Health Care Infrastructure for Development Karnataka

Item

Title: Health Care Infrastructure for Development
Karnataka
extracted text: C.H- 16

Health Care Infrastructure for Development
Karnataka
By
Dr. C.M. Francis,
Ph.D (Cambridge)
Dr. Ravi Narayan, M.D., DTPH (Lend), DIH (UK)

Community Health Cell, Bangalore

"Health and sustainable development are inter-linked", Brundtland, Gro Harlem. Address to World Health Assembly, 1988

"Without good health, individuals, families and communities and
nations cannot hope to achieve their social and economic
aspirations" - Health For All for the 21st Century,

World Health Organisation, Geneva, March 1997.

What is the status of health of the people and health care infrastucture in Karnataka?
conducive to development?

Is it

Factors affecting health of the people
Many factors play a role in determining the health of the people

•

Food and nutrition, adequate in quantity and quality

•

Safe water supply and sanitary disposal of waste

•

Quality and extent of coverage of health care services

•

Education, particularly female education

•

Improved purchasing power with equity

•

Housing and shelter

•

Clean air, water and soil and quality environment

There is need for intersectoral action for health.
Health problems

If we consider the health of the people of the whole of India, Karnataka is an average State. If
we consider our neighbours Kerala and Tamilnadu, Karnataka lags behind. All the health
indices are worse. Further, there are great disparities between the districts within the State,
with respect to Health and Health Care Services and development. While Bangalore, Dakshina
Kannada, Mandya and Shimoga are better off, Bellary, Bidar, Bijapur, Gulbarga, Raichur and
Tumkur are worse off.
Existing health problems

The major existing health problems are microbiological (gastro-enteritis, diarrhoeas, acute
respiratory infections and other communicable diseases), malnutrition, inadequate basic services
(such as water supply, sanitation and waste disposal, health care) and pollution.

I

(\

Evolving health problems

Industrial growth and urbanization bring on more problems. The most important is pollution.
Related to this are micro-chemical problems. An area of growing concern is psychosocial.
This is shown by the climbing suicide rate, increasing violence and crime, drug abuse,
alcoholism, stress and anxiety and increasing incidence of diseases of heart and blood vessels.
Added to this is poor housing and shelter.
The two sets of problems have additive effects.
All of them lead to lower productivity,
increased absenteeism at work and poor quality of life.

Tackling the problem helps to enhance productivity and development.
Existing

Evolving

Microbiological

Pollution

Malnutrition

Microchemical

HEALTH

Lack of basic services

Psychosocial

PROBLEMS

Pollution

Shelter

Accidents

Accidents

Infectious Diseases
While many countries have been able, or are on their way, to control infectious diseases, the
situation in India (including Karnataka) is different. There is progressive deterioration over the
years. Control of communicable diseases has shown a negative trend in Karnataka. A few
examples are given.
Number of cases

Year

Gastro-enteritis
Acute respiratory infections
Malaria 70,012

1990

1993

8,565
4,23,803
1,96,466*

36,206
8,96,076

*Smear positive. There is significant increase in P.falciparum infection.

"State still caught in the grip of gastro-enteritis wave".
Out of 16 water samples collected, 10 were unfit for human consumption".
----- Dr. G. Rangaswamy, Joiont Director, Directorate of Health and Family
Welfare, Karnataka as quoted in Indian Express, Bangalore, May 14, 1997.

Other major infectious diseases
Tuberculosis continues to take its heavy toll. Karnataka, as rmost other States in India, has
failed to control it. The new method of treatment, Directly Observed Treatment Short Course
(DOTS) is being tried. Whether it will make a better impact is to be seen.

In 1993, 41,786 cases and 537 deaths from pulmonary tuberculosis have been reported from
the State. If the percentage distribution of deaths by major groups is considered, ‘coughs’
accounted for 19.7%. Of these, TB of lungs accounted for 29.4%

HiV/AIDS . The number of persons infected with Human Immuno-deficiency virus and
pr pressing to Acquired Imune Deficiency Syndrome is alarmingly increasing. It is the major

emerging disease. The combination of tuberculosis and AIDS
health, killing the young adults in their productive life.

is the greatest threat to public

Diseases peculiar to Karnataka : Handigodu syndrome (a permanently crippling genetic
disorder) and Kysanoor Forest Disease (commonly known as monkey disease) are special for
Karnataka.
Urbanization ; migration ; slums

Uncontrolled urban growth leads to spread of infectious diseases and other health problems.
The growth is mainly of slums with all attendant social and health problems.
Urban
overcrowding and poor working and living conditions can lead to anxiety, depression and
chronic stress. Changes in family structure and living arrangements have significant impact on
peoples’ health and their capacity to cope with health and social problems.

Karnataka is more urbanized than the Indian average.
Ratio of urban'population to total (%) = 1991 Census

India
Karnataka

25.70
30.90

A few centres in Karnataka are growing very rapidly. The decennial growth rate has been
39.9% in Bangalore, 39.1% in Mangalore and 36.2% in Mysore.
Growth of towns and cities strain the health care services but it has an advantage also; delivery
of services can be more efficient if planned properly and the plans are implemented.

Industrialisation can help in alleviating poverty and improve health, but, Industrialization
without proper consideration of posible impact on the health of the people, can lead to
deterioration of the workers, their families and the community.

Types of industries
The type of industry has an effect on the health of the people. Distinguish between one kind of
industry and another. Choice of socially appropriate technology and promoting such industries
lead to better qualitative development.
Plastic industry
Tests done in Britain, Australia, New Zealand and Taiwan in recent years have shown that toxic
chemicals in plastics can leach into a wide range of foods from plastic packaging materials Utusan Konsumer, 1996.

Toxic waste recycling
There is a tendency to transfer 'dirty' (meaning most polluting) industries to less developed
countries. Government had declared itself against dumping of toxic waste by the developed
countries. But now the opposite is being done. An example is the Bharat Zinc plant near
Bhopal (Bhopal again?), which is recycling hazardous waste shipped from Germany and
Holland chiefly.

Granite quarrying and stone crushing
This is an industry present very much in Karnataka,
conditions.

It leads to silicosis and other respiratory

Silk reeling and powerlooms

The industry produces dust and other particles. There is also noise pollution.
Every type of industry has some social/health costs that have to be minimised by built in
safety/preventive provisions. It is important that the plans of development that evolve must

include health and environmental impact assessments as an integral part of the
planning/management process. The unintended health and social consequences of economic
development should not become counter productive to sustainable development.
According to size
Larger units are often healthier because it is easier to "police" them. But large industries have
greater clout and may get away with greater violation of the rules. Also, large industries may
contract out "dirty and dangerous" work.

Smaller industries are desirable on economic and social considerations. They are also happier
places to work.. The psychosocial factors are better. The morale is high. Small industries use
batch processing, whereas large factories often use automated flow processes or the conveyor
belt system of production. Health hazards are considerable, If we can organize preventive
health services, small industries will be better suited.
Cottage industries are satisfying,
satisfying. But the environmental sanitation and working conditions
(ventilation, heat and light) are often apalling.
There may be high morbidity related to
respiratory diseases, accidents and heat exhaustion.
Infrastructure for industrial development

There is need for development of supportive infrastructure :: transport
transport and
and communication,
communication,
power and increased availability of water, leading to additional demands on improved water
management and waste disposal. All these dimensions of infrastructure also have their social
costs and health consequences, not always
positive.
T
.
Poor
quality road infrastructive and
uncontrolled / unregulated transportation leads to increased road traffic accidents and injuries.
Power plants add to pollution of air, water and soil unless properly regulated. Poor water
management increases vector/mosquitogenic potential and causes the ill-effects of poor
environmental sanitation.

Environment
Adoption of sustainable development policies, whether industrial or agricultural, which seek to
conserve, protect and restore the health and integrity of the earth’s ecosystem is essential for
health. Environmental protection and health promotion are inseparable. This is the challenge
to all development planners and decision - makers.
The environment has a tolerance limit, beyond which it will not be able to sustain life and
health.
Meddling with the environment without thinking of the adverse effects for some
immediate economic gains in the name of development leads to disaster. Our activities should
not irreparably disrupt the health and stability of the ecosystem.

Pollution
Pollutants of various kinds are thrown into the environment, The pollutants emitted from
factories and vehicular exhausts are poured
|
into the atmosphere, river and soil, adding on to
the pollutants due to burning of domestic fuel, waste and other human activities, This double
burden can cause breakdown of the ability of the environment to cope with them.

Air

The main cause of pollution is vehicular and industrial emissions, the primary components being
hydrocarbons, carbon monoxide, and oxides of sulphur and nitrogen. Lead contamination
occurs due to lead in petrol. Symptoms of lead poisoning in children in Bangalore has become
a cause for worry. Air pollution can cause diseases like chronic bronchitis. Reeling of silk, a
common activity in Karnataka, can cause dust and fibres being inhaled.
Spraying with
pesticides and insecticides can be hazardous.

Water

The natural cycles of hydrology may be affected by our ‘developmental’ programmes.
Contamination due to industrialization -distilleries, textile industries and organochemicals - occur
frequently; so also, microbiological contamination can occur. Contaminated water causes
gastro-intestinal disorders. Granite quarrying, carried out extensively in Karnataka produces
dust, which gets into the air and water systems , affecting the health of the people.
Building of canals for irrigation can lead to mosquito breeding, if precautions are not taken; so
also stagnant waters in ponds, cisterns and other places.
Soil

Excess use of pesticides, herbicides, fungicides and other chemicals affect the soil,
activities like construction may remove the top soil.

Human

Noise

Constant loud noise of particular frequencies can produce deafness to those frequencies, This
can occur in people involved in the powerloom industry.

Karnataka State Pollution Board
The Board is expected to ensure compliance with the various pieces of legislation, designed to
control pollution.

The Water (Prevention & Control of Pollution) Act, 1974.
The Air (Prevention & Control of Pollution) Act, 1981.
The Environmental Protection Act, 1986.
The Board is also the implementing authority under the Hazardous Waste Management Rules, 1989.

The Board, with its headquarters at Bangalore, has 11 Regional Offices, a Central laboratory
and Regional Laboratories.
The effectiveness of the Board has been limited. Even where the board wishes to take action
for the improvement of the environment, it has often found its hands tied. Prosecutions, when
launched, may not lead to results. There are delays and court rulings in the majority of cases
had gone against the Board. But recently, the courts in the State and at the Centre seem to
be seized of this problem.
There is need to forbid production of toxic chemicals, rather than limit its release into air and
water. Factories must adopt environmentally sustainable production processes. Pollution must
be seen as an economic waste; resources are being used inefficiently.

Bhopal Disaster
It is within our memory the worst human made disaster in history - the Bhopal tragedy.

Molasses leakage

"30,000 in 56 villages affected by molasses leak, Kampli town worst hit" - Indian Express,
Bangalore, May 14, 1997.
Polluted molasses containing hazardous chemicals leaked into the Thungabhadra river, when
the tank of the sugar factory burst, Kampli town, which depends on Thungabhadra river for
drinking water suffered most.

Injuries
Accidents and injuries lead to death and disability in increasing measure in recent years,
These result from rapid urbanization, motorisation, industrialisation and changing lifestyles. A
number of social factors contribute:

migration into cities
large scale construction activities
import of machines, without safety devices
lack of safety measures: road, home, worksite, playsite
problem of alcohol and drugs
increase in violence and crimes
steep increase in number of vehicles
adverse road situation
meagre facilities to attend to accidents

The estimated number of deaths annually in Karnataka from injuries is about 56,000 and about
10 times this number would suffer from disabilities.
Causes of injuries : Bangalore : percentage
Road traffic accidents
Violence
Domestic falls
Burns
Industrial Injuries
Fall of objects
Others

51.6
27.0
10.8
5.1
3.2
1.1
__ 1.2
100.0

Total

Motor vehicle injury rates have been on the decline in different parts of the world. But in
Karnataka, the rates are increasing.
There is need for scientifically designed, culturally
appropriate and economically feasible strategies based on epidemiological analysis of traffic
injuries, These must be adapted for pedestrians, two wheelers, cyclists, cars, buses and
trucks.

Health Care Infrastructure
The health system needs an infrastructure to make available health care services.
components :
___ ______

Management

l
Resources

<■

Organisation

> Services

T
Financing
There are many factors which play upon the health infrastructure and modify health.
Resources

: Technical and skilled personnel
Building and equipment
Drugs and Supplies
Scientific knowledge and technology

Finances

: Government : State, Central, Local
Voluntary Contributions
Insurance

Private : Individuals, families, communities

It has many

Management

: Planning, Communication, Coordination
Regulation, Supervision
Delegation of authority and responsibility
Monitoring and Evaluation
Community Participation

There are many factors which play upon the health infrastructure and modify health.

Intersectoral
action
Environment

Health
Problems

Social
conditions

Health Care
Infrastructure

T.

Economic
Political
Educational
Social

■>

Modified
Health
Status

Community
Participation

Attitudes
Values

Health Care Facilities
The health care facilities in Karnataka are not adequate,
There is need and scope for
improvement. The financial allocation by Government is not sufficient, Even the amount
allocated is not utilized efficiently.

The Voluntary sector is tending to become stagnant,
are lacking now.

The dynamism and growth seen earlier

The private-for-profit sector shows a different trend. There is increase in the larger, tertiary
care hospitals, utilizing costly technology. They are situated in the cities and, to some extent,
in the larger towns.

Primary Health Care (Government)
Primary health centres
Sub-centres
Primary health units
Community health centres

1,253 (1994)
7,793
621

146 (1990)

Hospitals (as on 1.1.1991)
Number

Beds

rural
urban
rural
urban

Karnataka
25
263
2,526
31,951

Kerala
2328
596
37,589
32,490

Tamilnadu

89
319
4,235
44,545

Population served per hospital bed

Karnataka
Kerala
Tamilnadu

:
:
:

1,311*
427
1,139

* There is wide disparity in the number of hospital beds
in the various districts : (Examples) :
District

Population per hospital bed

Mysore
Bangalore
Tumkur
Raichur

935
1,1015
2,450
2,552

Specialised hospitals and institutions

•

Minto Ophthalmic Hospital, Bangalore

•

T.B. Hospitals, Bangalore, Mandya, Gadag, Kolar, Bijapur & Madshedde (D.K.)

•

Leprosy Hospitals, Bangalore, Dharwad

•

National Institute of Mental Health & Neurosciences-Bangalore, Mental Hospital, Dharwad.

•

Kidwai Memorial Institute of Oncology, Bangalore.

•

Sri Jayadeva Institute of Cardiology, Bangalore.

•

Sanjay gandhi Institute of Accidents, Rehabilitation and Physical Medicine, Bangalore.

•

Epidemic Diseases Hospitals, Bangalore, KGF and Mysore.

•

Institute of Child Health, Bangalore.

Private for Profit

The major part of health care is provided by private practitioners. This is estimated to be 70%
including practitioners in modern (allopathic) medicine and other systems of medicine.
There are some hi-tech hospitals. Though their number is small and the number of patients
catered for is small, they have high visibility, because of the sophisticated

technologies. They cater mainly to the elite population and to the higher paid management and
administrative staff of the corporate sector. These hospitals often have health check-up and
health care packages.
Industries
Some of the larger indsutries in the corporate sector (public and private) have their own
hospitals. These are small or medium-sized. The staff and employees often depend on other
hospitals for major part of health care.
All these institutions must be linked together in a referral services complex. All of them must
be sensitized to the possible negative health and social consequences of development so that
their responses may be need based and adequate.

Health Insurance
Karnataka (and the country) has not caught on with health insurance, Only about 2 million
persons, out of a population of 950 millions have health insurance, The way the insurance
schemes - mediclaim, Bhavishya arogya, Jan arogya and others -

are functioning, it is very unlikely that insurance will have a major impact on the health of the
people of Karnataka. Even the new proposals for opening up health insurance to outside
agencies may not help much, except to make available sophisticated procedures to the

fortunate few.
people.

Health insurance should lead to better health care to the large majority of the

Employees’ State Insurance
This is a major social security programme. It provides some protection for workers in the
organized sector. Medical assistance is made available to the immediate family members also,
the working of the Employees’ State Insurance Scheme is not satisfactory. There is need to
have promotive and preventive orientation and positive lifestyles. It should consider the adverse
conditions prevailing and take concrete measures.

Regional Occupational Health Centre, Bangalore.

The National Institute of Occupational Health, Ahmedabad, has a Regional branch at Bangalore
to study the health hazards of occupations, both industrial and agriculture in South India. It is
also expected to monitor the environmental hazards of industries. A centre such as this should
be closely involved with development in Karnataka,
Its monitoring and research activities
should respond to local needs and priorities and help
to assess the human factors in
development.
Karnataka Health Systems Development
The Government is now in the process of implementing a programme for the strengthening of
the infrastructure for secondary health care with the assistance of the World Bank. The
Systems Development could have been utilised as an opportunity to tackle emerging health
problems. The plans for industrialisation are known. The health problems associated with
particular industries should have been taken into consideration and steps taken to anticipate
and prevent those problems. It is assumed that primary health care is already catered for,
though many will question this assumption. The need is to strengthen primary health care. It
is true of Karnataka as the whole of India.

"We have completely ignored primary education and primary health sectors which has resulted
in 70 per cent of the population still not having access to primary health and 50 per cent of the
population still being illiterate". _ Finance Minister P. Chidambaram, The Economic Times,
Bangalore, 5 May, 1997.

Other systems of medicine
The indigenous systems of medicine are very popular in Karnataka. Apart from Ayurveda,
Unani, Naturopathy and Yoga, other systems like homoeopathy, acupuncture, acupressure and
magnetotherapy are practised widely. Herbal medicine is also practised extensively, though this
is threatened by the deteriorating conditions of medicinal plants.

Indian Systems of Medicine & Homoeopathy
Number of hospitals and beds (31.3.91)
System

Hospitals

Ayurveda
Unani
Homeopathy
Siddha
Yoga
Naturopathy

12
4
15
1
3
1

Beds

573
111
350
10
15
6

The practitioners of the alternative systems of medicine must be considered as an integral part
of the health care system and, therefore, of the health care infrastructure.

Expenditure on Health
State Plan allocations for health have been always meagre and it has been coming down. The
actuals for 1988-89 were 4.24 per cent of the total outlay and the budget estimates for
1995-96 came down to 3.32 per cent.

The expenditure on health, per capita, in Rupees in 1994-95 was Rs.103.84 while it was
122.07 for Kerala.

What is to be done?
1.

Health has to be considered as central to sustainable human development. The currently
dominating economic approaches with negative health and social consequences must give
way to ones which are human-centred and economically and environmentally
sustainable.
Think ’health’ when planning developmental projects and programmes.

2.

There is need to ensure that primary health care is made available to all.
affordable, accessible and acceptable.

It has to be

Disparities between different regions must be minimised.
Budget allocation for health care services must be increased. The services must be
made more effective and efficient. There has to be better commitment and motivation on
the part of all the health personnel.
while quantititive increase is necessary, more
importantly, there has to be qualitative improvement.

3.

Health care must be participatory. The community must be enabled to take care of their
health and demand that their right to health be honoured.

4.

There is need for caring for the environment, so that it is stable and healthy,
exploitation leading to irreparable damage must be prevented.

5.

There has to be legislation, both prescriptive (what shall be done to improve health and
proscriptive (what shall not be done so that health is not damaged).

6.

Newer industries should use technologies which do not add on to pollution; this is
especially so for the chemical industries. The location should also be carefully considered.
In the already existing industries, measures should be taken to bring pollution much below
the limits prescribed, by way of dispersion, suppression, change of fuel, etc.

7.

Continuous monitoring of developmental activities should be done to see the impact on the
health of the people - health check-ups, mortality rates and causes, morbidity rates and
causes, traffic and other accidents, absenteeism from work.

Undue

This monitoring of the human/community factor should be done by a network of agencies
which include centres such as ISEC, ROHC, Departments of Community Health/Social and
Preventive Medicine of the local Medical Colleges and Departments of Social Work
/Sociology of the local Universities.
Voluntary Organizations, Consumer groups and
representatives of people’s organizations should also be included, so that all aspects of
development are appraised, positive features enhanced and negative features kept in check.

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