE
' BELGAUM
CHIKKAMAGALUR
DHARWAD,
HASSAN, HAVERI
MANDYA,MYSORE
TUMKUR
HIGH
CHAMARAJNAGAR
BANGALORE (U)
DAKSHINA KANNADA
UTTAR KANNADA
UDUPI, KODAGU
SHIMOGA,
BANGALORE (R)
Observed Agreement 19/27 - 70.4%
Kappa Coefficient: 0.532,
P = 0.000059
It is obvious from the above table that the districts with the low value on health
determinants have low health status and districts with high value of health determinants
have the high value of health status with an agreement of 70.4% and Kappa Coefficient
0.532, which is significant.
I
I
:-4-
Stalus a"d Prim^ H-'"’
"he
health
STATUS
LOW
moderate
LOW
PRIMARY HEALTH CARE FACILITIES
MODERATE
HIGH
BELLARY
KOPPAL, RAICHUR
GULBARGA
KOLAR
BIDAR
CHITRADURGA
. BAGALKOT
BANGALORE (U)
BELGAUM
DHARWAD
BIJAPUR
DAVANGERE,
'GADAG, HAVER!
MANDYAJUMKUR
CHIKKAMAGALUR
HASSAN
MYSORE
DAKSHINA
KANNADA
UDUPI,
BANGALORE (R)
CHAMRAJNAGAR
KODAGU
UTTAR KANNADA
SHIMOGA
HIGH
"r
.1
’T
Facilities among
Observed Agreement 12/27 - 44.44%
L.
Kappa Coefficient: 0.1234,
IT
L
i.
P = 0.1862
Government Primary Health Care :
with r\hc.^
” services and health status are not very much related
with observed. agreement
agreement of
of 44.44%
Kappa Coefficient
Coefficient 01234
44.44% and
and Kappa
0.1234 S is not
igm icant. This may be due to the utilization and availability of private health services.
S2S seSXsaS '°W Hea',h Sla,US even th0U9h “ has 900d S^ment Primary
11
Relationship between Health Status and Utilization of Primary Health Care
services among the Districts of Karnataka State:
HEALTH
STATUS
UTILIZATION OF PRIMARY HEALTH SERVICES
LOW
MODERATE
HIGH
LOW
BELLARY,
GULBARGA, BIDAR
KOPPAL, RAICHUR
.BAGALKOT
BELGAUM
MODERATE
KOLAR
CHITRADURGA
BIJAPUR
HIGH
DHARWAD,
'DAVANGERE
HASSAN, HAVERI
MAN D YA, GAD AG
TUMKUR, MYSORE
BANGALORE (U)
CHIKKAMAGALUR
BANGALORE (R)
CHAMRAJNAGAR
DAKSHINA KANNADA
UTTAR KANNADA
UDUPI, KODAGU
SHIMOGA
Observed Agreement 19/27 - 70.4%
Kappa Coefficient: 0.532,
P = 0.000059
-
All districts with high health status continue to use Primary Health Care services and
the districts with low health status have low utilization of primary health care services.
The above table, observed agreement and kappa coefficient denotes that the health
status is more related to the utilisation rather than the availability of services.
I
I
1
u
Relationship in between Primary Health Care Facilities and Health Facilities
Utilization among the Districts of Karnataka State
HEALTH
FACILITIES
UTILIZATION
LOW
LOW
PRIMARY HEALTH CARE FACILITIES
MODERATE
HIGH
BELLARY
BAGALKOT
BELGAUM
RAICHUR
KOPPAL
GULBARGA
BIDAR
MODERATE
•BANGALORE (R)
BIJAPUR
CHAMRAJNAGAR
DAVANGERE,
GADAG, HAVERI
MAND YA, KOLAR
TUMKUR
DHARWAD
- r
J
HIGH
BANGALORE (U)
DAKSHINA
KANNADA
UDUPI
LI
HASSAN
CHITRADURGA
MYSORE
CHIKKAMAGALUR
KODAGU
UTTAR KANNADA
SHIMOGA
Observed Agreement 18/27- 66.7%
Kappa Coefficient: 0.474,
P = 0.00031
It is clear from the above table the relationship between Primary Health Care utilisation
and Primary Health Care facilities is significant where observed agreement is 66.7%
-• and Kappa Coefficient is 0.474. This shows the availability of health services leads to
utilization of the health services.
In case of Bangalore Urban though the availability of government primary health care
facilities is low, the utilization of health services is high. This may be due to availability
of health care services in the private sector.
I
17
H
'^SDlTr tbatJhe Hyderabad - Karnataka region (Bidar, Gulbarga,
■
an
u ary), Bijapur and Bagalkote lack on all indicators in the
a=.egories.
, ?Jdealth reSuires equity in the distribution of the determinants, availability
==:tn care sen/ices and the utilization of health care sewices.
-
enclosed indicates the districts which require top priority (red), moderate
and districts where existing facilities, utilization and health stat"<=
- ■ coined at an acceptable level (green).
EMENDATIONS
^™r'^tlanit7iOn,'[1Cludin9 availability of dean water, housing and access to
J
llies hke electricity should be improved in entire Hyderabad-- -■-■'Y -Sion, Bijapur, Bagalkote, Gadag, Hassan and Haveri districts For this
•
K3r"atal? Pra9ram under Rural Development and Panchyat Raj
09 aWareneSS °n Sani,ati°n and provision °f
JciteTrXS?
»
15+ should be improved in Hyderabad-Karnataka
region, Bijapur,
-^gaiAore. uhamrajnagar, Mandya and Bangalore Rural districts.
econ°mic status of household in Hyderabad' Chamrajna9ar’ Chitradurga, Dharwad, Gadag
t0
anSS districts
reaion^B.Su^R0!
Sh°Uld be imProved in entire Hyderabad-Karnataka
region, Bijapur, Bagalkote, Davengere, Gadag and Haveri District.
llStote^SS t0 nSL ^dU^d in Hyderabad-Karnataka region, Bijapur,
-agaiAOtc, Chitradurga, Dakshma Kannada, Hassan, Kolar and mandya districts bv
implementing
Malaria Program aggressively.
Y
7
impiementing National
National Anti
Anti Malari.
BXlSrr? TB Sh°Uld redUCed in Hyderabad-Karnataka region, Bijapur
■' ’rbar and
b Cb;tradursa’ Kolar' Mandya. Mysore and Bangalore
^roan ana Rural districts by extending RNTCP to these districts on priority basis.
rST tCa„e fac',itief t0 be improved in Hyderabad-Karnataka region,
-Jj, -r, ..c^dlmote Bangalore Urban, Dharwarand Gadag districts.
*
M°[e than establishing new primary health care facilities the utilization of existing
facilities the utilization of existing
’ ‘■ ■n care services should be encouraged. This could be done by making
-xistmg primary, health care facilities functional in real sense through monitoring of
ivailacilityc’staff including MOH and drugs
'l
AA AAAAXAA-AAA AAAAA *■**-*-*-* A ★
fi
L
■
h
t
II
ANNEXURE
I.
HEALTH DETERMINANTS INDICATOR
c.
Prevalence and level of poverty * - 1998
Educational levels * -1991
Adequate sanitation and Safe water coverage * - 1998
d.
Housing *-1991
a.
b.
IL
HEALTH STATUS INDICATORS
a.
b.
c.
d.
e.
f.
g-
111.
1
Under five year mortality rate * -1991
i
Nutrition of children * - Nov. 2000
Maternal mortality ratio: Not Available
Life expectancy at birth: Nbt Available
Incidence & Prevalence of relevant infectious diseases *-1999
i Infant mortality ratio: Not Available
Child mortality (1-4 years): Not Available
HEALTH CARE RESOURCES ALLOCATION INDICATORS
a.
Per capita distribution of qualified personnel in selected categories eg.,
medical officers: physician, obstetrician, paediatrician, surgeons &
paramedical workers. * - Sept. 2000
b.
Per capita distribution of services facilities at Primary, Secondary and
Tertiary levels. * - 1999
h.
IV.
Per capita distribution of total health allocation and expenditure on
personnel and supplies as well as facilities: Not Available
HEALTH CARE UTILIZATION INDICATORS
b.
c.
Immunization coverage * -1998
Antenatal Coverage * -1998
Percentage of births attended by qualified attendant * -1998
d.
Current use of contraception * -1998
a.
* Indicators used in the present report
I9
0000000000000.00000000000000000 - ^&&0000000
0
0
0
'■ ERNME VT OF KAR.X \TAKA
0
0
0
vask rosr:-: on health and family well \
0
0
0
'tnmissioned Research Studv
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
ROLE
OF
PRIVATE
SECTOR
IN
HEALTH
(
ARE:
0
0
0
0
QI ALITY AND ACCESS
0
0
0
0
0
r
0
0
0
0
0
0
IT 0
0
0
i
0
0
0
0
r
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
Bv
0
0
0
0
A. F. FERGUSON & CO
0
0
MANAGEMENT CONSULTANT DIVISION
0
0
BANGALORE
0
0
0
0
0
0
0
0
0
0
0
0
■r
0
0
0
I
0
0
000 03000000300
3000000000
s
I
Strictly Confiderwaf
ic/e
. •; s.r:tcr in Health Cjre: OutiUtY & Access
1.Background
Introduction
i.i
Health care and public health being one of • e r'.rust areas for development and
improvement, the Government of Karnataka as considered the need for review of
the current state of Health System so as to •_ ^su-e 'Health for air with equity and
quality.
1.2
In order to propose measures to improve : e public health care systems in the
State of Karnataka, the Department of Healtr anc Family Welfare (DHFW) has set
up a Task Force, consisting of eminent persor s in various fields, which will examine
the issues involved and propose measures wnich could be adopted by the
Government.
1.3
In this regard, the Task Force has conductec s preliminary study and presented an
interim report dealing mainly with short-te n 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 arc. iong term.
1.4
A.F.Ferguson & Co. - MCS division (AFF) ha- been retained by Karnataka Health
Systems Development Project (KHSDP) for review of private sector role in improving
health service programs (access and quality).
Terms of Reference
1.5
The Terms of Reference (ToR) for the study is as follows :
♦ To review existing role of the differer c sectors viz. voluntary-not for profit
hospitals, for profit hospitals and public (Government) hospitals in providing
health care services and determining the possibility of a partnership between
them
♦ To review the various health care serv.ces offered by private sector in terms
of access and qualities and suggest improvements thereof
♦ To review the role of private sector
in preventive/promotive and
rehabilitative Health Care deliver/
♦ To determine the willingness of private sector to be regulated in delivery of
their services either by legislation, self-regulation or accreditation.
Approach & Methodology
1.6
Our approach to the study included:
♦ Preliminary Study
♦ Primary Survey
♦ Analysis - Findings and Recommendat: >ns
Preliminary Study:
This phase of the study involved the following
!
AFF-MCS
1
i
i
Slrct/v .?
• ■in
♦
*
1.8
Jjrc; (Duality & Access_
Discussions with Relevant Personnel: Detailed discussions were held
wiui che members of the Task Force a; d other relevant personnel, reqardinq
Ci'.e various aspects of the proposed study.
Secondary Data Research:
-----: Basec on the discussions, information was
compiled from various secondary
!
sources viz., Government of India
duplications, Government of Karnata □ publications, World Bank reports,
other research findings etc., on ■•.oe factors affecting public health
programmes and the private sector.
~ .:TatZ SUrVSy ofa sample comprising of Pr yate hospitals, Government hospitals,
no[nes' Pnvate practitioners, Govern."-,ent doctors and alternate systems of
i.^u.c.ne. i-or every hospital and clinic visitec exit proformas from both in-patients
ano out-patients were administered to assess the quality of care delivered. The
details of coverage is given in chapter 2.
Analysis - Findings and Recommendation s
1.9
The information collected from the primary and secondary sources was analysed to
determine the role of private sector in public health services. The perceptions on
ti.e existing services received from the cross section of society was considered
wnile providing recommendations on enhancement of private sector role in health
care distribution Recommendations are provided on the improvements in Quality
arc . .lcsss to be incorporated by the private sector in line with their proposed
acc; Lt on a I role.
1.10
The various aspects of the study are presented in different chapters.
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♦
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Chapter 2: Primary Survey Coverage
Chapter 3: Review of Quality and Level of Care
Chapter 4: Access to Healthcare
Chapter 5: Regulation and Accreditation
Chapter 6: Public Private Partnerships
Chapter 7: Conclusions and Recommendations
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Role of P' i 'to Sector in Health Care; Quality. ± Access
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2. Primary Survey Coverage
2.1
This chapter presents the objectives, methodology followed and coverage of
primary survey made as part of the study.
Objectives of the Survey
2.2
The primary survey was made with the following objectives
♦
♦
♦
♦
Comparative study of quality of services offered as perceived by patients Reviewing the level of care in private hospitals vis-a-vis public hospitals at
the Primary, Secondary, Tertiary levels to the extent relevant for the study.
Private Sector hospital review in terms of
• Physical Access
• Social Access:
• Services Availability
• Quality as perceived by patients
Involvement of private sector in national programmes
Whether the private sector can be motivated towards greater access to
society
Willingness of Private sector for regulation, self-regulation and accreditation.
Methodology
2.3
Exhaustive questionnaires were prepared covering all aspects of the study. The
questionnaire (please refer Annexure 1) which served as a basis for fact finding
were
♦
♦
♦
♦
Private Hospital Proforma
Government Doctors Proforma
Private Practitioners Proforma
Exit Proforma - Patient Satisfaction
2.4
Discussions with key Department of Health members/ Task Force were also held.
Their suggestions were duly incorporated in the questionnaires.
2.5
The concerned hospitals/health care centres were visited by the consultants of AFF
covering the following :
.
♦
♦
A tour of all services/ facilities
Detailed discussions with the management to obtain their views on key
issues.
2.5.1 The results of primary survey are as provided by the respondents verbally/or in the
filled-up questionnaires, these could not be verified with their documents as the
hospitals/practitioners were reluctant to provide any records of statements to
substantiate their claims especially in cases like percentage of patients provided free
treatment.
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Coverage
Adequate care was taken to make the sample representative in terms of
2.6
Category of respondents - Hospitals, Practitioners and Patients
Geographical Coverage - Urban/Rural composition and Spread
♦
♦
Hospitals
By Management: All categories of hospitals with different management styles
were part of the study as is shown in table 2.1.
2.7
II
Table 2.1: Coverage as per Different Category of Hospitals - Management
Particulars
S.No.
1.
2.
3.
4.
Private Hospitals_____
- ’Corporate Hospitals
- Trust Hospitals
- Teaching Hospitals
- Missionary Hospitals
Nursing Homes_________
Indian System of Medicine
Government Hospitals
Total
Number In Number In
urban Areas Rural Areas
2
_ ___ 6 ___
2____ ~
_____ 2__ ~__
1
_____ 1_____
1
_____ 1__ _
7
_____ 2__ _
1
___ n1_2_
8
18
12
Total
Number
8
2
2
2
2
9
2
11
30
I
By Level of Care: To the extent possible, a mix of primary, secondary and tertiary
level of care offered by different hospitals was provided for in the sample.
2.8
Table 2.2: Coverage as per Level of Care Provided
S.No
Particulars
Private Sector___________
- Primary______________
- Secondary____________
- Tertiary______________
Government Hospitals
- Primary Health Centre
- Community/Taluk Health
Centre___________________
- District Hospital________
Indian System of Medicine
Total
1
2
3
Number In
urban Areas
_____ 8
_____ 2
_____ 4
_____ 2
3
__3
_ 1
12
Number In
Rural Areas
9
2
Total
Number
17
9
6
2
11
6
2
1
18
3
2
30
2
2
8
Practitioners
2.9
Adequate coverage of general physicians, specialists in private sector and
Government doctors was provided for in the sample as is shown in table 2.3.
AFF-MCS
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Role o' -- ■ -
Table 2.3: Coverage of Practitioners
Particulars
S.No.
1
Number In
urban Areas
_____ 13 ’____
Private Practitioners
- General Physicians
- Specialists________
Government Doctors
Indian System of Medicine
Total
2
3
____ 8______
’
5_ ______
_ 2 .C__
’____
1________
19
Number In
Rural Areas
11
7
4
23
1
35
Total
Number
24
15
9
28
2
54
Patients
2.10
A minimum of 3 questionnaires was administered to patients in every hospital and
clinic visited in the private sector. In all, a total of 112 exit proformas were
administered to patients.
2.11
Break-up as per IP/OP: Equal representation was given to both the in-patients
and out-patients in the sample as is shown in table 2.4.
Table 2.4: Break-up of IP/OP Patients
S.No.
1
Number In
urban Areas
Number In
Rural Areas
46 '
10
Total
Number
56
56
102
10
56
112
In-Patients (including Indian
system of medicine)_______
Out-Patients_____________
Total
2
2.12
Particulars
Classification as per Sex of patient:
Table 2.5: Sex wise Classification of Respondents
S.No.
1
2
2.13
Particulars
Males
Females
Total
Number In i Number
patients^
t- patients
33
22
55
Classification as per Age of Patients:
L__ 38
L___19____
57
Total
Number
71
41
112
t
Table 2.6: Age wise Classification of Respondents
S.No.
_1_
2
4
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Particulars
Less than 12 yrs
12 - 35 yrs
36 -50 yrs
Above 50 Yrs
Total
Number Inpatients
28
13
14
55
Number
Out-patients
_8_____
33_____
12_____
_4___
57
Total
Number
8
61
25
18
112
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Role pi t'r • -
Strictly Confidential
2.20
2.21
t<'ctoi m Hedlth Core: OudHt\- R Access
Discussions with owners of certain hospitals, ' jrsing homes, IMA members anc
hospital administrators were also held to get a
-I of various qualitative parameters
for setting up an accreditation body.
T
I
Break-up of respondents by number of beds, ownership, system of medicine and
services provided is presented below
2.21.1 Number of Beds: Majority of respondents were nursing homes having less than 25
beds as is shown in exhibit 2.1
Exhibit 2.1: Classification as per Number of Beds
I
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Diagnostic
Centre and
Polyclinic
8%
More than 250
beds
12%
Between 101 to
250 Beds
10%
Less than 25
Beds
52%
Between 20 to
100 Beds
12%
Between 26 to
50 Beds
6%
7
2.21.2 Ownership: Majority (62%) of the respondents had proprietorship concern as is
shown in exhibit 2.2
Exhibit 2.2: Classification as per Form of Ownership
Trust
28%
Government
4%
...
II
Corporate
Partnership
2%
4%
a*™
roprietorshi
P
62%
2.21.3 System of Medicine: Majority (88%) of them were allopathic graduates, 6% of them
were from other disciplines and responses for other 6% were not available.
AFF-MCS
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2.14
in Health Cere: OudHty f Access
Classification as per Income of Patients:
Table 2.7. Classification of Respondents on Income
S.No.
Monthly Income
1
2
2
Upto 1000________
Rs. 1000- Rs. 2000
Rs. 2000 - Rs. 3600
Rs. 3600 - Rs. 5000
Above Rs. 5000
4
5
Total
Number In- I Number
patients j Out-patients
3_____
4
_3_____
13
11
18
46
_______
J____
~i—
Total
Number
3
7
19
23
12_____
12_____
30
36
82 ___
I
Note : 30 respondents did not indicate family income
Coverage as per Spread
2.15
The respondents were mainly from the urban and rural
areas of Bangalore,
Belgaum, Kolar and Gulbarga.
2.16
Thus, to an extent possible, adequate effort was made to make the sample
representative in terms of both categories of respondents and geographical
distribution for the purpose of the study.
Primary Survey for Assessing Willingness for Accreditation
2.17
For assessing the willingness of private sector hospitals and practitioners for
accreditation, a separate structured questionnaire (Annexure II) was mailed to 600
hospitals/nursing homes/Private Practitipners/Specialists through IMA and also
through distribution at IMA sponso/pd seminars at Gulbarga, Belgaum and Kolar. '
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2.18
•
'
The break-up of responses received is shown in table 2.8. Though responses were
received only from 36% of hospitals, the break-up of responses by number of beds
ownership, system of medicine and services (as has been detailed below) indicates
that the sample was representative of the whole.
Table 2.8: Responses Received From Different Categories
Number of Hospitals
Number of Specialists
Number of CP's
Total
2.19
Proforma
Sent
"500
50
50
600
Responses Percentage
Received
Responses Recd.
180 ~
36%
35
70%
40
80%
255
42.5%
The respondents were different stakeholders in hospital services. Though only 36%
of responses were received from hospitals category, the responses were
representative of the whole as could be seen from the break-up of total
respondents presented below.
6
Strictly Confidential
Rple of.Pri:
2.21.4 Services Provided: Majority were providers
is presented in exhibit 2.3
t'ecior in Health Care; Quality & Access
multiple services and the break-up
Exhibit 2.3: Classification as per Services provided
Mainly
Any Other
(Eye/ENT
etc.)
8%
16%
.-.Si
me
Mutliple
Services
76%
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Access
3. Review of Quality and Level of Care
3.1
Quality of service provided in hospitals are usually determined by either of the
following two methods
♦
♦
Review of service offered such as effectiveness of treatment, hospital
infection rates etc and facilities available (Equipment, Investigation, Staff
etc)
Review of patient's perception of the quality
3.2
This study has focused on review of level of care and quality in the private sector
through exit patient perception of quality. This was conducted through a detailed
patient survey, wherein around 102 exit proformas were administered to patients
visiting Hospitals, Private clinics etc. In addition, around 10 patients from an
alternate system of medicine namely Ayurvedic Medicine were covered. This chapter
presents the findings of the survey on review of quality and level of care.
3.3
In order to retain the distinction between Allopathic medicine and the Indian system
of medicine, for the purpose of review of patient perception, the observations from
the patients of Ayurvedic hospital have been indicated separately.
Quality of Service
3.4
The quality of service offered by the private sector has been reviewed on the
following parameters :
♦
♦
♦
♦
♦
♦
♦
Patient Expectation
Repeat Visit / Recommendations
Doctor - Patient communication
Nursing care
Ward Staff Support
Support Services
Administrative Support
Patient Expectation
I
3.5
Quality of care is perceived to be high, when the expectations of patients with
respect to outcome of service is met.
3.6
Majority of the patients were of the view that their expectations of service were
either fully met or have been met to a certain extent. None of the In-Patients (IP)
were of the view that expectations have not been met. This holds true for the rural
sector also. Around 3% of the out-patients(OP) were of the not satisfied with the
treatment given.
3.7
Table 3.1 presents the response with regard to patient expectation.
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Access
Table 3.1: Patient Expectation Response
Expectation :
Fully met
To some extent met
Not met
In-Patients
54%
46%
0%
ioo%
Total
3.8
-I QutrPatients
_i
49%
!
48%
3%
~ibo%
In case of Indian Systems of medicine a majority of the patients were of the view
that the patient expectation were met only tosome'extent
Repeat Visits/Recommendations
3.9
Satisfaction of care and meetinc of care c^.p^^tcLiuHo
expectations, is an indicator that the
patient would visit the hospital for any subsequent illness'
—> as well as recommend the
hospital to others.
3.10
SiXXTot^^
3.11
Table 3.2 presents the response on repeat visits and recommendations
Table 3.2 : Response on Repeat Visits and Recommendations
Response
Surely
Maybe
Not at all
Total
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Recommend to others
42%
56%
______ 2%
______ 100%
3.12
complaints. This reinforces the response received from patients.
T
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Repeat Visits
54 %
____ 43 %
3%
Doctor - Patient Communication
3.13
A Doctor's role is critical with respect to perception of the patient in reaard to the
quality of any hospital/clinic. Most patients visit the hosnitak fnr mne n- <-•
specific doctors. The doctor's role is reviewed both b terms^of technical SpabilS
as well as the comfort level the patient perceives with the dnrtnr Ac
patient wenid not
able to Judge the 1«h„,ca^^LXsOo^etedoX^
often, on successful treatment, the confidence
1
? on the doctor's capabilities rise. The
different factors reviewed in the exit proforma
survey are:
♦ Communication on the illness and treatment process
♦ Sense of Comfort
♦ Opinion on treatment
♦ Doctor Behavior.
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Communication on illness and treatment process.
Responses were elicited on whether adequate information was provided by the
doctor about the illness and treatment meted oy. it must be noted that extent for
requisite information would vary from patiem to patient. Around 84% of the
patients were fully satisfied with the explanation', given. In cases where the patients
felt that adequate information about illness has r,ot been provided, they were barely
satisfied with the doctor's service. Thus, the survey indicated that communication
played a key role in the overall satisfaction of the patient on the quality of services.
3.14
Sense of Comfort
The comfort level felt with the doctor plays a key role in removal of most
apprehensions of patients. The patients were queried on whether they felt free to
talk to the doctor regarding their concerns and worries. Majority of the patients
were at a comfort level with regard to patient- ooctor communication. In the rural
areas, almost all patients with an exception or two, were very comfortable with the
doctor communication.
3.15
Opinion on Treatment
Empirical studies have proven that a physician's task competence have a significant
influence on patient decision on quality. Opinions on the doctor's competence are
formed on recovery history of previous illness as well as patient's response to
current treatment. The respondents were divided closely between 'good' and
'satisfactory' treatment. A small percentage (2%) was dissatisfied with the technical
capabilities of the doctor.
3.16
Doctor Behaviour
3.17
Doctor's behaviour with the patient were reviewed in terms of whether the doctors
were kind and helpul, indifferent or they needed improvement in the same. Around
14% of the respondents were of the view that there is a need to improve behaviour
of doctors. This may be a response to behaviour of specific physicians and has been
noted in a rural nursing home as well as in three other instances..
Overall Satisfaction
3.18
Majority of the patients were totally satisfied with the overall service provided by
the doctors thereby, reflecting in the quality standards perceived by them. Table 3.3
provides the responses of the Doctor — Patient communication parameter.
Table 3.3 : Responses on Doctor Patient Communication Pa rameter
Response
Commu Comfort
nication^ Level
' 78%
84%
12%
22%
Fully Satisfied
Satisfied
to
some extent
Not Satisfied
4%
3.19
Treatment
Quality
55%
43%
Doctor
Behaviour
81%
5%
Overall
Satisfaction
87%
11%
i
2%
i 14%
2%
The exit proforma conducted on patients visiting the Ayurvedic Hospital indicated
that majority of patients (~ 70%) weie only satisfied to some extent with the
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doctor's treatment. While ~80 % of the respondents felt that the communication
between patient doctor could have been bettor, the responses were mixed with
regard to the doctor behaviour (50 ~ 50 between Kind and Indifferent)
Nursing Care
3.20
Nursing care provided by the private sector was reviewed for in-patient care. High
level of interaction between nurses and patient results in Nursing care being a key
aspect in determining patient satisfaction thereby perception of quality. Nursinq
care determinants reviewed were :
♦
♦
♦
ul
3.21
The majority of hospitals and nursing homes do not have nursing manuals.
Missionary hospitals have standing orders for nurses for certain departments. Many
of the hospitals are now planning to have manuals.
3.22
The survey revealed that most patients felt that the nurses were fairly friendly and
courteous in the urban areas, while in rural hospitals it was predominantly found
that patients felt that nurses need to improve their behaviour in terms of kindness
and warmth. The feedback on quality of nursing care was equally distributed
between 'good; 'satisfactory' and 'needs improvement'.
3.23
The major hospitals had trained and qualified nurses whereas the smaller hospitals
and nursing homes have poorly trained nurses and not as per Nursinq council
norms.
y
3.24
Majority of the patients with the exception of the rural hospitals were of the view
that the nurses responded promptly on patient. Table 3.4 presents the exit
proforma findings on Nursing care offered in the private sector.
Table 3.4: F
r
Responses
L
Good (Kind & Helpful)
Satisfactory (Indifferent)
Needs Improvement
Total
L
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Support and kindness of nursing staff
Perceived competence thereby quality of service
Prompt answer to call
3.25
Nursing Staff
Behaviour
58 °/(?
12 %
30 % _____
100%
Quality of Nursing
Care
32 %
________
32 %
36 %
100%
I
In the Ayurvedic hospital, the responses closely distributed across the three
parameters i.e. 50 %, 30% and 20% respectively. Most in-patients were of the view
that the nurses were indifferent and the quality of nursing care was only at a
satisfactory level.
Ward Staff Support
L
3.26
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Ward attendants are the key support staff assisting the quality care of the in
patients. Service in terms of promptness to calls and their behaviour with the
patients reflect on the atmosphere of the hospital. Around 46% of the respondents
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: • "i Health Care: Quality S Access
felt that these attendants were prompt in their service, while 38 % (predominantly
rural) felt that they needed improvement.
Support Services
3.27
Hospitals are complex entities with multiple range of functions being conducted
within. Though primarily clinical and para-medical ca-e forms the key functions of
the hospital, other areas such as Pharmacy, Housekeeping, Admissions and Food
service play critical roles in ensuring quality care to the patient. Respondents were
queried on the efficiency of these services and their satisfaction from them. The
areas covered were :
♦ Medical Supply Procurement
♦ Quality of meals
♦ Housekeeping
Medical Supply Procurement
3.28
Easy availability of medical supplies in the medical/surgical shops located in the
hospital is critical to the patient especially in emergency situations. While no
respondent had any concern regarding availability, around 86% did not face any
problems in procurement of medicine from these shops.
3.29
In the ayurvedic hospital, certain section of patients (60%) had difficulty in
procuring medicines, in certain situations while the remaining 40% did not face any
problems.
Quality of Meals
3.30
Provision of hygienic and good quality meals are a requisite for smooth recovery of
the patient and also reflect on the quality of the hospital. However, it has been
observed that unless made mandatory by the hospital, most patients do not avail of
the hospital meal services. Further, the respondent's view on the quality would be
highly individualistic and subjective to factors such as taste etc.
3.31
Around 62% of the in-patients (who availed of the facility) were satisfied with the
meal quality and timely service while 38% felt that there is scope for improvement
of meal service and quality.
3.32
All respondents of the Ayurvedic Hospital covered felt that there is a need to
improve the quality and service of meals offered.
House-Keeping
3.33
Hospitals being at a high risk in terms of cross - infections, good housekeeping
reflects on the overall quality care offered by hospitals. Housekeeping has been
reviewed in the exit proformas in terms of cleanliness of wards, toilets etc as well as
provision of linen and other supplies.
3.34
Responses on cleanliness of wards, toilets and bathrooms were highly hospital
specific with certain hospitals rating very high (100 % satisfaction) and certain
others quite low (75 % dissatisfaction). This is true for both rural as well as urban
hospitals. On an overall basis, around 54% found that the toilets were clean.
!
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3.35
WiCh regard to linen supply, most of the rural respondents had used their own linen,
This may be due to bad quality of linen supplied by hospitals or the hospitals do not
provide for the same. The responses of other patients revealed an equal distribution
between satisfactory and need of improvement parameters.
3.36
Majority of the in-patients felt that the facilities of sweeper, security and power
were adequate.
3.37
Table 3.5 presents the responses on Housekeeping facilities of the hospitals.
Table 3.5 : Responses to Housekeeping Facilities
Responses
Satisfactory_______ _
Needs Improvement
Totally Dissatisfactory
Total
3.38
Cleaniness
of Quality of Linen
ward. Toilets &
Bathrooms
54 %____
51 %
______
46 %________ ____ 49 %
0%
rp %
100%
100%
In the ayurvedic hospital, all patients felt that there was a distinct need for
improvements of the cleanliness levels and the linen supply.
Administrative Support
3.39
.1
Quick and simple administrative procedures facilitate in l.hh.
enhancing the comfort level
°f th6^601
the h°Sp,tal' The administrative support: was reviewed in terms
♦
♦
♦
1
Admission & Billing Procedure
Attitude of Reception staff
Waiting time
Admission and Billing Procedure
3.40
Majority of the patients (76%) felt that the admission and billing procedure was
t^Pr L7/ h 2°nehOf the view that * wa? very complicated. This is applicable to both
the rural/ urban hospitals as well as the Ayurvedic Hospital.
Attitude of Reception Staff
3.41
Around 38 % of the respondents were of the view that the reception staff was
courteous, prompt and answered their queries satisfactorily, while 57 % felt that
there was a need for improvement in their attitude.
Waiting Time
Wa7 d“"ed for
of enquiry/regrstration, doctor
consultation and investigation. In all the three cases the majority of the
witf°i
T'6 ?!
'hat the aVerage Waitin9 time was 30 - 45 minutes
with 56 % feeling that though long, the waiting time was acceptable. 30 % of the
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respondents were of the view that the overall v.a * eg time was reasonable and
within their expectations.
3.43
In the OPD, most of the waiting time (73%) v/as spent in waiting for doctor
consultation. The average waiting time at each stage s. presented in the Exhibit 3.1
Exhibit 3.1: Waiting Time
70%-|
60%-
50%40%30%20%-
I I IK
|g|
10%-
0%-
Registration
=
Consultation
Investigation
15%
15%
□ 30-45 min.______ ______46%
69%
15%
54%
15%
15%
23%
______ 0%
0%
0%
8%
0%
8%
B Less than 30 min.
□ 45-60 min.______
□ 60- 120 min
B More than 120 min
Level of Care
3.44
Level of care provided in the private sector was determined through the availability
of services in the hospital and the perception of the patients of the same.
Services Availability
3.45
The various services available in the private sector can be summarised as under:
♦
♦
♦
3.46
With regard to investigation facilities the following observations have been made:
♦
♦
♦
3.47
Super speciality services are generally available in Corporate / Teaching
hospitals
The Trust and Missionary hospitals generally provide secondary level of care
i.e. internal medicine, paediatrics, general surgery etc.
Most of the nursing homes have only minimal services for emergency care.
Corporate / Teaching hospitals usually have facilities for all investigations
Missionary / Trust hospitals offer secondary level of investigations
Most nursing homes have only basic investigation services.
This has been confirmed in the exit proformas wherein most of the corporate /
teaching hospitals had their own investigation facilities.
AFF-MCS
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3.48
Facilities in terms of adeouate water and power supply and the drainage facilities
were found in all the hospitals covered. However, water purifier facilities were not
available in the nursing homes.
3.49
While the private hospitals had adequate number of ambulances, the nursing homes
did not have any. In terms of ward facilities, the nursing homes had only general
wards and no ICU facilities while all the private hospitals covered had Emergency
wards, general wards and ICU facilities. The nursing homes do not seem to follow
any kind of standard protocols regimes.
3.50
The facilities available in the private sector are presented in Table 3.6
Table 3.6: Facilities Available in the Private Sector
Facilities
Private
Hospitals
(%)
Emergency Ward
___________
% Beds in General Ward________
ICU_____________________ ___
ICU Beds/Total Beds (%)________
Ambulance___________________
No. of Ambulances (No.)________
Overhead Water Tank__________
Water Purifier________________
Hot Water Facility_____________
Generator____________________
Elevator___________________
Drainage Connection_________
Laundry______________
Space for Washing Patients Clothes
r
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Declared Baby Friendly by Govt.
Nursing
Homes (%)
100
___61
100
5-10%
__ 67
__ 1-4
100
100
100
__ 83
__ 83
100
100
83’
_J0
50'
“0
36
__ 0
__ 0
__ 0
_l0
100
0
100
75
0
100
67
100
i
3.51
Majority of the private hospitals and nursing home laboratories-are not standardised
and' none of them are participating in standardisation programme accreditated to
the 'National Bard of Accreditation of Laboratories'.
3.52
There is thus an urgent need to set up minimum standards for hospitals and
nursing homes of varying capacities and classified as primary, secondary and
tertiary.
3.53
Currently, there are no permissions
|
from any government authority required to setup nursing homes. As a result, there has beeni a proliferation of poorly planned and
ill-equipped nursing homes.
r
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Strictly Confidential
Roic of mt van- s ■■'
• health Care: Quality S Access
Patient Perception on Services Availability
reviewed in terms of the
The patient perception on services availability
following :
3.54
♦
♦
♦
♦
Extent of investigations conducted
ORD facilities such as
♦ Physical Space
♦ Drinking water
♦ Seating arrangements'
♦ Fan & Ventilation
♦ Toilet
In-patient facilities such as water, power and security
Equipment Availability
Extent ofInvestigations conducted
Investigations, normally conducted to confirm diagnosis, have become more or less
a routine matter in most hospitals/nursing homes. The patient perception with
regard to the extent of investigations conducted, elicited the response as indicated
in exhibit 3.2
3.55
Exhibit 3.2: Patient Perception on Extent of Investigations Conducted
The most common investigation done for the in-patients was Blood (70%) and
Radiological -X-Ray (62%), C.T Scan (12%) etc. A sample detailed exit proforma
3.56
None
11%
More than
sufficient
49%
Low
34%
Fairly enough
6%
was conducted for around 13 patients to determine investigations conducted
against specific illness/symptoms. Table 3.7 presents a summary of the responses
received.
AFF-MCS
17
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Strictly Confidential,
Privgtc $,r!c - - Health Care: QudHtv & Acce^
Table 3.7: Illness Specific Investigations conducted
_______ Illness/Symptom
Hernia - Swelling in groin
Appendicitis
Investigations_________
Blood, Urine. CxR etc
i U.S Abdomen, Routine Blood and
■ Urine
Lower Respiratory Liactxerfection, | Chest X-ray, PA view, Routine Blood
cough, expectoration, fever
and Urine analysis
__ ______
Intestinal
Perforation,
Pain
in Urine, Blood, Chest X-ray
abdomen, Fever
Amenorrhea in labour
US scanning of Abdomen
Congestive
cardiac
failure,
breathlessness,
cough
and
expectoration
Pregnancy________________
Acute Gastritis - Pain in abdomen
Fever for evaluation
Chest X-ray PA, Routine Blood and
Urine
Blood, Urine, USG, CxR
Endoscopy
Blood, urine CxR etc
OPD Facilities
3.57
1
se^ce'"^Xri^TeSol) o? ihTSpond^ntT(specificallyThose“SinTeSnicXf
that there was a reasonably good space in the OPD while around 27 % (mostly
constituting of hospital patients) felt that the OPDs were quite spacious.
3.58
of the view that these facilities were fairly sufficient. Table 3.8 presents the
responses with regard to the above.
H
Table 3.8 : Extent of OPD facilities
Response
Less____________
Fairly sufficient
More than sufficient
r
3.59
Drinking
water
31%
53%
15%
Seating
i Fan and
Arrangement Ventilation
21% ' _______ 20%
60% i
______
64%'
18% '
15%
Toilet
26%
56%
17%
tXXwaX.15 <'80%’ °f ‘he flyU,VediC toSPtelS f°U"d the 0PD
In-Patient facilities
3.60
SS*"6 felt that in-patient faci"ty such “
power end security
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Stfictly Confidential
C
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ScctQ- m Health Care' Oud/itv 8- Acceo:
Equipment A vailability
3.61
The exit proformas addressed the query of to what extent the respondent felt that
the hospital was well equipped. Around 41% of the respondents were not able to
comment on the same while 35 % felt that the hospital was well equipped.
However, this observation cannot be considered, as most patients are not qualified
to judge the extent of equipment availability in the hospitals.
Comparative review of private sector with public sector (as perceived by
the patients)
3.62
The exit proformas addressed the various reasons for visiting the private sector for
treatment vis-a-vis the public sector.
3.63
Majority of the patients visited the private sector as they were either satisfied with
the service or they distinctly preferred a private hospital over the government
hospital. This is represented in Exhibit 3.3
3.64
Specific responses were elicited from a certain section of patients on their choice of
Near to residence
26%
Satisfied with care
56%
Prefers Pvt. Sector
18%
hospital if both the private hospital as well as the government hospital were close to
one another. All of the respondents preferred the private hospitals and the reasons
for choice are :
♦
♦
♦
♦
Promptness of service
Reliability
Quality care
Better services
Overall Rating of Private Sector (As perceived by the patients)
AFF-MCS
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Strictly Confidential
1I'iivate Secto'm He.:
Care: Quality & Access
3.65
As discussed in the previous paragraph!., majority of tne parents are quite satisfies
with the quality of service and level of care offered by the Private sector
hospitals/health care units. The overall rating of the private sector as perceived by
the patients is depicted in the chart below :
3.66
The patients visiting ayurvedic hospital have rated the hospital to be average/poor.
Exhibit 3.4: Overall Private Health Care Centre
Rating
Poor.
Excellent
11%
Average
22%
j,;;
Good
64%
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Strictly Configentid!
—1Sector m Health Care: Quality & Acces.1
.
4. Access to Health Care
4.1
This chapter presents the accessibility' of health care services to poorer sections of
the society both in terms of Physical and Social Access
Physical Access
4.2
Physical Access has been assessed by the following
♦
♦
♦
♦
Availability of Hospitals
Availability of beds in the districts
Distribution of treatment of Out-patients and In-patients over source of
treatment
Physical distance traveled to reach hospital
Means of transportation used to reach hospital
Availability of Hospitals
d
4.3
According to a sun/ey conducted in 1995-96 by the Centre for Symbiosis of
Technology, Environment and Management (STEM), Bangalore, there were in
1995-96, 2,624 public hospitals (hospitals, community health centres, primary
health centres and primary health units) and 1709 private hospitals (clinics nursinq
homes and hospitals).
4.4
Thus, the number of public health sector units is only slightly higher than that of
private health institutions. In terms of number of patients treated also the role of
private health sector is increasing (this is presented below in section distribution of
patients over sources of treatment).
4.5
The Exhibit 4.1 presents district-wise distribution of Public and Private Hospitals in
Karnataka
1
11
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AFF-MCS
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i-oie . '
Strict'^ Confidently!
\
(S Access
Exhibit 4.1:
Muter of FWic and Rivate Fbspttafe in Karnak by Dstrict
r-E£^T;»sa]
■■
5"
.Af. .
Tinfar
F&dir
K
K/bb/a
Kccbgj BBEHHE®
E FUjichbsprtds
C Riv^eFteptds
o
w
"A
Q
Cd^ire Karafa
ZK
]
vinscca]
Gikmadir I
ft • •
-H
• r.r E^aMHEzzanl
-18.
0
33
100
153
200
250
300
390
433
400
Mrrter of Ftefital
Source: Health Care Facilities in Non-Government Sector in Karnataka, STEM, 1996
Availability of Beds
4.6
The number of beds in the private sector in Karnataka is 40,900 compared to
43, 868 beds in public sector hospitals. A vast majority of private sector hospitals
provide curative health care, while public sector hospitals promotive, preventive and
curative services in rural areas and only curative services in urban areas. Thus, with
the population of 44806468 (Census 1991), this translates into a mere 1.89 beds
per thousand of population.
r
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Strictly Confidential
6 Access
Exhibit 4.2:
Source: Health Care Facilities in Non-Gove: : ,-
Public and Private Hosp:;; Beds in Karnataka by District
Utara Kamada
t
Tumkir
X-C. -■ jccy
Shirroga
Rai chur
Mysore
Mandya
Kodagu ■SffiK30
Hassan
I
0 ^ublic Hospita' Beds
Gulbarga
i
T. ^nvaie Hospital Beds
■
....
Changed
7334-----
Dakshina Kamada
Chitraduga
:
1
Chikmaglir
Bijapir
Bidar
>1
■MB
Bellary
Bel gaum
Bangalore (R) hOMO
Bangalore (U)
ggg—EMe“~-; ■‘--SE.t,
r
0
2000
4000
6000
8??<
L
10000
12000
14000
16000
18000
Number o' Hospital Bed
L
Bed Capacity at Ayurvedic Hospital
r
^•7
The Ayurvedic Hospital covered har . bed capacity of 325 beds in the general ward
snd25 beds in the semi-private ward., with a n average occupancy rate of 30-40%
Distribution of Treatment of Out-Patier ts over Sources of treatment
4.8
r
Only 27% of the OPD patients
oatients ir w. cn areas of Karnataka get their treatment at
Public Hospital Centre. Majority c
(43.19%)-gets their treatment from private
doctors and 22% of them from
. .•< hospital in urban areas and similar trends
are seen in rural areas. The detail.
m table 4.1
Table 4.1: Percentage Di: . : .non of Out-patient treatment
L
over Son ..
W Treatment
<
AFF-MCS
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Strictly Confoentidi
:. ar al %
Type of He .-.pi tai
Urbanc
i
~25.72
Public Hosp::s
8.47
Primary Heel?' Centre i
_J_.
Public Dispense-v
_Y.'23
1.27
22.07
18.48
Private hospita______
Nursing Home_______
__ l_.01
1.16
0.17
Charitable Hussda;
0.24
1.36___
(ESI) Doctor_________
0.94
Private Doctor_______
43J9 __ 41.51
2.28
Others____________ I
Total______________ |
100.00
100.00
Source:Gol, CSO, -i2 r^jnc of National S:-i/]ipie Survey Na. 364
Distribution of Treatment of In-Patients over Sources of treatment
4.9
There is almost equal dis-rbucion of In-patiems treatment in public and Private
sector in Karnataka Urban areas and whereas... in rural areas 60% get their
treatment in public hospita and primary healm centre and the balance 40% in
private sector. The detailed break-up is presented in table 4.2
Table 4.2: Percentage Distribution of In-patient treatment
over Sources of Treatment
Type of Hospital
Urban % Rural %
Public Hospita!______
48.51
55.31
Primary Health Centre
0.39
2.71
Private hospital______
32.94
40,49
Charitable Hospital run
1.26
2.59
by Public Trust______
Nursing Homes______
9.06
5.62
Others____________
0.29
0.91
Total_____________
100.00
100.00
Source.'GoI, CSO, 42 round of National Samplt ■ Survey No. 364
i
Distance Traveled to Reach Hospital
4.10
One of the most important means of assessing physical access of healthcare
services is to identify the distance traveled by patients to reach hospitals.
4.10.1 Hospitals: The primary survey reveals that more than 70% of OPD patients across
categories use hospital within 10 kilometres of distance from their home. A very
noticeable difference is that, in Urban Government hospital as much as 60% of the
patients come from a distance of more than 10 kms.
4.10.2 There is no particular noticeable difference in accessibility in urban and rural areas
in private hospitals. This is necause many oationts in rural hospitals are also from
neighboring villages. Table 4.3 gives details of the accessibility
AFF-MCS
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Strictly Confioen'ial
Cc
Quality S Access
Table 4.3: Physical Accessibility by Distance Traveled
Average
Distance
from
Residence
to Hospital
< 3 km.
3-10 km.
>10 km
Corporate
A
B
Percentage of Patients Visited
Trust
j Teaching
Missionary
B
I
A
[~B
~A
I B
N.H*
Avg.
Govt.*
A
[B
_____ I
Urban Urban urban Urban |Urban Rural Urban iRural
___ 20
N.A ___ 20 __20i
20 ___ 20
—60l 70
___ 50 __ N.A~ ___ 55 ___ 30:
60 ___ 60
20:
20
20'
30
n.a'
251
4Q:
20
20j 10
—r
~~
r
Urban Rural
30 ____ 15 ___ 50
50 ____25 ___ 30
20
60
20
Source: Survey
*Only Representative cases of surveyed Govt Hospitals and Nursing Homes is presented.
4.10.3 Practitioners: A general trend that is visible is that more than 75% of the patients
visiting General Physicians are rrom the radius of less than 3 kms from clinic and
another 20-25% from 3 to 10 kms radius. In case of specialists the percentage of
patients who came from the radius of p kms from clinic were in the range of 3060% (with an average of 42%) and those from a radius of 3 to 10 kms was about
30-45%.
Exit Proforma Findings: The exit proforma survey reveals that
-4.10.4
t.xv.-t cail rrurorma rmaings: me exit prororma survey reveals that a lot of patients
(38%) travel even upto 10 km to reach the private hospital. However, around 53%
of the patients reside within a radii of 5 km from the hospital.
4.10.5 In the Ayurvedic Hospital around 60% of the patients travel
,
u
.
----------- 1 more than 10 kms to
reach the hospital while 30% reside within the range of 3-10 kms.
1
Means of Transportation Used to Reach Hospital
4.11
f -
Except in case of Corporate Hospitals, Majority (50-80%) of the patients visiting
other hospitals reaches by walking or public transport. Use of public buses to reach
hospitals is greatest in Government hospitals and teaching hospitals. Whereas in
Missionary and teaching (in that order),hospitals patients walking to reach hospitals
is also common.
Table 4.4: Means of transportation used by patients to reach hospital
Means of Transportation
Percentage of Patients Visited*
Corporate I Trust I Teaching Missionaty~
N.H_ Govt.
65|
251 io
io
Own Vehicle
20 ____ 9
5i
SO?
40
Bus ______
30 ___53
10
------- ---™------------- _______________
Auto/Taxi
2-V_
10
10
20 ___ 17
Walk
2U!
’ 40
70
30
21
r
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221
j
Source: Survey
*Only Representative cases/cases in which intormatio- was provided is presented.
rT
AFF-MCS
1
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Strictly Confidentidi
Role cf f^ivdic
JotiR' 6 Access
4.12
Exit Proformc Findings:
transport (bus service.
two-wheeler
vehicle are the common modes of transportation fc/o.voc by the patients
constituting 37% and 53 % respectively, of the total respondents.
4.13
In ayurvedic hospital, Majority of the patients (70%) use- bus as the mode of
transport to reach the hospital.
Social Access
4.14
The Social Access was examined from the view point of
♦
♦
♦
♦
♦
♦
Sex-wise distribution of patients across hospitals
Age-wise distribution of patients across hospitals
Income group profile of patients
Payments Category
Treatment of Low income group patients at Hospitals
Cost of treatment as perceived by patients
Sex-wise Distribution of Patients across Hospitals
4.15
No significant difference in treatment of male or female patients is noticed across
categories of hospitals. However, except in case of missionary hospitals, the
percentage of male patients treated is a little higher than female patients.
Table 4.5: Sex-wise classification of Patients Treated across Categories of Hospitals
Percentage of Patients Visited______
Sex
Corporate
Trust
Teaching Missionaryj N.H Govt. Avg.
A
B
A
B
A
B
A
B | Avg.
A
B
Urban Urban Urban Urban Urban Rural Urban Rural |
Urban Rural
Male
___ 60 ___ 55 ___ 50'___ 50 ___ 60 __ 60 ___ 49
401 57 ___ 57 __ 54
Female
40
45
50
50
40
40
51
60; 43
43
46
----- 1----Source: Survey
4.16
In the ayurvedic hospital, majority (80%) are male patients.
Age-wise Distribution of Patients across Hospitals
4.17
About 50% to 80% of the patients across categories of private hospitals are from
the age group 12 years to 50 years. But there is no significant noticeable difference
in access of patients of different age groups in rural or urban areas to treatment
facilities in private sector vis-a-vis public sector.
?
AFF-MCS
26
f
Strictly Confidential
/iQA. ■l'/<’ Health Core: Ouolitv S Access
Table 4.6: Age-wise classification of patients across categories of hospitals
Age Group
Profile
<12 yrs
T2-35 Yrs
36 -50 Yrs.
50 yrs.
Percentage of Total Patients Visited
Trust
Teaching Missionary N.H
A
B
A__
B
A
B
Avg.
Urban: Urban Urban Urban’ Urban Rural Urban Rural
_____________
Corporate
A | B
10;
Toj
40
3
lo Jo
20
20
30
30
__ 40j
30 _^0!
201
30
I
20
30
30
20
10
To
60
20
15
44
22
19
10
To
60
20
9
26
35
30
Govt.
A
Urban
20
TT
30
30
B
Rural
30
20
20
30
Source: Survey
4.18
In the ayurvedic hospital, there is an equal distribution of patients (30%) across
the age group oth?- than less than 12 years, which constitutes 10% of the total
patients.
Income Group Profile of Patients Hospitals
.1
4.19
The corporate hospitals had 60-90% of the patients from the upper middle income
group and high-income group.
4.20
In case of trust hospitals, only 20% of the patients were from the lower middle and
low income groups. dO-50% of the patients were from middle income orouDs (Rs
3000-5000 p.m.).
k
4.21
Teaching hospitals had the maximum percentage (80-85%) of patients from the
lower middle income and low-income groups.
4.22
Missionary hospital also had 60% of patients from lower middle and low-income
groups. Both the missionary hospitals visited get a lot of donations and grants from
India and abroad for charitable purposes and are hence able to provide free and
concessional treatment to majority of patients who cannot afford the cost of
treatment.
»
4.23
The nursing homes mainly cater to the middle income and upper middle income
group, who form 75% of the total patients treated.
f
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Strictly Confidential
Table 4.7: Inc
■ c-file of patients across Hospitals
Income Groups
Corpora
A
E
Urban] Ur w
High Income Group
(>Rs. 10000 p.m.)
Upper Middle Income
Group (5000-10000 p.m.)
Middle Income Group
(3000-5000 p.m.)
Lower Middle Income
Group (Rs.600-3000 p.m)
Low Income Group (<600
p.m.)
401
________ Total
Source: Survey
4.24
; .-• ■■, 0^0/'tv S Access
y privpie Sector m
’1
• ercentage of Total Patients V i si ted
Trust___ Teaching Missionary N.H
Govt.
B
A
B ~A | B Avg.
A
B
JI Urban Urban Rural Urban Rural
Urban Rural
20
5
N.A
10 12.5
5
5
•°i
50
20
30
10;
23
30
20
I
100
1C<
Over 60% of the patic
income and lower income :
income group.
00
5
N.A
15
50
10
10
20
5
n.a'
15
25
30
15
10
70
80
N.A
30
7.5
25
20
10
10
5
N.A
30
5
30
50
100
100
100
N.A
100 100
100
100
•0 ayurvedic hospital are from the lower middle
while only 10% of the patients are from the high
Payment Category
4.25
Most of the patients in A
diagnostic tests and treair
concessions, usually in the w
: orate hospital are fully charged for consultancy,
A very minimal percentage of them are provided
;. of 10 to 30%.
4.26
In hospitals run by trusts .
religious communities, pro . :
50 to 60% of patients were :
was a mixed trend. A few of them, those run by
•ree treatment to about 20% of patients and about
ided treatment at concessional costs.
4.27
Teaching hospitals also pro-, . free and concessional treatment to about 50% of
the patients but the purpose • seating free/at concessional rates poor patients is
to use them as clinical tear-/- : ;.?.ses for medical students.
1
4.28
Missionary Hospitals get sor : ■ :ial amount of their funding in the form of grants
and donations from India a-. . iroad for treating the poor patients. They are thus
able to provide free and con:
onal treatment to majority (70%) of their patients.
4.29
Nursing homes usually run
middle class and usually
provided any form of free :
AFF-MCS
•idividuals, cater to mainly middle class and upper
m in full for treatment. A very few of them are
■jssional treatment.
28
f
Strictly
.-
O^lit]' S Access
Table 4.8: F-Tyment Category o! Patients across
Percentage of Total Patients Visited
Payment Category (%) Corporate Trust Teaching |Missionary JN.H.
Consultant__________
Full Charges_______
100
30:
501
nT
50
Qi
90
Concessional Charges _______ 0
70
30
10
Free____________
o
100 ’
20
0
Diagnostic Tests______
Full Charges_______
90
3?r
50
20
70
Concessional Charges
60:'
10
30
30
20
Free_____________
0
10
20
50
10
Treatment___________
Full Charges________
9030:
50
30
80
Concessional Charges
10
50 j
30
70
10
Free ______
0!
20i
20
0
10
Source: Survey
*Only Representative cascs/cases in which informatio:: v.-as provided is presen:ed.
—ot
4.30
From our discussions with various doctors, patients, hospitals and diagnostic
centres, there appears to be a widespread nexus between the various hospitals,
nurs.ng homes, diagnostic centres, specialists and family physicians in ordering
unnecessary investigations, treatment in order to share the fees among themselves.
Treatment of Low income Group Patients
4.31 83% of the private hospitals and nursing nomes charged low-income groups
(income less than 600 p.m.). However, 75% of hospitals and nursing homes
provided concessions in fees in treating these patients. The concessions ranged
from 15% to near about 100%. 92% of the hospitals made referrals to other
hospitals. Referrals were usually made for patients requiring super-speciality care
25 percent of the hospitals always ordered investigations'for patients and also
charged interpretation fees. None of the hospitals had any follow-up procedure.
25% of them (both the corporate hospitals and a nursing home) considered it as a
sole responsibility of Government to provide free treatment to the low-income oroun
patients.
L k
.1
L
4.32
The ayurvedic hospital, being a government hospital, offered free treatment to their
patients. None of the patients were corporate patients.
r
Cost of Treatment as Perceived by the patients
4.33
The cost of treatment as percieved by the patients were
reviewed through
were reviewed
through the
the exit
exit
oHbecha Whereiri thS patients were queried on the reasonability and affordability
4.34
Majority of the OPD patients (~58%) were of the view that the charges were
reasonable while around 30 % felt that they were a bit high. Similarly around 76 %
of the in-patients felt that the charges w-ere reasonable while around 19% felt that
they were high.
r
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AFF-MCS
29
Strictly Confident,? ‘
'w-'. St>ctO’ ir Hcciltf Zd-e: Oudhty S Access
A.35
Almost al! the paiionts met tnc
marges on their own. A fevv of them
borrowed funds from friends and reim /es. A cross section of patients were queried
on their affordability of these expenses and a majority of them (62%) felt that the
medical care expenses constituted upto 5 % of their income. However, a sizable
number (31%) also were of the view that the said expenses constituted more than
20 % of their income.
4.36
A sample exit survey was conducted covering patients visiting private health centres
to determine the various chrages for treatment. Table 4.9 presents a summary of
various charges incurred by the patients.
Table 4.9: Summary of Charges incurred by Patients
Private
Health
Centre
Teaching Hospital
Nursing Home
Corporate Hospital
Nursing Home
Nursing Home
Nursing Home
Teaching Hosptial
Teaching Hospital
4.37
Consultation Diagnostic ' Treatment
Charges_____ I?sts
250
750_
; 3000
150
_
_400_
tsoo
loop
2 Jpoq
500
300
4500
450
600
' 500
_ _300_
" 1200
250
”
450
^4000
I 400
I 600
5000
~ 1000
! 1000
Drugs
400
300
1000
200
400
1500
500
650
The Ayurvedic patients availed of free in-patient treatment at the hospital covered.
Hence, while the in-patient charges were considered reasonable, most patients
were of the view that external procurement of drugs is as expensive as the
allopathic medicines.
5. Accreditation
5.1
This chapter presents the primary survey findings in regard to willingness of private
sector for accreditation.
Accreditation
5.2
Accreditation is a professional and national recognition reserved for facilities that
provide high quality of care (Lewis, 1984). It is the process by which an agency or
organization evaluates and recognizes a program of study or an institution as
meeting certain pre-determined standards. Accreditation is usually granted for the
purpose of assuring th public of the quality of institutions. The concept of
accreditation exists in many countries. This is now also being applied to Health Care
organizations.
Need for Accreditation
5.3
In Karnataka, and in rest of India as well, the private sector is more dominant than
public sector. In fact about 70-S0°v of the total health care expenditure is from the
private sector. With increase in demand for health care, the private sector has been
growing at a very fast pace offering ei wide range of facilities and services. The legal
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regulations have not been effectively implemented to ensure a proper regulated
growth.
5.4
There is also a wide variation in their range and quality of sen/ices provided.
Presently there exists no appropriate mechanism of reliable information regarding
quality of care. There also exists no adequate system of certification for the private
organizations. There are no timely reviews undertaken to ensure that the standards
are maintained.
5.5
Though, some private hospitals do carry out Medical Audit internally occasionally
but do not share this information to the public or to the peer group. The
performance data on these hospitals are termed "Confidential documents" by the
concerned hospital management. Data for the hospitals under study was not
available and also not forthcoming especially on the number of re-admissions,
repeat operations, hospital acquired infection, blood utilisation, tissues removed etc.
There are also cases of nursing homes which do not even maintain any medical
records nor’do they have any medical audit.
5.6
There is thus, an urgent need for an agency to set standards, ensure that the
standards are met and maintained, and also provide information to public to judge
the quality of care provided.
Willingness of Private Sector to Accreditation:
5.7
The following are the results of responses received from 255 respondents. The
details of the respondents have been provided in chapter 2.
Need Felt for Accreditation Body
5.8
88% of the respondents felt that there was a need for an accreditation body which
should lay down standards and grade hospitals. The break-up is presented in table
Table 5.1: Need felt for Accreditation Body
Need for Accreditation Body
No Need for Accreditation
Body________________
Undecided
j
88
8
4
Role of Accreditation Body
5.9
Majority of respondents wanted the accreditation body to set standards, upgrade
standards, assess hospitals for compliance of standards, certify quality and provide
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education and infornnation on best practices etc. Details of responses are presented
in table 5.2.
Table 5.2: Role of Accreditation Body
Assess Hospitals for Compliance of Standards
Assist in Upgrading Standards____________
Assist in Certifying - Quality Assurance_____
Educative & Informative Role_____________
Serve as Forum for Consumer Redressal
Take Punitive Action Against Hospitals
86
88
88
78
30
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Aspects to be monitored by Accreditation Body
5.10
Majority of the respondents wanted accreditation body to monitor physical aspects,
equipment, quality and number of personnel, type of treatment, follow-up of care,
patient satisfaction. Only 42% favored monitoring of professional fees charged by
doctors. The details are presented in table 5.3
Table 5.3: Aspects to be monitored by Accreditation Body
Physical Aspects_____________
Equipment_________________
Quality and Number of Personnel
Type of Treatment___________
Follow-up of Care____________
Patient Satisfaction___________
Professional Fees Charges
96
95
95
88
80
80
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Benefits Envisaged
5.11
Majority of respondents felt that setting up an accreditation body would help in
improving standards, aid in certifying quality and help in comparison of performance
vis-a-vis other hospitals. About half of them felt that it would also serve as an useful
marketing tool, regulate and manage competition among hospitals and create a
level playing field among hospitals.
Table 5.4: Benefits Envisaged from Setting-up an Accreditation Body
[Help in Improving Standards
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Aid in Certifying- Quality Assurance
Comparison of Performance vis-a-vis
other Hospitals____________ _____
Useful Marketing Tool
_________
Regulate & Manage Competition Among
Hospitals___________________
Create Level Playing Field Among
Hospitals
5.12
86
62'
52
48
46
We feel that an accreditation body would also help in
♦ Assisting organizations in improving their quality of care
♦ May be used to meet certain Medicare certification requirements
♦ Enhancing community confidence
♦ Providing a staff education tool
♦ Assisting organizations to fulfil state licensure requirements
♦ Enhancing access to managed care contracts
♦ Favorably influencing bonds rating and access to financial markets
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Willingness to Participate in Accreditation Process
Majority (88%) of the respondents was willing to participate as soon as the
Accreditation Body. They (92% of respondents) felt there was an urgent need for
grading and classification of existing hospitals. They wanted that the body to initially
give them an opportunity for self-evaluation and then finally assess compliance by
way of an external assessment.
5.13
Organization of Accreditation Body
Independent, self-regulatory, non-profit body: In the discussions with
respondents regarding the organization of the body, the respondents were of the
view that the accreditation body should be an independent body without any
Governmental/political interference. The body should have its own guidelines/code
of governance i.e., it should be self-regulatory. It also has to be a non-profit body
managed by professional experts.
5.14
5.14.1 The body should not bring an other sort of 'license raj'. It should have total
transparency in its process of accreditation.
Responses of General Physicians/Specialists
5.15
94% of the respondents (General physicians and Specialists) felt that there was a
need for accreditation body, while only 6% felt that there wasn't any need for such
body. Majority (90%) was willing to participate as soon as it was set-up.
5.16
The accreditation body should be an external independent non-profit body without
governmental interference.
5.17
The body's main role should be to lay down standards especially the minimum
standards that are required to be fulfilled. It should mainly monitor the physical
standards and process factors in case of General Physicians and specialists,
5.18
Majority (90%) was of the view that professional fees and charges should not be
monitored.
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Proposed Accreditation Body for Hospitals
5.19
We propose the framework of a workable accreditation body for hospitals. We
would like to mention that this framework is by no means a blueprint but only the
broad sketch of an idea. Various factors affecting the stakeholders as well as the
existing social, political and economic ground realities need to be taken into account
while implementing it. Much would depend on the involvement and initiative of the
stakeholders. The accreditation system itself should be an outcome of discussions
and debates on issues of concern among all the stakeholders. Collaboration,
transparency between related parties and open communication are the hallmarks of
the system whose framework we are proposing. Only then would it be meaningful
and viable.
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Objectives of the Accreditation Booy:
5.20
The objectives of the Accreditation Body should be to
♦
XXdo" h0SPita,S “mp,y
standards a"d
reason to
♦
♦
Upgrade standards in the light of a changing health
care environment
Assist hospitals to upgrade their standards
♦ Play an educative, consultative and informative i„
role
♦ Act as a bridge between the various stakeholders
• 3 and provide a platform for
continued dialogue.
Constitution of The Body:
5.21
The establishment of such a '
a body calls for representatives from the various
stakeholders involved in health c.
are delivery. This is necessary in order to make
the system acceptable to all and
J to ensure its creditability from the start The
specific groups that we have identified are as follows:
♦
Representatives from the hospital owners
Representatives from specialists' associations
♦ Representatives from professional associations
♦ Representatives from consumer organisations
♦ Representatives from Non Governmental Organisations (NGO)
♦ Representatives from the state government
♦
5.22
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This would further establish the creditability of tte body.
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Status and Structure:
5.23
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We see the accreditation body r: :
as a non-profit, registered and autonomous entity. At
a later stage, when the body has achieved
_ _J stability and creditability, legislative
support could be sought.
i
5.24
s
We visualize the body with a Governing Board at its helm. It would be a statutory
entity entrusted with the responsibility of managing the body ‘ It would be a fined
au honty in decision making and an arbitrator of major issues
wouW frame
policies intended to develop the system and fulfil its stated objectives evolvinq a
consensus would be the principle guiding all decisions. When seTuTXences of
opinion occur, however, the majority would have to decide. The Governing Body
would have to meet at least four times in a year.
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5.25
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The Board would comprise of nominees of representative associations and
organisations as well as government and other stakeholders. In its composition it
should allow each of the stakeholders to be equally represented. This would
prevent the Board from being monopolised - and overtaken - by dominant
stakeholders. The composition of the Board could be changed every two years with
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a fresh set of nominations. Totally, there would be 7 to 9 members. A Chairperson
and a Secretary' elected by this group would have tenures of two years each.
5.26
The composition of the Governing Board could be comprised of the following
members, with one representative each from
hospital owners' association
♦ medical association
♦ two specialists' associations
♦ the nurses' association
♦ consumer organisations •
♦ NGOs
♦ state government
♦
Functioning:
5.27
The main function of the body would be to assess whether hospitals comply with
set standards, to assist them to upgrade their standards and to play an educative
and informative role.
5.28
To carry out these functions in an efficient and effective manner, staff needs to be
employed. The staff could work either full time or part time depending on the
availability of finances. There would be a Director assisted in turn by four Assistant
Directors in charge of handling specific aspects of functioning of the accreditation
system.
In other words, the four Assistant Directors would be individually
responsible for the Assessment Division, the Educational Division, the Marketing and
the Administration Division. The number of staff assigned to each division would be
dependent on the nature of work. Each division would be responsible for the work
in its own area.
5.29
This would be the constitution of the Executive Body. The Executive Body would be
accountable and answerable to the Governing Board. It would be entrusted with
the responsibility of implementing the decisions of the Governing Board.
Assessment division
»
5.30
This division would evaluate the compliance of hospitals. Two methods would be
employed to assess compliance: self-evaluation by the participating hospital
followed by an external assessment. Reconsideration of assessment findings would
also be handled by this division but with a different team of assessors. Different
assessment teams would assist this division. A team would consist of two post
graduate doctors, one health administrator and one health specialist. The assessors
could work full time or part time, depending on the finances, but would need to
undergo training in the method of assessment.
5.31
Standards with regard to physical aspects, equipment, qualification, number of
personnel employed or attached, type of treatment and follow up of care would
have to be assessed. The body should not only set minimum standards but also
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periodically review the same, considering the changing environment and the
existing ground realities in which the consumer and provider co-exist.
5.32
One area of prime concern that the accreditation body should include in their
assessment is consumer satisfaction. It is necessary to develop a framework or
guidelines to measure consumer satisfaction in a scientific manner. The fees
charged by the hospitals needs to be examined and linked to the size of the hospital
and the kind of services and facilities that are available. Most importantly, the
needs of the provider and consumer need to be balanced.
Initially' the
accreditation body could start monitoring physical standards but then gradually
move on to process and outcome standards. A handbook for hospital standards
depending on the size, kind of service and facility offered should be developed'
This, in turn, would assist in the process of accreditation.
Educational division
5.33
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Marketing division
5.34
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The accreditation body would assist hospitals to upgrade standards. They would be
aided in this by a group of experts from various concerned with hospital
management. A participating hospital wanting to upgrade its standards could avail
of the services of this committee. The focus would be on educating and providing
information to the interested hospitals. Furthermore, it would hold regular
workshops, training sessions and seminars in fulfillment of the objectives of the
accreditation body. It would also assist in disclosing the assessment findings to the
public at large. Disseminating the list of accredited hospitals could be one way of
doing this. This information would be educative for the providers and informative
for the user.
This division would lie at the interface of the accreditation ibody and society.
Among other things, it would be involved in public relations, advertising,, consumer
education and creating awareness among the stakeholders.
Administration division
5.35
T
It would be responsible for general administration, which would encompass
finances, human resources, operations,'documentation and legalities
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Pre-Survey
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The hospital first submits and application to the accreditation body together with
fees for survey.
5.37
The Assessment Division determines the appropriate standards for the participating
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5.38
The Assessment Division provides self-evaluation schedules, forms, scoring
guidelines etc. to the hospital and collects them after they have been completed by
the hospital.
5.39
The Assessment Division analyses the self-evaluation schedules and forms filled and
returned by the participating hospital.
5.40
The Assessment Division co-ordinates the assessment schedule and procedure or
protocols to be followed. This includes setting the survey dates, assigning an
assessment team, the length of the assessment and setting the survey agenda with
the hospital.
On-Site Survey
5.41
The assessment team gathers information by observing structures and processes in
the hospital during visits to different units and departments, while on a tour of the
building and by interviewing patients, the hospital owner or administrator, the
clinical and support and, -finally, by reviewing records and documents.
5.42
The team uses the information thus gathered to determine whether the hospital is
complying with standards for various functions. These functions could be patient
focused (for example, assessment of patients), organisation focused (for example,
organisational performance improvement) or structure-and-function focused (for
example, procurement of appropriate equipment and its maintenance)
5.43
The team identifies the areas of partial or non-compliance with standards.
5.44
The findings from the surveyors in the team are integrated into a single report.
5.45
The findings are reviewed and validated with the hospital owner or administrator.
Post-Survey
5.46
The self-evaluation of the hospital and the findings of the assessment team are
validated by comparing them to the scoring guidelines.
5.47
The accreditation status and the appropriate recommendations are determined
through a number of stages. These are :
5.48
The compliance findings are aggregated to generate an accreditation decision grid.
This is essential as hospitals offer different kinds of facilities. Moreover, each facility
would have an individual score of compliance to the set standards. If there is a
high score in one facility and not in the other, the total average for that hospital
would still be high. Would this then be truly reflective of the standard of that
hospital? A decision grid would provide flexibility in determining the final score such
that it would be as close to reality as possible.
5.49
The level of accreditation as minimum, optimum or excellent is determined. Also,
whenever necessary, recommendations are made.
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If indicated, the findings and final decision to be taken by the accreditation body is
reviewed.
5.51
5.52
Should a hospital challenge the accreditation findings or decision, an appeal may be
sent to the assessment division.
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Period of Assessment
5.53
The assessment could be done every two years.
Financing
5.54
During the initial period of three to five years, the accreditation body can depend on
grants, but the long-term objective would be to attain self-sufficiency. Corporate
houses insurance groups and various associations could be approached for funds.
The costs could also be reimbursed in part by the participating Hospital, which in
turn could be used for developing the system. The constitutive elements of the
system, namely the representative associations or organisations, could contribute to
a corpus fund. Thereafter, other incentives could gradually be offered to the
participating hospital to help expand the coverage of the accreditation body.
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HartlCipnuou.
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* 'm prev . nu <
6. Public-Private Partnerships
6.1
This chapter presents the private sector participation in public health programs,
need for health insurance for low-income group and scope and mechanisms for
public-private partnerships.
Public Health Programs
6.2
The Government has taken certain steps to combat communicable, noncommunicable and other major diseases which cause disability not only to improve
the health status of India's population but also to prevent and control disabilities.
For this purposes several National Health Programmes (NHP's) are carried out by
State with Central assistance.
Current Private Sector Participation in NHP's
•
Hospitals
6.3
Awareness about NHP's: All the hospitals and nursing homes visited were aware
of National health programs being conducted from time to time by Government.
However only 11% of them could right answers as to the exact number of such
programs.
6.4
Participation: 55% of the hospitals and nursing homes visited indicated their
participation in preventive programs. But their participation was more by way of
self-organized camps for treatment of poor people or participation in camps
organized by voluntary associations, IMA or pharmaceutical companies.
6.5
Major Responsibility for Such Programs: Almost all of them were of the view
that major responsibility for such programs was of the Government and the private
sector can only compliment the efforts of the Government by way of their
participation in such programs.
6.6
Envisaged Role in NHP's: None of them were clear as to the role they can play in
the success of NHP's. Most of them considered that they help by creating awareness
by way of participation in such programs and health camps, and health education
during OPD treatment.
6.7
Government Initiatives: Out of the hospitals and nursing homes visited, none of
them had any Government functionary visiting them for such programs or DHS
inviting them for CME/ training for these programs.
6.8
Government should encourage the private sector to adopt appropriate therapeutic
norms and regimens recommended by national health programs and provide
incentives to develop schemes to finance, train and integrate private providers in
case finding, diagnostics and treatment for priority health programs that are of
public health significance.
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Need for Insurance Cover
6.9
Our primary survey reveals.that currently 70-95% of patients (other than those
getting free treatment) across categories of hospitals pay directly (i.e., on their
own). The patients' availing insurance cover ranged from 0-4% across categories of
hospitals.
6.10
The millions of individuals paying out of pocket have limited leverage in the private
health care market. Moreover, the health insurance schemes in India are based on
an indemnity basis i.e., benefits in the form of cash payments rather than services.
An indemnity insurance contract usually defines the maximum amount that will be
paid for services. In most cases, after the provider of service has billed the patient
in the usual way, the insured person submits to the insurance company proof that
he/she has paid the necessary bills. He/she is then reimbursed by the company for
the amount of covered costs and makes up the difference him/herself. The
indemnity type of contracts accelerates expenditure growth and over-servicing and
also does not give enough leverage to influence the provider behavior. In contrast,
the aggregation and application of purchasing power in large-scale pre-payment
plans could have a powerful and positive influence on provider behavior particularly
in private sector.
Current Government Mandated Insurance Schemes
6.11
India has two main systems of publicly mandated contributory health insurance The Employees State Insurance Scheme (ESIS) and the Central Government Health
Scheme (CGHS) and other insurance policies are from Government owned GIC and
its subsidiaries.
6.12
ESIS: ESIS was initiated in 1948 and became operational in 1952. It applies to nonseasonal factories using power and employing 10 or more persons, as well as to
other establishments that do not use power but employ 20 or more people (several
state governments have extended the scope). The employees covered under this
scheme are those earning less than Rs. 6500 per month. Employers currently
contribute to ESIS an amount equal to 4.75 percent of the wages payable to
employees, while employees contribute 2.25 percent of their wages. Employees in
the lowest wage group (i.e., who earn average daily wages of up to Rs. 15 per day)
are not required to contribute their share with regard to such employees. State
governments contribute a minimum of 12.5 percent of the total ESIS medical care
in their respective states.
6.13
Though the scheme is extensive in its coverage, it has come under severe criticism
Ellis et al (1996) noted that "detailed patient surveys conducted in Gujarat found
that more than half of all survey respondents covered by ESIS did not seek care
from ESIS facilities for treatment". Another report by the center for Social Services
the Administrative Staff College of India (1996), was similarly critical noting
problems with "complex office procedures, abnormal delays in the settlement of
cases and lack of specialists services, non-availability of ambulance vans and low
quality, of medicines".
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CGHS: The Central Government Health Scheme was introduced in 1954. It covers
16 major cities and a large proportion of Central Government employees. The
central government heavily subsidizes the scheme. The employee's contribution
ranges from Rs. 15 to Rs. 150 per month depending upon salaries. Treatment can
be obtained at from more than 300 dispensaries, clinics, laboratories and dental
units. The CGHS scheme has been criticized for slow reimbursement and incomplete
coverage of private care.
Voluntary Private Insurance:
6.15
GIC Schemes: GIC's medical insurance consists of several levels of group and
individual coverage, collectively known by the brand name Mediclaim. In general,
Individual Mediclaim function on an indemnity basis, whereby the patient (or his
employer on his/her behalf) pays the provider and is subsequently reimbursed. The
individual Mediclaim has lengthy list of exclusions and does not cover "any existing
disease or illness of chronic nature". The policyholders expect large out-of-pocket
expenses in the event of a serious or chronic illness.
6.16
Group Mediclaim policies are available to any centrally administered group or
corporate body of more than 50 persons and are also extended to dependants.
Benefits are similar to to those contained in individual policies. Employees prefer
group Mediclaim policies to the ESIS because the former offers a choice of
providers. However, ESIS is mandatory for lower income employees and requires
lower premium contributions from employers. Thus, emloyers prefer ESIS to group
Mediclaim. They often use a combination of ESIS for those earning less than 6500
per month and group Mediclaim benefits for those earning more.
6.17
In late 1996, GIC introduced a low-premium scheme, Jana Arogya Bima, that
requires payment of Rs. 70 to Rs. 140 p.a. depending upon subscriber, with a
charge of Rs. 50 for each dependant child over the age of five. The low premiums
makes the scheme attractive for rural middle class and some urban residents who
fall outside the ESIS coverage. However, Jana Arogya Bima, payments are capped
at Rs. 5000 per insured person per annum. This makes the beneficiaries to still rely
on free care in public hospitals for any major illnesses.
Primary Survey Findings
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6.18
In our primary survey, All the respondents (hospitals, nursing homes and private
practitioners) replied in affirmative that there was a need for health insurance for
poor people.
6.19
As regards affordability of premiums by the poor people, 47% of them felt that they
would not be able to afford it, 13% of them were of the view that they would be
able to afford it if they are sure of the benefits, and the rest 40% of them were 'not
sure' as to affordability of premium.
6.20
All the respondents suggested group insurance. 7% of the respondents also
suggested individual insurance policy. By group insurance here it is meant that
insurance policy should be such that it provides for insurance cover for all the
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members of family. However, none of them were clear as to nature of the policy
and its functionality.
6.21
A sample exit survey was conducted to determine the extent of premium payable by
the cross section of society. The premium affordable ranged from Rs. 300 per year
(by the lower income group) to Rs. 500 per year (middle income group).
Public Private Partnerships
Need for Public Private Partnerships
6.22
Most of the state Governments in India are finding it difficult to expand their public
facilities to cater to the growing health care needs of their population. The
budgetary support to this sector is shrinking and currently most of it is used to
finance the recurring expenditure like salaries of employees. As a result, the non
salary component has reduced dramatically. The areas affected most are the
secondary and tertiary facilities and basic facilities in remote areas. Many state
Governments are hence, exploring the options of promotino public-private
partnerships (PPP's) in health sector.
6.23
The health needs of the community are changing fast. The number of deaths due to
non-communicable diseases has increased and are likely to increase
disproportionately in future. This health transition will place considerable demand
on the Government to expand and upgrade their facilities in curative and tertiary
areas to meet the health care requirements of population in coming years.
6.24
Recognizing the severity of financial crunch particularly in super speciality care, The
Government of India in its national Health Policy of 1982 had recommended
"...planned attention would also require to be devoted to the establishment of
centres equipped to provide speciality and super speciality services, through a well
dispersed network of centers, to ensure that the present and future requirements of
specialist treatment are adequately available within the country".
6.25
Currently in Karnataka, about 50% of the in-patients and 60-70% of the out
patients get their treatment form the private sector. Given the role of the private
sector in the state, there is a need to fqster PPP's to influence the growth of private
sector with public goals in mind.
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6.26
In general, the focus of public private collaborations has been on (Bhat, 1998)
Developing Strategies to utilise untapped resources and strengths of private
sector
♦ Enhance the capacity to meet growing health needs
♦ Reduce financial burden of Government expenditure in speciality and super
speciality care
♦ Reduce regional and geographical disparity in health care provision and
ensuring access
♦ Reaching to remote areas or targeting specific groups of population
♦ Improving efficiency through evolving new management structures.
♦
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Primary Survey Findings
6.27
All the respondents were willing to provide free or concessional treatment to low
income group patients and take part in National Health Programs, if adequate
support from Government was provided.
6.28
The support expected from Government was in terms of subsidies, grants, IT
exemptions, and Schemes from Central and State Governments for free drugs and
free vaccines. The table 6.1 provides the details
_________ Table 6.1: Support Required from Government
Subsidies____________________________
Grants___________
IT Exemption_________________________
Central State Schemes for drugs & Free Vaccines
80
67
50
50
Scope for PPP's
6.29
From our literature survey and efforts of other state governments in this regard, we
feel that the following areas could be explored for PPP's
6.29.1 Clinical Service Tie-ups: There could be tie-ups with regards to hiring out
services of doctors, management of PHC's, tertiary and high-tech curative care etc.
Some of the clinical service tie-ups efforts of other state Governments are listed
below
♦
♦
♦
When West-Bengal was facing problems with regard to manning of primary
health centres, it hired the services of private doctors on contract basis
under the supervision of Panchayat Samities.
In Gujarat SEWA-Rural was handed over the entire primary health care
services in entire district by the State Government. The Government was to
provide finance to entire PHC services in SEWA-Rural Project area. The
SEWA Rural had the responsibility of managing the PHC's (including the
freedom to recruit its own workers). SEWA-Rural was to fulfil the same
targets which the government set for time to time.
In Tamil Nadu Government took the initiative to invite industry to adopt a
local PHC, health sub-center or district hospital. The.industry was given
responsibility of building, maintaining and equipping facility and the
Government was to provide staff and medicine.
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6.29.2 Non-Clinical Areas of Tie-ups: The areas of non-clinical tie-ups could be many
like hiring out of ambulance facilities, Contracting out services of catering, laundry,
security etc. The states of Maharashtra, TaminNadu, and West-Bengal have initiated
such arrangements.
6.29.3 Technology Tie-ups: The technologies such as CT Scan, MRI are very expensive.
The Government can subsidize the investment or provide other incentives like
duty/tax exemptions and in return purchase the services for poor people.
6.29.4 IEC Training: Government can have tie-ups with private sector specialists for IEC
training, CME, updates for conducting regular training programs.
Mechanism for Collaboration
6.30
Joint Ventures: In JV, Government's contribution can be in the form of cost of
land and it can be treated as part of equity capital of the proposed organizations for
providing speciality and super specialty care. The Government contribution can be
in the range of 26% to 49%. In cases were cost of land is less than 26% of the
total share capital, the government can contribute additional resources to meet the
requirement. As a return on its equity capital, the facility should provide for free
care to certain percentage of ORD and IPD 'poor' patients. Care needs to be
exercised in choice of partner and clearly defining the 'poor' patients. Appropriate
mechanisms needs to be put in place to check that the free care is offered to
intended beneficiaries.
6.31
Subsidizing Inputs/Providing Fiscal Benefits: Another form of PPP could be in
the form of Government providing inputs to private party at subsidized rates and/or
fiscal exemptions. The Government of Rajasthan announced policy of providing land
at subsidized rates and also included other fiscal benefits to institutions interested in
setting up health facility. The quantum of facility depended upon whether the
facility was to be set-up in rural or urban areas The fiscal incentives that were
announced were
J
Exemption from payment of sales tax on purchases of medical equipment
plant and machinery
'
♦ Exemption from payment of pctroi on medical equipment, plants and
machinery whether imported from abroad or other state.
The one other form of incentive could be providing finances from banks and other
state financial institutions at subsidized rates.
♦
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6.32
Contracting-out Services: As has been stated earlier, there could PPP through
contracting out services both in clinical and non-clinical areas. Some of them are
♦
♦
♦
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♦
♦
Hiring services of doctors to man Primary health centres
Hiring vehicles for ambulance purposes
Contracting of services in the area of diet and catering, laundry security
IEC programs etc.
Contracting out high technology services like CT scan , MRI
Contracting out maintenance of equipment and facilities
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Precautions to be taken for a Successful PPP's
6.33
Before initiating PPP's the Government should come out with explicit policy
document which should be publicly available.
6.34
The implementing agency with in the government need to be decided - whether it
should the Directorate of Health or Urban development authority etc.
6.35
Before attempting a single window clearance, the committee in charge need to get
all the clearances from departments concerned like (Department of Health and
Family Welfare, Finance, Industry, Revenue etc.) to avoid delays and litigation after
the process is initiated. Some of the clearances required may be
♦
♦
♦
Amendments in Land Revenue Act
Exemption orders for offering Sales tax exemption etc
Other clearances from urban development authority etc.
6.36
A detailed brochure containing information and guidelines on selection process,
eligibility requirements, proposed form of participation etc need to be clearly stated
and provided to all prospective bidders.
6.37
All the incentives and conditions need to be clearly stated to the prospective bidders
for e.g., Incentives like subsidized rates at which land would be offered, the location
need to identified, any fiscal exemptions and incentives etc. also need to be clearly
finalized before the process is initiated and provided to all prospective bidders. Also,
Conditions like making the facility operational in a specified time-frame, free care to
poor, any price specifications need to be carefully detailed and finalized before the
process is initiated.
6.38
Finally, public support for the process needs to be ensured to avoid any sort of
litigation after the process is initiated.
6.39
MAPPING of the private sector is of utmost importance since there is no reliable
data on the same.
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Policy issues and policy measures for public private partnerships
Expanding hightech super
speciality services
Unintended
implications
Cost
Quality
*
Demand Inducement
Unethical practices
Geographic Distribution of
Facilities
Equity Access to
facilities
Financing of New
Investments
Cost
Quality
Utilization Patterns
Equity:
Access in terms of
ability to meet cost
Issues/ Concern
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policy measures
Protecting poor from
catastrophic financial burden
• Protecting and increasing
government budgetary allocation
to public sector
• Development of monitoring
mechanism and appropriate
regulations
• Rate regulation (change provider
payment system)
• Continuing medical education
programmes______________
• Regulatory interventions such as
• Licensing
• Creating health map
• Various types of incentives
• Drawing definite plan where
money should be spent
• Remote area subsidy programs
to allocate
______________
• Creating specialised financial
channels within the existing set
up of financial institutions to
provide funds to private health
care sector for financing their
new investments in appropriate
technologies after examining its
cost effectiveness_____________
• Developing appropriate financial
mechanisms
• Protecting poor
•
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7. Conclusions and Recommendations
Quality of Service
7.1
This study has focused on review of level of care and quality in the private sector
through exit patient perception of quality. This was conducted through a detailed
patient survey, wherein around 102 exit proformas were administered to patients
visiting Hospitals, Private clinics etc. In addition, around 10 patients from an
alternate system of medicine namely Ayurvedic Medicine were covered.
7.2
The quality of service offered by the private sector has been reviewed on the
following parameters :
♦
♦
♦
♦
♦
♦
♦
Patient Expectation
Repeat Visit / Recommendations
Doctor - Patient communication
Nursing care
Ward Staff Support
Support Services
Administrative Support
7.3
Only 54% of Inpatients & 48% of outpatients were of the view that their
expectations of service were fully met.
7.4
The above is reinforced with the fact that 54% of patients mentioned that they
would surely revisit at the same hospital and only 42% mentioned they would
recommend to others.
7.5
14% of the respondents were of the view that there is a need to improve behavior
of Doctors.
7.6
The quality of Nursing care in private sector needs to improve although it is
satisfactory in urban areas as compared to rural areas.
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7.7
Many private nursing homes both in urban & rural areas, employed oniv "non
qualified nurses" mainly ayahas given on the job training. Majority of the Nursing
Homes especially did not have qualified trained Registered Nursing staff and
followed staffing norms as per Nursing council norms.
7.8
Majority of the hospitals and nursing homes especially did not have administrative /
nursing / standing orders , procedures manuals at all.
7.9
Majority felt that drugs were expensive (both allopathic
or Ayurvedic) bur were
easily available.
7.10
Around 38% of respondents felt that the quality of meals
provided needs to
improve.
7.11
Only 54% felt that the house-keeping facilities (hygiene of hospital, clean toilets
cean linen etc.) were adequate. Majority of the nursing homes did not provide
clean linen and patients had to use their own linen.
P
7.12
57% of respondents were of the view that the reception staff needs to improve
their attitude.
7.13
The average length of stay was in the range of 7-10 days.
Level of Care
Services Availability
J
3.67
There is wide disparity in terms of services availability
within same category of
hospitals and among different categories of hospitals.
3.68
The various services available in the private sector can be
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3.69
summarised as under:
hospital’60'31'17 SerV'CeS are generally available in Corporate / Teaching
The Trust and Missionary hospitals generally provide secondary level
of care
i.e. internal medicine, paediatrics, general surgery etc
Most of the nursing homes have'only minimal services for emergency care.
With regard to investigation facilities the following observations Tiave been made:
♦ Corporate / Teaching hospitals usually have facilities for all investigations
♦ Missionary / Trust hospitals offer secondary level of investigations
♦ Most nursing homes have only basic investigation services.
3.70
Facilities in terms of adequate water and power supply and the drainage facilities
ava^ablP in th
h°SP'talS covered- However, water purifier facilities were not
available in the nursing homes.
7.14
While the private hospitals had adequate number of ambulances, the nursing homes
did not have any. In terms of ward facilities, the nursing homes had only general
wards and no ICU facilities while all the private hospitals covered had Emergency
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wards, general wards and ICU facilities. The nursing homes do not seem to follow
any kind of standard protocols regimes.
7.15
Most private Nursing homes have only basic investigation service facilities.
7.16
Majority of the private hospitals and nursing homes Laboratories are not
standardized and none of them are participating in standardisation programme or
accreditated to the "National Board of Accreditation of Laboratories".
7.17
The nursing homes do not have ambulances. Quick referral of serious cases is a
major handicap.
7.18
Majority of the Nursing Homes does not have proper emergency wards/ ICU or
equipment or manpower. At best they are suited to give 'first aid '. But they
somehow manage to retain the patients in "ill equipped and ill planned" emergency
rooms and ICU's.
7.19
The Nursing Homes are very poorly planned in terms of space planning and some of
them are also located in remodeled residential houses and also located in residential
areas.
7.20
There are no physical standards currently available for private hospitals. There is no
proper space utilization since there are no norms.
7.21
There is a urgent need to set up minimum standards for hospitals of varying bed
capacity and classified as primary, secondary and tertiary.
7.22
No permission is required to start a Nursing Home from any statutory body. As a
result, there has been a proliferation of poorly planned ill-equipped nursing homes.
Patients Perception on Services Availability
3.71
The patient perception on services availability was reviewed in terms of the
following :
i
♦
♦
♦
♦
Extent of investigations conducted
OPD facilities such as
♦ Physical Space
♦ Drinking water
♦ Seating arrangements
♦ Fan & Ventilation
♦ Toilet
In-patient facilities such as water, power and security
Equipment Availability
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7.23
49% of the patients were of the view that 'more than sufficient' investigations were
made.
7.24
The most common investigation done for the in-patients
was Blood (70%) and
Radiological -X-Ray (62%), C.T Scan (12%) etc.
7.25
The facilities in the OPD were found to 'Fairly Sufficient' by majority of patients
However, in Ayurvedic Hospital the majority (80%) found OPD facilities to be 'less
than satisfactory'.
7.26
Majority of the patients felt that in-patient facility such
as water, power and security
were adequate.
7.27
Most the patients could not comment on the adequacy of the equipment availability
in hospitals.
7.28
7.29
The^ Ayurvedic hospital, in general, was overall rated by patients as 'average or
Physical Access
4.38
Physical Access has been assessed by the following
♦
♦
♦
£
♦
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♦
7.30
£
ISS
Tn’? 4^ in«i«95‘2624
2h 24 public
PU,bliC ihospitals
0SpitalS and
and 1709
1709 private
private hospitals
hosPitals (STEM
(STEM,
h d -T? d 43, 868 PUb ,C hosp,tal beds as comPared to 40,900 private hospital
beds. Thus, there are 1.89 beds per 1000 population
r
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Availability of Hospitals
Availability of beds in the districts
Distribution of treatment of Out-patients and In-patients
over source of
treatment
Physical distance traveled to reach hospital
Means of transportation used to reach hospital
7.31
Only 27% of the OPD patients in urban areas of Karnataka get their treatment at
are seen in rural areas.
7.32
There is almost equal distribution of In-patients treatment
in public and Private
sector in Karnataka Urban areas and whereas, in rural
areas 60% get their
treatment in public hospital and primary health centre and the balance 40% in
private sector.
7.33
The primary survey reveals that more 1than
‘
70%: of OPD patients across categories
use hospital within 10 kilometres of distance from
- their
----- • home. A very noticeable
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difference is that in Urban Government hospital as much as 60% of the patients
come from a distance of more than 10 kms.
7.34
There is no particular noticeable difference in accessibility in urban and rural areas
in private hospitals. This is because many patients in rural hospitals are also from
neighboring villages.
7.35
More than 75% of the patients visiting General Physicians are from the radius of
less than 3 kms from clinic and another 20-25% from 3 to 10 kms radius. In case of
specialists the percentage of patients who came from the radius of 3 kms from clinic
were in the range of 30-60% (with an average of 42%) and those from a radius of
3 to 10 kms was about 30-45%.
7.36
Except in case of Corporate Hospitals, Majority (50-80%) of the patients visiting
other hospitals reaches by walking or public transport. Use of public buses to reach
hospitals is greatest in Government hospitals and teaching hospitals. Whereas in
Missionary and teaching (in that order) hospitals patients walking to reach hospitals
is also common.
Social Access
4.39
The Social Access was examined from the view point of
♦
♦
♦
♦
♦
♦
Sex-wise distribution of patients across hospitals
Age-wise distribution of patients across hospitals
Income group profile of patients
Payments Category
Treatment of Low income group patients at Hospitals
Cost of treatment as perceived by patients
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1.31
No significant difference in treatment of male or female patients is noticed across
categories of hospitals.
7.38
About 50% to 80% of the patients across categories of private hospitals are from
the age group 12 years to 50 years. But there is no significant noticeable difference
in access of patients of different age groups in rural or urban areas to treatment
facilities in private sector vis-a-vis public sector
7.39
Corporate Hospitals cater mainly to the upper middle and high-income group of
people.
7.40
In Trust/ Missionary hospitals majority of the patients belong to the middle and
lower income group. These hospitals give maximum concession to the poorer
section.
7.41
Teaching hospitals had the maximum number of poor patients (probably due to MCI
regulations)
7.42
Nursing Homes mainly cater to the middle income and upper group of people
7.43
Over 60% of the ayurvedic hospital are from the lower middle income and lower
income group.
Payment Category
7.44
Most of the patients in the corporate hospital are fully
f ", charged for consultancy,
diagnostic tests and treatment. A very minimal percentage of themi are provided
concessions, usually in the range of 10 to 30%.
7.45
In hospitals run by trusts there was a mixed trend. A few of them, those run by
religious communities, provided free treatment to about 20% of patients and about
50 to 60% of patients were provided treatment at concessional costs.
7.46
Teaching hospitals also provide free and concessional treatment to about 50% of
the patients but the purpose of treating free/at concessional rates poor patients is
to use them as clinical teaching cases for medical students.
7.47
Missionary Hospitals get substantial amount of their funding in the form of grants
and donations from India and abroad for treating the poor patients. They are thus
able to provide free and concessional treatment to majority (70%) of their patients.
7.48
Nursing homes usually run by individuals cater to mainly middle class and upper
middle class and usually charge in full for treatment. A very few of them are
provided any form of free or concessional treatment.
7.49
83% of the private hospitals and nursing homes charged low-income groups
(income less than 600 p.m.). However, 75% of hospitals and nursing homes
provided concessions in fees in treating these patients. The concessions ranged
from 15% to near about 100%. 92% of the hospitals made referrals to other
hospitals. Referrals were usually made for patients requiring super-speciality care.
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25 percent of the hospitals always ordered investigations for patients and also
charged interpretation fees. None of the hospitals had any follow-up procedure.
25% of them (both the corporate hospitals and a nursing home) considered it as a
sole responsibility of Government to provide free treatment to the low-income group
patients.
7.50
There appears to be a widespread nexus between the various hospitals, nursing
homes, diagnostic centres, specialists and family physicians in ordering unnecessary
admissions, investigations, treatment in order to share the fees among themselves.
7.51
Majority of the OPD patients (~58%) were of the view that the charges were
reasonable while around 30 % felt that they were a bit high. Similarly around 76 %
of the in-patients felt that the charges were reasonable while around 19% felt that
they were high.
7.52
Almost all the patients met the treatment charges on their own. A few of them
borrowed funds from friends and relatives. A cross section of patients were queried
on their affordability of these expenses and a majority of them (62%) felt that the
medical care expenses constituted upto 5% of their income. However, a sizable
number (31%) also were of the view that the said expenses constituted more than
20% of their income.
7.53
The Ayurvedic hospital patients availed of free in-patient treatment at the hospital
covered. Hence, while the in-patient charges were considered reasonable, most
patients were of the view that external procurement of drugs is as expensive as the
allopathic medicines.
7.54
Presently there exists not adequate certification and standards
(structure/Process/ outcome) in private health sector in Karnataka.
7.55
There is an urgent need to set up standards, ensure that standards are met and
maintained. This information should be transparent and on website also. The
public should be able to judge themselves the quality of care provided.
7.56
Some private hospitals do carry out Medical Audit internally occasionally but do not
share this information to the public or to the peer group. The performance data on
these hospitals are termed "Confidential documents" by the. concerned hospital
management.
7.57
The nursing homes do not maintain any medical records nor do they have any
medical audit. Data for the hospitals under study was not available and also not
forthcoming especially on the number of re-admissions, repeat operations, hospital
acquired infection, blood utilisation, tissues removed etc.
7.58
All the respondents suggested group insurance. 7% of the respondents also
suggested individual insurance policy. By group insurance here it is meant that
insurance policy should be such that it provides for insurance cover for all the
members of family. However, none of them were clear as to nature of the policy
and its functionality.
of care
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References
i
1.
Ramesh Bhat, 1998. Public-Private Partnerships in Health Sector in India: Issues
and Prospects. August 1998.
2.
C.David Naylor, et al, 1999. A Fine Balance: Some Options for Private and Public
Health Care in India. Human Development Network
3.
Centre for Social Services, Administrative Staff College of India. Beneficiary Social
Assessment for Karnataka, Secondary health Systems Expansion. Hyderabad.
4.
Rama V Baru, 1998. Private Health Care in India: Social Characteristics and trends.
Sage Publications
5.
Lipika Nanda. Designing an Accreditation System for the Health Care Organizations
in Andhra Pradesh. Hospital Administration, Volume XXXVII, March/June 2000,
Official Journal of Indian Hospital Association.
6.
Suresh Balakrishnan and Anjana Iyer. Bangalore Hospitals and the Urban Poor: A
Report Card. Public Affairs Centre, Bangalore
7.
V.R. Muraleedharan, 1999. Characteristics and Structure of the Private Hospital
Sector in Urban India: A study of Madras City. Partnerships for Health Reforms
8.
Prof. A.K.Roy, Patient Satisfaction Survey: A Tool for Total Quality Improvement.
9.
Others as specified.
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