Supplement to the Final Report Volume - II
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KARNATAKA
TOWARDS EQUITY, INTEGRITY AND QUALITY
IN HEALTH
Focus on
Primary Health Care
and
Public Health
SUPPLEMENT TO THE FINAL REPORT
VOLUME - II
APRIL 2001
TASK FORCE ON HEALTH AND FAMILY WELFARE
GOVERNMENT OF KARNATAKA
PHI Building, Sheshadri Road,
Bangalore 560001.
Ph: 2271021, email: khsdp@vsnl.com
PREFACE
The Task Force on Health and Family Welfare is happy to present this Final Report. It would be
recalled that the Task Force had presented an Interim Report in April 2000. It made
recommendations therein which, the Government of Karnataka, we are pleased to record,
received with appreciation and more importantly acted upon. The issues of concern and key
messages of that Report have been considered and studied further in greater detail, against the
backdrop of a vision for better health in the State. The conclusions of the deliberations on these
issues are presented in this Final Report.
At first sight, the recommendations may seem rather detailed, extensive and wide ranging.
However, in view of the importance of health as probably the most important element in the
effort to achieve an acceptable standard of quality of life for all, the consideration of issues had
to cover all aspects of the health services and closely inter-related sectors of development. It is
rarely that such an opportunity arises, which permits examination of issues in full of the health
services and in conjunction with the sectors that lend these services strength and support. A
holistic view of health services as an integral part of the entitlement of the people to basic
services has, therefore, been taken. Consequently, this Report, has considered the content,
quality and reach of health services, and administrative and management issues in the social and
economic context of the State.
In the course of examination of the issues relating to health services it has repeatedly become
apparent that the key factor that influences the efficiency of these services and ensures the social
accountability of the system is the issue of governance. It is apparent that professional skills,
financial allocations and departmental infrastructure, important as they doubtless are, can
contribute to performance only up to a point. The core issue, however, remains the motivation
and commitment of the staff. There is need to nurture the young health professional and other
allied health workers, supervising and facilitating them. There is also the need to institutionalise
discipline tempered with morale building, peak performance and accountability to the public,
together with the involvement of the people in attaining and maintaining their own health. The
recommendations on restructuring of the health services have been made keeping these essential
parameters in view. It is appreciated that the recommendations call for basic structural changes.
They have been made in the full confidence that such changes are not merely desirable, but
essential, and would be viewed by those in the system in this light.
It is recognised that the examination and implementation of many of these recommendations by
Government would take some time. Others can be implemented without delay, as had been done
for the short term recommendations. It is hoped, and indeed urged, that the same sense of
urgency and concern on matters relating to health, that induced the constitution of this Task
Force, would continue to prevail, and that no time would be lost in establishing mechanisms for
implementation of the recommendations. Such a mechanism has been suggested in the Report.
Priority in setting up these mechanisms is urged. As responsible and responsive persons, the
members of the Task Force would be happy to contribute their expertise in this effort. As an
effective measure for implementation of these recommendations and for monitoring
implementation and generally to further the objectives of rapid improvement of the health
services, the early constitution of the Commission on Health recommended herein is urged.
The Task Force has attempted to cover as much ground as possible. However, it need hardly be
emphasised that many aspects would still need consideration. At best, what has been presented
is a detailed blueprint. This would have to be built upon by those who constitute the health
services and, therefore, have direct functional responsibility. In fact, one looks forward to an
internalisation of the recommendations and their improvement by those within the system. The
Task Force had numerous occasions to have detailed discussions with members of the Health
Services at various levels and exchanged ideas and views freely. We look forward to their active
and total involvement for quantitative and qualitative improvement in the system. This would be
the test of total acceptance of the need for change, and change at a quick pace.
In April 2000, the Task Force presented an Interim Report. It is gratifying to note that the
recommendations made therein have been welcomed enthusiastically and many of them have
been implemented by the Government in a short span of time. This response evokes confidence
in the Task Force that the recommendations made in this Final Report would be implemented
in the same spirit in which they have been made, namely of concern for the health of the people
of the State and their welfare. Once these recommendations are implemented, the health
services in the State will achieve both professional competence and efficiency of a high order,
with equity, so as to serve the people of the State to their full expectations, contributing to the
enhancement of their quality of life.
Sri Arvi nd G Risbud
Member Convenor
Dr. H. Sudarshan
Chairman
Members:
Dr. Chandrashe kar She tty. S
Dr. C. M. Francis
Dr. T. Jacob John
Dr. Jayaprakash Narayan
Dr. A. Kamini Rao
Dr. Latha Jagannathan
Dr. M. Maiya
Sri Padmanabha. P
Dr. Rame sh S. Bilimagga
Swami Japananda
Dr. The lma Narayan
ACKNOWLEDGEMENTS
The Task Force is very happy to record its gratitude for our Hon'ble Chief Minister, Sri S.M.
Krishna for giving the opportunity to prepare this report on Health and Family Welfare, with
Equity, Integrity and Quality, so as to take measures to enable the more than fifty two million
people of our State.
We are grateful to our Hon'ble Minister for Health and Family Welfare Dr. A.B. Maalaka
Raddy, for his advice and guidance and the Hon'ble Minister of State for Medical Education,
Ms. Nafees Fazal, for her suggestions and views in formulating the Report.
We are thankful to Dr. B. K. Chandrashekar, Minister for Information for his valuable
suggestions for health promotion and improved transparency.
We wish to thank Sri. Abhijit Sen Gupta, former Principal Secretary for Health, for his intense
interest and involvement and for the efforts and time spent in discussions with the Task Force.
We express our gratitude to Sri A.K.M. Naik, Principal Secretary, Health, for his great advice in
improving the impact of the Report.
We are grateful to Sri. Sanjay Kaul, Commissioner for Health, for his keen interest and
involvement in the transactions of the Task Force and the early implementation of the
recommendations.
Our gratitude goes to Sri. D. Thangaraj, Secretary for Medical Education for his involvement
with the Task Force and giving suggestions for improving education for health.
We are thankful to Sri. Sreenivasa Murthy, Secretary, RDPR for the various valuable
suggestions.
We are thankful to Dr.S. Subramanya former Project Administrator, KHSDP, Sri G.V.K. Rao,
Project Director, IPP IX and the officers of KHSDP, IPP IX and IPP VII.
We thank Dr. G.V. Nagaraj, Director, Department of Health and Family Welfare Services, Dr.
Seethalakshmi, Director, Medical Education, the Director, State Institute of Health and Family
Welfare, the Drugs Controller, the Additional, Joint and Deputy Directors and the other officials
of the various Directorates for their active participation.
We are thankful to the Secretaries, Directors and other officials of the allied departments for
their valuable help and co-operation. We wish to thank Sri. Gautam Basu, Joint Secretary, RCH,
Smt. Shylaja Chandran, Secretary to Govt., Dept. of ISM&H and other officials of the Central
Government, who have given their suggestions.
We are thankful to Dr. Ravi Narayan of Community Health Cell for his valuable contribution
and also to Dr. Suresh Kulkarni, for his contribution during his tenure as the member of the Task
Force.
We thank the large number of experts and representatives of organisations, associations,
institutions and the public who have personally discussed matters of interest or sent letters to us,
for effective improvement of the health of the people.
We are thankful to the staff of the Task Force on Health and Family Welfare, Dr. N. Girish, Dr.
Deepak M.G., Mrs. Lakshmi C. and Mr. B. Shivalingaiah for their efforts in handling various
aspects of providing this report.
We are sure that this list is incomplete. To all those who have helped us in preparing this report,
our heart felt thanks. Together, we will make Karnataka march forward in its quest for better
quality of life.
CONTENTS
A
B
C
D
E
F
G
Preface
Contents
Glossary
The Process
Strengths and achievements of Karnataka's Health System
Issues of concern and an agenda for action
Implementation of the short-term recommendations
1
Equity in Health Care
1.1
Regional disparities: Health status; Infrastructure and
Human Resources
1.2
Gender disparities
1.3
Socio economic (Caste and Class) disparities
2
Quality of Health Care
2.1
Standards
2.2
Quality Assurance
2.3
Accreditation
3
Primary Health Care
3.1
3.2
3.3
4
Rural health
Urban Health
Referral Services
Secondary and Tertiary Health Care
4.1
Secondary / Tertiary Hospitals
4.2
Emergency Health Services
4.3
4.4
4.5
Diagnostic Services
Blood Banking and Transfusion Services
Bio-Safety
4.5.1
Radiation safety in diagnostic services
4.5.2
Universal Precautions
-a-
5
Public Health
5.1
Public Health and Primary Health Care – A Continuum
and Synergy
5.2
Water Supply and Sanitation
5.3
Pollution and Solid Waste Management
5.4
Communicable Diseases
5.4.1
Vector borne diseases – Malaria, Filariasis,
Japanese Encephalitis (JE), Dengue,
Kyasanur Forest Disease (KFD)
5.4.2
Tuberculosis
5.4.3
Vaccine Preventable Diseases
5.4.4
Food and Water borne diseases
5.4.5
HIV/ AIDS, RTI and STDs
5.4.6
Leprosy
5.4.7
Rabies
5.4.8
Other infectious diseases
5.5
Disease Surveillance
5.6
Non Communicable Diseases
5.6.1
Diabetes Mellitus
5.6.2
Cardiovascular diseases
5.6.3
Bronchitis and Asthma
5.6.4
Cancer Control
5.6.5
Other Non-communicable diseases:
5.6.5.1
Fluorosis
5.6.5.2
Handigodu Syndrome
5.7
Oral Health
5.8
Occupational Health
5.9
Blindness control
5.10
Tobacco Control
5.11
Alcohol & Health
5.12
Health aspects of Disaster Management
-b-
6
7
8
Mental Health and Neurosciences
6.1
Mental Health
6.2
Neurological disorders
6.2.1
Epilepsy
6.2.2
Stroke
6.2.3
Neurology and Neurosurgery services in
Government Medical Colleges
6.2.4
Head injuries and traffic accidents
Nutrition
7.1
Vulnerable groups
7.2
Integrated Child Development Services
7.3
Public Distribution System (PDS)
Women and Child Health
8.1
Women's Health
8.2
Child Health
8.3
Reproductive and Child Health Programme
9
Population Stabilization
10
Focus on Special groups
11
10.1
Persons with disability
10.2
Health of the tribal people
10.3
Health of the elderly
Health Promotion and Advocacy for Health
11.1
Health education (IEC)
11.2
Health promotion in schools
11.3
Advocacy for health promotion
-c-
12
Human Resource Development for Health
12.1
Education
12.2
Training
12.3
Continuing Education
13
Research in Health
14
Health Systems Management
15
16
14.1
Administration
14.2
Planning and Monitoring
14.3
Health Management Information System (HMIS)
Health Financing
15.1
Allocations and Expenditure
15.2
External Assistance for Health
15.3
Management Structure
15.4
Budget Planning and Control
15.5
Information for Health Financing
15.6
Community Financing and Insurance
Rational Drug Management
16.1
Introduction
16.2
Essential Drugs
16.3
Legislation affecting use of drugs
16.4
Rational Prescribing and use of drugs
16.5
Procuring drugs
16.6
Drugs Control Department
-d-
17
18
Law and Ethics
17.1
General
17.2
Quackery
17.3
Ethics
Indian Systems of Medicine and Homoeopathy
18.1
Department of ISM&H
18.2
Medical Education
18.3
Drug Controller
18.4
Problems
18.5
Community based local health cultures
18.6
Other healing practices
19
Panchayat Raj and Empowerment of People
20
Strengthening Partnerships
20.1
Private and Corporate Hospitals
20.2
General practitioners
20.3
Voluntary Organisations
21
Multisectorality and Intersectoral Coordination
22
The Karnataka State Integrated Health Policy 2001
23
Vision 2020
24
Implementation of the Report
25
Major Recommendations and Expected Outcome
-e-
Annexures:
1.
Government Order appointing the Task Force on Health and Family Welfare
2.
Schedules of the Meetings and Consultations
3.
Sub Groups and Team members
4.
List of Research Studies undertaken by the Task Force
5.
List of Individuals / Organisations / Associations who interacted with the Task Force
6.
List of persons who responded by Post / email (Kannada / English)
7.
The Karnataka Private Health Care Establishment Bill 2001
8.
Report on Janaarogya Sabhe Process in Karnataka
9.
Information on Karnataka
-f-
GLOSSARY
ABC
ADR
AFB
ANM
ARI
BCSC
BCG
BHI
BMP
BT
CBR
CDR
CFTRI
CHC
CNA
CSW
CT
C&R
DALY
DC
DHO
DHFWS
DHF/DSS
DISM&H
DLDS
DMHP
DME
DOTS
ELISA
ENT
ESI
ESR
EQA
FOGSI
FRU
GHI
GMP
GMS
GIS
HDL
HDI
HIV/AIDS
HMIS
IAP
Airway, Breathing, Circulation
Adverse Drug Reaction
Acid Fast Bacilli
Auxillary Nurse Midwife or Junior
Health Assistant (Female)
Acute Respiratory Illness
Blood Component Separation Centre
Bacille Calmette Guerin
Bureau of Health Intelligence
Bangalore Mahanagara Palike
Bleeding Time
Crude Birth Rate
Crude Death Rate
Central Food Technology and Research
Institute
Community Health Centre
Community Needs Assessment
Commercial Sex Worker
Clotting Time
Cadre and Recruitment
Disability Adjusted Life Years
Differential Count
District Health Officer
Directorate of Health & Family Welfare
Services
Dengue Haemorrhagic Fever / Dengue
Shock Syndrome
Directorate of Indian Systems of
Medicine & Homoeopathy
District Level Disease Surveillance
System
District Mental Health Programme
Directorate of Medical Education
Directly Observed Therapy, Short
Course
Enzyme Linked Immunosorbant Assay
Ear, Nose, Throat
Employee State Insurance
Erythrocyte Sedimentation Rate
External Quality Assessment
Federation of Obstetrics &
Gynaecologists Societies of India
First Referral Unit
Gender related Health Index
Good Manufacturing Practice
Government Medical Stores
Geographical Information System
High Density Cholesterol
Human Development Index
Human Immunodeficiency
Virus/Acquired Immuno Deficiency
Syndrome
Health Management Information
System
Indian Association of Paediatrics
ICMR
ICDS
IEC
NRR
NTI
NTP
ORS
PAHO
PD
PDS
Indian Council of Medical Research
Integrated Child Development Services
Information, Education,
Communication
Iron and Folic Acid
Indian Medical Association
Infant Mortality Rate
Indian Systems of Medicine &
Homoeopathy
India Population Project
Internal Quality Control
Joint Director
Japanese Encephalitis
Karnataka Antibiotics and
Pharmaceuticals Limited
Karnataka Health System Development
Project
Kidwai Memorial Institute of Oncology
Kyasanur Forest Disease
Karnataka State Aids Prevention
Society
Leprosy Control Centre
Low Density Cholesterol
Life Expectancy at Birth
Liver Function Test
Maternal & Child Health
Medical Council of India
Member of Legislative Assembly
Member of Legislative Council
Maternal Mortality Rate
Malaria Parasite
Medical Termination of Pregnancy
National Association of Biological
Laboratories
National Anti Malaria Programme
National Aids Control Organisation
National Family Health Survey
Non-Governmental Organisation
National Institute of Mental Health &
Neurosciences
National Institute of Biologicals
National Nutrition Monitoring Bureau
National Programme for Control of
Blindness
Net Reproduction Rate
National Tuberculosis Institute
National Tuberculosis Programme
Oral Rehydration Solution
Pan American Health Organisation
Project Director
Public Distribution System
PHA
PHC
PHU
People's Health Assembly
Primary Health Centre
Primary Health Unit
IFA
IMA
IMR
ISM&H
IPP
IQC
JD
JE
KAPL
KHSDP
KMIO
KFD
KSAPS
LCC
LDL
LEB
LFT
MCH
MCI
MLA
MLC
MMR
MP
MTP
NABL
NAMP
NACO
NFHS
NGO
NIMHANS
NIB
NNMB
NPCB
PHI
PLWA
PRA
RCH
RGUHS
RNTCP
RTI
RUD
SC & ST
SGPT
SGOT
STI/STD
Public Health Institute
People Living With Aids
Participatory Rural Appraisal
Reproductive and Child Health
Rajiv Gandhi University of Health
Sciences
Revised National Tuberculosis Control
Programme
Reproductive Tract Infection
Rational Use of Drugs
Schedules Castes and Scheduled Tribes
Serum Glutamate Pyruvate
Transaminase (ALT)
Serum Glutamate Oxaloacetate
Transaminase (AST)
Sexually Transmitted Infection /
Sexually Transmitted Disease
SRS
TC
TTD
UIP
UTI
UFWC
VDRL
VO
WHA
WHO
ZBTC
ZP
Sample Registration System
Total Fertility Rate
Transfusion Transmissible Disease
Universal Immunisation Programme
Urinary Tract Infection
Urban Family Welfare Centre
Venereal Disease Research
Laboratories
Voluntary Organistion
World Health Assembly
World Health Assembly
Zonal Blood Testing Centre
Zilla Panchayat
THE PROCESS
The Government of Karnataka under the leadership of the Chief Minister, Sri S M Krishna,
constituted the Task Force on Health and Family Welfare with Dr. H. Sudarshan as Chairman.
The terms of reference were broad and included:
1. Suggestions for improvement of Public Health in the State;
2. Proposals for stabilization of the population;
3. Recommendations to improve management and administration of the Department of
Health and Family Welfare;
4. Recommendations for changes in the education system covering both Clinical and Public
Health; and
5. Monitoring the impact of the recommendations, especially in the initial stages of
implementation.
The process adopted has been participatory in nature. The deliberations have been undertaken with
the spirit of inclusion and involvement.
The Task Force had 59 sittings starting on 21st December 1999. The Principal Secretary, Health and
Family Welfare, addressing the members made it clear that the Task Force may deliberate on any
issue it feels concerned about, apart from those mentioned in the terms of reference and invite any
person who can contribute to the deliberations.
The Task Force formed subgroups, to consider the issues better. The meetings of the subgroups,
which often invited many outside experts, were very productive. The Task Force has attempted to
review the situation with the implementers, experts, policy and decision-makers, administrators, and
the public. Many individuals, organizations and associations have been consulted. The consultations
included:
a) Dr. A B Maalaka Raddy, Minister of Health and Family Welfare, Karnataka and Smt Nafees
Fazal, Minister of State for Medical Education, Karnataka
b) Prof. B. K. Chandrashekar, Minister for Information, and the Secretary and Director,
Information
c) The Principal Secretary (Health), Government of Karnataka; The Secretary, Medical
Education, Government of Karnataka; The Commissioner for Health and Family Welfare;
The Project Administrator – Karnataka Health Systems Development Project; The Project
Director - India Population Project IX; The Deputy Secretary, Health.
d) The Directorates of Health and Family Welfare Services, Medical Education and Indian
Systems of Medicine and included the Directors and other Officials from the State, District,
Taluka and Primary Health Centre Level.
e) The Joint Secretary Health and Education and Health Officials from Bangalore Mahanagara
Palike - The Health Officer and the Project Co-ordinator, India Population Project VIII.
f) Representatives from the Professional Bodies: Karnataka Medical Council, State Councils
for Indian Systems of Medicine and Homeopathy, Dental, Nursing and Pharmacy, Indian
Medical Association, Karnataka State Pharmacy Council, Associations of Karnataka
Government Medical Officers, Ayurvedic Physicians, Medical and Dental Teachers
Association, Contract Doctors, Integrated System of Medicine, Federation of Obstetrics and
i
Gynaecological Societies of India, Indian Academy of Paediatrics, Junior Doctor's
Association.
g) Representatives from Voluntary Organisations and Associations networking in the area of
Health - Voluntary Health Association of Karnataka, Catholic Health Association of IndiaKarnataka, Christian Medical Association of India, Society for Service to Voluntary
Agencies - Karnataka Chapter, Federation of Voluntary Organisations for Rural
Development in Karnataka, Family Planning Association of India, Community Health Cell,
AIDS Forum Karnataka, Foundation of Organ Retrieval and Transplant Education.
h) Representatives from Autonomous / National and Premier Health Institutions of Karnataka:
National Institute of Mental Health and Neuro Sciences, National Tuberculosis Institute,
Regional Occupational Health Centre, Kidwai Memorial Institute of Oncology, National
Institute of Virology, National Institute of Communicable Diseases, Regional Office of
health and Family Welfare, National Law School of India University, Malaria Research
Centre, Indira Gandhi Institute of Child Health, Institute of Social and Economic Change,
Sanjay Gandhi Accident Hospital and Research Institute.
i) Representatives of Corporate Hospitals, Teaching Hospitals, Private Hospitals and
Association of Nursing Homes and Private Hospitals.
j) The members of the World Bank team during their visits to Bangalore.
Health determinants are multidimensional and multi-sectoral. An interaction was undertaken with
sectors, which influence Health. They included the Departments of Women and Child Welfare,
Education, Agriculture, Urban Development, Food and Civil Supplies, Social Welfare,
Environment, Ecology and Forests, Rural Development and Panchayat Raj. Another important area
of Interaction was with representatives of Consumer Groups, Women’s Organisations, Civic /
Citizen Groups, Peoples Organisations and Movements and Corporate Bodies.
Recognising the crucial role of Print and Electronic Media consultation was held with
representatives of the media. Press releases were made in the National, State and local Newspapers
both in Kannada and English, requesting the Public to contribute towards the deliberations of the
Task Force.
Experts both within the State and outside were invited to share their concerns and suggestions for
improvement of health. The response has been wonderful. A very large number of persons have
given their views and suggestions. These have been very useful.
Elected representatives are the Policy and decision makers. An interaction- discussion was
scheduled with the MLAs, MLCs and ZP members. Letters were also addressed to all the MLAs,
MLCs and Zilla Panchayat Presidents requesting them to contribute towards the deliberations of the
Task Force. Sri P G R Sindhia, MLA and formerly Health Minister, Karnataka, met the Task Force,
while Sri Kariyanna, MLA, Sri Cheluvanarayana swamy MLA, Sri Chikkamadanayaka, MLA, and
Sri Ramesh Kumar Pande, MLA and Sri NeelakanthaRao Deshmukh Garmpalli, President Zilla
Panchayat (Gulbarga) sent their views in writing.
An attempt was also made to study the policies and provisions for Health Care Delivery in other
States of our country by dispatching request letters to the Health Secretaries of the States and Union
territories of the Union of India.
The Task Force was happy to meet and interact with the Secretary to Health, Indian Systems of
Medicine, Government of India.
ii
The members of the Task Force individually or in groups visited the different districts to interact
and understand the ground realities. Discussions were held with the Zilla Panchayat members, Chief
Executive Officers, District Health Officers, District Surgeons, Taluka Health Officers, Primary
Health Centre staff and the public. In addition, detailed interactions were held with the District
Health Officers and District Surgeons during their monthly meeting. Members of the Task Force
also visited some of the institutions.
The members of the Task Force, individually or in groups, participated in various discussions where
health was the subject for discussion. These were fruitful in expanding the horizon.
The above efforts of the members of the Task Force provided a large body of information and
evidence. The process brought forth various issues and concerns. Some required simple
interventions. Some related to the structural changes and policy decisions. These needed much more
detailed study and have long term implications.
Recognising and realising that each one of us can contribute towards ensuring equity, integrity and
quality in health for all of our people, this Final Report is presented. The suggestions and
recommendations herein have been discussed with the Secretaries to the Government, and the
Directors of Health and Family Welfare, who have to take action to implement them.
The Terms of reference also gives the Task Force the mandate for monitoring the implementation of
its recommendations and the outcome. The Task Force had a number of meetings with the Principal
Secretary, Health and Family Welfare, the Commissioner for Health, Secretary, Medical education
and the Directorates on the progress of implementation of the short term recommendations
contained in the Interim Report. Detailed notes were also received. The Chairman and the Members
of the Task force had visited the District, Taluka and peripheral health care institutions and
observed the changes. The Task Force is happy that the short-term recommendations have been
received serious consideration and many of them have been implemented. (The report on the
implementation, as on March 20001, is given in the supplement to this Final Report).
The Final Report is given with full confidence that the recommendations given herein will be
implemented expeditiously, to bring out marked improvement in the health of the people. The
process of inquiry, consultations followed by action have to continue till the goal of health for all is
achieved.
iii
STRENGTHS AND ACHIEVEMENTS OF KARNATAKA’S
HEALTH SYSTEM
Karnataka has done well in many aspects of Health. But, there have been areas where it has not
performed as well as it might have. Hence, Karnataka has been often described as an “average”
State with respect to the health of its people. There are many strong points of which Karnataka can
be happy about. The Task Force has tried to identify these areas of strengths and build on them. But,
there are also many issues and areas of concern. The Task Force has interacted and deliberated and
will continue to address them. A few key messages have come out of the deliberations, reflections
and suggestions from within the Health System and outside it.
The Government of Karnataka has over the last few decades taken measures to improve the health
and wellbeing of its citizens in line with the constitutional pledges, National Health Policy
guidelines and the State’s own policy initiatives. The Task Force through all its interactions and
reviews to date identified the following areas of strength and health care issues on which the State
has achieved a great deal. By recognising them the Task Force hopes to indicate the context and
base on which a comprehensive and people oriented Health Policy can be enunciated and put into
action.
1. Karnataka State has emerged as having an overall health status and health care delivery system
above the national average inspite of some continued inter-regional disparities.
2. A wide network of Health Care Institutions – primary, secondary and tertiary levels - have
been established in the State on a planned basis using population norms. They provide
comprehensive health care and the services are utilised more by the poor.
3. State policies have fostered the establishment and running of Medical, Nursing and other health
professional educational institutions. A large number of Doctors and Nurses and other health
manpower have been trained. The establishment of the Rajiv Gandhi University of Health
Sciences has brought under one umbrella over 240 educational institutions training health
manpower for the State. This augurs well for the evolution of a more relevant, rational and need
based Health manpower development for the State. Trained graduates from these institutions
whether working in the public / private / voluntary sector have increased access to health care.
4. There has been an overall improvement in the health status of the people evidenced by
•
Increased Life Expectancy at Birth from 26 years in 1947 to 66.3 years for women and 65.1
years for men in 1997.
•
Decline in Crude Birth Rate from 41.6 to 22.7 / 1000 population from 1961 to 1997.
•
Decline in Crude Death Rate from 22.2 to 7.6 / 1000 population from 1961 to 1997.
Infectious Disease
•
Eradication of smallpox, plague in humans, and most recently guineaworm infestation.
•
Control to a considerable extent of Vaccine Preventable Diseases such as polio diphtheria,
whooping cough, tetanus and to a smaller extent measles.
Family Welfare
•
The effective Couple Protection Ratio has increased from 23.8% in 1981 to 57.7% in 1997
5. Some of the other policies and initiatives in the State:
•
The Externally Aided Projects have contributed to the infrastructure available for health
care delivery and to the efficient and effective work cultures.
•
The Community Mental Health initiative in Bellary
•
The State has been entering into partnership with Voluntary Organisations for the more
efficient and effective running of Primary Health Centres.
•
The State has also recently made available anti-tubercular drugs to fight the menace of
Tuberculosis in the entire State.
•
The State has brought out the report on Human Development in Karnataka, 1999
These indicate the growing sensitivity to Health care needs and addressing the formidable
challenges of Equity in Health and Development.
6. Karnataka has in the past regularly invited participatory evolution of Health Care initiatives and
dialogue with professionals and voluntary organisations. The involvement of NGO’s has been
sought in the past in the Development of the perspective plan for Government of Karnataka
(1989-2004); the preparation of the plan documents and brainstorming on other policy
initiatives as well.
7. Perhaps the greatest strength seems to be the increasing openness and receptivity among the
health policy makers – both bureaucrats and technocrats - to ideas and suggestions from a wide
cross-section of professional and public opinion.
ISSUES OF CONCERN AND AN AGENDA FOR ACTION
Over 14 months, the Task Force on Health and Family Welfare, Karnataka has had the benefit of a
very wide range of interactions and discussions with a large number of health care providers,
decision makers, policy makers, representative of professional associations, voluntary and private
sector health care organizations, elected representatives of the people, representative of citizens
groups and the community. These discussions were open and frank, in a sprit of dialogue and very
constructive. Concerns were shared and suggestions and ideas to improve the health care system in
Karnataka were freely given. Many of these have been included in the different chapters included
in the final report.
There are some major concerns and cross cutting themes that affected all aspects and sectors of
health care. These need to be tackled on an urgent and sustained manner through what we have
suggested as an Agenda for Action. Many of these factors are not specific to the health care system
itself. They are also problems of the larger society within which our efforts in health care are
located. Therefore they impinge and distort our efforts to evolve a health care system that is
committed to equity, quality and integrity with a special focus on primary health care and public
health. We need to tackle them seriously.
1. Corruption
Throughout the discussions, the task force was informed through a wide variety of sources of the
widespread and growing ‘corruption’ at various levels of the system and in all aspects and sectors of
health care. This took many forms.
•
Monetary considerations for appointments, promotion and transfer.
(Every level had a price and a hierarchy of amounts depending on importance of job.)
•
Corruption at the time of selection of candidates for educational institutions / programmes
and at the level of examinations.
(The process had become so vitiated that students were now paying not to pass but to prevent
being failed. Even awards and distinctions had a price.)
•
Monetary factors distorting access and utilization of health care services at different levels.
(Whether it is a charge for a sputum cup for a tuberculosis patient, or to get facilities in an urban
or rural health centre; or taluka hospital for an emergency surgery; or even just to see a newborn
baby in a corporation hospital with rates for male babies exceeding that for female babies!
Monetary demands for routine services that are supposed to be free are rampant).
While such widespread corruption is nowadays often passed off as a world wide phenomena; or as
being linked to our political system and its funding mechanism, and so on, it is essential that the
leadership of the state at all levels be committed to tackling this problem and move actively
towards a zero-tolerance level. We have particularly been encouraged at steps including
counselling during recent appointments made after the Interim report, during which monetary
transactions did not play a role.
1
Agenda for Action
a.
We suggest a ‘vigilance system’ in the directorate and health ministry that will monitor and
help proactively counter this widespread problem. (See section on Administration) We believe
there is already political and bureaucratic will, as demonstrated by decisions taken on our
interim recommendations and by the recommendations of the Administrative Reforms
Committee.
b.
We also suggest that senior leadership of the health care system should discuss and monitor
this issue so that a new climate against corruption is built up proactively at all levels.
2. Neglect of Public Health
There is an overall neglect of public health principles and practice in planning, organisation and
management of health care services, and this has shown worsening trend. The neglect is symbolized
by
•
Inadequate emphasis on tackling the determinants of ill health particularly nutrition, water
supply and sanitation, housing, literacy and poverty alleviation, which are crucial to public
health and were even identified as early as in 1946 in the Bhore committee blue print that was
accepted by independent India as a framework for health service development. Further by
compartmentalization of the ongoing efforts in these directions by different departments and
ministries, the intersectoralilty of all these with basic health has been lost.
•
The key to good public health is a robust health information system which monitors both the
health status indicating / problems and health care inputs and outcomes, supported by an
efficient epidemiological, microbiological and entomological surveillance system. Inspite of so
many projects and programmes the quality, reliability and scientific validity of all the data that
is being routinely collected and published leaves much to be desired and is another aspect of this
overall neglect.
•
The overall lack of emphasis on preventive, promotive and rehabilitative care, except
perhaps for some focus on immunization and family welfare and some relatively inefficient
nutritional supplementation is another key factor. Curative care and the increasing privatization
and commercialization has resulted in over 65% of health care being in the private sector today,
mostly unregulated and unrepresented in the State’s ‘health monitoring’ or health planning
systems.
•
In addition health education has been neglected at all levels and rational drug management
policies not adequately addressed.
•
Inspite of the presence of good public health resource persons in the state, public health
cadres have neither been nurtured nor strengthened. Also at different levels of health care,
decision makers with no skill or capacity in public health policy making have been allowed to
make decisions that have therefore supported individualized curative care or the market
economy of medicine, rather than sound public health.
2
Agenda for Action
a. There is urgent need for strengthening public health competence and skill at all levels of the
system to improve health for all without distinction or discrimination. This must include a two
pronged approach.
•
All decision makers at all levels beginning from the medical officer of a primary health
centre to the leadership both technocratic and bureaucratic at the state directorate level,
need to be given short public health orientation and skill development as a ongoing
continuing education process for capacity development.
•
Public health competence through relevant training for Diploma, MD, Masters and
Doctoral programmes should be built up and a cadre of public health consultants /
specialists should be built up who will take over health planning decisions making in the
state over a period of time. These must have the competence to make a broad social –
economic - cultural – political situation analysis of the health and health care situation, and
be skilled in the challenges both technological and managerial, to address the problem
through good team work and empowered community participation.
b. As a complementary action, the agenda with focus on:
• determinants of health;
• comprehensive health information system and surveillance; and
• preventive, promotive and rehabilitative aspects of every priority problem,
must become the sheet anchor for health planning and service development in the
state.
This will again mean a proactive reorientation effort at all levels of health care administration and
in all the training programmes geared to producing health human power for the health care system.
3. Distortions in Primary Health Care
Though the state has promoted primary health care, this has not been well defined at policy level
and has been, additionally distorted by various factors which include:
•
Inadequate efforts to involve the people in the health planning and management process so that
community participation if at all has been very passive and adhoc.
•
Increased verticalisation and selectivisation of programmes at the cost of more integrated and
comprehensive approaches and at the cost of greater flexibility and local planning effort.
Externally aided projects have contributed particularly to this verticalisation and selectivisation.
•
Inadequate preparation to empower the evolving Panchayatraj system to participate and be
actively involved in health decision making at community level.
•
Lack of adequate involvement of general practitioners; local healers and healing systems;
voluntary agencies; NGO’s and civic society and the private sector in complementing and
supplementing the governments primary health care system.
•
Lack of development of appropriate technology and very slow up-gradation of the
technological competence of the health care system at the primary care level.
3
•
Increased compartmentalisation of health care from intersectoral action that is so crucial to
address the deeper determinants of health, and lack of integral linkages with nutrition
programmes including the ICDS scheme; the school system; the cooperative movement; poverty
alleviation and development programmes; water supply and sanitation programmes; and
women’s credit cooperatives.
Not surprisingly the comprehensive concept of primary health care including focus on equity;
appropriate technology; intersectoral action; and community participation has been diluted
or nearly forgotten.
Agenda for Action
a. There is urgent need to reiterate the commitment to primary health care as a core principle of
health care service development in the state at all levels and sectors within the directorate and
the ministry and its associated institutions.
b. There is need to improve orientation and capacity for the promotion of primary health care by
improving quality of primary health services by strengthening human power resources,
maintenance, logistics and supplies and supportive referral systems.
c. Simultaneously the strengthening of the community partnership in the ownership and
management of the programme should be undertaken orienting and involving Panchayatraj
institutions actively in the process.
d. A complementary strategy to involve and enhance the participation of local community
organisations, voluntary agencies and NGO’s; local practitioners of all systems of health care
including folk healing traditions, must be actively promoted.
e. Finally the crucial intersectoral linkages required to address the determinants of health income, gender, literacy, housing, water supply and sanitation and environmental pollution and
make the primary health care system more integrated and comprehensive, must be urgently
promoted
Making primary health care work must be a renewed commitment.
4. Lack of Focus on Equity
There is growing evidence that inequalities in health between regions and districts of Karnataka and
between groups within our society / community are widening and despite some efforts the present
health care system and programmes do not address these inequities adequately.
The inequities identified are
•
The northern districts of Karnataka especially the seven districts (category C) have the lowest
figures for most health, development and social indicators. Certain talukas in some of the
southern districts also show poor development indicators.
•
Rural - urban differentials continue to exist and are also widening.
4
•
Gender discrimination is seen in the continuing neglect of the girl child, the increase in female
foeticide (sex linked selective abortion); continuing disparity between male and female
malnutrition; in violence against women; and in lower access to care.
•
The gaps between the scheduled caste and tribes (SC / ST) sections of the population, and the
rest including other backward castes (OBC’s) continue to exist, in spite of programmes trying
to address this caste / ethnic inequity.
•
Other neglected groups in our society include growing numbers of the elderly; continuing
numbers of working children including increasing numbers of street children; people with
disabilities and a large group of people socio-economically or socially marginalised through a
variety of factors in our society.
Inadequate responses to tackle these continuing or growing inequities is an important concern. The
lack of focus on equity and disparities is further complicated by inadequate monitoring of these
inequities and the continuing lack of disaggregated data to help understand the situation and mount
more focussed responses.
Agenda for Action
a. There is urgent need to address the equity issue by establishing a health monitoring system that
focusses on regional disparities, gender inequalities; class and caste / ethnic inequalities; the
geographical (rural / urban) divide and collects disaggregated data.
b. Equity as a policy imperative must be built into the situation analysis; the goals of the health
policy and health care system, and the monitoring of inputs and outcomes. When equity
becomes a crucial indicator of health care process then suitable responses will emerge in the
health planning and implementation process. Special packages for the seven category c
districts; scheduled castes and tribes; women; and other vulnerable groups are required,
besides an overall focus on improving rural health care. The best administrative and
management expertise must be utilised to work on these areas.
5. Implementation Gap
Over the last few decades the state has invested in public health, primary health care as well as
secondary and tertiary health care. In the last two decades external aid has also been substantially
increased to meet new challenges and widen the focus and outreach of existing programmes. A lot
of efforts have been put into planning programmes and strategies, and implementation guidelines
and manuals of every sort have been evolved. However at all levels and sectors of public health
and primary health care, one sees a widening gap between policy intent and implementation;
between what is professed and what is practiced. This implementation gap is a major area of
concern and a major obstacle to improving the health status of our people.
The ‘gap’ is contributed to by multidimensional factors
•
There is lack of political will in that health is not high on the agenda of governance. Health
budgets are stagnant and often under utilised. The commitment and capacity to get plans off
the ground and reach those who need to be reached is lacking.
5
•
There is overall lack of vision and mission, and perspectives of health are neither
comprehensive nor integrated, with increasing programmatic compartmentalisation that ‘misses
the forests for the trees’.
•
The planning, administration, supervision and evaluation of the health system are poor,
often adhoc and not always evidence based or quality conscious. This is true particularly at
programme, district and subdistrict levels. The work of good people get neutralised with
resulting frustration and demoralisation.
•
Leadership of the department has lacked a problem solving orientation, team building and
team motivating capacities. Lobbies and interest groups work to further their own narrow, short
term interests, at the cost of the greater common good.
•
Individual agendas based on caste or local politics have often predominated over collective
good.
•
The continuation of key and critical vacancies not being promptly filled up has also greatly
contributed to a vacuum affecting implementation. In addition, frequent transfers affecting
continuity and lack of younger people at district level also affects the implementation process.
Surprisingly even in departments and programmes when many of the above factors are not at
play there is a phenomenal apathy further affected by bureaucratic red tape and delays, or the
burden of not taking responsibility that has contributed to this growing mismatch between
plan and implementation.
•
Agenda for Action
a. There is urgent need for a comprehensively articulated State Health Policy which provides the
vision / mission / goals and framework for an integrated health plan that has long term
perspectives built into the system.
b. There is urgent need to raise the status of health on the political agenda and to ensure that
adequate financial and budgetary resources are provided to reach health for all goals, in
keeping with constitutional and health policy obligations.
c. There is urgent need to monitor and improve the quality of health services by increasing
competence of health staff; improving logistic support and ensuring supplies; preventing
duplication and compartmentalisation; strengthening monitoring of quality care and setting
realistic and achievable quality of care standards.
d. There is urgent need to increase accountability and transparency to prevent distortions due to
extraneous influences of the market economy; of lobbies; social and political agendas; and
money power.
e. There is urgent need to nurture competent, committed and capable leadership at all levels to
maintain, motivation, morale and ethical commitment of health personnel at all levels.
6
f. There is an urgent need to introduce a supportive and problem solving, decentralised,
supervisory system so that implementation gaps are constantly monitored and their causes
addressed proactively and effectively.
6. The Ethical Imperative
Over the years there has been a gradual decline in the commitments to ethical values at the
professional level which has allowed the market forces and economic gain to distort professional
values and commitments. In addition there are an increasing number of social developments and
new technologies that have now been included under various legal acts / provisions to ensure that
they benefit human development and not cause harm by misuse, abuse, overuse or exploitation.
The increasing connivance of the medical profession in sex-selective abortion by misuse of prenatal
diagnosis; and the unethical practices, recently exposed in getting donors for organ transplantations
are significant examples of these trends.
Ethics and law which are complementary are crucial for the evolution of a comprehensive health
policy and health care system - the former providing the spirit and inspiration, the latter the
safeguard and framework. If both these are ignored the health care structure will weaken and the
framework will no longer respond to the needs and aspirations of the people. The loss of the ethical
imperative and the disregarding of legal framework and law determined responsibilities is another
contemporary phenomenon which needs an immediate response.
Agenda for Action
a. The state must evolve a charter of citizens rights and rights of patients and participants of
health programmes. These should be distributed widely and people made aware of them
through formal and informal programmes. Provisions under the Right to Information Bill
should be published and utilised.
b. Ethics and law as they relate to medicine and health must be taught as an integral part of
training of all health care professionals at all levels.
c. All health professionals must be made fully aware of all the legal provisions that relate to the
health care system and be conversant with the legal framework, guidelines and implications.
d. Finally some form of monitoring of ethical and legal issues must be professionally determined
and organised and government should support all such endeavours in this regard. Citizens
groups must be part of this.
7. Human Resources Development Neglected
There has been an overall neglect of planning and policy for human resource development and
deployment inspite of the training of an army of health functionaries of all types and at all levels,
through a wide network of institutions including governmental, non-governmental and private
institutions.
This neglect is symbolised by
• A lack of clarity of the capacities and skills required by each member of the team;
• An inadequate estimate of the numbers required to be deployed to enhance the efficiency
and effectiveness of the system;
7
•
•
•
•
The absence of any clarity in policies of nurture, career development or career advancement;
inability to maintain morale and motivation of the health teams;
Little or no efforts at continuing education excepting some adhoc and sporadic efforts for
the doctors;
Lack of clarity in promotion policies; and
The absence of social accountability,
In recent years the commercialisation and the unplanned and unregulated growth of health human
power training institutions - medical, dental, nursing, pharmacy, other systems of medicine etc - has
led to fall in standards, poor quality of training, and infiltration of market values into these
mushrooming network of institutions.
Agenda for Action
a. There is need to urgently develop a state policy on health human power development that is an
integrated part of a comprehensive health policy.
b. There should be well planned estimates of quantum or number of personnel required currently
for every category along with predictions for the next 5-10 years and the norms for recruitment
and deployment including promotion.
c. There should be sound programmes for nurture, career development, skill / capacity training
and continuing education for all categories at all levels. Plans for retraining may also be
required.
d. The trend towards commercialisation and unregulated mushrooming and growth must be
countered by an imaginative HHRD policy which stresses quality over quantity; is competence
based; accountable and transparent and which develops in response to the needs and
aspirations of the people, and not the changing demands of market forces – local, national or
international.
8. Cultural Gap and Medical Pluralism
As identified in the National Health Policy of 1982 there is a major cultural gap between the
aspirations and needs of the people and the culture, personal aspirations, attitudes and work ethic of
the health care system and health professionals who work in it. This is symbolised by:
•
Continuing lack of awareness or sensitivity of the health teams to:
- local health traditions and health centre;
- herbal and folk medicine; and
- the work of the local health practitioners and traditional birth attendants.
This is further complicated by the dominance of one system over others in our training
programmes. This cultural alienation between the health system and the people becomes an
obstacle to work.
•
Lack of a positive attitude towards medical pluralism that affords to all systems and traditions
both respect and an open-minded evidence based scientific approach, promoting dialogue,
debate, sharing of ideas and resources.
8
•
Lack of fruitful dialogue between the organised systems of medicine, inspite of state support to
educational institutions and research of other systems.
•
Lack of a cogent, congruent state policy that considers this rich diversity as an important
resource for health planning and is keen to evolve a framework for integration.
Agenda for Action
a. There is urgent need to strengthen the functioning and development of Indian Systems of
Medicine and Homeopathy and to build up better, working linkages, with potential for dialogue
between the systems moving gradually towards a more integrated and comprehensive health
policy utilising the potential of all these systems at different levels of health care, particularly
primary health care and public health.
b. At the community level there is urgent need to bridge this cultural gap by making health teams
more sensitive to people’s needs, life situations, belief systems and aspirations and building
primary health care systems and the new public health systems with the full and enthusiastic
involvement of the members of the community as empowered participants not passive
beneficiaries. This paradigm shift in the dialogue between professional medical culture and
peoples health culture is urgently required.
9. From Exclusivism to Partnership
The health planning and monitoring efforts of the directorate focused only on government health
care. This view is too limited and is particularly a matter of concern when it is common knowledge;
people's experience; and now researched evidence; that apart from the government there are a large
number of other groups who contribute significantly to primary health care and also substantially to
secondary and tertiary health care as well. This includes local community organisations and
schools; village cooperatives and women, youth and farmers clubs; voluntary agencies and NGO’s;
the private sector including both general practitioners and the corporate sector; and the large
‘mission’ sector in health care as well. This isolationist and compartmentalised attitude which
ignores the contribution of all other groups / sectors must change radically if the substantial gaps in
health needs and health responses have to be bridged.
Agenda for Action
a. There is urgent need for a comprehensive partnership policy that must enable the health
secretariat and health directorate to continue to play the key leadership role in health care
along with proactively designing and operationalising functional partnerships with all these
sectors and groups.
•
These partnerships should be well planned, well regulated, well supported and committed to
predetermined primary health care and public health goals.
•
The policy should ensure accountability and transparency of the partners and their
supportive supervision, public health orientation and commitment to quality.
•
Like the government programmes these new partnerships should also move towards
community empowerment and increase the ownership and participation of the community.
9
10. Ignoring the Political Economy of Health
Over the last decade neo-liberal economic policies have been promoted at both international and
national levels. New international trade related agreements like WTO, TRIPS and others are
affecting the economies and development strategies of many developing countries. Structural
adjustment programmes and conditionalities linked to international development assistance are
geared towards reducing social sector spending, removal of subsidies, greater privatisation and
contracting out of services. Within the country, new economic policies that favour globalisation,
liberalisation and privatisation are also affecting the marginalised sections of society inequitously
with widening disparities between classes, between districts and within regions. All these new
economic trends adversely affect various aspects of health care delivery systems, with reduction or
stagnation of public sector and public health budgets; rise in prices of drugs and diagnostics;
contraction of the public sector; the potential impact of WTO and change in patent laws on
pharmaceuticals and health care options; increasing corruption and scams; and the impact of all
these factors on public health and access by poor to health services and medical care
An important concern is that there seemed to be no group at the state level which was monitoring or
studying the political, economic, social, institutional dimensions of these new trends and their
impact on health. This is an urgent imperative.
Agenda for Action
a. There is urgent need for a multidisciplinary, intersectoral resource group to study the impact of
all these new economic trends on the health of the poor and the public health and primary
health care goals of the state. This group should not only monitor these trends but also suggest
counter strategies and policy responses as well.
11. Research
Finally one of our greatest concerns was that ‘research’ of any type – basic or applied; biomedical
or socio-epidemiological; field research or action research and operational research was totally
neglected in the health sector. In spite of large numbers of ongoing programmes including over ten
externally aided projects the focus, the commitment, the outlay, or the importance given to research
was surprisingly poor. Research seems to have become a very neglected, under funded activity
reflected in the overall poor quality, efficiency or effectivity of health care programmes and
initiatives. A radical and renewed commitment is urgently required, since it is through ‘research’
and objective enquiry that the strengths and weaknesses of our existing system can be identified,
and only through research can evidence based solutions emerge.
Agenda for Action
a. There is urgent need for a multidisciplinary research programme to be initiated so that the
study, monitoring, evaluation and problem solving approaches to health care development can
be greatly strengthened. This programme should be very strong on behavioural and the social
sciences and not just be biomedically oriented.
10
b.
Research by the Rajiv Gandhi University, the medical and other professional colleges; the
department of social work, sociology, psychology of the university and NGO’s and health policy
resource groups and consumer groups and civic society should be encouraged, and supported.
Greater linkages between the health care system and these research projects would help to
generate more evidence-based support to change and improve health services.
12. Countering the Growing Apathy in the System
While all the above factors seem more tangible with definitive agendas for action, the greatest area
of concern is a growing apathy and cynicism in the health care system. Many enthusiastic members
of the health team at different levels have become more passive and even cynical, due to
unfortunate experiences of corruption, political interference, lack of accountability and
transparency; routinisation of effort and loss of meaning and a growing cynicism in the larger
society. This seems to have reached very substantial proportions. The task force process because of
its interactive discussions and its wide range of dialogue has helped to address this apathy and
cynicism (which had developed over years) and may have created a short term break through, by
providing a large number of people in the system with
• a stake in a change of the system;
• a hope in a more concerted effort to tackle problems;
• a vision for a more people responsive health care.
However unless this inspirational process is maintained and the process of dialogue and
involvement enhanced and sustained, all the cross cutting concerns may never get adequately
addressed.
Agenda for Action
a. Therefore the most important agenda for action is the nurture and sustained support to the top
health sector leadership. Vision, capacity and enthusiasm must over ride the seniority factor or
the caste politics linkages.
b. There is need to nurture visionary leadership at other levels that can improve the morale and
motivation of the health teams and move them from cynicism and apathy, to enthusiastic team
work, so as to reach primary health care and public health goals and to meet the aspirations of
the people.
This is both a challenge and an urgent imperative.
11
INTERIM REPORT AND ITS IMPLEMENTATION
" I never did anything worth doing by accident,
nor did any of my inventions come by accident,
they came by hard work."
- Thomas. A. Edison
The Task Force on Health and Family Welfare, Government of Karnataka, had given in April 2000, an
Interim Report, with short term recommendations. These were expected to be implemented within 6
months. The Task Force had also been given the responsibility to monitor implementation. The terms of
reference included the following:
"The Task Force shall not only make recommendations with regard to the above issues but is also
expected to monitor the impact of the recommendations especially in the initial stages of implementation".
The Task Force had been monitoring the implementation of the short term recommendations through
•
Periodical meetings and discussions with the Principal Secretary, Health, the Commissioner for
Health, the Secretary, Health, the Commissioner for Health, the Secretary, Medical Education, the
Directors and other Officers in the Directorates of Health and Family Welfare, Medical Education,
Indian Systems of Medicine and Homoeopathy and other allied areas, and the Project Directors of
Karnataka Health Systems Development Project, IPP VIII, IPP IX and other concerned officers;
•
Visits to Government health care institutions, primary, secondary and tertiary and discussions with the
officers and others;
•
Discussions with members of the public and organisations and associations concerned with the
improvement of the people of the State.
The Task Force is very happy with the responses of the officers of the departments, who have given their
reports on the implementation of the short term recommendations, either verbally or in writing. The
detailed report on the action taken is given in the supplement to this Report, but a few of the more
important ones are given here:
-1-
Sl.No.
1.1
1.2
1.3
Recommendations
Action Taken
1. PRIMARY HEALTH CARE
RURAL HEALTH CARE: All vacancies Currently there are only 141 vacancies of doctors
of Doctors, Laboratory Technicians and in PHCs, after filling up most of the vacancies
ANMs at PHCs and Sub Centres must be through KHSDP. 403 doctors have reported for
filled up immediately
duty out of the 568 appointments made.
Directions have been given by Government to all
DCs to fill up these vacancies on contract basis.
Govt. has also notified the recruitment of 550
more GDMOs.
The DCs have appointed 380 Lab. Technicians
on contract basis out of 946 posts sanctioned by
the Govt.
With regard to ANMs, out of the total sanctioned
10255 posts, 514 posts are vacant. 124 ANMs
were working on OOD basis in various
institutions under the control of Indian Systems of
Medicine, Bangalore. The services of these
candidates are withdrawn and are posted in
vacant places of this dept.550 vacancies will be
filled up shortly after the trained candidates are
made available from the training institutes of the
dept. There is also a proposal to fill up these
vacancies by taking staff nurses as ANMs on
contract basis.
Applications have been called for the following:
550 Medical Officers, 80 Dental Surgeons.
Government has also recently created 100 new
posts of leave-cum-reserve Doctors.
All key staff, including Doctors, Staff
Nurses / ANMs and other essential staff,
attached to the Primary Health Centres must
stay in the quarters. Where repairs are
necessary they should be carried out
immediately; where there are no quarters,
action may be taken to construct them; if
quarters are not available, houses may be
taken on rent;
The allotment for Essential Medicines
(including Life Saving Medicines) must be
increased by at least Rs.25,000/- per annum
-2-
CEOs / DHOs have been asked to initiate
disciplinary action on Doctors and the staff who
are not staying in the head quarters.
An amount of Rs.200-00 lakhs is provided for
2001-02 for construction of Medical Officers
Quarters. Wherever Govt. accommodation is not
available, to meet the rent and other expenditure,
doctors will now be entitled to Rs.1000 per month
as special allowance.
G.O has been issued increasing the allotment as
recommended. Action has been taken to supply
drugs after preparing the list of essential drugs
per PHC. All Essential drugs must be required by PHCs.
available at the PHC at all times.
1.4
PHC must have a Telephone
1.5.
Atleast 1000PHCs in the State must be Lab equipment worth Rs 50 lakhs (Rs.5000/- per
made fully functional satisfying the above Primary Health Centre) was finalised and the
criteria, within the next 6 months
procees of supplying it is being completed.
Rs.200.00lakhs worth of supplies has been
proposed through KAPL. In addition, through
IPP-IX, essential furniture and equipment is also
being supplied to fill the gaps.
REFFERRAL SERVICES - Secondary
and Tertiary Health Care:
Complete the Secondary Care Institutions in KHSDP has completed 105 Secondary Care
progress under KHSDP (100 Secondary
hospitals in all respects. Action has been initiated
Care Hospitals) in the next Six months and
to make them fully functional. A final decision on
make them fully functional with adequate
the management lease to a non-Profit
Human power, equipments and accessories. organisation for the OPEC Raichur Hospital is
The OPEC Hospital in Raichur must be
expected shortly. KHSDP has also initiated steps
made functional as early as possible. Work for establishing an effective referral system from
out effective linkages of Primary Health
PHCs to Secondary Level Hospitals.
Care Institutions with the referral hospitals.
EMERGENCY HEALTH SERVICES
Improve the capability of the Health Care The Medical personnel at the Primary Health
Personnel at PHC to attend to emergencies. Centre are capable of treating Dog bite and Snake
The Emergency services should also cater to bite cases. Adequate stocks of ARV and ASV are
all emergencies, including Obstetric and being supplied to Primary Health Centre's
through District Health & Family Welfare
Gynaecological cases, poisoning cases and
Officer's.
Dog and Snake bites. Polyvalent anti-Snake
Venom Serum must be made available at all
PHCs at all times as a life saving measures.
1.6
1.7
1.8
1.9
DHOs have been addressed on 17/2/2001 to make
arrangements for provision of telephones.
Already 555 PHCs have telephone facilities and
several Zilla Panchayats have taken action to
install telephones.
Well-equipped Ambulance Vans with welltrained paramedics must be positioned on
the National and State Highways to attend
to accidents. Network the Trauma Centres
with the Taluka / District Hospital; with
adequate Communication facilities. Sanjay
Gandhi Accident Hospital and Research
Institute and NIMHANS to be the nodal
Centres.
LABORATORY SERVICES
All laboratories must be staffed with trained
technical persons and equipped with the
necessary instruments, accessories and
reagents. Fresh appointees must be given
-3-
Karnataka Health Systems Development Project
is addressing this by establishing 40 Trauma Care
Centres. Sanjay Gandhi Accident Hospital and
Research Institute and NIMHANS are referred as
State Level Referral Centres for Trauma Care.
880 laboratory Technicians have been recruited
on contract basis and all these laboratories are
equipped with necessary articles and laboratory
wares. Information regarding number of Lab
orientation training before posting and Technicians who are working and newly recruited
existing staff should be given refresher in all PHCs has been collected Training
Programme has been chalked out with syllabus,
training.
Trainers training for DSO's and Senior
Laboratory Technicians have been given in 2
batches of 3 days each in the months of August
and September 2000 who in turn are imparting
training to both the existing and newly recruited
lab technicians in all districts of the State.
1.10
1.11
1.12
2.1
2.2
The PHC laboratories must provide prompt
and efficient service for the diagnosis of
TB, malaria, leprosy and RTI/UTI; other
routine investigations must be available.
At present leprosy diagnosis is a vertical
programme and leprosy slide examination is not
done at Primary Health Centre. However, PHC
has taken up training of lab technican, and they
are given training in leprosy slide examination by
the leprosy officer.
After integration of NLEP, the lab technician will
do the leprosy slide Examination at PHC as the
staining material is same as of TB.
Rs. 200.00 Lakhs for purchase of Chemicals
Rs. 30,000/- per PHC to be initially
Glassware's equipments, Microscopes for 1000
earmarked for the purchase of Microscopes PHCs has been provided in the supplementary
(about Rs. 15,000/-), glassware, equipment, budget for 2001other accessories and reagents.
The Department is contemplating to procure the
chemicals, Glasswares, Microscopes and other
equipments for use in about 1000 PHCs in the
State from M/S. Karnataka Antibiotics and
Pharmaceuticals Ltd. Bangalore
BLOOD BANKING AND
TRANSFUSION SERVICES
The eight districts in the State which do not
have a Blood bank to have atleast one blood
bank each.
The Blood Banks as per the statutory needs have
been sanctioned to all the District and Major
Hospitals in the state. Blood Bank in U.K. district
has started. In Kodagu, the Blood Bank Officer is
under going training and functioning of the Bank
will commence soon. In the remaining districts,
Blood Banks will be started after the completion
of the buildings under Karnataka Health Systems
Development Project.
2. PUBLIC HEALTH
Human Resources for Public Health
A short two week course on Public Health
The programme has been initiated. Training has
principles and practice for Taluka and
been completed for two batches.
District Health Officers at the State Institute
for Health and Family Welfare. Short inservice orientation courses on public health
principles and programmes for PHC
Medical Officers.
Structural Issues in the Public Health
System
A review of the Externally Aided Projects
KHSDP has already commissioned a study.
to be initiated to facilitate their absorption
Sustainability Plans are being developed both for
-4-
into the Health System. Sustainability and
consolidating the gains/ achievements to be
the primary objective.
2.3
2.4
2.5
2.6
2.7
KHSDP as well as IPP-VIII and IPP-IX.
NUTRITION
Define and establish the items of At present Monthly Monitoring reports are
coordination between the Health Sector and collected form CDPOs through medical froms.
On ICDS Projects, the reports are received at the
ICDS. These must include:
Directorate of Health & Family Welfare Services
(a) mechanism to detect, take corrective and consolidated report on items like Nutritional
steps and monitor children with mild to status of children, vital events, number of ANC's
visited by Medical officers is prepared and
moderate undernutrition.
feedback is sent to DJD/DHFWOs every month.
(b) coordination in detecting and treating Regular Joint review of the programme is done at
infectious
diseases
in
children, the Sectoral level, lock level & District level
especially diarrhoea, skin and ear every month at the Divisional level, where
infections with appropriate care.
officers from the both the departments of state
level also participate.
In some projects reformal services are well
established and children are being adopted for
providing treatment for different diseases.
Systematic promotion of kitchen gardens Women and Child Development, Health &
supported
by
seed/seedling
supply. Family Welfare Departments have initiated
Drumstick, Chakramuni (Chikermane), discussion with Horticulture Department.
Amaranthus, Papaya, local beans, are some
examples.
Upgrade the post of Deputy Director of
Nutrition (Dept. of Health) to Joint Director
and expand the role and job description of
the JD to fulfill the responsibilities and
implement and monitor Nutrition
programmes.
WATER SUPPLY AND SANITATION
Ensure regular water quality testing
facilities in all the districts. The monitoring
to be facilitated and coordinated by the
District Surveillance Units. The PHC and
Taluka Medical Officer should visit all
sources of Drinking Water periodically.
The post has been upgraded and job description
of the Joint Director includes monitoring of all
nutrition programmes.
District Surveillance Units are functioning in all
districts. Analysis of drinking waters is
undertaken. Samples are received from the
peripheral institutions also. Instructions to
districts to visit all sources of drinking water have
been issued.
WASTE MANAGEMENT
Ensure proper segregation of Waste and Action has been taken under the KHSDP Project
total waste management at all health care in all Secondary Level and district teaching
hospitals.
institutions.
-5-
2.8
Initiate orientation and training of Health Action has been taken for training and workshops
Care Personnel for proper waste on waste management under KHSDP.
management practices including practice of
Universal Precautions.
2.9
The government should support initiatives
for common waste management treatment
facilities.
2.10
COMMUNICABLE DISEASES
Sputum (TB) and blood smear (Malaria)
results on every sample to be reported
within 24 hours of specimen collection; 5%
random sample check by supervisory staff.
Induction training and refresher course of
Laboratory technicians by rotation.
Action has been taken in Hospet as a Pilot
Project. In Bangalore city dialogue has been held
with BMP.
Results of Sputum examination are given on the
same day. Random check is done by supervisory
staff (100% of positive smears and 10% of
negative smears). Training is provided.
As per guidelines of Govt. of India (NAMP) the
time lag between collection of blood smears and
administration of Radical Treatment should not
exceed 10 days. There are 1237 Jr. Laboratory
technicians in order to make the peripheral
laboratories functional. Hence, quick examination
of blood smears, detection of positives for
Radical Treatment has been ensured. As per the
guidelines of NAMP, Central Malaria Lab is
crosschecking 3% and regional office is checking
1.5% of the slides.
For induction training to the newly recruited
laboratory technicians in the State, KHSDP
organized a 6-day trainer's training programme
for the trainers of the districts during August
2000 and they in turn are imparting training for
21 days in their respective districts. The Regional
Directors, Government of India, Bangalore is
conducting the refresher course training is under
Enhanced Malaria Control Programme.
2.11
One Day Workshop each for Tuberculosis
and Malaria to help the rational
implementation and vitalise the TB control
and Anti-malaria programmes in the state.
The participants to include State and
District Officers and all Professors of
Medicine of all Medical Colleges in the
State and representatives of all relevant
-6-
The State level and district level officers are
being trained every year by the Directorate of
NAMP, Delhi and course is for 1 month.
Nominations are being sent from this Directorate
every year, as and when called for.
One-day workshop was held up on 18.8.2000 at
NTI for teachers of Medical Colleges, doctors
working in major hospitals and sanatoria. About
52 doctors participated.
Sensitisation programme for districts arranged on
25-9-2000 to 26-9-2000 for RNTC districts.
Another workshop is proposed with participation
of Task Force Members.
Professional Associations.
2.12
NON COMMUNICABLE DISEASES
Diabetes Mellitus
All PHCs to have facilities to detect and
manage / refer patients with Diabetes.
On 15-9-2000 a meeting of District Health and
Family Welfare Officers of Five districts along
with leading Diabetologists was held and
instructions to conduct training to medical
officers, paramedical workers, social workers,
and public was issued. Given Budget of Rs.5/lakhs is allocated to five districts i.e., one lakh to
each district (Dakshina Kannada, Hassan,
Chitradurga, Bellary and Belgaum.) it was
decided that in the above districts where medical
colleges are available, the programmes for
training will be taken up. Printed Books have
been supplied to the above districts.
2.13
Mental Health and Epilepsy
The Community based Mental Health
Programme in Bellary District should be
strenghtened.
Train
Primary
Care
physicians and paramedical workers in the
diagnosis and management of epilepsy.
Make available the needed drugs
(phenobarbitone and phenytoin) without
break, through the Primary Health Centres.
Under the Mental Health and Epilepsy
Programme three types of clinics are conducted.
1. Districts Mental Health Programme in
districts of Kolar, Bijapur, Mysore,
Chitradurga, Bellary and Gulbarga.
2. District Mental Health Clinics are conducted
in Bijapur, Karwar, Mandya, Chitradurga,
Chickmagalur, Kolar and Raichur.
3. With the assistance of NIMHANS, clinics
are conducted at Maddur and Mudhugiri,
Anekal, Jigani, Gowribidanur.
With the help of District Health & FW
Officer's, doctors are being trained to treat
them at village level.
Phenobarbitone and Phenytoin are already
supplied.
2.14
Improve the facilities and conditions in the NIMHANS proposal was examined and the
Karnataka Institute of Mental Health, Institute of Mental Health, Dharwad has been
Dharwad which should continue as the provided with improved facilities.
major speciality institute with autonomy in
governance.
2.15
Cancer Control
Downstaging of Cancer Cervix programme
to be initiated on priority.
-7-
Project for 200 PHCs has been initiated along
with St. John's Medical College and NGDS.
2.16
3.1
Oral Health: All Taluka hospitals to have As per Government order No. Health and Family
Welfare: 2:HSD:2000 dated 26-08-2000, 113
qualified dental surgeons.
Dental Health Officers were appointed and
vacancies filled up in various Taluk Hospitals and
other hospitals. All the Taluk Hospitals have
dentists excluding 25 Taluk Hospitals. These
vacancies can be filled up only after fresh
recruitment. Applications have been called for 80
more dental surgeons.
3. MATERNAL AND CHILD HEALTH
Increasing the skills of ANMs in the CAN
ANMs are being trained in assessing community
methodology. Revision of the existing
needs and calculating the subcentres
training syllabsus to incorporate enhanced
requirements. Subcentre action plan is being
technical and communication skills.
prepared by the concern ANM under the
Sensitisation regarding the importance of
supervision of LHV/BHE.
the timing, spacing and number of births,
and exclusive breast feeding for the first 6
Continuing Education to ANMs is being
months.
continued.
Mothers meetings are being conducted by
involving MSS members, trained Dais, NGOs,
stressing on the important of spacing, birth timing
and importance of exclusive breast feeding for
first six months. For 2000 – 01, action was taken
to prepare the plan and RCH Officers were given
training. Two workshops have been conducted
for SOS and DNOs.
3.2
The role of Dais in safe deliveries should be
supported
and
training
enhanced.
Disposable Delivery Kits of good quality
cost effective components should be
provided.
Out of the 31540 Dais in the state, 25940 Dais are
trained in conducting safe deliveries. Remaining
5600 Dais are to be trained.
Proposal and action plan to train 2600 dais 'C'
category districts during the year 2000-2001 is
under implementation.
The remaining 2000 dais in category B districts
will be trained in 2001-02.
The procurement of SSDK (Good quality cost
effective) is under progress. Orders have been
issued.
3.3
Where services of ANM are not available,
the AWW to be trained to undertake the
specified activities till a regular ANM is
posted.
Action taken in 'C' category districts including
sub project, Bellary. Government Orders have
been issued for payment of additional incentive in
this regard and the order has been implemented.
3.4
Ensure 100% registration in the first
trimester, proper antenatal, natal, and
postnatal care with involvement of Private
Sector.
Attempts are being made to ensure 100%
registration in the first trimester and also
involvement of private sector has been initiated in
Bellary district utilising the services of FOGSI
members.
3.5
Ensure uninterrupted supply of IFA at all
Attempts are made to ensure uninterrupted supply
-8-
times at all Health Care Institutions.
of IFA tablets.
3.6
Ensure 24-hour delivery services at FRUs
with involvement of Private Sector.
Action taken to ensure 24 hour delivery services
at FRUs. Where the Obstetricians and
Gynecologist are not available, utilisation of
services of OBG specialist from private sector has
been proposed and approved.
3.7
A Pilot Project has been taken up in the
Clinics are been conducted by FOGSI members.
district of Bellary with proactive
involvement of FOGSI. The identified
FOGSI members would undertake
Antenatal Clinics for those at high risk
within a radius of 10 Kms from the FRUs,
complement the available services in Public
Hospitals and also involve in Training
Programmes.
4. POPULATION STABILISATION
A Population Policy as part of the Decisions of Population and Development
comprehensive Health Policy will be Commission is under consideration and will be
drafted for wider discussions for eliciting examined further on receiving the Draft Health
public and professional opinion.
Policy from the Task Force on Health.
4.1
4.2
5.1
5.2
5.3
5.4
Commence a strong IEC programme Regular IEC programme is under implementation
regarding the health hazards and social ills with IPP-IX and Family Welfare Fund.
of early marriages, the need to raise the age
at marriage and advantages of postponing
the second child.
5. WOMEN AND HEALTH
Sensitise all Health Care Personnel on
Specific programmes under formulation to
issues relating to gender inequalities.
promote gender equity. The programme is
integrated into general health services to improve
effectiveness.
Educate and promote personal hygiene
especially during menstrual period by the
distribution of subsidised menstrual
pads/cloth.
Services of Lady Medical Officer to be
available at al Primary Health Centres.
Government Order is issued. Supply of kits is
under process.
30% of posts are reserved for LMOs. Ongoing
efforts are made to post more number of LMOs to
PHCs.
Improve diagnostic, medical and counseling FHA camps are being held twice a year for
services for STI & HIV/AIDS for women as providing RTI / STI treatments and counseling
with special focus on women. The next FHAC
well as the sexual partner.
will be held between 16th to 30th April 2001.
6. PERSONS WITH DISABILITIES
6.1
Utilise Media to create awareness and A comprehensive media plan is under
-9-
training of parents and other care-givers on formulation
specific disabilities.
7.1
7.2
8.1
9.1
9.2
10.1
10.2
7. TRIBAL HEALTH
Strengthen the Mobile Health Units and the It is proposed to activate the existing ten mobile
PHCs in the Tribal areas and make them all units in tribal areas out of IPP-IX funds. Proposal
has been submitted to the govt. for infrastructure
functional.
and full fledged staff for all Primary Health
Centre's sanctioned in tribal areas.
Strengthening of the Tribal ANM project.
This is being done.
The current batch of 27 needs to be posted
on priority and a fresh batch of training to
be initiated.
8. SCHOOL HEALTH
Initiate action for greater coverage of all Action Plan is already prepared is made available
students in all the schools in the state with to the all District Health & Family Welfare
health (including Dental) checkups and Officers for implementation. It is being
health education. Train students in First implemented now. The students have been
examined by Senior Health Assistant with the
Aid.
help of Junior Health Assistant. The programme
is being reviewed every month at the district and
at the Directorate. Dialogue has taken place with
the education department to strengthen the
programme further.
9. HEALTH HUMAN RESOURCES DEVELOPMENT
Redeploy teaching and non-teaching staff 133 lecturers have been recruited.
according to the needs.
Increase the intake for the training of
Attempt will be made to increase the capacity of
Auxiliary Nurse Midwives (ANMs)
ANM training students from 30 to 40 per batch.
Encourage NGOs with the capacity for
Proposals for 7 new ANM training centres in new
training to take up the training of ANMs.
districts is under examination.
10. ADMINISTRATION
The process of regularisation of the contract Proposal for regularisation of services of 342
Doctors on Contract Basis, out of 400 Doctors
doctors to be commenced.
who have completed 3 years of service, has been
submitted to Govt. The balance of 58 posts to be
selected under K.H.S.D.P. 592 Contract Doctors
will be considered for regularisation after their
completion of 3 years of service.
A transfer Policy to be evolved on the basis
of well-defined criteria, and implemented.
The criteria could include a) a three to five
year limitation in a particular post or place,
b)a compulsory posting in the rural post
(ensuring that positions in the less favoured
areas such as Northern Karnataka are
particularly covered) , c)postings to the
urban areas being available as seniority and
- 10 -
During General Transfers 2000-01, as far as
possible doctors are posted according to their
speciality. There is a proposal to reduce the rural
services from 6 years to 3 years for PostGraduates, to facilitate the postings to Taluks and
District Level Hospitals.
personal
responsibilities
increase,
d)transfers
of
primary
health
center(including subcentre) staff should be
preferably be within the district. In making
transfers the mismatch between the
qualifications of the officer and those
required for the post should be corrected.
The principles adopted by the Education
department would provide useful guidelines
10.3
The selection of In-service Doctors for This is being done.
postgraduate courses to be based on the
needs of the Department for quality health
care.
10.4
The practice of postings of officers OOD
should be kept to the bare essential. This
would ensure that postings based on
individual preferences or to avoid transfers
are minimised.
The practice of posting of the Officers on OOD is
kept where there is urgency and utmost necessity
and in order to keep the programme functioning
continuously. Directions will be issued to Chief
Executive officers to obtain concurrence of Govt.
whenever postings of officers on OOD basis are
required to be effected.
10.5
The role and responsibility of the
Commissioner, Health and Family Welfare
may be defined (as in the Annexure)so as
to enable him to function efficiently.
Government Order issued on the lines
recommended.
11.1
12.1
12.2
13.1
11. PLANNING
A suitable structure for the Planning Unit in Manpower Planning Study initiated
the Directorate, and descriptions of its
functions to be prepared to address the
issues of long time, 5 year and annual plans,
the Physical, Financial and Human
resources Plan.
12. FINANCING
Additional resources to be provided during Additional funds were made available to an
2000 – 2001 to carry out the reforms extent of Rs.10 crores during 2000 – 01.
suggested.
Monitoring of expenditure, especially plan The monitoring system is in place in the
programmes to ensure adequate utilisation Directorate as well as at the state level.
and results must be done.
13. HEALTH MANAGEMENT INFORMATION SYSTEM
An integrated Geographical Information Action has been initiated. Personnel and disease
System based HMIS to be initiated and reporting modules are finalised. Work on
Geographical Information System has also been
implemented.
initiated.
- 11 -
13.2
All the District Health Offices should be Action is being taken to train staff through IPPcomputerised for efficient management and IX and KHSDP. Computers are also being
supplied.
control of Health System in the district.
13.3
The formats / registers needed at various Action has been taken to print adequate reporting
levels to be updated, printed and supplied in formats.
adequate quantities and on-time.
13.4
Annual reports and monthly updated The Annual Report of the year 2000-01 will be
programme performance to be placed on placed on KHSDP web site.
website of the Directorate.
14.1
14. MEDICINES PROCUREMENT AND SUPPLY
RC List for 2001- 2003 is prepared. Tender
The Rate Contract System
process has been initiated.
a) to be based on the exhaustive list
incorporating the features of the WHO
and the National Essential drug list;
b) if there is no bidder for any essential
drug, suitable alternative arrangement
to be delineated for purchases to be
made.
14.2
The RC should specify the total requirement To get the yearly requirement of drugs a circular
of the drugs for the entire State including has been sent on 19.7.2000 to all the institutions.
that of ZPs and include all sources and not
just 40% of the GMS quota.
14.3
The ZP or any other drugs procurement A Circular has been initiated to all institutions to
agency for Government Health Care implement the same.
Institutions in Karnataka should restrict to
the drugs listed in the RC. Exceptions to be
made with not greater than 10% of the
allocated norm.
15.1
16.1
16.2
15. LAW AND ETHICS
The legislation introduced in the Legislative Original bill had several lacunae and is being
Council to regulate the functioning of withdrawn. The revised bill suggested by the
Health Care Institutions should be sent to a Task Force is under examination.
Select Committee to elicit views from all
concerned (stake-holders, professionals and
public).
16. INDIAN SYSTEMS OF MEDICINE AND HOMOEOPATHY
Plan and initiate planning to have ISM&H Pilot initiative undertaken in Mandya district
wings in the existing District / Taluka hospital. Implementation of the same at the other
district hospital is being considered.
hospitals.
The drug licensing authority should ensure
- 12 -
This is being followed and monitored strictly.
16.3
the printing of the date of manufacture and
date of expiry of drugs on the containers.
The budget allocation per dispensary should The budget to PHCs has been enhanced and the
drug supply increased.
be increased to Rs. 36,000/- per annum.
16.4
The stipend for the Interns
Postgraduates to be enhanced.
16.5
Steps to be taken to conduct Entrance Tests The system has been streamlined and the work
has been entrusted to Rajiv Gandhi University of
for selection to Postgraduate courses.
Health Sciences.
17.1
18.1
18.2
18.3
and The stipend has been enhanced.
17. PANCHAYAT RAJ AND EMPOWERMENT OF PEOPLE
The Gram Panchayat should appoint a
Anganwadi workers are being asked to perform
woman health functionary at Villages,
this role at the village level, where there is no
where there is no ANM or Anganwadi
ANM posted, in category 'C' districts.
worker for the management of Health,
Nutrition, Drinking Water and Sanitation,
Population. This could be initiated atleast in
a few districts where Human Development
Index is low.
18.STRENGTHENING PARTNERSHIPS
Involve organisations of doctors in IEC
IMA and FOGSI are being extensively involved
activities and national programmes.
in all the national programmes
Provide drugs and vaccines in the national This has been accepted for the TB programme.
programmes to the private practitioner for
the benefit of the economically poor.
Tertiary hospitals in Private sectors to also Tertiary hospitals are being involved in the
provide training programmes for the training of doctors.
government doctors.
The Task Force on Health and Family Welfare wishes to thank all the persons concerned for the action
taken. It is hoped that the Final report will also be dealt with the same spirit and action will be taken
without any delay, so that people’s health, and especially the health of the disadvantaged, becomes a
reality.
- 13 -
1. EQUITY IN HEALTH CARE
Equity is fairness. The principle of equity in health is rooted in the recognition of health as a
human right. Equity requires the elimination of unnecessary, unjust and avoidable differences in
the opportunity to enjoy health and having similar opportunity to meet the needs in case of being
ill or incapacitated. There has to be access to and utilisation of services according to the needs.
The equity issue has been uppermost in those countries interest in ensuring reduction in
inequities in health, e.g., U.K. After the Black report 1980 (Douglas Black: Working group on
Inequalities in Health, setup in 1977) efforts had been made to reduce the inequities. Due to
political changes, dilution occurred in these efforts. Recently a new committee was set up,
chaired by Donald Acheson (Independent inquiry into inequalities in health). The terms of
reference were:
1. Summarise the evidence of inequalities of health and the expectation of life and identify
trends.
2. Identify priority areas for future policy development to reduce health inequalities.
Definite links had been established between health and wealth (income), and between health and
social class.
Recently (2001), the High Power Committee for Redressal of Regional Imbalances, chaired by
Prof. D.M. Nanjundappa, has submitted its first phase of recommendations. This is based on
general backwardness and imbalances.
It is necessary that the State sets up a committee to go into the broad nature of inequalities in
health and their determinants, as also what can be done, especially what can be done by the
health system.
Equity in health requires that
•
Health care services should be accessible to all the people equally; it should not be less
accessible to disadvantaged populations in the State than the services to the better off areas
or regions (districts, talukas, municipalities or villages) or on the basis of gender or socioeconomic or other considerations (a pro-poor and pro-disadvantaged people policy);
•
Health care services to the disadvantaged people are not of poorer quality (primary health
care and referral services);
•
Allocation and application of resources (human, financial and material) are in relation to the
health needs of the people (re-distributive health spending based on people's needs);
•
Positive efforts are made to reach those people in the State whose health is worse;
•
Emphasis has to be on public health whose benefits are shared more equally by all sections
of the society.
-1-
Inequities in access to health care may be due to supply and demand factors: geographical
(regional) distribution, availability of health care personnel, range and quality of primary care
facilities, levels of training, timing and organisation of services; distance to the first contact of
care, availability and affordability of communication and transport. Added to them is people's
awareness of the services available locally and on referral as also the social and economic
influences.
While discussing health status (indicators of health), we take averages for the State or district. It
is necessary to have disaggregated data based on gender, age, socioeconomic status,
geographical location, and other factors. There are various other criteria: widows, widowers,
elderly men and women, persons with disability and orphaned children. These categories of
persons need greater care. Having the same care will not ensure equity.
How to measure equity?
1. Access to health care services: physical, based on distance and time; number of first contact
health services providers, referral services.
2. Utilisation of health care services. Do individuals with the same type of health problem get
similar treatment, whatever be their socio-economic status?
3. Health outcomes across different groups
4. Public expenditure on health.
5. Mortality and morbidity indices (infant mortality rate, under-5 mortality rate, maternal
mortality rate, life expectancy at birth, etc) of different socio-economic groups.
6. Chance of becoming ill at any given time.
7. Incidence/prevalence of physical and mental disabilities.
1.1. REGIONAL DISPARITIES:
Some of the disparities in health and development in Karnataka are a part of the historical
legacy, with the formation of the State by the merger of Kannada speaking regions of Mysore,
parts of Bombay, parts of Hyderabad, parts of Madras and Coorg. The princely State of Mysore
had been in the forefront in matters of basic health services and other determinants of health
(and development ingeneral), while the other parts lagged behind. This and other factors have
led to some of the districts having health indices that are behind others, leading to disparities and
therefore, inequities.
Disparities between districts:
A large number of indices can be used to measure health or lack of it.
(i)
Life expectancy at birth
The life expectancy at birth was more than 68 in Dakshina Kannada and Kodagu, while it
was less than 61 in Bellary and Tumkur.
Four districts with high life expectancy (1991)
1. Dakshina Kannada
: 68.82
2. Kodagu
: 68.04
3. Uttara Kannada
: 66.96
4. Bangalore Rural
: 66.69
-2-
Four districts with low life expectancy (1991)
1. Bellary
: 60.32
2. Tumkur
: 60.64
3. Chitradurga
: 61.92
4. Shimoga
: 62.09
(ii)
Infant Mortality Rate:
Infant Mortality Rate is one of the best indices to find out the health status. There are wide
variations between the districts. It is a low (29) in Dakshina Kannada and a high of (79) in
Bellary (Registrar General of India, 1991).
(iii) Crude Birth Rates, 1995-98.
(RCH Survey, 1998-99, Government of India)
Four districts with low crude birth rates (less than 20)
1. Bangalore Rural
: 17.1
2. Hassan
: 17.5
3. Uttara Kannada
: 19.5
4. Shimoga
: 19.6
Four districts with high Crude Birth Rates (Source same as above).
1. Kodagu
: 34.2
2. Bidar
: 31.6
3. Gulbarga
: 30.1
4. Raichur
: 29.1
If we look at the Crude Death Rates, again we find differences between the different districts.
Dakshina Kannada
Shimoga
:7
:7
Gulbarga
Bidar
: 10.5
: 10.5
Human Development Index and Literacy Rate:
There is a very good relationship between the human development index, which includes health
indices and literacy, which is an important determinant of health.
i) HDI Ranking and Literacy Rate
Top 4 districts:
Rank District
HDI
Rank District
1.
2.
3.
4.
0.630
0.601
0.592
0.533
1.
2.
3.
4.
Kodagu
Bangalore Urban
Dakshina Kannada
Uttara Kannada
Udupi is a new district.
-3-
Dakshina Kannada
Bangalore Urban
Udupi
Kodagu
Literacy
Rate
76.7
76.3
74.6
68.3
Bottom 4 districts:
Rank District
HDI
Rank District
1.
2.
3.
4.
0.399
0.412
0.419
0.429
1.
2.
3.
4.
Raichur
Gulbarga
Bidar
Bellary
Raichur
Gulbarga
Koppal
Chamarajanagar
Literacy
Rate
34.3
34.3
38.2
38.2
Koppal and Chamarajanagar are new districts.
(ii). Health Index, which is a composite index, also shows wide variation between the districts.
Bellary has an index of 0.589, whereas Dakshina Kannada has an index of 0.730 (Human
Development in Karnataka, 1999).
Rural : Urban Differences:
There are wide differences between the rural and urban health indices.
(i) Infant Mortality Rate, 1997
Urban : 24
Rural
: 63
(ii)
Crude Birth Rate, 1998
Urban : 19.3
Rural
: 23.1
(iii) Crude Death Rate, 1998
Urban : 6.9
Rural
: 8.6
Health Care Services
Many factors contribute to health care services: quality and number of health personnel (doctor:
population ratio, nurse: population ratio), health care institutions, bed: population ratio and
others.
Bed: Population ratio
There is wide variation in the bed: population ratio in the different districts. While it is one bed
per 395 people in Kodagu, it is only one bed per 2330 population (not counting the new
superspeciality hospital) in Raichur. It is necessary to ensure at least one bed per 1000
population, of which two-thirds (66.7%) must be government-owned, and they must be equally
distributed.
Health Personnel
There are a large number of vacancies of health professionals and trained personnel in the
disadvantaged northern district. It is necessary to fill up these posts. Since there is reluctance
on the part of health personnel to join these posts and work there, the possibility of recruiting
personnel on a district basis (on condition that they will continue to work there up to a certain
level) must be explored and implemented without delay.
Study on disparities
A study was sponsored by the Task Force on Health and Family Welfare to look into the
disparities in Health and Health Care in the State. The study "Disparities in Health and Health
Care Services – 2001" used the following four parameters.
-4-
•
•
•
•
Health determinants
Health status
Health resources allocation
Health care utilization.
-5-
EQUITY IN HEALTH
INDICATORS
Health Policy
•
•
•
Political commitment to equity in health
Community involvement
Organisation and management
Health care resources (inputs)
•
•
•
•
Budget allocation and utilisation according to needs.
Health personnel per 100,000 population
Coverage by primary health care (PHCs per 100,000 population)
Coverage by referral system (number of hospital beds)
Health Determinants (inputs)
•
•
•
•
•
•
Education (Primary education; adult literacy)
Access to adequate safe drinking water
Sanitation; latrines; waste disposal; environment
Nutrition security (Calories; proteins; micronutrients)
Housing
Income; purchasing power.
Health care utilisation (output)
•
•
•
•
•
Utilisation of health care services
Immunisation coverage
Antenatal check-ups
Deliveries by trained health personnel
Use of family planning methods.
Health status (outcome)
•
•
•
•
•
Infant mortality rate
Under – 5 mortality rate
Life expectancy at birth
Nutritional status
birth weight; under – 5 nutrition; anaemia.
Reduction in incidence / prevalence of common diseases
malaria, tuberculosis, diarrhoeas.
-6-
(a)
For health determinants, the following indicators were used in the study:
•
Percentage of literates in 15+ age groups.
•
Percentage of houses in which both wall and roof were made of permanent materials.
•
Percentage of households with access to clean water.
•
Percentage of families with latrine.
•
Percentage of households with electricity.
•
Percentage of families above poverty line.
(b)
For disparities in health status, no single indicator can adequately describe the status. A
limited number of specific indicators was used. Child health indicators being more
sensitive to equity, the following indicators have been used.
•
Under – 5 mortality rates
•
Percentage of under – 5 children whose nutritional status is within normal limits,
based on weight for age
•
Annual parasite index of malaria.
•
Point prevalence of tuberculosis (pulmonary and extrapulmonary).
•
Percentage of children below 5 years reporting diarrhoea during the previous 2
weeks.
(c)
For disparities in the provision of government primary health care facilities, the
following parameters have been used:
•
Primary health centers per 100,000 population
•
Number of medical officers working at the primary health centers per 100,000
population.
•
Number of paramedical personnel (staff nurse, block health educator, laboratory
technician, auxiliary nurse midwife, male health worker) working per 10,000
population.
(d)
For disparities in the pattern of utilisation of health services (public and private), the
parameters used were
•
Immunisation coverage of children, 12-23 months, under the Universal Immunisation
Programme (6 vaccines).
•
Percentage of pregnant women who received 3 or more antenatal check-ups during
recent pregnancy.
•
Percentage of women who received 2 tetanus toxoid / booster injections during
recent pregnancy.
•
Percentage of deliveries conducted by Trained Health Personnel during recent
delivery.
•
Percentage of current users of any family planning method.
Utilisation of health care presupposes the need, availability and accessibility of health care
services.
Based on the findings, composite rankings were worked out. The following seven
districts came up high in the ranking.
•
Kodagu
•
Uttara Kannada
•
Chickmagalur
•
Udupi
•
Dakshina Kannada
•
Shimoga, and
•
Bangalore Urban.
-7-
Except for Bangalore Urban (incorporating Bangalore City Corporation), the other districts
belonged to the coastal and contiguous areas. The last seven districts were
•
Koppal
•
Gulbarga
•
Raichur
•
Bellary
•
Bagalkot
•
Bidar, and
•
Bijapur.
Relationships
The districts with low health determinants (Bellary, Gulbarga, Koppal and Raichur) had
low health status. The relationship was highly significant.
Most highly significant was the relationship between utilisation of primary health services
and health care services. The districts with low utilisation of primary health care services.
(Bellary, Gulbarga, Bidar, Koppal, Raichur) had low health status, whereas the districts
with high utilisation of primary health services (Dakshina Kannada, Uttara Kannada,
Udupi, Kodagu and Shimoga) had high health status.
Equity in health care requires equality (?) in the distribution of health determinantas
(outside the narrowly defined 'health' services) but more importantly in the utilisation of
health care services. It is not enough to make available the health care services but they
must be of good quality so that the people will utilise the services.
1.2. GENDER DISPARITIES
There are significant differences between the health indices for men and women in the different
districts.
(i) Life expectancies at birth:
The differences between men and women were almost 9 years in Kolar and Hassan
districts, whereas it was less than one year in Bangalore Urban District.
District
Kolar
Hassan
Bangalore Urban
(ii)
Men
67.42
70.00
66.10
Women
58.54
61.02
65.48
Difference
8.88
8.98
0.62
Gender related Health Index (Human Development in Karnataka, 1999) 4 districts
with better GHI:
Dakshina Kannada : 0.807
Kodagu
: 0.718
Uttara Kannada
: 0.677
4 districts with low GHI:
Bellary
: 0.484
Bidar
: 0.523
Bijapur
: 0.523
Gulbarga
: 0.530
These differences are the composite effect of regional and gender disparities.
-8-
(iii) Gender disparities are seen in the nutritional status:
Girls are worse off than boys, if we consider weight for age (under nutrition) or height for
age (stunting).
Percentage weight for age (12-71 months), 1996-97.
Percentage
> 90%
75-90%
60-75
<60%
Boys
11.2
37.9
45.2
5.7
100.00
Girls
7.6
40.1
45.5
6.8
100.00
NNMB Rural, 1999
1.3. SOCIO-ECONOMIC INEQUALITIES AFFECTING HEALTH
The income differentials have widened after adopting the liberalisation, globalisation and
commercialisation. This has affected health. While the rich have become richer, the poor are
left with less purchasing power, which affects health.
Very little data are available in the relationship of health status to the socio-economic
inequalities in the State. It is important to focus on the disparities based on the social and
economic status. One way of finding it will be to study the differences between the social
classes based on their occupations
•
•
•
•
•
•
•
•
•
Professionals
Managerial / Technical
Skilled
Semi-skilled
Unskilled
Businessmen
Land owner
Landless labour
Unemployed
A survey in different parts of the State will be useful to bring out the differences in health status,
using the common indicators, such as infant mortality rate, under – 5 mortality rate, crude birth
rate, crude death rate and life expectancy at birth (healthy life expectancy?).
It is also necessary to conduct studies on the Scheduled Castes and Scheduled Tribes population.
Decentralisation and equity
If care is not taken, decentaralisation of health care resources management and allocation of
resources may result in an unequal inter-regional distribution that may adversely affect the most
vulnerable populations. Decentralisation may result in the transfer of power from the central to
the regional or local elites. Decentralisation may lead to transfer of the financial burden of
health care to local communities, who may not be in a position to carry that burden.
-9-
Many questions need to be answered:
•
Is decentralisation of health care services taking place? If yes, how are decisions being made
on resource allocations between regions?
•
How is the community involved in making the decisions?
•
Is the civil society involved?
•
Has decentralisation brought about a transfer of providing care from institution to the
family/community? Are they able to cope with the situation? Is there any support given to
them?
Recommendations
•
All policies of the Government (State and local), likely to have direct or indirect effect on
health, should be governed by the principle of equitable access to effective care to meet the
needs of the people; they should be formulated such that disadvantaged less forward are
addressed to reduce inequity.
•
Data must be collected to get the actual inequities, based on gender, age, region and
disabilities. Monitor inequities in health based on social, economic and health care
services, disaggregated with respect to age, gender, socio economic status, geographical
regions and others.
•
The Health System must improve availability and access to quality health care (particularly
primary health care and public health) in the underserved talukas / districts and for the poor
and vulnerable population. Ensure better utilisation of the primary health care services by
making the facilities fully functional and people friendly and through monitoring and
supervision improve the quality of service.
•
Health Services must work across organisational boundaries in partnership with the local
government and the sectors that play important role in determining health, such as
education, nutrition, water supply and sanitation, labour and others. Schemes such as
Nirmala Karnataka Programme under Rural Development and Panchayat Raj should be
implemented vigorously in the backward (healthwise) talukas / districts.
•
The State Government and the local governments should take special steps to bring up the
health status in areas where the health status is below the State average, by discriminating
positively (with additional inputs) in favour of the disadvantaged areas.
•
In the large and undivided districts like Gulbarga and Belgaum the districts should be
divided into two and a post of Additional DHO / DMO should be created with Additional
team of Programme Officers.
- 10 -
(iv)
Sex Ratio:
There has been adverse female sex ratio. This has shown a slight improvement in 2001 census
(964) compared to the 1991 census (960). But there is a startling decrease in the sex ratio of the
population in the age group 0-6 years.
Population in Age Group 0-6 years and sex ratio
1991
2001
District
Bangalore
Bangalore (U)
Belgaum
Bellary
Bidar
Bijapur
Bagalkot
Chikmagalur
Chitradurga
Davanagere
Dakshina
Kannada
Udupi
Dharwad
Gadag
Haveri
Gulbarga
Hassan
Kodagu
Kolar
Mandya
Mysore
Chamarajanagar
Raichur
Koppal
Shimoga
Tumkur
UK
KARNATAKA
1991
2001
Percentage
Decadal Growth
Rate 1991-2001
F/M*1000
Male
Female
940
0.56
0.45
941
-1.74
-1.87
924
-0.15
-0.47
949
-1.77
-1.84
967
-0.86
-0.82
971
-0.52
-0.52
939
964
-1.04
-1.16
946
1.54
1.40
949
952
-1.46
-1.57
Sex Ratio
Male
Female Male
Female
F/M*1000
355711 337912 375585
353030
950
133378 127599 110216
103705
957
316944 302531 312304
288418
955
187804 179800 154587
146630
957
130458 125531 119195
115300
962
284405 271791 138293
134302
956
0
0 131239
123240
74432
72760
66726
64321
978
185013 177524
97220
91941
960
0
0 116375
110498
193036 186417 109227
104030
966
0
0
55647
311296 296234 106675
0
0
67982
0
0
98899
269659 258689 262848
121120 117177
98048
36313
34760
33796
180627 175464 161002
123204 118152
98949
247858 239338 154955
0
0
55137
240742 232267 136273
0
0 102481
150434 144609 101473
177259 171970 149272
96139
91254
87095
3815832 3661779 3501499
53131
100671
64644
95009
246385
94477
33013
157069
92728
150292
52782
131145
96134
97290
142099
82385
3324669
952
959
967
957
971
959
966
965
961
970
949
960
955
944
951
961
937
964
977
976
937
970
957
962
938
959
952
946
949
-1.21
-1.21
-0.25
-1.90
-0.69
-1.09
-1.97
-1.52
-0.48
-1.94
-0.50
-1.05
-2.15
-1.52
-0.08
-0.21
-3.25
-1.58
-0.94
-0.82
-3.27
-1.74
-0.97
-0.92
There is improvement only in the districts of Bidar, Bijapur, Kodagu, Kolar and Mysore. All other
districts have shown worsening of the sex ratio. This is a matter of concern. Is it due to deterioration of
the utilisation of health services for the girl child by the parents or neglect of the girl child? Is there
worsening female infanticide? These and other possible factors need further analysis by single years in the
0-6 year age group and action arising therefrom.
2. QUALITY OF HEALTH CARE
Quality of health care has not been addressed to any extent in Karnataka as the preoccupation of the
Government and the health system has been on increasing the availability and accessibility of health
services. It is important to consider the quality of care, which is being provided by the existing
health care institutions, health personnel and programmes of individual health care and public
health.
Definition:
Quality of Health care has been defined in various ways:
•
•
•
“Quality of care is the degree to which health services for individuals and populations increase
the likelihood of desired outcomes and are consistent with current professional knowledge”. –
Institute of Medicine, 1990.
“Quality is the totality of features and characteristics of a product or service that bear on its
ability to satisfy stated or implied needs”. – Bureau of Indian standards, 1992.
“Quality of care may be defined as anticipating, meeting and exceeding clients needs and
expectations”. – Willy De Geyndt, 1995.
All the definitions are applicable but none of them are fully satisfactory. But certain characteristics
stand out. Quality of health care applies to individuals and populations. The outcomes of the
care are important and they depend on the current professional knowledge. It is therefore a moving
target. Quality must be able to satisfy the needs and even exceed the needs and expectations.
The present situation of quality of care is not satisfactory, whether it be regarding the facilities
available, the process, the procedures or the output. These affect the outcome. There are many
instances of unacceptable infections because the procedures are not followed, e.g., laparoscopic
operation in the hospitals due to improper sterilization of equipment or cataract operations in camps,
due to contamination of fluids used.
Factors affecting quality of care:
Various factors affect Quality of Care. Among them are:
• Competence, compassion and courtesy shown by the health providers and carers.
• Consistency, dependability and reliability of performance.
• Responsiveness: readiness to provide appropriate service on time.
• Access, approachability; ease of contact.
• Communication; information.
• Understanding the needs of the individual, the family and the community.
• Credibility, trustworthiness, integrity.
• Confidentiality, privacy, dignity of the person.
• Best interests of the person; safety.
• Autonomy, informed consent.
• Facilities available.
-1-
Dimensions of health care quality:
There are many dimensions to quality of health care.
•
Efficacy
: Is the procedure / care useful?
•
Appropriateness : Is it right for this person / community?
•
Accessibility
: Can the person / community get it?
•
Effectiveness
: Is it carried out well?
•
Relevance
: Does it meet the needs of the community?
•
Equity
: Is if fair to all concerned?
•
Efficiency
: Is it cost-effective?
•
Continuity
: Did it progress without interruption? Was there appropriate follow-up?
•
Outcome
: Was the result of the intervention satisfactory and improve the health of
the person / community?
Public / Private Health Care Services
Quality must be assured whether the services are provided by the public or private sectors. It must
also be assured whether it is primary, secondary or tertiary care.
2.1 STANDARDS
To maintain acceptable quality, it is necessary to have certain standards.
What are standards?
Standards can be defined in various ways. They can be ‘degrees of excellence’, ‘minimum
acceptable’ (necessary, reasonable and possible), a basis for comparison or they can be models for
imitation. We often set standards as ‘minimum acceptable’. These minimum standards should be
set in 6 months and implemented within one year thereafter. The optimum standards (based
benchmarks and best practices) will be developed for all levels of institutions; these must be
implemented in 5 years.
Why standards?
• Health care institutions and programmes: The standards will ensure effective and efficient care
of the people.
• Government and organizations use standards to protect the health of the population.
• Consumers are helped to know whether they are getting the right care, delivered by the right
personnel at the right time.
• Standards help to determine whether the expectations can be met, provide guidelines for
establishing a new health care facility and can be a defense in case of litigation.
There are different types of standards:
•
Structure: What we use (inputs)
- Human, financial, physical and other resources, buildings (space required),
maintenance, drugs, equipment, diagnostic facilities, transport, etc.
-2-
•
Process: What and how we do (procedures)
- Care; service; management. It includes access, diagnosis, interventions, and
technical and administrative support and health promotion activities.
•
Outcome: Results of care
- Clinical; non-clinical. It includes health status, improvement of function and quality
of life.
Process factors:
• Type of service (patients; public)
• Standing instructions (patient care; Public)
• Documentation: medical records; programme records.
• Medical / nursing audit.
• Deaths during surgery / anesthesia
• Rational use of drugs: antibiotics, analgesia, etc.
• Un-indicated transfusions
• Iatrogenic complications
• Hospital acquired infection
• Sterilisation procedures.
• The manner of carrying out public health measures.
Outcome Measures:
• Immunisation: Number of people covered; area covered; result
• Length of stay in hospital; patient satisfaction
• Functional result.
• Performance appraisal.
• Avoidable deaths.
• Re-admissions
• Cost of treatment.
• Efficiency: Cost: benefit ratio.
• Effectiveness: outcome vs. objectives.
How are standards set?
Standards are based on collective judgement, through consultations. They should reflect values of
the society and profession and include competence, efficiency, effectiveness, equity and ethics.
Who sets standards?
Standards may be set by Government, health care providers, health care facilitators or the people.
The ideal is to have a combination of all of them, bringing in different points of view.
Requirements for developing standards:
To rationally develop standards it is necessary to have knowledge about the type of the health care
institution (or programme), the location (urban, rural, remote area), services provided (primary,
secondary or tertiary) and the clientele. It is also necessary to have the skills and resources for
developing, implementing and maintaining standards.
-3-
Standards may be set for various activities, procedures, and institutions. They can be set for
outpatients, inpatients, departments (such as Obstetrics and Gynaecology; nursing) or for specific
diseases (such as HIV / AIDS), Community Health, Health Administration of Financial
Management.
How are standards used?
Standards may be used for self-assessment of health care institution, department or programme),
inspection (power to recognize or impose penalty) or accreditation, certification and registration.
Standards are dynamic
Standards are not set once for all. They change with changes in health care (professional practice,
preventive and treatment modalities, consumer expectations, economic, social and political situation
and changes in technology). They also change with changes in the collective judgment of the
stakeholders.
2.2 QUALITY ASSURANCE
Quality assurance ensures quality of services.
This includes development of optimum
infrastructure, organization of facilities and the delivery of services.
Infrastructure would include:
•
•
•
•
•
•
Buildings: adequate space for the functions and maintenance.
Equipment, appropriate for the level of care.
Diagnostic facilities.
Trained personnel, adequate numbers and quality, following the staffing norms.
Range of clinical services at each level.
Availability of essential drugs at each level.
It is also necessary to ensure proper management and scope for continuous improvement.
Organisation for Quality Assurance
• Establish methods and procedures for
- Systematically monitoring the quality of care given to the patients.
• Make regulation and assessment a permanent component of health professional’s activities.
• Provide all health personnel with training in Quality Assurance.
• Quality assurance involves
- provider groups,
- researchers,
- public health authorities,
- consumers and
- civil society.
The strategy for Quality Assurance should balance
• Rights of the management (health care provider)
• Rights of doctor and other health personnel to participate in self-improvement; and
• Rights of the patient and people to receive efficient and effective care.
-4-
There is the potential for conflict between clinical freedom, management control and patient
satisfaction.
Data for Quality Assurance
Various data are required to assure quality.
•
•
•
•
Medical Records.
- The condition of the person.
- All significant interventions between the person and care providers.
- Information regarding response.
Incident review relating to
- attendance by the health personnel
- investigation
- medication; management
Hospital / Health Information system.
Patient and people satisfaction / outcome of intervention surveys.
Disadvantaged groups
Quality assurance measures must specially address utilization and satisfaction by the disadvantage
groups. These should include the poor, scheduled castes and scheduled tribes, women, children and
the elderly.
Regulation of health care services
It is the responsibility of the State to ensure quality of health care. For this, there is need to have
regulations which would assure quality. The State Government had enacted a law for the purpose
but it was not enforced. In 1998, the Government introduced a bill in the Legislative Council but
this was not followed up. The bill requires considerable modifications. The Task Force has
forwarded to the Government, at Government's request, a draft legislation which could serve the
purpose and is likely to meet the needs of all the stake holders. It provides for the registration and
maintenance of certain standards based on the type, size and location of all health care institutions.
2.3 ACCREDITATION
Quality of health care can be ensured by mandatory regulations or by voluntary accreditation.
Voluntary accreditation is the preferred method and is followed by a large number of countries.
Accreditation is a process where standards are set, compliance with standards is measured and the
institutions are recognized of adherence to the standards of care. It means that the particular health
care institution has voluntarily sought to be measured against the standards for the particular level
of health care and has been found to be in substantial compliance with the standards.
The major groupings of accreditation include professional (medical, nursing and allied professions),
departmental (organization, emergency services, investigating services, operation theatre, etc.,) and
management and support services (hospital management, medical records, library, catering,
transport and environment).
-5-
Recommendations
•
Have the legislation for the registration and regulation of health care institutions enacted and
implemented. Have minimum acceptable standards worked out by independent committees for
health care institutions at different levels and locations and for public health measures.
•
The Joint Directors, Medical and Public Health, will be designated as the persons in charge
of Quality Assurance. The Administrative Medical Officer in charge of each hospital will be
responsible for ensuring quality of care in each institution.
•
The professional bodies may be encouraged to have accreditation of their member
institutions. The Indian Medical Association, Karnataka State Branch may take the initiative.
-6-
3. PRIMARY HEALTH CARE
Primary health care is essential health care, universally accessible and acceptable with
community participation and includes promotion of health, prevention of diseases and
rehabilitation and management of common illnesses at affordable costs.
Primary Health Care is "the key to attaining an acceptable level of health care for all by the year
2000, as part of overall development and in the spirit of social justice" - The Declaration of
Alma Ata 1978.
The year 2000 has come and gone. We have to ensure " HEALTH FOR ALL – NOW!"
What is meant by "Health For All"?
"With the objective of continually improving the state of health of the total population, every
individual should have access to primary health care and, through it, to all levels of a
comprehensive health system"
- Strategies for health for all by the year 2000, W.H.O. Geneva, 1979
Primary health care has to be the hub of the health system. It has to ensure complete coverage of
the total population of the State.
Comprehensiveness
Primary Health Care has to be comprehensive. It addresses the main health problems in the
community, providing promotive, preventive, curative and rehabilitative care. These services
reflect and evolve from the social and political conditions prevailing in the state and the values
upheld by the people. The services include
• Health Education and its promotion
• Promotion of nutrition
• Adequate supply of safe water
• Basic sanitation
• Maternal and child care and family welfare services
• Immunisation against the major infectious diseases
• Prevention and control of the locally endemic diseases
• Appropriate treatment for common diseases and injuries
Community Participation
Primary Health Care requires and promotes maximum community participation. Primary Health
Care can succeed only with the active involvement and empowerment of the people. It also
needs decentralized governance, which can bring in the much needed community participation.
Community participation is the process by which individuals and families assume responsibility
for their own health and the health of the community and contribute to their and the community's
development. The healthier the people are, the more likely that they are able to contribute to the
social and economic development. In turn, such development helps in better health. They are
mutually supportive.
-1-
Intersectoral Collaboration
Many of the determinants of health are outside the confines of the narrowly defined "health
services". Primary health care involves all related sectors, such as education, agriculture, food
and nutrition, industry, housing, women and child welfare and others. It demands coordinated
efforts of all these sectors.
Decentralisation
Primary health care requires decentralization. There is need for delegation of responsibility and
commensurate authority. Ideally, community itself provides managerial control. Control of a
technical / professional nature has to come from other levels of the health system.
Logistics and Supply
Once the goals and objectives are set, it is necessary to make available the supplies on a priority
basis. Decisions have to be made on the components to be included in the community's primary
health care programme and the appropriate technologies to be employed. The seasonal
fluctuations in incidence of diseases, changes in demand for health care and local variations
must be taken into account. A list of essential drugs and equipments must be made and action
taken for budgeting, procurement, storage, distribution and control.
Appropriate Health Technology
Appropriate technology is one of the core components of primary health care. Appropriate
technology includes practical, scientifically sound, health measures, for promotive, diagnostic,
therapeutic or rehabilitative purposes, that are accessible and affordable to the community.
Through this approach, technology is made to serve society's needs. Machinery or equipment, if
involved, is simple to run and repair, and locally produced and maintained. It is used to develop
self-reliance and self-determination.
Examples of appropriate technology for health are:
a) Home-based oral rehydration solutions (ORS) have proven efficacy to combat
dehydration.
b) Use of herbal and home remedies for treatment of minor ailments.
c) Use of neem sticks for brushing teeth, massage of gums and gargling after every meal for
promoting good oral health.
d) Use of Jaipur foot as an aid for orthopaedically disabled persons.
e) Intraocular lens at low cost and indigenously produced.
f)
Use of hay-boxes as incubators for newborns.
g) Use of sputum microscopy for diagnosis of pulmonary tuberculosis, over chest x-ray, as
was accepted by the National Tuberculosis Programme.
h) Simple kits for Traditional Birth Attendants (dais) with a sterilised blade, clean tie, swab,
soap and polythene sheet.
i)
Nutrition bangles for detection of malnutrition in children.
j)
Dip sticks for urine testing of sugar and albumin in the field.
k) Low cost, effective health education kits with messages painted on cloth and use of
puppets.
l)
Bicycle driven ambulance.
m) Low cost lightweight rehabilitation aids.
-2-
Essential Drugs
Primary health Care requires the availability of all essential (including life-saving drugs) drugs
appropriate for the level of health care. This should depend on the expertise available and the
needs. The Task Force had recommended that the provision for the drugs must be increased by
Rs. 25,000/- per PHC so that all essential drugs are available at the PHC at all times. The
Government has responded positively and allotted the additional Rs. 25,000/- per PHC for the
purchase of essential drugs.
Laboratory Services
Health Care depends on diagnostic quality, which in turn requires laboratory tests in specific
instances. Many of the laboratories attached to the Primary Health Centres have been nonfunctional because of lack of trained laboratory technicians and equipments, such as
microscopes and reagents. The Task Force had recommended that all laboratories must be
staffed with trained technical persons equipped with the necessary instruments, accessories and
reagents. Government has taken action to fill up most of the vacancies. The newly appointed
technicians have been given training. The Government has also allotted additional funds for the
purchase of microscopes (where not available), equipment, glassware and other accessories and
reagents.
3.1 RURAL HEALTH
Primary Health Care is channeled in the rural areas mainly through the activities around the
Primary health Centres (1676 centres as on 31.12.98), the sub-centres (8143 as on 31.12.98) and
Community Health Centres (252 as on 31.12.98), which are the first referral units. There is need
for partnerships at various levels between the first contact care, the first referral unit and the
local people. The PHC and CHC should have sufficient freedom to develop partnerships at the
local level. Co-ordination Committees can be formed to have more effective functioning of these
centres.
Primary Health Centres are of different types, varying in the population and area covered, the
number of subcentres, the facilities and the staff. It is necessary to reorganize the PHCs,
considering the population and area covered.
Vacancies
There have been a large number of vacancies of doctors, laboratory technicians and ANMs. The
interim Report had made a recommendation to have them filled up. Many of them have been
filled up mainly through contract appointments, but a number of vacancies still remain. It is
necessary to have a continuous process of anticipating the vacancies (caused by promotion to
higher post, deputation for higher studies and attrition due to retirement, etc) and having them
filled up promptly.
Male Health Worker
There are a large number of vacancies of male health worker. Considering the work being done
and the need, all the vacant posts need not be filled. We can have one male health worker, one
for each gram panchayat. The technical control of the male health worker will be vested in a
designated PHC doctor.. Administrative control will be with the Gram Panchayat.
Availability of Staff
The Interim Report had recommended that all key staff attached to the Primary Health Centres
must stay in the quarters. Such a recommendation has been made long ago as early as 1961 by
the Mudaliar Committee. “Recommendation 8: The Primary Health Centre should provide
-3-
residential accommodation to all the personnel of the center….”. Where quarters are available,
the District Health Officers should ensure that the staff stays in the quarters. Where repairs are
necessary, they should be carried out urgently. If quarters are not available, action must be taken
to have quarters constructed. In the meanwhile, houses may be taken on rent.
Working timings
The working times of the primary health centres and subcentres should be suitably fixed. The
people must be consulted as regards their convenience to attend these centres.
Medical Colleges and Primary Health Care
Training of medical students has been mainly on hospital care. Efforts to make them more
community based have met with limited success.
The Medical Colleges in the state should take up the running of 1-3 PHCs, together with the
sub-centres. It would be ideal to include the Community Health Centre to which the PHCs are
attached. The Medical Colleges should have full administrative and technical control. They will
be given grant-in-aid. This arrangement would enable the Medical Colleges to implement the
concepts of Primary Health care and train the medical students in Primary Health care and the
management of Primary Health Centres.
Nurturing the Doctor at PHC
Doctors are often reluctant to work at PHC due to a variety of reasons, including remote,
difficult to reach locations and the lack of social and professional facilities. It is necessary to
nurture the young doctor, making him / her competent and comfortable to deal with the
situation. The doctor has to work as leader of the health team at the PHC.
A rethinking is necessary whether the fresh graduate should be posted to the PHC; "Posting to a
Primary Health Center should be normally after one or two years of service in a hospital under
the supervision of a senior medical officer” (Mudaliar Committee 1961)
Incentives to practice in disadvantaged regions
There are certain areas in the State, particularly in the northern parts, where government doctors
are not willing to serve in the PHCs. Vacancies continue to exist for years. A trial may be made
to induce doctors to settle down in these areas and practice as general (family) practitioners by
giving incentives. This may be in the nature of each Rs.5,000 p.m in the first year and gradually
reduced so that it disappears at the end of 5 years.
Women’s Health
The utilization of the services of PHC by women has to be made optimal; a study may be carried
out. It is also necessary to study violence against women and child abuse. The Medical Officers
must be trained to recognize such problems and take appropriate actions. Having a Lady
Medical Officer at every PHC will be an advantage. The aim will be to have one lady medical
officer (additional) in every PHC within the next 10 years.
Alternate Practitioners
In view of the reluctance of MBBS qualified doctors to work in rural areas, should we think of
alternate practitioners {family physicians with shorter period of study like LMP; physician
assistants; nurse practitioners} trained for rural health service? Can they be selected or trained
from Staff Nurses or Auxiliary Nurse Midwives who have already worked in rural areas? On
completion of appropriate training, they will work in rural areas, providing comprehensive
primary health care. One suggestion was to have two streams in the MBBS course. After a
general common course (of 2-3 years), one stream will follow the usual course of study; the
-4-
other stream will be limited to those who are interested in rural service and public health. They
will be taken into government service in the rural area. Their further career will be in public
health, if they specialize in public health.
Induction Programmes
It is necessary to have induction programmes for the staff. To start with, it will be for all newly
appointed doctors. Later, orientation programmes can be provided to all staff at all levels.
Subcentres
There is need to strengthen the working of the subcentres and make optimum use of them. It is
necessary to improve the buildings and where they are not available, take on rent appropriate
buildings.
Primary Health Units (PHU)
Karnataka has 583 PHUs as on 31.12.98. It is necessary to make optimum use of these PHUs.
The alternatives would be to convert them into PHCs (depending on the need), or have them
operated by the Indian Systems of Medicine and Homeopathy or have them abolished, if its is
decided that particular PHUs are not needed. The decision may be taken in consultation with the
people in the region.
Water Supply and Sanitation
The Department of Health must be involved in drinking water supply and sanitation. The
Medical Officer and other staff of the PHC must ensure the safe quality of drinking water. He /
She should also promote the construction and use of toilets.
Nutrition
The health professionals and workers must get involved in the nutrition adequacy of the people,
especially the young children and women.
Village Health Committees
Each village can have a village health committee as part of the village development committee
(intersectoral). The committee can be involved in micro planning and monitoring of health care
services at the village level. Two representatives from each Committee will be members of the
PHC level co-ordination committee (other than the board of visitors); the co-ordination
committee will include representatives of voluntary organizations, professional bodies and
people’s representatives. The committee will help the health team at PHC to improve the
services.
3.2. URBAN PRIMARY HEALTH CARE
Urban health is not better than rural health as far as the poor are concerned. Disaggregated
health indices show that the health of the urban poor (in the slums and scattered through the
towns and cities) is often worse. There is need for comprehensive health care, especially in the
slums, where the people do not have social support, which is present in the rural areas.
The Urban Family Welfare Centres and the Health Centres under IPP VIII (in Bangalore City
and now being extended to 11 other cities in Karnataka) are expected to concentrate on Family
Welfare. They have to be involved in Comprehensive Health Care.
-5-
It is necessary to ensure primary health care in the urban areas. There must be one Urban
Primary Health Centre for 50,000 or less population in cities and towns. The existing resources
such as health centers, urban family welfare centers and maternity homes must be mapped and
their services consolidated. These primary health centers will be the responsibility of the local
body (Corporation or Municipality). Technical guidance will be provided by the Directorate of
Health and Family Welfare Services. Some of the smaller municipalities may not be able to
raise sufficient finances; they will need support.
Medical Care at the first contact level is provided mainly by private practitioners (present in
relatively large numbers) and by nursing homes, Teaching and other hospitals in the cities and
municipalities. But this is not Comprehensive Health Care; it is almost completely curative
medicine. Including the district, teaching, major, specialized, general and maternity hospitals,
there are 176 government hospitals with 23,223 beds (1997-98) apart from the voluntary and
private hospitals.
3.3. REFERRAL SYSTEM
Primary Health Care requires the support of successive levels of referral facilities (secondary
and tertiary) for its effective functioning. Primary Health Care looks after the common ailments.
Other complex health problems cannot be managed at the first contact level; they require more
specialized care. Patients have to be referred to an appropriate health facility, which will have
more highly trained staff capable of dealing with a progressively wider range of specialized
health interventions that require more sophisticated technology.
At present the referral system does not work. The lower levels are bypassed. This leads to
overburdening the higher levels. We have to work out an effective health system chain of
specialized clinical and public health care.
The first referral is the Community Health Centre and where it is not available, the Taluk
Hospital. The next level is the sub divisional level hospital and above it the District Hospital.
These provide secondary care services. Beyond the district hospitals are the Specialty hospitals
and the Teaching Hospitals, which can provide secondary and tertiary levels of care.
When a patient is referred, there should be
•
•
•
No Delay; no waiting
Priority for Critically Ill Patients
Availability of the required specialists and facilities
The Referral Centre must be strengthened through:
•
Creating awareness among the people of the advantages of referrals
•
Peoples Committees at all levels to ensure effective functioning of the referral system.
Effective communication requires availability of linkage by the telephone. Hence every PHC
must have a telephone. The Government is taking action to install a telephone at the PHC.
Immediate advice can be given and received over a communication link.
There is also need for transport. “Recommendation: There should be suitable conveyance
including an ambulance and a jeep” (Mudaliar Committee, 1961).
-6-
The referral centre must:
•
Cater for a defined geographical area and all the PHCs in that area;
•
Give periodic consultancy services and training;
•
Provide feedback on the patients referred.
Referral is a two way process- from the primary health centre to the secondary care centre and
back to the primary health centre.
The Task Force had recommended that the secondary care institutions in progress under KHSDP
should be completed expeditiously and made functional with the required manpower,
equipments ands accessories. These buildings are understood to be in good progress. The OPEC
Hospital at Raichur has been opened. It has to become fully functional.
Recommendations
•
Have the philosophy of comprehensive primary health care accepted through training and
advocacy and implemented by all concerned: the people and the health services.
•
All existing vacancies of doctors, pharmacists, laboratory technicians and ANMs in the
primary health centers and subcentres must be filled up immediately. Appointments made on
contract basis must be regularized. Have regular appointments made based on needs for
which there must be a continuous assessment and monitoring of vacancies likely to occur in
the PHCs and subcentres.
•
Appoint staff nurses at all PHCs, creating posts where there are none at present.
•
All essential staff, including doctors, pharmacists, nurses and ANMs attached to the Primary
Health Centres must stay at headquarters.
•
Have a construction and renovation programme such that every PHC will have a suitable
building within the next 5 years and quarters for the essential staff within the next 10 years.
In the interim period, take suitable buildings on rent for PHCs and staff quarters.
•
Consider the possibility of making available rural medical practitioners / physician
assistants / nurse practitioners / nurse obstetricians available for service in the rural areas,
where qualified MBBS doctors are not available.
•
There is need to have the telephones at the PHCs installed without delay for better
communication. Make arrangements for the speedy transport of patients to the referral
centers by provision of ambulance vans or funds for the speedy transport of patients to the
referral centers by provision of ambulance vans or funds to hire available transport, in the
case of the poor.
•
There is need to have fully functional laboratory services, with trained technicians.
-7-
•
Have Village Health Committees at Gram Panchayat level. Two representatives each of the
committees will be members of the PHC level co-ordination committee, which will include
representatives of voluntary organisations, professional bodies and elected representatives.
•
The Department of Health must stipulate the working hours of PHCs and subcentres to suit
the community needs.
•
PHCs must have round the clock service. Make available the services of Lady Medical
Officers. Progressively increase the number of lady medical officers at PHCs such that, in
the course of the next 10 years, every PHC will have one male and one female medical
officer.
•
Every Medical College must take up the running of a minimum of 3 PHCs for the service of
the people and training of students.
•
An appropriate referral system (with feed forward and feedback) and linkages between
PHCs and Secondary Care Institutions must be put in position to make primary health care
more efficient and effective.
•
Have Urban Primary Health Centres, one for 50,000 population in cities and towns,
converting the existing resources such as health centers, urban family welfare centers and
maternity homes. While these Urban Primary Health Centres will be the responsibility of
the local body (Corporation or Municipality), technical guidance will be provided by the
Directorate of Health and Family Welfare Services.
•
Every PHC will display prominently a Charter of Rights of patients.
•
Where there have been vacancies of 3 years or more at PHCs, graduates in Medicine will be
encouraged through incentives to settle down and have General (Family) Practice.
•
Distribute the male health worker, one for each Gram Panchayat / 2 Subcentres, redefining
his job responsibilities. He will belong to the District Cadre. The technical control will be
with a designated PHC medical officer.
•
Reorganise the PHCs, PHUs and subcentres (including staffing) considering the population
and area covered and accessibility.
•
Provide interest free loans for the purchase of two wheelers for the transport of health
workers at PHCs and subcentres.
•
The state should encourage the spirit of local innovation, including research by a variety of
institutions to develop simple, indigenous technological solutions to health problems.
•
Appropriate technology that is tried and tested should be introduced into the health system
and promoted among the public.
-8-
4. SECONDARY AND TERTIARY HEALTH CARE
4.1 SECONDARY AND TERTIARY HOSPITALS
Primary Health Care is the most essential health care but it requires the support of Secondary
and Tertiary Health Care. Referral to higher levels of care is necessary when primary health
care is unable to manage patients with difficult health problems. Realising this, Karnataka State
has embarked on various projects to improve secondary and tertiary care.
Karnataka Health Systems Development Project (KHSDP)
KHSDP took up the renovation and expansion of 201 secondary care hospitals in the three
Revenue Divisions of Bangalore, Mysore and Belgaum. The project is with World Bank
Assistance and the estimated expenditure is Rs.546 Crores.
The original proposal was to add on 3825 beds to the selected hospitals. But it was observed
that the estimate of available beds in these hospitals was not correct; it was an over estimate.
Hence an additional 6100 beds will be added on, under the project. The construction of
additional buildings for the additional beds and equipping of 198 of these hospitals will be
completed by December 2001. Action has to be initiated now itself to ensure smooth transition
from the project to the Directorate of Health and Family Welfare services.
Training of health personnel is an integral part of the project. This will involve the professional
and technical upgrading of the knowledge, skills and attitude of the doctors, technicians and
others. It will also involve capacity building in administration and management.
KfW Project
The KfW Project is with German assistance. The intention was to develop 51 secondary care
hospitals in Gulbarga Revenue Division. It was proposed to increase the bed strength by
adding 1306 beds. In the first phase, 26 hospitals are to be covered. The main objective is to
strengthen the referral system. Hence large numbers of equipments are to be procured and
installed, those not working are to be got repaired. The project has run into some difficulties.
Items not provided for under KfW will be taken up under KHSDP.
OPEC assisted project, Raichur
This is a superspeciality hospital (tertiary care), with bed strength of 350. It is proposed to run
this tertiary care hospital in collaboration with the private sector. The District Hospital will be
improved and will function as a women and children Hospital.
Secondary and Tertiary Health Care providers may be of different types. Among them are:
1. State Government run health care institutions
2. Central Government Health Care Institutions; Central government health services,
railways, defence services and others
3. Hospitals under the Employees State Insurance Scheme, Plantation Act and others.
4. Hospitals run by Public Sector Undertakings
5. Hospitals attached to Medical colleges and other institutions.
6. Voluntary and charitable (Not- for- profit) hospitals
7. Private (for- profit) hospitals and nursing homes, including corporate hospitals.
-1-
Bed Strength:
Government Health Care Institutions
There were a total of 31,675 beds in the various Government Health Care Institutions. These
do not include the institutions belonging to Defence Services, Railways, Employees State
Insurance Scheme and Public Sector Undertakings. They do not include the facilities in the
Voluntary and Private-for-profit sectors. If we exclude the institutions for specific diseases
such as tuberculosis and infectious diseases, the number of beds for secondary and tertiary care
will be 23,263 beds in the State Government Sector.
Hospitals
District
24
Teaching
9
Major
8
Specialised
16
General/Maternity 120
Total
177
Beds
7616
5907
1521
3320
4899
23,263
The District and other hospitals serve as referral institutions. They also cater to the needs of
the patients coming directly.
Each district hospital has got the following specialties: General Medicine, General Surgery,
Obstetrics and Gynaecology, Pediatrics, Orthopaedics, Ophthalmology, Ear, Nose, Throat
diseases, Skin and Sexually Transmitted Diseases, Pathology and Microbiology, Radiology,
Anaesthesia and Dentistry. There are also psychiatric clinics in District Hospitals. There are
Burns wards in Victoria Hospital, Bangalore, SNR Hospital, Kolar and District Hospital,
Bijapur.
Other Governmental Hospitals (as on 31.3.1998)
Institutions
Beds
Central Government
: 1,854
Employees State Insurance
: 1,125
Autonomous
: 1,228
Other departments
: 336
Local bodies
: 714
District (secondary care) Hospitals (31.3.98)
District
Beds
District Hospital, Bidar
: 283
District Hospital, Bijapur
: 316
District Hospital, Chikmagalur
: 279
District Hospital, Chitradurga
: 405
District Hospital, Dharwad
: 170
District Hospital, Hassan
: 344
District Hospital, Madikeri
: 410
S.N.R. Hospital, Kolar
: 260
District Hospital, Mandya
: 250
District Hospital, Raichur
: 250
Mc Gann Hospital, Shimoga
: 429
District Hospital, Tumkur
: 325
District Hospital, Karwar
: 250
-2-
Other Major Hospitals (31.3.98)
Hospital
General Hospital, JayAnagar, Bangalore
HSIS Women and Children Hospital, Bangalore
K.C. General Hospital, Malleswaram, Bangalore
Women and Children Hospital, Chikmagalur
General Hospital, KGF
Women & Children Hospital, KGF
Specialised Hospitals (31.3.98)
Hospital
Leprosy Hospital, Bangalore
T.B. Hospital, Bangalore
T.B. Hospital, Bijapur
T.B. Hospital, Mangalore
MGM TB Hospital, Gadag
KNTB Hospital, Kolar
TB Hospital, Mandya
Wesley, TB Hospital, Bellary
Mental Hospital, Dharwad
Minto Ophthalmic Hospital, Bangalore
:
:
:
:
:
:
Beds
300
120
433
88
110
65
:
:
:
:
:
:
:
:
:
:
Beds
260
234
110
100
62
264
148
288
375
280
KHSDP would establish/upgrade the emergency services and also upgrade the clinical
effectiveness of the staff through the training of doctors, specialists, dentists, nurses, laboratory
technicians and others. The training will focus on the human, technical and management
aspects of caring.
Number of patients treated in district hospitals, 1996
Inpatients
:
8,29,975
Outpatients
: 2,43,84,272
There is great disparity between the number of hospital beds in the districts. While Dakshina
Kannada has 3.3 beds per 1000 population, Raichur had only 0.6% bed per 1000. This will be
raised to some extent with the functioning of the OPEC sponsored hospital.
Most of the 23 Medical Colleges have their own teaching hospitals. But some of them use
Government Hospitals to satisfy the requirements of the Medical Council of India for
recognition. The Government may ask the Private Medical Colleges to put up the required
hospitals with sufficient beds in a phased manner so that the Government Hospitals may revert
to their original function.
Autonomous Institutions:
There are 6 autonomous institutions:
1. Kidwai Memorial Institute of Oncology, Bangalore
2. Jayadeva Institute of Cardiology, Bangalore
3. Indira Gandhi Institute of Child Health, Bangalore
4. Sanjay Gandhi Accident Hospital and Research Institute, Bangalore.
5. Karnataka Institute of Medical Services, Hubli
6. Vijayanagara Institute of Medical Sciences, Bellary
-3-
Central Government and Public Sector Undertakings
There are hospitals run by the Central Government, Railways, Space Center and Public Sector
undertakings, which serve the staff and employees and their families. Among the public sector
undertakings are the hospitals attached to Indian Telephone Industries, Bharat Electronics
Limited, Hindustan Aeronautics Limited and others.
These hospitals generally provide secondary care. Patients are referred to other hospitals for
tertiary care
Voluntary and Private Sectors:
There are a large number of institutions in the non-governmental sector providing secondary
and tertiary care. The following data is taken from the publication "Health Care facilities in
non-government sector in Karnataka", Government of Karnataka, 1996.
Distribution of hospitals by type:
Type
Number
Percentage
General Hospital
Maternal & Child Health
Ophthalmology
Oncology
Total
1215
451
42
1
1,709
71.09
26.39
2.49
0.06
100.00
Bed Strength Percentage
Number
36,402
89.00
4,105
10.04
385
0.94
8
0.02
40,900
100.00
Distribution of Hospitals by ownership (non-governmental)
Individual
Partnership
Charitable Trust
Registered Society
Religious Mission
Limited Company
Number
Percent
1,425
128
68
42
27
19
1,709
83.38
7.49
3.98
2.46
1.58
1.11
100.00
Number
of beds
21,066
3,458
4,326
7,945
2,725
1,380
40,900
Percent
51.51
8.45
10.58
19.43
6.66
3.37
100.00
These hospitals provide secondary and tertiary care in the following specialties: General
Medicine, Gynaecology, Obstetrics, Maternal & Child Health, Family Planning, General
Surgery, Orthopaedics, ENT diseases, Ophthalmology, Skin and Sexually Transmitted
Diseases, Psychiatry, Dentistry, Cardiology, Urology, Nephrology and Oncology.
Staffing of Voluntary and Private Hospitals:
Excluding visiting doctors and technicians, the total strength of doctors and nurses employed
full-time in the non-government sector hospitals is 21348. On an average, there is one doctor
per 6 beds and one nurse for every 4 beds. In addition, there are visiting specialists.
-4-
Distribution of users by level of charges:
Full Charge
Concessional charge
Completely free
Consultation%
58.1
23.7
18.2
100.0
Diagnostic tests%
82.8
11.2
6.0
100.0
Treatment%
76.2
16.4
7.4
100.0
Indian Systems of Medicine and Homeopathy:
There are a total of 93 hospitals
System
Hospitals
Ayurveda
68
Unani
11
Homeopathy
7
Nature Cure
3
Yoga
3
Siddha
1
Total
93
Beds
1077
202
100
26
15
10
1430
Ayurveda Hospitals were 17 at district level and 3 were teaching hospitals. Many of these
hospitals need improvement and renovation. The level of patient satisfaction is not high in most
of them.
Hospital Administrator
The Hospital Administrator is the key executive of the hospital. It is the hospital administrator
who largely determines how efficiently and effectively the hospital functions. Success or
failure of the hospital depends to a great extent on the competence and other qualities of the
hospital administrator.
It has been the general rule to appoint a senior clinician to be the Chief Executive of the
hospital (Administrator / Director / Medical Superintendent). But being relatively untrained in
management, he / she is unable to cope with the demands of management / administration
(personnel, materials, financial, etc.) the net result has been that the hospital has lost an
excellent clinician but gained a poor administrator, if he / she is appointed as a full-time
administrator; or, the hospital gets a poor administrator and the clinician performs below
par (being saddled with administration), if it is a part time or additional charge appointment.
The solution to the problem may be to appoint as hospital administrator
•
a medically qualified person, who is also qualified or trained in hospital administration
(there are many courses now available and many doctors to take up such courses); or
•
a non-medical person, who is qualified in hospital administration.
As an interim measure, two alternatives are available to improve hospital administration:
•
the clinician who is / will be appointed as hospital administrator to be given intensive
short term training in administration (6 months?); or
•
the clinician chief executive officer to be supported by a person qualified in hospital
administration.
-5-
Many problems: Some solutions
A major factor affecting the efficiency and quality of care provided by the secondary and
tertiary care hospitals in the government sector is the mismatch between requirements and the
provision of buildings, number of beds, equipments, laboratory and other facilities on the one
hand and the actual human (medical, dental, nursing, allied health professionals and support
services) and material resources. Sometimes, these resources are less than the norms;
sometimes they are more. Often there are differences in the quality. A study conducted by the
Karnataka Health Systems Development Project on the situation in the 252 hospitals that were
upgraded under the project (and KfW) has shown this mismatch to be very widely prevalent in
almost all of them (Mismatch of staff in hospitals, Sept. 2000). The same is true of other
hospitals also.
The reasons for the mismatch are very many.
The availability of staff was not as per the norms for the provision of buildings, inpatient
beds and other facilities.
Positions were created but not filled up.
Equipment was purchased but trained and qualified technical personnel not available. It
could be the reverse also: trained personnel available but there was no equipment or the
equipment was not in working order for every long periods.
Equipment is available but consumables like chemicals, reagents and X-ray films not
available.
It is essential to ensure better match. Planned efforts are needed to address these issues
effectively to improve the performance quantitatively and, more importantly,
qualitatively.
•
Limited resources: unlimited demands
Financial and other resources are limited. But there are ever increasing demands. People
are aware of the developments in diagnosis and therapy in the affluent parts of the world.
Medical personnel trained in the use of sophisticated technology in those countries also
demand the costly equipment, so that they could carry out such interventions here also.
Ethical and other dilemmas occur in decision-making. Even when the equipment is
purchased at high cost, the equipment may remain non-functional, if it needs maintenance
or repairs and there is no one to set it working.
•
User fee
User charges have been considered as one way of augmenting public financial resources
in health care. This, however, can only be a very small proportion of the budget of the
health care services. Another reason advanced is that, when a user of the services pays an
amount, he/she will be in a position to demand better services.
One principle that should govern the collection of user charges in government health care
services is that the charges so collected should be utilized for improvement of the services
(non-salary component). Government of Karnataka, in its order in 1995, created District
Development Committees to operate the user charges, with the Chief Executive Officer of
the Zilla Panchayat as Chairman.
As on 1-2-2001, the total amount collected as user charges was about Rs.3.30crores, of
which about Rs.1.12 crores were utilized for improving the services of the hospital.
-6-
Percentage of collection and utilization of user charges - Division wise
(KHSDP up to 22-01-2001)
No. of
Sl.
No. of
Hospitals
Division
No.
Hospitals collecting user
charges
1
Bangalore 68
48
2
Mysore
71
50
3
Belgaum 67
22
4
Gulbarga 47
09
•
Percentage
of
collection
No. of Hospitals
utilizing User
charges
Percentage
of
Utilisation
70.58%
70.42%
32.8%
19%
21
28
11
05
43.7%
56%
50%
55%
Ownership:
Among the problems facing the secondary and tertiary hospitals in improving patient
care, the most important probably is the lack of a feeling of "ownership". There are
probably many reasons for this. Frequent transfers of the staff can affect the attachment
to the institution and building up a team.
All the staff of the Directorate of Health and Family Welfare Services must develop an
attitude of ownership of the health care institutions and programmes. The training
programmes must have the 'creation of ownership' and 'motivation' as important
components.
There is also need for 'supervision' and 'facilitation'. The District Surgeons and the
District Health Officers must help in this process. Functioning Hospital Boards can serve
a useful purpose in improving the quality of care. The possibility of having a Chief
Medical Officer or an Administrator to help in this process must be considered.
•
Contracting out:
There are many non-clinical areas in the health care institutions where contracting out
may be beneficial. These include housekeeping, cleaning the hospitals and the premises
and appointment of watchmen. But such contracting out must ensure that there is no
exploitation of labour by the contractor. The laws of the land, like Minimum Wages Act,
etc., must be followed by the contractor.
•
Needed: quality of care
With about 38,000 hospital beds in the Government Sector and 40,900 beds in the private
sector, the State will have a total of 88,900 beds for secondary and tertiary care
(excluding the beds in Primary Health Centres). This represents about 1 bed for 614
people. This is ample. But the proportion of Government to Private Hospital beds is
skewed. The Planning Commission recommendation is two-thirds in the Government
Sector and one-third in the private Sector. What is most needed is improvement in the
quality of care.
General Practice Unit
At present, many patients with vague symptoms and requiring primary health care come to
secondary care hospitals. They are directed to one specialist unit or another by a non-medical
person. The patients go from one queue to another, wasting considerable time of themselves
and of the specialists before a diagnosis is made and treatment given. One way out is to have
only patients referred from a primary health centre (or equivalent unit) to be seen at the
-7-
secondary care hospital. But this can cause inconvenience to patients from the neighbourhood
of the secondary care hospital, unless there is a general practice unit at the secondary hospital.
The general practice unit can work in the outpatient department, manage a large proportion of
the patient and refer others to the specialists, who can devote greater attention to these patients.
In the case of teaching hospitals, there is an added advantage if there is a general practice unit.
The patients with the vague symptoms and requiring primary health care can be very useful for
teaching / learning about the common types of patients met in the community.
Recommendations
•
Make the secondary and tertiary health care institution fully functional, with the required
staff (avoiding mismatch) and equipment in good working condition.
•
The emphasis must be on quality in addition to quantity. Quality assurance is needed.
•
Appoint an expert committee to examine the needs of the State with respect to the
specialities and their rational distribution in the districts and talukas, together with
requirements of personnel, equipments, etc.
•
Make the hospitals under the Indian Systems of Medicine and Homeopathy function well.
The proposal given by the Department may be considered. Standards for these hospitals
must be worked out and implemented.
•
Steps must be taken during training (in-service) programmes to inculcate the feeling of
'ownership' of the hospitals by the staff at every level.
•
'Supervision' and 'facilitation' are needed.
•
CHCs need the post of anaesthetists for the functioning of the Departments of Surgery
and Obstetrics & Gynaecology.
•
Secondary and Tertiary care hospitals must have Dharmashalas.
•
Secondary and Tertiary Care Hospitals must have social workers (preferably volunteers)
to help the patients.
•
The equipments must be maintained in good working condition; the downtime must be
reduced to the absolute minimum.
•
One of the staff members (senior most office assistant?) may be designated as Hospital
Manager, to work under the Administrative Medical Officer to look after non-technical
matters.
•
The Administrative Medical Officer must be trained in Hospital Administration.
-8-
-9-
4.2 EMERGENCY HEALTH SERVICES
Emergency services provide immediate resuscitative, diagnostic and therapeutic care to persons
with injuries by accidents or sudden attacks of illness or acute exacerbation of an existing disease.
These persons require immediate attention. Time is the essence. Timely management can make all
the difference between life and death.
Problems
There are many problems in providing immediate and adequate response. These include prehospital care system and in-hospital services.
Pre-hospital care system
It is essential that the management of persons who are subject to accidents or injury or acute illness
start at the earliest. This calls for an early access system. Communication is most important. This
includes transfer of information through telephone, wireless or other systems. There is need for
dedicated emergency ambulance services, as opposed to the routine ambulance services.
The ambulance services must have fully trained and committed staff, which would include medical,
nursing and paramedicals. Most often trained paramedicals are the personnel available. Hence their
training is most important.
Pre- hospital emergency care services require:
commitment from the state and local health authorities to work together towards unified prehospital care services;
cooperation from other departments and particularly the police;
identifying the main problem (ambulance service) of pre - hospital emergency care;
developing an easy and early access to Emergency Medical Services; ambulances , ambulance
stations and receiving hospitals. It is essential to have a system of efficient maintenance of
vehicles and equipment;
drawing up and implementing systems of identifying various categories of sick and injured
persons by trained paramedics, nurses and doctors;
developing protocols to send patients to appropriate levels and types of hospitals.
Medical and nursing staff will accompany the emergency ambulances as required. The ambulances
must have all the necessary equipments such as oxygen, infusion sets, fluids, appliances and
accessories.
Categorisation of hospitals
The hospitals forming part of the network of emergency services must have the necessary standards
of care. Hence the hospitals must be categorised depending upon availability of facilities. There is
need for competent and dedicated personnel, with appropriate medical equipment (not necessarily
sophisticated equipment, which may not work); the cost: benefit ratio must be worked out when
purchasing equipment. The pre-hospital health care system must be able to refer the patients to the
appropriate hospital, based on the facilities.
-1-
Care provided by emergency departments
These departments should be oriented to manage the persons requiring immediate treatments. They
should not be 'traffic policemen', directing emergency patients to various inpatient departments. The
staff of emergency departments must be capable of giving the treatment, calling the specialists as
necessary. Once the patient is stabilised, the patient may be transferred to the respective
departments for further definitive therapy.
Triage system
It is necessary to having sorting of patients, based on need for immediate attention, when there are
more patients. We should have a practical triage system, with a rapid provisional assessment. This
will lead to efficient and effective management.
We must minimize
patient waiting and process time
administrative activities of staff and patients ; and
movement of patients and relatives (attendants).
Communication
The role of communication systems (apart from the ambulance services) must be emphasized.
Electronic data communication must be in place to facilitate transfer of information
from place of accident or emergency illness to ambulance, and
from the ambulances to the receiving hospitals.
This will ensure that the hospitals are alerted early of the arrival of the patient and delay can be
avoided. Use of the police department communication system will be useful. It can also help in
networking available agencies and personnel.
Quality management
Hospitals must maintain performance standards. There can be many indices of performance:
1.
Operational Index: Ability of the emergency department (hospital) to provide quality
service. A part of it is patient turnaround rate - the average number of patients seen over an
hour period.
2.
Service Index: Personalised service to the patient. This can be assessed through patient
satisfaction rating.
3.
Organisational Development: This can be assessed by the degree of satisfaction of the staff.
4.
Clinical Quality: This is based on outcome studies;
ability of the emergency department to manage patients well;
ability of the department to diagnose and admit accurately;
ability of the department to discharge the patient accurately; and
average length of stay of the patient.
Audit
An audit must be conducted periodically to assess the performance of the department. It must
include a cost: benefit analysis and the mean cost per patient.
-2-
Training in Emergency Medicine and Trauma Care
Emergency Medicine is becoming a specialised discipline. It is necessary to train doctors, nurses
and paramedics in Emergency Medicine and Trauma Care.
The goals of Emergency Medicine are the early and rapid diagnosis of medical and surgical
emergencies (trauma and non-trauma) and early initiation of treatment in timely fashion. Such early
intervention can minimise mortality and morbidity and help in the early return of the individual to a
useful role in society cost-effectively. Academic Emergency Medicine and Trauma Care would
include undergraduate and postgraduate training; a one-year advanced diploma programme could be
considered.
Advanced postgraduate training will include the special areas of Emergency Trauma Care, Cardiopulmonary Care, Toxicology, Pediatrics and Disaster Management.
Cardiopulmonary resuscitation
It is necessary to train as large a number of persons as possible in first aid cardiopulmonary
resuscitation. This is particularly important with respect to industries, transport personnel and
others who are likely to be the first on injury spots. In addition, some persons can be trained in
advanced trauma life support.
Trauma Management
This would include injuries of various kinds; there can be multiple injuries (polytrauma). They can
be life-threatening conditions, which would necessitate primary survey and resuscitation. The first
requirements are looking after airway, breathing and circulation (ABC). There may be dysfunction
of the central nervous system. Management of shock is important in tackling emergencies.
Secondary Survey will look into skull injury, spinal injury and injury to the chest, abdomen or limbs
or the blood vessels.
Investigations are then carried out as necessary, following which definitive treatment will be started.
Trauma primarily affects the young, leading to loss of productivity.
Management of other emergencies
These would include management of medical emergencies
•
•
•
•
•
•
•
•
•
unconscious patient
acute myocardial infarction
acute pulmonary oedema
status asthmaticus
anaphylaxis
Emergency situations also arise in
•
drowning
•
hanging
•
electric shock
•
others
-3-
diabetic ketoacidosis
hypoglycaemic coma
status epilepticus
cerebrovascular accidents
Snake bites can cause deaths. Between 1993 and 1997, 3000-5000 outpatients were treated for
snake bites every year; 2000 to 4000 patients with Snake-bites were treated as inpatients and 116 to
210 patients with snake-bites died, as per the bulletin of the Department of Health and Family
Welfare Services (1997-1998). Prompt treatment with polyvalent anti-snake venom serum can save
lives and reduce suffering.
Poisioning may be due to over dosage of drugs such as antidepressants or barbiturates. Carbon
monoxide poisoning or poisoning with pesticides or insecticides (e.g., organophosphorous) can
cause emergencies.
Obstetric emergencies can be caused by conditions such as eclampsia.
Paediatric emergencies may be due to seizures or other conditions.
Psychiatric emergencies can require management of aggressive and violent or suicidal patients.
Sanjay Gandhi Accident Hospital and Research Institute, Bangalore
This is an autonomous institution started in 1984, to treat victims of traffic accidents. It has been
expanded and has been shifted to new premises, which can accommodate 125 beds. When the
project is completed, there will be 250 beds and may further be expanded to 350 beds. The Institute
has a certificate course in Traumatology; this is of one-year duration (after postgraduation).
Trauma Care Centre
The Karnataka Health Systems Development Project has identified 44 hospitals to be developed
into Trauma Care Centres, spread throughout the State. These Centres will be situated near the
National Highways and State Highways so that they can cater to the needs of road accidents and
also provide easy access. Each of the Trauma Centres will have 10 beds. They are all supplied with
the necessary equipments and furniture. Among the equipments supplied are equipments and
instruments for resuscitation, surgical procedures, conducting deliveries and gynaecological
procedures, ophthalmic surgery, laboratory tests and other medical equipments and vehicles. There
are also X-ray machines and operation theatre tables and operation lights, as also oxygen cylinders
with trolleys.
Emergency Medicine and Trauma Care Centres
The Task Force considered the needs of the State and has suggested that the needs for Emergency
Care and Trauma Care be combined and the Centres be designated as Emergency Medicine and
Trauma Care Centres. There will be 44 such centres to start with. These will gradually be
expanded to include other larger hospitals (with more than 50 beds) and distributed such that they
will be at distances of 50-60km and the time taken to reach them will be 1 hour or less. Other
necessary equipment will be supplied. The centres will be staffed with trained personnel. A good
communication system including telephone and wireless facilities and well-equipped ambulance
services with trained staff will be developed.
Recommendations
•
Develop Emergency Medicine and Trauma Care Centres to provide comprehensive medical
care, including medical, surgical, obstetric, paediatric and trauma care. To start with there
will be 44 such centres developed by the Karnataka Health Systems Development Project.
This will be expanded gradually to include more hospitals, spread throughout the State
-4-
•
Each center will have 10 beds for emergency medicine and trauma care.
•
The Centres will have trained personnel, all necessary drugs, sera, equipment and furniture.
•
A good and working communication system will be developed. This will include telephone
facilities and wireless sets. Well-equipped ambulance services with trained personnel will be
provided
•
Training will be imparted to the personnel, doctors, nurses and paramedics, in first aid and
life and trauma support systems.
•
The help of the police will be taken to ensure early and easy communication.
•
A system of community insurance will be developed.
•
Helmet wearing should be made compulsory for two wheeler users (including pillion riders).
Seat belts should be worn while driving cars.
•
First aid training should be mandatory to drivers and conductors of buses, trucks and other
vehicles. These vehicles will carry functional first aid boxes.
•
General public, especially those working in factories and children and teachers in schools
must have training in first aid. The services of St. Johns Ambulance Association may be
availed of.
•
The Additional Director, Medical will be the Chief Nodal Officer for coordinating all work
with respect to Emergency Medicine and Trauma Care.
-5-
4.3 DIAGNOSTIC SERVICES
Introduction:
Modern health care and Public health depend heavily on evidence. In health care the diagnosis must
be evidence based, and therapy chosen on the basis of previous evidence. In public health,
intervention is directed against specific causes of diseases and the transmission pathways of specific
pathogens. Much of the diagnostic evidence, both in health care and public health comes from
laboratory investigations.
Both the public and health care workers are familiar with the dependence on tests in the
management of cardiovascular, renal, nervous system or liver diseases. However the basic need for
diagnostic tests in the more common infectious diseases is not sufficiently acknowledged by the
medical profession nor understood by the public. This is partly due to the lack of reliable or
adequate laboratory diagnostic services at all levels and partly due to the availability of a wide
range of antimicrobial drugs which are used without specific aetiological diagnosis. The
consequences of treating without specific evidence may have serious repercussions on human life.
For example, if a treatable bacterial infection of the central nervous system is clinically
misdiagnosed as Japanese Encephalitis (without laboratory investigations for bacterial aetiology),
the likely outcome is death or permanent disabling sequelae. In the case of bacterial diseases there is
need to have, in at least a proportion of cases in an outbreak, the identification of specific pathogens
and their antimicrobial sensitivity patterns. In the absence of such laboratory evidence the choice of
antimicrobials may be inappropriate. Moreover many non bacterial diseases may be treated with
antimicrobials. Such commonplace practice of treatment with a number of antimicrobials has lead
to the emergence of antimicrobial resistance among a large number of bacterial pathogens. To cite a
few examples, today bacterial meningitis may be due to microbes resistant to Penicillin and
Chloramphenicol which were the mainstay of treatment until recently. Similarly many cases of
Typhoid fever are no longer amenable to the recommended drugs of choice (Chloramphenicol,
Ampicillin or Co- Trimoxazole). Consequently the newer Fluroquinolones have become standard
treatment in many centers in India. Recently several investigators have reported Typhoid fever
resistant to even these newer drugs. Third generation Cephalosporins, which may be needed to treat
Typhoid fever, are very expensive and not afforded by the common man who is in the first place at
risk of disease. A concerted effort, not only to prevent Typhoid fever, but also to introduce and
sustain rational therapy to restore some of the lost ground, is urgently needed.
The importance of diagnostic evidence in public health programmes against specific diseases
(example TB, malaria, leprosy) must be appreciated. Even for other public heath problems (e.g.,
Cholera, Typhoid, Dengue, JE, Leptospirosis, etc) specific aetiological diagnosis of at least a
sample during an outbreak is essential for mounting rational and targeted interventions. Thus the
public health system must also have ready access to diagnostic laboratory services.
The diagnostic services for health care include clinical pathology, biochemistry, histopathology,
microbiology (including bacteriology, virology and mycology), serology, imaging (X ray,
ultrasonography, echocardiography, CAT scan, MRI scan), electronic diagnostics
(electrocardiography, electroencephalography, nerve conduction etc.), endoscopies, nuclear
medicine and molecular medicine. It is important to define the appropriate tests for the different
levels of primary and referral health care institutions.
-1-
The laboratory services for public health include many of the above diagnostic modalities and
microbiology of water and food, toxicology, and medical entomology.
Laboratory Services – Situation analysis
There are Diagnostic Laboratories attached to PHC, CHC, taluka hospitals, district hospitals,
teaching hospitals and speciality hospitals. In the public health system there are district health
laboratories and the Public Health Institute (with sections for diagnostic microbiology, bacterial
analysis of water, testing of IV fluids, pesticide examination, chemical examination and food and
water analysis). The laboratory of the Divisional Public Analyst cum Regional Assistant Chemical
Examiner is also in the Pubic Health Institute.
There are laboratories at district and State level dedicated to malaria (laboratory attached to Deputy
Director of Malaria in every division, Central Malaria Laboratory, Bangalore), filariasis (laboratory
of Filaria Eradication Programme), leprosy (laboratory attached to District Leprosy Officer and
Central Leprosy Laboratory, Bangalore), tuberculosis (laboratory of the District TB officer,
laboratories of District TB Sanatoria, Central TB Laboratory at Lady Wellington Hospital,
Bangalore), sexually transmitted diseases (STD laboratory of District hospitals, Central VDRL
Laboratory at Bhatkal) and guinea worm ( Central Guinea Worm Laboratory). In addition there are
laboratories at the Vaccine institutes at Belgaum and Shimoga.
Under the Revised National TB Control Programme centralized sputum smear laboratories are
planned to serve clusters of primary health care institutions. Under the Karnataka State AIDS
Contol programme HIV testing facilities have been established in several centers.
There are 2 laboratories for virology in the public sector. One is in Bangalore Medical College,
manned and maintained by the Indian Council of Medical Research and the second is in NIMHANS
(deemed university).
Thus Karnataka State has a total of about 2000 laboratories. However most of them are beset with
chronic problems such as poor supervision, inadequate equipment, reagents, personnel and budget
provision. These laboratories must be made fully functional, efficient and with quality management.
The State also needs to examine how best to integrate all the laboratories under two umbrella
systems, namely diagnostic service for health care and laboratory services for public health.
Essential diagnostic services for health care delivery
The following tables will provide the lists of investigations, equipment and personnel essential for
various levels of health care system. At the distrct level, the district hospital laboratory and the
district public health laboratory may be integrated into one District Health Laboratory. The
dedicated laboratories for TB, leprosy, STD etc must be integrated with the District Health
Laboratory
-2-
Table 4.3.1: Primary Health Centre (PHC)
Sl.No. Tests
1
Urine analysis
2
3
4
5
6
7
8
9
Equipment and reagents
Personnel
Microscope,
Centrifuge, Lab Technician –
Slides, test tubes and other 1*
glass ware, Stains, reagents
for serology, Test kits for
pregnancy
Stool examination
Clinical haematology TC,
DC, ESR, Hb, BT, CT
Blood smear examination
for Malaria & Filaria
Sputum for Acid Fast
Bacilli
Microbiology:
Hanging
drop, smear examination
Pregnancy Tests
Serology: Widal, VDRL
Skin smear for lepra bacilli
* There should be provision for replacement of lab technician during leave vacancy.
Table 4.3.2: Secondary Health Care – CHC / Taluka hospitals
Sl.
No.
1.
2.
3.
4.
5.
6
Tests
Equipment and reagents
All the tests mentioned under All equipment mentioned
PHC
under PHC, Colorimeter
with its kits, Relevant Kits,
Incubators, Culture media,
Antibiotic discs, ELISA
equipment and kits
Bio-chemical Tests: for
glucose,
Blood grouping / Cross
matching
Tests for HIV / HBsAg
Microbiology:
Imaging and miscellaneous.
X ray unit, ultrasound
X ray, ultrasonography, ECG equipment.
Personnel
Lab. Technicians-2
Doctor with DCP
qualification*
X-ray technician,
ultrasonologist**
* selected taluka hospitals or CHC to have an additional technician to cover leave vacancy at PHC.
Similarly selected taluka hospital or CHC to have one DCP to supervise several PHC laboratories.
** in house or visiting
-3-
Table 4.3.3: District Hospital
Sl.
No
1.
2.
3.
4.
5.
6.
Tests
Equipment and reagents
All tests mentioned for Taluka All equipment and reagents
Hospitals
mentioned at under taluka
hospitals, Various kits and
reagents,
Autoanalyser
incubators
Complete
Biochemical
/
Haematological examination
Microbiology,
culture
/
sensitivity
Histopathology;
used
as Histopathology laboratory
reference lab from taluk equipment, Microtome and
hospital
other facilities for making
paraffin slides.
Bacterial
and
chemical
analysis of water, isolation of
vibrio cholera, salmonella etc.,
Imaging and miscellaneous:
X-ray, ultrasound scanning
X-ray machine, portable xEndoscopy, ECG, access to ray, Portable ultrasound
CAT scan/ MRI scan
scanner, Endoscopes, ECG
Personnel
Technicians - 6
Biochemistry:
M.Sc/MD/PhD
Pathology: MD
Microbiology: MD/PhD
X-ray technician,
Radiologist, Ultrasonologist,
Visiting
endoscopist
or
private participation
Table 4.3.4: Tertiary Care Hospital, Medical College Hospital, Speciality Hospital
All tests, equipment and reagents described under Table 3 must be available.
1.
All relevant haematological, Relevant instruments
biochemical
and equipments
microbiological tests.
2.
Immuno Histopathology
Imaging and miscellaneous
and Technicians. Departments
of
Pathology,
Microbiology,
Biochemistry
Department of Imaging
Nuclear Medicine
X-ray, ultrasound, Echo
Cardiography, CT Scan,
MRI,
Angiography
depending on the specialty
hospital
Miscellaneous
Endoscopy, Bronchoscopy,
Hysteroscopy,
Nuclear
Medicine in addition to all
tests at district level.
-4-
Specialised laboratory facilities
Access should be available in the state for several modern diagnostic facilities, e.g., there should be
at least one Electron Microscope center with access of service to pathologists at different levels.
Similarly, as need arises molecular methods must also be made available appropriately. For
example the antiviral treatment of AIDS requires monitoring of virus RNA copy numbers in blood.
The correct diagnosis of Hepatitis C virus and Cytomegalovirus in organ transplant recipients
requires facilities for Polymerase Chain Reaction (PCR). The health service must establish a
mechanism for needs assessment for these specialized laboratory facilities and they should be
provided at State or regional levels.
The Karnataka government has proposed to create Regional Diagnostic Centres in 5 regions, with
Central government grants. Once these laboratories are established, they may provide access to the
specialised services listed above.
Diagnostic Laboratory services at other hospitals.
Every hospital, governmental or private, with inpatient admission facilities must have a functional
diagnostic laboratory. The range of laboratory tests available in such laboratories would depend on
the expertise at the hospital and the facilities, such as equipments. Manuals must be available,
appropriate for the laboratories at various levels.
Quality Control and accreditation
Quality Management in diagnostic services is extremely important for accuracy and reliability of
diagnostic tests. Total Quality Management includes internal quality control (IQC) and external
quality assessment (EQA). All laboratories must be provided with detailed laboratory manuals,
which should contain specific IQC procedures. Currently there are two national EQA schemes, one
for clinical biochemistry and one for clinical microbiology. The State must make use of these, to
begin with for key laboratories, and later establish (within 5 years) appropriate EQA system to
ensure participation by all CHC, Taluka hospitals and District Health Laboratories.
A laboratory accreditation system must be established and made functional by the year 2005.
Supervision and administrative support
Laboratories tend to deteriorate unless supervised adequately and supported administratively.
Therefore it is important to establish a management system for supervisory control and
administrative support for all the laboratories within the health system in the State. A cluster of
PHC laboratories must have a supervisor with DCP qualification. The CHC and taluka hospital
laboratories must have supervisory support from the district health laboratories. All district health
laboratories must have supervisory support by a central health laboratory.
All vertical laboratory facilities at the district level and above must be integrated. Thus the District
Health Laboratory will encompass the District Hospital Diagnostic Laboratory, District Public
Health Laboratory and all other district laboratories such as those for TB, STD, leprosy, malaria etc.
The District Health Laboratory must have a medical entomology laboratory for dissection and
species identification of larvae and mosquitoes, and for testing insecticide resistance of vectors.
The administrative lines of control of the laboratory network must be defined by the health system.
An assessment for the required personnel and cadres (to man and supervise laboratories at all levels)
must be prepared before the end of 2001. This will help in the planning of preparing and training,
with the necessary qualifications of an adequate numbers of personnel, with defined promotion
-5-
avenues, within the health systems. The Public Health Institute must be modernised to function as
the technical apical lead centre for the laboratory system and network within the state.
Recommendations
•
All diagnostic service laboratories must be strengthened or restructured as shown above
and all vacancies should be filled up and equipment and reagents provided in a time bound
fashion so that the entire system is fully functional before the end of 2005.
•
The Public Health Institute must be redesigned and strengthened to encompass
Epidemiology and laboratory components. This State Level Laboratory should have
expertise in Bacteriology, Virology, Mycology, Parasitology, Medical Entomology and
Toxicology. Its functions include Supervision, Training, Quality Management, Reagent
preparation and Standardisation.
•
The District Hospital Laboratory and the District Health Laboratory will be integrated; the
District Laboratory will fulfill both functions – diagnostic service for health care, and for
public health. The District Laboratory should be supervised by one MD / DCP
(Microbiology) and MD / MSc (Biochemistry) and one MD / DCP (Pathology), and
adequate respective staff, technical and administrative. The Taluk Hospital Laboratory
should be supervised by one specialist of DCP qualification, supported by other staff. CHC
and PHC laboratories will be managed by Trained Technicians.
•
The personnel requirements, their training needs, cadres and promotion avenues for all
laboratories must be prepared before the end of 2001.
•
The quality management procedures with provision of laboratory manuals including IQC
must be initiated immediately. The participation of all relevant laboratories in EQA and
appropriate accreditation process must be completed by the year 2005.
•
Imaging and miscellaneous investigative services will be provided to meet the requirements
for diagnostic tests at various levels.
-6-
4.4 BLOOD BANKING AND TRANSFUSION SERVICES
Preamble:
Ensuring availability of safe blood and blood components to all persons who need them,
irrespective of socio-economic status is the responsibility of the government of Karnataka
Back-ground of the Blood Transfusion Services in Karnataka
Blood banks in Karnataka come under the regulatory control of the Drug Control Department,
Karnataka.
The other stakeholders are:
•
•
•
Blood Banks; Hospitals, Patients and the medical community; Voluntary blood donors,
motivators & donor organisations;
Advisory & Policy bodies such as Karnataka State Blood Transfusion Council Karnataka, State
AIDS Prevention Society; Dept. of Health & Family Welfare, Karnataka, Rajiv Gandhi
University etc.
Accreditation bodies such as National Institute of Biologicals, other International Quality
Assessment agencies like ISO.
Existing facilities- Strengths:
•
•
•
•
•
There are several NGOs, supporting voluntary blood donation, whose networking and
strengthening can lead to increased voluntary blood donations & donor base.
Under NACO (National Aids Control Organization) phase I & II, the Blood Safety Programme
was given priority and several Government and NGO blood banks were strengthened.
Presently there are 110 licensed blood banks, 75% are government & private hospital- based
blood banks; 25% equally divided between private non-profit, and private commercial blood
banks.
Of the 7 component separation centers, KMIO, NIMHANS, Victoria Hospital (yet to be fully
commissioned), St. John's Hospital, Manipal Hospital and Rotary-TTK Blood Bank are in
Bangalore; one in Mangalore -University Medical Centre. Two more have been sanctioned this
year under Karnataka State AIDS Prevention Society (KSAPS) and 2 more on the anvil for
2001-2002.
There is sufficient technical expertise available for training of medical and para - medical staff.
Areas of concern in the present blood banking & transfusion services:
• Inequitable distribution of blood bank services. Bangalore for instance has 40 blood banks,
whereas many districts have only one.
•
The existing system is not able to cater to the needs at the periphery. In remote areas far away
from existing licenced blood banks, emergency requirements at smallest hospitals and nursing
homes are being met by drawing blood from the relatives and screening for Transfusion
Transmitted Diseases (TTD) by rapid tests.
-1-
•
•
•
•
•
•
There is sub-optimal & irrational use of blood for two reasons. Firstly because most blood banks
supply Whole Blood only, and secondly, there is lack of awareness about optimal & rational use
of blood by the medical community. A recent study revealed that as much as 72% of adult
transfusions and 49% of child transfusions were inappropriate. Upto 50% of all blood collected
was wasted as unnecessary, One-unit Transfusions.
All Blood banks are linked (on paper) to the 10 Zonal Blood Testing Centers. These centres
were established during Phase -1 of the HIV/AIDS Control programme to screen samples from
all blood banks for HIV. But sub- standard, poor quality testing, delay in testing and reporting at
the ZBTCs has resulted in all blood banks carrying out screening at their own centres.
Many blood banks do not meet required quality standards, including many of the ZBTCs;
Many small blood banks are economically un-viable.
Most blood banks have inadequate infrastructure:.
a. The blood banks have the required equipment but no provision for maintenance and
repair
b. Many blood banks are manned by Medical Officers without training in blood banking.
Many of them are postgraduates in subjects other than Pathology e.g. OBG, surgery,
orthopaedics etc. therefore their interest in blood banking is limited if not absent.
c. The other staffing requirements e.g. technicians are not adequate.
d. There is no social worker in most blood banks.
e. The staff is not trained in blood banking.
Most private commercial blood banks continue to draw blood from paid donors, who come in
the guise of ‘Replacement donors’.
Improving the blood banking and transfusion services in Karnataka will entail:
I. A data base of blood requirement and available facilities
A GIS with details of a needs-based assessment as well as available resources detailing the
following:
• Hospitals and blood requirement;
• Blood banks; trained personnel, trainers / training institutions;
• NGO, community groups, College and industries- as a source of Voluntary blood donors
II. Upgradation of identified blood banks & centralization of some of the services:
The critical service of TTD screening should be carried out only at identified Blood Centres and
ZBTCs that meet required standards to ensure quality & economic viability.
Screening for blood safety could be combined with tests performed for other requirements, example
Voluntary Testing, Diagnostic, Sentinel Surveys and so on. The kits used, criteria for testing,
procedures etc. will certainly differ. But capital and (trained) staff will be common.
Small, economically unviable blood banks lead to massive & unnecessary drain of monetary as well
as human resources. Therefore, facilities like component separation and testing for TTD should be
centralized and tested blood components stored and issued at peripheral level hospitals.
-2-
The medical facilities available in Karnataka in the hospitals at various levels are known. It is easy
to identify and classify the specific blood / blood components requirements at each level. On the
basis of this, a need-based, 3-tier system of blood centres of excellence can be established.
First tier: Blood Component Separation Centre (BCSC), based preferably in a teaching hospital.
This should:
• Collect and process at least 1,000 units of blood per month and issue 2-3000 units a month
• Test for TTDs by ELISA,
• Process Whole Blood into components,
• Store & issue components to patients after pre-transfusion tests, and
• Supply blood components to district and taluka blood banks.
• At least 3 Zonal Blood Component Separation Centres, 1 per zone, should be established in
teaching hospitals (except in Bangalore, which already has 5 centers).
Second tier -district blood bank, large taluka hospital or equivalent, this should:
• Collect at least 500 units of blood per month,
• Test for TTDs by ELISA,
• Retain single bags (WB) and send multiple bags to BCSC for component preparation,
• Store and issue components to patients after pre-transfusion tests
Third Tier: (Smaller taluka hospitals, CHC or equivalent), storage and issue centre. This should:
• Store & issue WB / RC supplied by the designated district blood bank or BCSC, to patients
• Collect WB from patients' relatives only in emergencies, test by rapid tests for TTDs & issue to
patients.
III. Evaluation and accreditation of blood banks to ensure quality:
Quality systems in all blood banks and blood transfusion centres and regular monitoring &
evaluation by Drug control department and External Quality Assessment agencies.
IV. Increasing voluntary donation and retention of donors:
Blood from a voluntary donor is the basis for ensuring safe blood supply. Therefore:
•
Efforts should be made at all three (tiers) levels to motivate and collect volunteer blood.
•
Every blood collection centre should have a social worker/motivator. Social Workers should
start motivation and mobilisation of donors, with the help of local NGOs and the community to
establish a system to ensure availability of blood throughout the year. The social worker should
be made responsible for coordinating the voluntary blood donation movement in the district.
•
The voluntary and private sector support for voluntary blood donation, and should be utilized to
the maximum extent possible. This should be reciprocated by ensuring blood availability when
required by the donor or donor organisation.
-3-
V. Ensuring rational and optimum use of blood
Blood is a very precious commodity. Therefore along with efforts to increase voluntary blood
donation, equal emphasis should be laid on rational use to avoid wastage of blood and blood
component therapy to optimise use of blood available.
•
Both the medical community as well as the end user -the patient, should be sensitised about this.
•
Every hospital should have a Hospital Transfusion Committee, to audit blood use.
VI. Education, training and cadre development in the above areas:
The Rajiv Gandhi University of Medical Sciences should institute the following:
•
Including the subjects of Blood Banking, Transfusion Medicine, correct, rational and optimum
use of blood in the MBBS and all post graduate courses, and a posting in a blood bank during
internship. A degree / diploma course in transfusion medicine for medical officers (?).
•
Systematic training for blood bank Medical Officers, laboratory technicians, nurses, QC officers
and motivators; all personnel at the storage and issue points and drug control inspectors, should
be implemented.
•
Support with preparation of SOPs, IEC material etc.
•
Research programs initiated and supported in relevant areas.
VII. Re-examination of and recommendations for The Drug Control Act and Rules:
The Drug Control Act and rules may need to be re examined to cater to emergency blood
requirement at remote areas because:
•
The setting up of an effective centralized blood banking and transfusion services as per the
above plan, including logistics of transport of blood / components to all storage and issue points
(hospitals) will take considerable time.
•
Even then the system may not be able to meet the total requirement for blood and blood
components at all levels and especially not the emergency requirement at remote (PHC) level
hospitals.
-4-
Recommendations
I. General:
•
All blood banks should have the required equipment, and be supplied with adequate reagents
and testing kits in a timely manner. They should be equipped with adequate number of trained
staff.
•
All blood banks should put in place a quality control and assurance programme.
•
NGOs have taken a proactive role in the voluntary blood donation movement. A comprehensive
plan to motivate and mobilize voluntary blood donors to ensure adequate supply of safe blood
throughout the year and all over the state should be developed with their help.
•
The medical community should be sensitised to make optimal & rational use of blood. Every
hospital should have a blood transfusion committee to ensure this.
II. Recommendations for Urban Health Care Services:
•
Smaller, nonviable blood banks should be closed; the infrastructure facilities (both
equipment and staff) redistributed into a rationalised & centralized blood banking &
transfusion services.
•
A pilot project to study the logistics, management and monitoring of the centralized 3-tier
system comprising – “Blood Component Centre- blood collection -blood storage & issue
points” as elaborated earlier, should be initiated in Bangalore; and this model replicated
later in other major cities.
III. Recommendations for Rural Health Care Services:
•
It will not be feasible to establish an Urban model of 3-tier centralized blood banking and
transfusion services for the Rural areas for some time to come. Therefore an adequate
number of well-equipped (Whole Blood) blood banks will have to be set up, keeping the
blood needs and regional disparities in mind.
•
Since the numbers of blood units processed at the peripheral blood banks may be small,
measures to conserve resources may be undertaken by using common testing facilities and
staff of the hospital.
•
The Drug Control Act & Rules need to be seriously examined and modified to cater to
emergency blood requirements, particularly in remote areas. The State Government may
make specific recommendations to this effect.
-5-
4.5. BIO-SAFETY
There is constant danger to patients and staff in the hospital, unless precautions are taken. These
may be from radiation during diagnostic procedures (X-rays and nuclear medicine) or from
infections. Radiotherapy is used in specialized institutions. Health care workers, patients and public
are at the risk of exposure to radiations from both diagnostic and therapeutic procedures using
radiation, but radiotherapy is available only in specialised institutions.
4.5.1 Radiation Safety in Diagnostic Services:
1. Patients Protection in Diagnostic Radiology:
Aims:
a. Reduce the absorbed doses received by tissues in the region of the body under examination
to the minimum compatible with obtaining the necessary information for the particular
patient.
b. Limit as far as is practicable the irradiation of other parts of the body.
c. Reduce the frequency of unnecessary repeat irradiation.
The above points are highly dependent on technical factors such as
a. Size of the X-ray field.
b. Shielding of the organs
c. Distance from the focal spot to the skin or image receptor (Mobile: District Should not be
less than 30 cms; Stationary: Distance should not be less than 45cms; Photoflourography
and Radiography of the chest: at least 120 cms.) (Table Top Dose: should not exceed 5.75
R/minute)
d. Total Filtration: Conventional Diagnostic Radiology: not less than 2.5 mm of aluminium
e. Carbon Fibre Materials: Over all reduction of absorbed dose in the skin of the patient facing
the X-ray tube is in the range of 30% to more than 50%.
f. Control of irradiation and Recording of Irradiation time (in case of Fluoroscopy
examination)
g. Intensifying screens and Radiographic films
h. Radiographic film processing
i. Error in positioning of the patient, proper use of reference list of technical factors such as
kVp and mAs based on patient size.
j. Patient Record Maintenance
k. Elective radiological Examination of females: Lower abdomen and Pelvis of woman in the
reproductive age should be carried out preferably within first 10 days from the onset of
menstruation. For pregnant woman, the foetus should receive minimum radiation dose.
2. Radiation Protection Programme:
a.
Function of RSO: Conduct periodical protection surveys, competent to face radiation
emergencies and accidents, to ensure maintenance and calibration of radiation measuring
and monitoring instrument, maintenance of records.
-1-
b.
c.
d.
e.
Personnel monitoring service
Storage of Radiation sensitive materials
Quality Assurance of the Equipment
Maximum Permissible Dose Limit
Radiation Worker: 20mSv/year or not more than 100mSv in 5 years
Public:
1mSv/year
Pregnant Worker: Once the pregnancy of radiation worker is established, she shall not
receive more than 10mSv at a uniform rate during the remaining period
of pregnancy
3. Safety Gadgets on Diagnostic Radiology:
a.
b.
c.
d.
e.
f.
g.
h.
Protective Lead Glass: 2mm lead equivalent thickness for 100kV for higher voltages
increased at the rate of 0.01mm per kV
Lead Rubber Flaps: Not less than 0.5mm lead equivalence
Protective Barrier: 1.5mm lead equivalence thickness and 1.5mm lead equivalence
window
Fluoroscopy Chair: 1.5mm lead equivalence
Protective Aprons: 0.25mm lead equivalence
Protective Gloves: 0.25mm lead equivalence
Gonad Shield: 0.5mm lead equivalence
Cassette Pass Box: 2mm lead equivalence
4. Regulatory Controls:
a.
b.
c.
d.
e.
Equipment Design Certification
Registration of X-ray equipment
Records for Inspection / Decommissioning
Stipulated Minimum qualifications and experience required for personnel
X-ray room layout:
(i) Location of X-ray installation: As far away from high occupancy areas, as possible
(ii) Room size: Not less than 25 sq.m
(iii) Shielding: Dose equivalent limit to radiation worker and public should not 20mSv
and 1mSv.
(iv) Opening and Ventilation: above a height of 2 meters from the ground or floor level
(v) Illumination Control: Suitable red light must be provided in the room after dark
adaption.
(vi) Patient waiting areas: Outside the X-ray room
(vii) Warning Signal and Placard: Red light must be provided at a conspicuous place
outside the X-ray room and kept on when the X-ray unit is in use.
5. Present Scenario: Status of Radiation Safety
Karnataka specific data regarding the number of units in use and safety precautions taken are not
available. Currently more than 50,000 units are used in India. Nearly 1500 new units are added
annually (1990).
-2-
a.
b.
c.
d.
e.
f.
44% of the fluoroscopic units had tabletop dose rates in excess of the recommended
limits.
On a more extensive survey of 750 units, it was found that one of three units had
improper tube-screen alignment. The beam limiting was inadequate in 25% of units.
Appropriate protective accessories were not in use in 20% in installations.
Beam alignment, Anode potential, and linearity of mA were not found proper in most of
the equipments.
Lay out of X-ray installations and display of red lights and caution note were found
unsatisfactory in most of the X-ray units.
Training of Staff and availability of Personnel monitoring service were inadequate.
QA tests and Protection surveys should be made compulsorily for all X-ray installation
at least once a year.
Recommendations
•
All the X-ray installations must be registered with AERB.
•
All personnel handling the equipments must be qualified / trained / certified.
•
Services of Radiation Safety Officer must be utilised by all the institutions, which are using
X-ray equipments.
•
All diagnostic X-ray equipment users should possess and use radiation safety gadgets.
•
Radiation Protection programmes must be strictly followed by the X-ray equipment users.
4.5.2. Hospital Acquired (Nosocomial) infections:
Hospital Acquired (Nosocomial) infection is a source of danger to the patients admitted in the
hospital and to the staff working in the hospital. All personnel in the hospital must take adequate
measures to prevent spread of infection.
Universal Precautions
Health care workers are constantly at risk of infection as they are exposed to any number of
potentially infectious agents (blood and body fluids), in the course of their work. Patients at health
care settings are also at risk of acquiring new infections. (nosocomial or hospital acquired
infections).
The level of risk of exposure to infections depends on the type of exposure and can be due to injury
(cuts, needle-stick) or mucous-membrane contact (eyes, nose and mouth by splashing of blood etc
or with skin abrasions). It is therefore very essential that safe working practices are instituted and
maintained in the health care settings to reduce the risk of occupational exposure of staff to
infections and of the patients to hospital acquired infections.
-3-
Guidelines for routine “Universal Precautions” and Bio-safety measures are available from WHO,
NACO and other sources. Health Care Staff are also aware and concerned about occupational
exposure and the safety precautions to be taken.
But unfortunately these are neither strictly enforced nor followed. Some glaring examples are:
•
Re-use of needles and syringes without proper sterilization – E.g. use of one common sterilizer
with no way of identifying the sterilized from the used needles and syringes.
•
Gloves not being used for a variety of reasons that range from non-availability to discomfort
because of hot weather. Once worn, gloves are not removed when touching door- knobs,
telephones, books, pens etc, thereby posing a hazard to the next user.
•
Transport and storage of specimens and samples; cleaning of spills etc are not according to
prescribed guidelines.
•
The simplest of precautions viz. hand-washing is not practiced regularly and correctly.
•
Eatables and drinks are allowed in laboratories and other quarantined areas and are often stored
in refrigerators along with drugs, reagents, testing kits, vaccines etc.
•
Often, the unskilled workers are not sensitized to bio-safety precautions.
•
There are areas of concern in disposal of biohazard waste. Segregation at point of origin may be
practised, but often there is mixing of the various types of waste at the end points; rag pickers
are constantly at risk from sharps; plastics are incinerated leading to pollution and so on.
•
Not all health care personnel are immunised against Hepatitis B; Post-Exposure Prophylaxis
procedures are not followed according to guidelines.
Recommendations
•
All health care workers should be given systematic training programmes regarding the risks
and precautionary measures to be taken to prevent infections which may be transmitted
through blood and body fluids.
•
Adequate consumables for barrier protection like aprons, masks and gloves should be
provided to staff.
•
All health care workers who are at potential risk for infections which may be transmitted
through blood and body fluids should be immunized against Hepatitis B.
•
Adequate measures for regular and periodic disinfection of the health care premises, work
tables, equipment etc should be instituted.
•
Minimum standards of cleanliness and tidiness should instituted.
•
All bio-hazardous waste should be segregated and disinfected before disposal.
-4-
•
Post-Exposure Prophylaxis procedures should be followed according to guidelines.
-5-
5. PUBLIC HEALTH
"Improvement in health is likely to come, in the future as in the past, farom modification of the conditions which
lead to disease, rather than from intervention into the mechanisms of disease after it has occurred."
- Thomas Mckeown, 1976
5.1 PUBLIC HEALTH AND PRIMARY HEALTH CARE : A CONTINUUM AND
SYNERGY
The Task Force on Health and Family Welfare is specifically mandated to improve Public
Health and Primary Health Care in the State. This was because public health though strong in
the state from the 1930s to 1960s, had subsequently gradually declined and got fragmented.
The Task Force found through discussions with a variety of people, over the past year, that most
people had very divergent views on what exactly public health meant. Hence this section1 is an
introduction to the entire chapter on public health, describing briefly public health concepts,
principles and practice as they have developed over time, and linking them with the situation in
Karnataka, India and elsewhere.
Defining Public Health
Public health is an evolving discipline through which major health gains for populations have
been made in several countries around the world, since the early nineteenth century, i.e., before
the development of antibiotics and vaccines.
It has been defined by the Association of
Epidemiologists as follows :
“Public health is one of the efforts organized by society to protect, promote and restore people’s
health. It is the combination of services, skills and beliefs that are directed to the maintenance
and improvement of the health of all people through collective or social actions. The programs,
services and institutions involved emphasize the prevention of disease and the health needs of
the population as a whole. Public health activities change with changing technology and social
values, but the goals remain the same: to reduce the amount of disease, premature death and
disease produced discomfort and disability in the population” (JM Last 1983).
In clinical or curative medicine, efforts are focussed on the individual person who is ill. In
public health, a population based approach is taken, focussing on disease patterns, distributions,
trends and risk factors. Public health interventions are organized usually through government
as larger collective action is required. The scope is wide and includes health protection,
promotion, diseases prevention, cure and rehabilitation.
State responsibility for health and health care
One of the key principles of public health, that the State is responsible for the health of its
people, was conceived over 150 years ago, leading to the first Public Health Act of 1848. The
importance of this social principle remains and has been reiterated by several bodies such as the
World Health Assembly, of the WHO (1977), WHO and UNICEF in 1978 and more recently by
the Peoples Health Assembly (PHA) in 2000. The role of the state remains critical, in present
times and for the future, to protect and promote the health of all people as a public good or
common good, where health is a human right. Public health has in particular an abiding concern
for the health and social conditions of the poor and vulnerable sections of society. The state is
also the only constitutionally, legally, mandated sector with the responsibility of improving the
health and living conditions of its citizens.
Public health has consistently struggled with and challenged structural roots underlying poverty.
The political economy dimensions of health and people’s access to care include the strong
underlying forces influencing the development, functioning and programme implementation of
the health system. This is evident in strong medical professional lobbies, and vested interests of
various groups of allied health professionals, both of which result in an unhealthy politicization
of the health system and in non-implementation of programmes. It is also evident in pesticide,
pharmaceutical, medical industry and insurance lobbies functioning at global and national levels
and influencing local policies and practices. Class, caste/ ethnicity, gender, age all play a role.
The unfettered play of political economy factors result in increased inequalities in health status
and in access to care. Public health emphasises the critical role required to be played by the state
in shifting the balance towards better health and access to care for all, but particularly the poor
and socially disadvantaged.
Addressing determinants of health
Diseases like cholera and typhoid earlier widely prevalent in Europe and the USA, were
controlled by public health systems that ensured a mandated supply of clean, safe or potable
water, functioning sewage systems, garbage and refuse disposal. Karnataka has initiated
measures for water supply and sanitation through different projects namely the Dutch assisted
project, DANIDA, UNICEF and the World Bank assisted Karnataka Integrated Rural Water
Supply and Environmental Sanitation Projects. However the need and demands of the public in
this regard are yet to be fully met. Water and sanitation related diseases still take a heavy toll in
terms of sickness (see section on communicable diseases) and person days of work lost. The
role of the Directorate of Health and Family Welfare Services will be in setting standards for
water quality, use of chlorination / other methods of water purification, monitoring through
regular water quality testing at local, taluk and district levels, and initiating quick containment
measures following any disease outbreak. Related measures include intersectoral collaboration
at different levels; health promotion of children, women and the community, and special
training of panchayatraj members, as water and sanitation fall specifically under their purview,
under the 73rd and 74th Constitutional Amendments. The specific responsibility and
accountability of the male junior health assistant needs to be clarified.
They also need
supervision in this regard. Provision of safe water supply and sanitation form the very basic,
first generation, public health interventions and need to be owned by the health department.
Another early development in preventive medicine, closely linked to public health, started in the
18th century relates to nutrition, another basic determinant of health. Use of fresh fruits and
vegetables was recommended in 1753 for the prevention of scurvy among sailors even before
the causative agent was known. There has been tremendous growth and development in the
science of the nutrition since then. Our own ancient Indian systems evolved food production
patterns, diets and method of cooking that provided a balanced diet in different seasons and
suited to various physiological conditions. Despite rich traditional and modern knowledge
bases, recent data from the National Family Health Survey II (NFHS II) and National Nutrition
Monitoring Board (NNMB), regarding nutritional status reveals widespread under nutrition
particularly in young children and among women in Karnataka. Nutrition has also been found to
have been very neglected by the DHFW. Malnutrition in Karnataka is a major public health
issue and is being accorded the highest priority as an area for intervention by the Task Force on
Health & FW. It is therefore being covered in a separate chapter (Chapter 7). Deeper
underlying issues of food and nutrition security are linked to irrigation, agriculture and seed
policies; to employment, income and purchasing capacity; and to access by the poor to public
distribution systems. These too need to be addressed.
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The Germ Theory and Infectious Diseases Control
The second generation of public health evolved with the discovery of bacteria and the growth
of microbiology. Development of diagnostics, therapeutics, vaccines, and an understanding of
disease transmission patterns made it feasible to initiate control programmes for communicable
diseases. The current disease burden due to communicable or infectious diseases in Karnataka
still accounts for a major share of morbidity and mortality. Cost effective public health
interventions exist for most infectious diseases. For newer emerging diseases such as
HIV/AIDS, research is taking place at a fairly rapid pace and diagnostics and anti-retroviral
drugs are already available. However about 30 new infectious diseases have been reported
globally over the past 2-3 decades and the State needs to be alert to them.
An important underlying public health principle is that the method of transmission of
communicable diseases determines the choice of the method of disease control to be used.
Diseases with similar modes of transmission are grouped or classified together e.g., water
borne diseases, faeco-oral diseases, soil mediated infections, food borne diseases, respiratory
infections that are air borne, insect or vector borne diseases, diseases transmitted via body fluids,
ectoparasite zoonoses, domestic zoonoses etc. Only important diseases that require priority
attention and intervention are covered in this report. The faeco-oral group of diseases include
amoebiasis, giardia, gastro-enteritis, bacillary dysentery, cholera, typhoid, hepatitis A & E, and
poliomyelitis. Breaking the faecal-oral chain is the basis of control, namely by personal
hygiene, increase in water quantity, improvement in water quality, food hygiene and provision
of sewage disposal and sanitation systems.
Another public health principle is that priority is given for control of infectious disease based
on criteria such as magnitude of problem using epidemiological criteria, severity of diseases,
and availability of effective, safe interventions at reasonable cost. Though appearing
commonsensical and obvious, a review of major public health programmes reveals the lack of
priority given to these priority problems and to practicing public health principles in their
control, with resultant heavy preventable burdens of morbidity and mortality. For example,
tuberculosis which was identified in 1947-48 as India’s foremost public health problem,
continues to be so in Karnataka in 2000-1, despite having a well researched and designed control
programme and despite the availability of diagnostics and cost effective drugs for treatment, all
of which are indigenously manufactured. The National Tuberculosis Programme (NTP) has not
received adequate attention or resources from politicians, decision makers, administrators and
the DHFW. Thus it has been neglected and poorly supervised and implemented. In the Revised
National Tuberculosis Control Programme (RNTCP) also, Karnataka is currently the second
poorest performing State in the country. This apathy has resulted in much avoidable suffering
and even in unnecessary death.
Another example is of malaria. The early successes of the National Malaria Control Programme
have not been sustained. The increased number of cases and outbreaks in different parts of the
state are of concern. Malaria was controlled in Mysore State in the pre-DDT era, through public
health interventions including public health engineering and larvicidal fish.
These
bioenvironmental methods were unfortunately later abandoned with complete reliance on
chemical pesticides and chemotherapy. Increasing resistance to drugs and pesticides and the
harmful toxic efforts of pesticides have resulted in a rethinking of strategy. Other vector borne
diseases also have a fairly high incidence and prevalence in certain regions e.g. filaria, dengue
fever, Japanese encephalitis, etc. Specific technical dimensions for each disease are given later.
Another simple public health principle in communicable diseases control is that the health
system should ensure early detection, complete treatment recording and reporting (or
notification) through a disease surveillance system (this is covered in greater detail later).
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Public health and non-communicable diseases
The major burden of disease in developing country situations is often thought to be mainly
“diseases of poverty”: which is thought of synonymously, as infectious diseases and
malnutrition. This is reflected in health planning and financing priorities, with little attention
paid to chronic, non-communicable diseases. It is now recognized that social, demographic and
epidemiologic transitions have been occurring over the past few decades, and countries and
states like ours have a substantial burden of these diseases as well. A public health approach
addresses the risk factors that predispose to these diseases such as tobacco, alcohol, exercise
and food habits, environment and occupational risk. For instance, lower salt intakes at a
population level are found to result in lower blood pressure levels and less hypertension. More
recently, it is found that poor nutrition and other factors during intra-uterine foetal life increases
risk to these diseases later in life. Reduction of risk factors through health promotion,
community and public action, are part of the control strategy along with early detection
and good clinical management.
Health systems and public health
An additional premise is that there are certain health system prerequisites and primary
health care principles that need to be met, in order to achieve good infectious disease control.
The strategy of improving the functioning of general health services especially at PHC and CHC
level is important in providing comprehensive, affordable, good quality, diagnostic and
treatment facilities as close to the homes of people as possible. Diseases control interventions
need to be integrated into the functioning of the general health services as part of a
comprehensive primary health care service. This horizontal integration at primary care level is
to be supported by more specialized referral and support services at taluk/district and state
level, through a referral system. The primary health care service needs to be credible so as to
win the confidence of people. Only then will people utilize it to meet their basic health care
needs and for what government may consider priority health programmes, be they
communicable disease control, family welfare, non-communicable diseases control, etc.
These basic tenets of a good community health care service have been found lacking in our subcentres, PHCs and CHCs in the state. The Interim Report of the Task Force recommended 24
hour services at PHCs, with filling up of gaps in infrastructure including residential quarters,
water supply, electricity, vacancy positions for different grades of personnel, supply lines for
drugs and laboratory equipment/stains, communication systems etc. These are prerequisites for
a good service and for infectious disease control.
Primary Health Care
The Primary Health Care approach, as a strategy to attain the international social goal of
Health for All by 2000, was articulated and accepted at a WHO-UNICEF conference in AlmaAta in 1978. It expanded the scope and strategies for public health. Recognizing the limitations
of medical science alone in improving the health of people, it emphasized the need to address
determinants of health through inter-sectoral collaboration, especially with departments of
agriculture, food supply, water supply, sanitation, housing and education. It emphasised the
need for equity and social justice in health, and health care. It recommended shifting control
over health care systems, with greater decentralization; and involvement of local people and
communities in decision making and planning health care systems to suit their own social,
economic and cultural conditions. It utilized scientific methods of proven effective, safe,
acceptable and affordable treatments and interventions in the preventive, promotive, curative
and rehabilitative areas, but also encouraged indigenous and traditional systems of medicine.
It had a social goal of improved health and quality of life; access to health care by all;
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maximum health benefits to the greatest number; increased self-reliance of individual persons
and communities, and the promotion of social means of reaching these goals. Thus public health
went through another paradigm shift. Experience and thinking from India along with those from
other countries, helped in making this shift.
The following excerpts from the original documents are given for a clear understanding of
concepts. These are being given in some detail as they form a core element of the task force
recommendations.
“Primary Health care is essential health care made universally accessible to individuals and
families in the community by means acceptable to them, through their full participation and at a
cost that the community and country can afford. It forms an integral part of the country's health
system of which it is the nucleus and of the overall social and economic development of the
community” (WHO-UNICEF, 1978).
“It means much more than the mere extension of basic health services. It has social and
developmental dimensions, and if properly applied will influence the way in which the rest of the
health system functions” (ibid).
“It is the first level of contact of individuals, the family and the community with the national
health system bringing health care as close as possible to where people live and work, and
constitute the first element of a continuing health care process " (ibid).
The four key underlying principles of primary health care are
• Equity through equitable distribution of health resources.
• Community participation and involvement.
• Intersectoral co-ordination between health and development.
• Use of appropriate technology for health.
The eight components of primary health care comprising the core technical package are :
• Education concerning prevailing health problems and about methods of identifying
preventing and controlling them.
• Promotion of food supply and proper nutrition.
• Adequate safe water supply and basic sanitation.
• Mother and child health services including family planning.
• Immunization against major infectious diseases
• Prevention and control of locally endemic diseases
• Appropriate treatment of common diseases and injuries
• Provision of essential drugs.
India was a significant contributor and signatory to the World Health Assembly (WHA), 1977
and the Alma Ata Declaration of 1978. The concept of comprehensive health care had already
been articulated in India through the Bhore Committee Report, in 1946, a document which
formed the early basis for India’s health planning. Primary health centres had been initiated
since 1952. The National TB programme, 1962, had the seeds of the primary health care
approach. The Shrivastava Committee report 1974, made links between education and training
of socially oriented doctors, all grades of health personnel and community health needs. A
national scheme for Village Health Workers was launched in 1977. Post Alma Ata, in 1981, the
Indian Council for Social Science Research and the Indian Council for Medical Research
brought out a publication “Health for All”. The National Health Policy based on principles of
primary health care was tabled in 1982 and passed by Parliament in 1983. It is still the operating
policy statement as of now. State governments, including Karnataka, accepted the Health for
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All (HFA) goals and Primary Health Care (PHC) strategies. The Ninth Plan document of the
Government of India committed itself to the goal of "Health for all, particularly for the
underprivileged".
However statements and public commitments are at risk of becoming rhetorical. They
need to be followed by action, resource flows, systems for accountability and measurement
of outcomes and impacts. Analysis reveals declining state expenditures on nutrition and lack
of responsibility and accountability for nutrition by the DHFW. Intersectoral work to ensure
potability of water and provision of sanitation facilities is ongoing since the early 1990s, but
coverage is incomplete. Data reveals the high, continuing preventable burden of water related
diseases. State health expenditure is stagnant and below norms. A large proportion of primary
health centres continue to function sub-optimally. Coverage and quality of basic antenatal care
and immunization continues to be low in Category C districts. Diseases like TB continue to take
a heavy toll with government health services providing complete treatment or cure to only 816% of expected sputum positive pulmonary TB patients. School health services are of poor
quality and have limited coverage. Community mental health care programmes at district level
have not been taken up seriously, though the epidemiological burden has been well documented.
The essential drugs concept is not practiced in spirit. Health education and promotion receive
little interest and is too focussed on Family Welfare. The public lack of confidence in public
health services. Public health and primary health care have been neglected and distorted and that
planned, systematic efforts are required to revive and institutionalize public health practice into
the Directorate of Health and Family Welfare Services.
Recommendations
•
All the staff of the Department of Health and Family Welfare Services must appreciate the
importance of Public Health and the synergy between primary health care and public health.
This will be reinforced through in-service orientation programme and short training
programmes for all health personnel.
•
The Public Health Institute will be upgraded to be a nodal centre for all laboratory services
and research. It will be headed by the Additional Director of Communicable diseases.
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5.2 WATER AND SANITATION
Water is variously considered as life giving, life sustaining, purifying, a vital nutrient and
essential for life. However, it can also spread diseases and kill. Predictions are that drinking
water is becoming a scarcer commodity. With ground water being used faster than it can be
recharged, shortage of drinking water is likely to become an important problem in the future.
Fifty percent of infant deaths are attributed to waterborne diseases. An estimated 1.5 million
under- five deaths occur in India every year, due to water related diseases, and approximately
1800 million person hours are lost annually in the country, due to the same. It is estimated that
poor quality and inadequate quantity of water accounts for about 10% of the total burden of
disease in developing country situations, as in Karnataka State.
Medical professionals and health providers are generally content to treat the symptoms of the
sickness or morbidity resulting from lack of access to safe, potable water supply. However, the
problem needs to be addressed at a deeper level through primary prevention of disease.
Therefore, the government of Karnataka and specifically the Directorate of Health are advised
to pay greater attention to their role in implementation of water supply and sanitation
schemes and extend access to these basic services to the entire population of the State as an
issue of citizens’ rights within a tight time frame of 3-5 years. This requires inter-sectoral
collaboration with Water Supply and Sanitation Boards, Pollution Control Boards and local
government bodies. Linkages with community groups and consumer groups, will help monitor
performance and also to reach out to individual households and families, with health promotion
messages, as personal hygiene practices and utilization of sanitation facilities are also important
for overall reduction of water and sanitation related diseases.
Pollution of water occurs through:
a) domestic sewage with organic matter and micro-organisms;
b) industrial effluents with organic matter, toxic chemicals and heavy metals;
c) agricultural run-offs also contaminate, through chemical fertilizers and pesticides;
d) urban run-offs have a combination of sewage and chemical contamination; and
e) excess of fluoride and arsenic in the water have adverse health effects such as on bone
growth and skin cancer respectively.
Chemical contamination produces cumulative toxicity after long exposure.
Microbial contamination is the more important and frequent cause of ill health, with 20-30
infectious diseases (viral, bacterial, protozoan and helminthic) being transmitted through water.
Examples of these diseases are,
a)
water washed diseases – scabies, trachoma, with inadequate water for personal hygiene
causing spread to occur through water used for bathing;
b)
water based diseases – infections transmitted through aquatic invertebrate animals e.g.
schistosomiasis and dracunculiasis (guinea worm disease);
c)
water related diseases – infections spread by insects that depend on water through vector
breeding in water – malaria, filariasis, dengue fever;
d)
water borne diseases through faecal contamination – diarrhoeas, dysentery, cholera,
typhoid, Hepatitis A, amoebiasis, giardiasis, helminthic infestations/ intestinal worms,
campylobacter, etc.
-1-
2
The group of diseases, in (d) called the faecal oral group are transmitted from person to person
through water or food via the oral route. Breaking the faecal-oral route forms the basis for
public health intervention for disease control. This is through a combination of good
personal hygiene, increased water quantity, improved water quality, food hygiene and
provision of sanitary facilities.
Inadequate access to water has important social dimensions with women, the rural poor and
scheduled castes and tribes being more adversely affected. One third of Indian villages do not
have safe water supply as of now. In Karnataka reportedly 86% of the total population have
access to safe water supply and 53% have access to sanitation.
Poor access of household to sanitation facilities (toilets) and lack of functional environmental
sanitation (drainage, sanitary waste disposal) are closely associated with microbial
contamination of water and soil. This is a major route of disease transmission through
contamination of water (diseases listed earlier) and soil. The latter include roundworm,
hookworm, whipworm etc. Lack of provision of sanitation facilities remains one of the most
neglected areas of intervention to improve public health. Schemes that are available are
inadequately publicized and poorly implemented due to corruption in undertaking construction
work. Where toilets are built, most often there is no water. Lack of access to toilets and privacy
is particularly a problem for girls and women. Lack of gender sensitivity in not providing for
such a basic need, should be rectified with the utmost urgency. Maintenance of drainage
systems is important for control of vector borne diseases as well.
Interventions
The central government has supported the state through several programmes, in introducing
interventions to provide safe water supply and sanitation facilities. These include the National
Water Supply and Sanitation Programme (1954), the Accelerated Rural Water Supply
Programme (1972), the Minimum Needs Programme (1974), the International Drinking Water
Supply and Sanitation Decade Programme (1981), the Twenty Point Programme (1986), the
Rajiv Gandhi National Drinking Water Mission and the Netherlands Assisted Project covering
Bijapur and Dharwad districts from 1991–97. The latter is developing uniform water sector
norms for the state. Karnataka more recently initiated the Integrated Rural Water Supply and
Environmental Sanitation programme in 1993, in 12 districts, (Bangalore Rural, Tumkur,
Shimoga, Mysore, Mandya, Hassan, Dakshin Kannada, Belgaum, Gulbarga, Bidar, Bellary,
Raichur). This project was with World Bank funding of Rs. 447.2 crores. The first phase from
1993 – 1998 was extended till September 2000 and closes by March 2001. The number of
districts expanded to 16. The next phase will cover the period 2002-07. Water quality testing
laboratories were set up or upgraded in 12 districts. A laboratory is planned . Village water and
sanitation committees were formed and this collaboration needs to be reviewed to learn from the
process so far. Local women and men are trained as masons to construct drains for sullage
water, with 50% labour charges from the community and 50% from the project. Building low
cost latrines and composting are part of the strategies. Developing the financial, technical and
administrative capabilities of gram panchayat members through training is being planned.
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Recommendations
While other departments are responsible for storage, treatment and distribution of water, the
department of health, has specific responsibilities. It needs to:
I.
Reduce water borne diseases through the following measures:
•
Set and make known standards for water quality and set timebound goals to reduce
mortality and morbidity due to water borne diseases.
•
Undertake regular, periodic testing for microbial contamination, while. new water
sources will need an initial detailed testing for chemical contamination. This is to
ensure that standards are maintained. Results should be reported to gram panchayats
and be available to the public.
•
Undertake, supervise and be responsible for water purification treatment e.g.
chlorination of wells in rural areas with collaboration between the panchayats / local
bodies and health personnel. Mapping of water sources should be undertaken at PHC
level.
•
Undertake surveillance and notifying of the concerned authorities regarding early
outbreaks of waterborne diseases. This will be part of the disease surveillance system.
•
Initiate rapid action in suspected outbreaks.
•
Integrate health promotion activities concerning water and sanitation related problems
at all levels - through schools, panchayats, women's sanghas, the print and audio visual
mass media and folk culture groups. The linkage between health status and water supply,
sanitation and drainage needs to be highlighted, focussing on how disease transmission
occurs. This will also convey positive messages regarding personal hygiene practices,
environmental hygiene and how to utilise government schemes.
II.
Improve sanitation by
•
Introduce schemes for toilets in schools, meeting halls, bus stands and other public
places, and for individual households, through partial subsidies and private and
voluntary sector participation.
•
Maintenance of drainage systems at local village and ward levels to be monitored by the
male health assistant.
•
Introduce solid waste management through popularising composting and vermiculture
for organic waste and other measures.
III.
Develop health promotion, advocacy and social mobilization.
•
Advocacy and social mobilization efforts to be undertaken proactively at local levels for
health personnel, communities and panchayats to view safe water supply, sanitation and
drainage of sullage as a package of services that have a positive impact on improving
public health.. Involvement of local communities in implementation and management of
systems is crucially important.
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5.3 WASTE MANAGEMENT AND POLLUTION CONTROL
5.3.1 Solid Waste Management and Pollution Control
Solid Waste Management has been receiving greater attention in the recent past. With the signing of
the International Treaty banning the import of hazardous waste into the country, there has been
accelerated efforts towards safer waste management practices. Different waste streams have been
identified for better management. Among them are Hazardous waste, Bio-medical Waste and
General Municipal Solid Waste.
The Centrally promulgated Environment Protection Act, 1986 and rules therein (Hazardous Waste
(handling and management); Biomedical Waste (handling and management) and Municipal Solid
Waste (handling and management)) currently govern the waste management practices.
While Management of Municipal Solid Waste is an obligatory function of the Municipalities and
the local governments, the principle of Polluter pays with the onus of responsibility on the generator
for safe management holds true of the other special categories of waste.
The State of Karnataka has been leading in terms of activities towards safe management of waste
especially the Solid Waste and Health Care Waste. Community Based Organisations and
Neighbourhood groups have been leading the endeavours. The Bangalore Agenda Task Force has
set for itself Night Collection of Garbage, Door to door collections of Household waste, Dumping
Yard, and modernisation of transport vehicles.
The Problems related to Waste Management are as follows:
• Lack of an efficient link and co-operation between the elected and assigned body
• Multiple departments with different responsibilities towards solid waste management.
• Lack of comprehensive policy and long-term planning
• Lack of appropriate trained staff in management and planning
Recommendations
General Waste Management:
• Set up a working group to look at the recommendations of the Supreme Court Committee for
management of solid waste in Class I cities and draw up an Action Plan for implementation
in Karnataka.
• Learn from experiences in Bangalore regarding primary (Door-to-door) collection of
Garbage and expand it to the other cities and towns.
• Accelerate the process of identifying and utilizing the Landfill sites.
• Delineate the elements of an Integrated Waste Management Policy at the State level.
• Identify mechanisms for improving the functioning of the local self- governments with
regards Solid Waste handling (Financial expertise and Technical expertise including).
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Special Waste Management:
Hazardous Waste
• Steps to be taken to publicise and bring in greater transparency in the functioning of the
State Pollution Control Board including the punitive measures taken against the polluting
industries.
• Set up the working group to examine the existing provisions of the Environment related acts
(Water Act, Air Act and Environment Protection Act) and the impact of the 73rd and 74th
Amendment to the Constitution of India (Nagarapalika and Panchayath Raj Acts).
• Regulate the use of Plastics including the implementation of the ban on plastics less than 20
microns thick.
• Steps to be initiated to regulate the use of Mercury and other heavy metals in industries.
•
Study the quantity and characteristics of the hazardous waste being generated in Small scale
industries and household industries in the state and take appropriate action.
Natural Resources depletion and Pollution abatement:
•
•
•
•
•
•
Steps to be initiated to study the recommendations of the Eco-committee report under the
chairmanship of Sri A N Yellapa Reddy and drawing up of an Action Plan for its
implementation.
Health Impact Assessment to be made mandatory along with Environment Impact
Assessment for developmental projects.
Initiate steps to address the abatement of indoor air pollution within households (efficient
and effective use of firewood and other fossil fuels; popularizing the use of LPG).
Steps and mechanisms to be identified to localise and regionalize the treatment of sullage
and sewerage before it is let into the water bodies.
A annual massive public health campaign to make the community work towards waste
reduction and recycling endeavours to be initiated along the lines of the National
Environment Awareness Campaign along with the Karnataka Rajya Vignana Parishad and
the network created by the Jana Arogya Sabhe.
Set up official transparent working mechanisms of independent monitoring systems with
active participation of the community to prevent natural resources depletion and work for
pollution abatement
5.3.2 Hospital Waste Management
Infectious waste from healthcare facilities poses a risk to the environment and to the people.
Medical waste should be scientifically and hygienically managed from the point of generation to
final disposal. Inappropriately managed medical waste can spread fatal diseases like Hepatitis B &
C and HIV/AIDS.
-2-
Legal Aspects:
The Bio-medical waste (management and handling) rules of the government of India has been
effected from July 1998 with a view to ensure safe and effective disposal of infectious and
hazardous waste. These rules define the role of administrative medical officers of health facilities
in waste management. Segregation, treatment and disposal options for different categories of waste
have been specified based on location and size of hospitals. While hospitals located in towns and
cities with population less than 5 lakhs may have simple disposal options like deep burial for
infectious waste, hospitals located in towns with more than 5 lakhs population will require to use
other options.
In Karnataka efforts are currently on to implement systems for safe management of health care
waste in all the secondary care hospitals under KHSDP.
Waste management activities under KHSDP
The short and medium term waste management strategies are at various stages of implementation in
all the re-commissioned hospitals.
An initial situational analysis at KHSDP hospitals revealed that:
• The total infectious and hazardous wastes form 15-20% of the total waste generated; the sharps
generated were 5-10% of the hazardous waste.
• The total infectious and hazardous wastes generated was only 0.24 kg as against the norm of 0.5
kg - 1.5kg per bed per day.
• The daily incinerable waste is low and does not warrant use of incinerators. The present system
of deep burial and landfill is adequate.
• The storing facility for recyclable is adequate and would need market sale once in a quarter.
Waste management audit in the hospitals revealed the following errors in practice:
•
•
•
•
•
•
Mistakes in segregation of waste at source;
Mixing of sharps with other recyclable waste; Ambiguity about final disposal of sharps and
plastics;
Disposables not being mutilated
Inappropriate location of bins
Biodegradable waste in deep burial not being covered properly with mud
Untrained contractual waste handlers are handling the waste
•
Ineffective disinfection
Therefore remedial measures including retraining and continuous monitoring is being put in place
In some of the bigger cities like Bangalore, several efforts are being implemented.
•
•
Individual private hospital-based efforts including segregation, incineration, deep burial etc. But
these attempts may give rise to environmental pollution due to individual institutions attempting
an incineration system, which does not meet quality standards.
Smaller nursing homes being served by private commercial waste-management companies.
-3-
•
Networking of some hospitals along with community-based neighbourhood groups. E.g. M.S.
Ramaiah Hospital and “Swabhimana”- This pilot project aims at using the “Ward approach” and
the common administrative machinery for safe and scientific disposal of solid as well as health
care waste within the defined geo-political area.
Issues of concern in Bangalore and other large cities
The several in depth studies undertaken by Tata Energy Research Institute (TERI) in the area of
Environmental Pollution including solid waste as well as hospital waste management in Bangalore.
have brought out several issues of concern, problems and lacunae in the system. The same can be
applied to other cities and towns in Karnataka.
•
•
•
•
•
•
•
•
•
There are multiple departments with different responsibilities towards waste management,
thereby making for unsatisfactory monitoring and enforcement of the rules and regulations.
Lack of a comprehensive policy and long-term planning to handle the waste in a scientific
manner.
Huge amounts of waste is being generated in large cities. Bangalore for instance with a
population of around 6 million generates 2,000 tonnes of solid waste per day. Of this, 12,500 kg
of health-care waste is generated by the hospitals and nursing homes and 1,000 kg from general
practitioners.
Only 15% of waste generated in a hospital is infectious. The current practice of mixing the small
amount of infectious wastes with a huge amount of non-infectious waste renders the entire
waste infectious to the general population. So rag pickers and other waste handlers outside the
hospital set up are under constant risk of infections from the waste.
Infected waste is transported in open trucks and there is open burning and dumping into low
lying areas and lakes. The several complaints by people about the malodor from hospital waste
and malodor and smoke resulting from open burning are generally ignored.
Infected waste including plastics and sharps are incinerated by cheap poor quality incinerators
within hospital premises.
Plastic waste is sold without adequate disinfection.
Single-use needles and syringes are not destroyed and are being repacked and rused.
There is lack of appropriate training of staff in health care institutions to manage waste and in
infection control measures.
There is urgent need to rectify this situation. We need to address the problem of waste management
in a proactive way, using the 3 R’s: reduce waste, recycle waste and reuse wherever possible.
Waste management involves careful segregation, processing, collection, transport, and final
disposal of various types of waste; effective training of staff, and supervision and monitoring of the
system.
The key strategy in healthcare waste management should include:
•
•
•
Institutional infection committees and policies.
Segregation of waste at the point of generation, using a convenient classification to identify the
different infectious components.
Disinfection of the waste by thermal inactivation (steam sterilisation autoclaving, hydroclaving),
incineration, gas / chemical disinfection, irradiation, microwave technology or certain other
innovative alternative technologies.
-4-
•
•
•
•
Destruction /disfigurement of sharps; shredding of plastics.
Recycling of recyclable material.
Lastly, safe disposal through discharge through sanitary sewage systems, land-fills etc.
Biomedical waste rules, 1998 prohibits incineration of chlorinated plastics.
Plastics and chlorinated waste should not be incinerated as this will lead to release toxic dioxins
and furans sulphur dioxide, oxides of nitrogen hydrochlorides etc., which are potent carcinogens.
Plastics are not bio-degradable and deep burial will result in leaching and contamination of soil and
surrounding water bodies. Therefore minimisation of use of plastics (and sharps); decontamination;
deforming and recycling should be practiced.
The solutions for cities and towns should be towards common health care waste management
facilities as an integral part of the solid waste management.
Recommendations
At Governmental level:
There is need for an integrated approach to safe management of health-care waste with
coordination between all stakeholders- Health-care settings, Doctors, civic authorities and the
community.
•
The Pollution Control Board should take steps to effectively implement its monitoring and
regulatory activities.
•
The Andhra Pradesh experience (Task Force for independent monitoring and reporting),
and Tamilnadu experience (Development of Model centres in each district) towards
development of systems for safe management of health care waste to be studied and
appropriately incorporated into the working of the Advisory committee to the Appropriate
Authority on Bio-medical Waste Rules in Karnataka.
•
The waste management initiatives at the KHSDP Hospitals should be strengthened.
•
The government should provide certain common facilities like collection & transport,
incineration, sanitary landfill sites etc. for all Towns and Cities.
•
The government should support private initiatives for common waste management and
treatment facilities including recycling units.
•
The expertise of organizations like TERI, and the experience from the pilot project of M.S.
Ramaiah-Swabhimana could be used appropriately.
•
All aspects of Safe Management of Health Care Waste should be Incorporated into the
curriculum for all health sciences
At individual level:
•
Ensure proper segregation of waste and total waste management at all health care
institutions. The segregated waste streams should not get mixed up with general solid waste.
-5-
•
The segregated waste should be disinfected; sharps should be destroyed /disfigured and
plastics shredded before final disposal through discharge through sanitary sewage systems,
land -fills etc.
•
Recyclable material should be sent for recycling.
•
Ensure training of Health Care Personnel for proper waste management practices including
practice of Precautions.
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5.4 COMMUNICABLE DISEASES
"The microbe is nothing; the terrain everything." – Louis Pasteur
Diseases are commonly classified as being communicable where there is a causative infectious
organism, non-communicable where there is not. This boundary has become less well defined in
certain conditions, for instance hepatitis B virus infection leading to liver cell cancer and human
papilloma virus leading to cancer of the cervix in women.
Communicable (infectious) diseases occur following the transmission of infectious organisms or
agents or their toxic products, from infected persons, animals or reservoirs to susceptible hosts
(persons), directly or indirectly through vectors, intermediate hosts (vertebrate or invertebrate) or
the environment. The method of transmission determines the method of control as a public health
intervention.
5.4.1 Vector-borne Infectious Diseases
Introduction
The vector-borne infectious diseases of public health importance in Karnataka are Malaria,
Filariasis, Dengue fever, Japanese Encephalitis (JE), and Kyasanur Forest Disease (KFD). In
addition, West Nile virus infection has been reported in Karnataka, but little is known about its
consequences. There have been occasional reports of Rickettsial fevers, but epidemiological
importance of such finding has not been established. In the past, outbreaks of Chikungunya virus
infection had been documented, but it has disappeared. It has the potential of re-emergence as long
as vector-control is not achieved. Although human plague has not been reported in Karnataka for
about 4 decades, the possibility of its re-appearance has to be borne in mind.
Malaria, Filariasis, Japanese Encephalitis and Dengue fever are mosquito-borne and Kyasanur
Forest Disease is tick-borne. The mosquito-borne infectious diseases are more widespread in the
State, with several districts being affected, whereas KFD is confined to essentially one focus and its
contiguous geographic areas.
Control measures for malaria and filariasis follow the guidelines and are supported by the National
Anti Malaria Programme (NAMP) and National Filariasis Control Programme. On the other hand,
there are no organised or systematic control activities against the remaining mosquito-borne
infectious diseases (Japanese Encephalitis, Dengue fever). The establishment of JE and Dengue
fever control measures, under the State Ministry of Health, must be considered seriously.
It is recommended that the four major mosquito-borne infectious diseases (Malaria, Filariasis,
Japanese Encephalitis, Dengue) are taken together for epidemiological investigations, disease
surveillance, monitoring of vector breeding and adult densities, vector control and reduction of
mosquito-human contact. This will entail leadership from the State health authorities to ensure an
integrated and holistic approach at the village, panchayat, taluka, town, city and district levels. This
will also entail the unification of the vertical programmes on Malaria and Filariasis with State
designed programmes on Japanese Encephalitis and Dengue fever, at the local levels. In this
manner, the entomological personnel and expertise, material and money, already available in the
1
districts but which are fragmented due to vertical restrictions, must be brought together, in a
streamlined manner. This will result in better effectiveness and efficiency in controlling all
mosquito-borne infectious diseases.
Vector borne infectious diseases and development strategies
There is increasing evidence today that the spread of vector borne diseases are also a bye product
or social cost of our development strategies that are mosquitogenic in various ways. Agricultural
development and the shift from dry to wetland cultivation, the increase of water availability due to
canals and tanks and the introduction of irrigated rice fields are all known to introduce or increase
the potential of mosquito breeding especially Culex tritaeniorhyncus, the vector for JE.
Urbanisation and especially increasing construction activity introduces the establishment of the
urban malaria vector potential (Anopheles stephensi) in cement tanks and ‘curing’ sites. Aedes
aegypti mosquito breeding is also enhanced by urbanization by increasing breeding sites such as
small containers, water coolers, flower pots and discarded tyres.
The spread of malaria and JE in many parts of Rural Karnataka can be directly correlated to such
development. The introduction of malaria into Mangalore is linked to a boom in construction,
establishment of Anopheles stephensi breeding and the migration of construction labour from
malaria endemic areas of the country, bringing the parasite along.
Epidemiological surveillance and laboratory diagnostic services
Malaria and Dengue are fever syndromes, easily suspected on clinical basis. Dengue virus infection
may cause dengue fever or the Dengue Haemorrhagic Fever (DHF) and Dengue Shock Syndrome
(DSS), which are also clinically recognizable. Japanese Encephalitis, an Acute Encephalitis
Syndrome, is one among a number of etiology-specific encephalitidis. Filariasis may cause a
variety of clinical diseases which may not be easily recognized, except when certain specific
conditions like orchitis or epidydimitis occurs. Thus, a disease surveillance system, depending
primarily on clinical diagnosis, can cover several of the above diseases. A district level
epidemiological surveillance system and the inclusion of malaria, dengue fever, fever with bleeding
tendency and acute encephalitis as diseases to be included under it may be established.
Malaria and microfilaremia are easily diagnosed by suitably prepared blood smear examination.
This diagnostic skill and the necessary microscope, slides and reagents are already made available
at the PHC and all higher levels of health care. On the other hand, there is no State level diagnostic
facility for Japanese Encephalitis or Dengue virus infections. Currently, help may be taken from
two laboratories – one, the Field Station of the ICMR National Institute of Virology, situated in the
Bangalore Medical College, Victoria Hospital and the neuro-virology laboratory of NIMHANS. In
fact, these laboratories themselves take leadership in conducting various investigations and the
results may or may not become available to the health authorities of the State.
There should be a State Level Diagnostic and Reference Laboratory for the purposes of diagnosis,
epidemiological investigations, monitoring and evaluation of mosquito borne virus infections in
addition to other diseases of public health importance.
New kits for sero-epidemiology and new diagnostic aids for enhancing potential of surveillance
and diagnosis are constantly being added in the area of vector borne diseases. These should be
2
carefully evaluated and introduced only if they are cost effective and operationally superior to
existing methods and not under the influence of marketing strategies by their promoters.
Entomological surveillance and Health Impact Assessment (HIA)
Vector surveillance is an important component of vector borne disease control programmes.
Entomological capacity needs to be greatly enhanced by filling vacancies with qualified
personnel and making regular entomological surveillance a crucial component of
epidemiological surveillance strategies at all levels.
Excellent work by the Malaria Research Centre (MRC) in Bangalore, has scientifically established
the potential of effective bio-environmental control strategies in rural Kolar and other parts of the
state. This has included the involvement of civic society and citizens’ groups in Mangalore city.
This potential must be urgently explored and promoted as an important core component of
Integrated Vector Borne Diseases Control Strategies in the state. Maharashtra, Andhra, Goa and
other states are investing in bio-environmental strategies as a long term, low cost, environmentally
sustainable strategy. Karnataka should also integrate it into their strategy. Linked to this approach
is also the need for urgent Health Impact Assessment (HIA) of all new and ongoing development
projects especially their ‘vector potential’. Capacity for HIA must be urgently developed in the
Directorate as another important component of an integrated vector borne disease control
programme.
Malaria in Karnataka
The National Malaria Eradication Programme of the 1950’s met with success, but malaria made a
come back in late 1960’s. By then the vector mosquitoes had developed resistance to insecticides.
Whereas malaria had been confined to rural communities previously, resurgent malaria is both
urban and rural. Earlier, malaria parasites had been fully sensitive to antimalarial drugs, but now
falciparum parasites are increasingly becoming resistant to chloroquine and other newer drugs as
well. Resistance has appeared even among vivax parasites. As malariologists realized that malaria
could not be eradicated, the programme was renamed as National Malaria Control Programme. In
the 1990’s even control was felt to be unattainable and the name has been changed to National AntiMalaria Programme (NAMP). In 1997, in Karnataka, 7,304,866 fever cases were investigated with
blood smear microscopy in various rural health care institutions and 161,775 cases of malaria were
detected. In addition, in 8 urban populations 103,671 cases of fever were investigated and 12,548
more cases were detected. The number of falciparum cases was 40,295. In 1998 there were 107,910
rural and 7521 urban cases diagnosed with positive smear examination.
One of the major deficiencies of the Anti Malaria Programme is the lack of systematic reporting
of malaria seen in the private sector health care clinics and institutions. Therefore, the statistics
tends to be skewed towards predominantly rural data. The government sector urban malaria scheme
covers only 8 cities / towns in the State, namely Bangalore, Bellary, Hospet, Belgaum, Raichur,
Hassan, Chickmagalur and Hassan. The State itself must take the initiative to establish the essential
ingredients of urban malaria programme in all cities and towns in which malaria has been detected.
With the establishment of the holistic integrated vector borne disease programme and the
epidemiological and vector surveillance systems, the state health authorities will be able to get a
comprehensive picture, with locality-specific prevalence , as well as time trends of malaria.
3
There is urgent need to investigate systematically the frequency and geographic distribution of
chloroquine resistance in Plasmodium falciparum and also in Plasmodium vivax. These may
require expert advice from the National Anti-Malaria Programme, but this process must be defined
and established by the state health authorities. The State Level Diagnostic and Reference
Laboratory may be entrusted with the continued investigations of drug resistance.
It is also necessary to investigate the susceptibility / resistance of Anopheles mosquitoes to the
currently used insecticides. Insecticide sprays / fogging to reduce adult mosquito population should
not be done 'routinely' but as specifically planned and applied judiciously, in chosen places and
times, as the last resort in Malaria Control. The use of insecticides under health programmes (such
as malaria and filariasis control) or under other Departments (such as Agriculture) should be
regulated and monitored by the State Health Authorities, through the integrated vector borne
diseases programme.
The statistics on malaria, under the Anti-Malaria Programme are given in the Table 5.1.
Table 5.1: The burden of malaria detected under the NAMP in Karnataka
Year
Blood
No. positive P.falciparum
ABER *
SPR *
API *
smears
examined
1993
70,98,579
1,96,466
49,246
17.70
1.1
2.0
1994
71,10,997
2,66,679
37,789
15.80
3.8
6.6
1995
71,11,888
2,85,830
39,601
17.45
4.0
7.0
1996
76,81,802
2,19,298
32,606
18.50
2.9
5.3
1997
77,26,572
1,81,450
49,245
15.40
2.2
3.3
*ABER: Annual Blood Examination Rate; SPR: Slide Positive Rate; API: Annual Parasite Index.
In 1998, the reported number of cases was 115,431 (the final tally not yet available). These
numbers are from the NAMP, and the burden of malaria detected and treated by the private sector
remains unknown. This is a large gap, since 70% of outpatient treatment occurs in the private
sector. Malaria also has a periodic cycle and longer time trends need careful monitoring.
The NAMP is organized into District Programmes in the following districts:
Gulbarga division
Belgaum division
Mysore division
Bangalore division
: Bellary, Bidar, Gulbarga
: Bijapur, Belgaum, Dharwad
: Chickmagalur, Dakshina Kannada, Hassan, Kodagu, Mandya,
Mysore
: Chitradurga, Shimoga, Tumkur, Kolar, Bangalore Rural, Bangalore
Urban
In these regions there are 688 malaria clinics, 2997 fever treatment units and 6702 antimalarial drug
distribution centers.
4
Filariasis in Karnataka
Karnataka is endemic for lymphatic filariasis. Its control is another centrally sponsored National
Filaria Control Programme. This programme is operative in only 8 districts endemic to the disease,
namely, Gulbarga, Bagalkot, Bidar, Koppal, Dakshina Kannada, Udupi and Uttara Kannada. Each
district has a Filaria Control Unit, and in selected towns in these districts there are 25 Filariasis
clinics. In addition to the above, there is a Filaria Survey Cell in Raichur.
The burden of disease and infection may be seen from the Table 5.2.
Table 5.2: Burden of disease and prevalence of microfilaremia / filarial diseases in Karnataka
Year
No.persons
examined
1995
1996
1997
1998
122,484
135,469
208,827
132,981
No.of persons
diagnosed
clinically
3480
4853
5615
5711
No. treated
No. of persons
positive for MF
MF rate
%
4444
5926
6959
6946
964
1073
1344
1235
0.79
0.79
0.64
0.93
The data in the above Table are revealing. Data collected through the very limited filaria control
system show that each year 4000-6000 people with clinical disease are treated, even though the
actual number of persons with microfilaremia is between 1000 and 1400. In other words, the
disease is rampant, but the diagnosis must be clinically made and laboratory evidence is not always
positive.
The personnel under the National Filaria Control Programme are involved in collection of blood
smears, looking exclusively for microfilariae (but not for malarial parasites); they treat people with
microfilaraemia with the antifilarial drug diethylcarbamazine (in parallel with malaria workers
treating fever patients with antimalarial therapy); and they carry out anti-mosquito larval measures.
Under the centrally sponsored programmes of malaria and filariasis, such vertical, parallel and
exclusive operational schemes may be justified, but nothing prevents the State from utilising these
inputs and resources and to weave them into one holistic vector-borne disease control strategy. A
state owned integrated vector-borne disease control programme must be instituted.
On the whole, filariasis control is neglected as compared to malaria, both in planning and
implementation. It needs priority in districts where its prevalence and incidence are high.
5
Japanese Encephalitis (JE) in Karnataka
In the 1950's JE was recognised only in northeastern region of Tamil Nadu and Pondichery. By the
1960's JE became prevalent in contiguous regions of Karnataka and Andhra Pradesh. In the 1970's
JE outbreaks appeared in Assam, West Bengal, Orissa, Bihar and Eastern Uttar Pradesh. In the
1980's it appeared in parts of Maharashtra, Haryana and Punjab. In late 1980's and early 1990's JE
has spread to western coastal regions such as Goa and Kerala. Thus JE is today a widely prevalent
problem in the country. Yet there is no defined policy or programme for its control either at the
national level or state level.
In Karnataka, JE outbreaks have been occurring periodically, annually in some cases, in the districts
of Bellary, Mandya, Kolar, Raichur, Mysore and Bangalore Urban. However, this does not mean
that all the other districts are free from the prevalence of JE. JE is a problem of great public health
importance since the victims are predominantly rural children, with high case fatality rates
(about 30%) and high frequency of severe neurological handicaps as sequelae in those who
survive.
The current method of information collection is unsatisfactory. JE is diagnosed clinically,
especially when outbreaks occur. In the experience of experts, such clinical diagnosis is fraught
with risks of misdiagnosis. Treatable central nervous system infections (meningitis, brain abscess),
and other diseases with encephalitis–like signs and symptoms (encephalopathies and septicaemias),
etc. may not be investigated or diagnosed once the label of Japanese Encephalitis is given.
Laboratory diagnostic services have to be made available at all levels of health care, so that all acute
central nervous system infectious diseases will be properly investigated. To illustrate the diagnostic
problem, the following table of Karnataka statistics is given in table 5.3
Table 5.3 : Japanese Encephalitis in Karnataka
Year
1994
1995
1996
1997
1998
No. of reported
cases
125
329
127
407
209
Death
47
102
17
85
38
No.of confirmed
cases
13
44
31
97
Death
2
12
As already stated, acute encephalitis should be included in the list of diseases for the district level
Disease Surveillance. Diagnostic facilities must be established in at least one State Level
Laboratory. The State Laboratory should establish linkages with District Laboratories/ teaching
hospitals for training laboratory staff in Japanese Encephalitis diagnosis, supply of reagents and
external quality assurance. The need for integrated approach for the monitoring, surveillance and
control of vectors, both at larval and adult levels, has already been identified.
6
Dengue Fever in Karnataka
Dengue fever, a viral fever transmitted through the mosquito vector Aedes aegypti, is an increasing
public health problem in South East Asia, including India. It is slowly beginning to occur and be
recognized in Karnataka as shown in the table 5.4.
Table 5.4: Dengue Fever in districts of Karnataka
1997
1999
2000
Districts / City
Cases
Deaths
Cases
Deaths
Cases
Deaths
Bangalore City
Bangalore Urban
Bangalore Rural
Kolar
Chitradurga
Dakshin Kannada
Bellary
Bijapur
Mysore
Mandya
Tumkur
TN / AP cases in
Karnataka
Total
16
28
145
69
-----3
---
2
-2
----------
5
1
-6
1
24
--2
----
-------------
5
9
20
67
--2
3
13
-16
5
-------------
262
4
39
--
140
These are underestimates, because some are asymptomatic and most patients with undifferentiated
fever are not advised investigations. Dengue hemorrhagic fever (DHF) and Dengue Shock
Syndrome (DSS) are more serious forms and were reported in the 1996 outbreak in Delhi.
Control measures
Control measures to be part of the integrated vector borne disease control package, through the
general health service. The vector, Aedes aegpyti should come under entomological surveillance
and control. Objects that collect water such as old tyres, tins, jars / bottles, coconut shells etc need
to be disposed off. Water should be changed regularly in water coolers, tanks, vessels etc. Health
education for administrators, medical and paramedical workers and for students and the general
public should be given through the mass media.
7
Recommendations
Institute an integrated approach to vector-borne disease control programme, with the following
components:
•
Use a mix between bioenvironmental and chemical methods for vector control (source
reduction, larva control, ensuring regularity and continuity. Adequate trained
entomological support to be provided.
•
Health promotion and social mobilisation, starting especially with taluks and urban areas,
with higher incidence/ prevalence rates.
•
Establish control measures for Japanese Encephalitis and Dengue fever / Dengue
Haemorrhagic Fever and Dengue Shock Syndrome in addition to ongoing programmes for
malaria, filaria and KFD
Establish District level integrated vector monitoring and control activities, integrating
malaria and filariasis programmes and including in it, JE / Dengue control programmes.
•
The State Surveillance Laboratory to also become a Reference Laboratory for mosquito
borne infections and other communicable diseases of public health importance.
•
The Epidemiological Surveillance System to cover these diseases and allow for rapid
analysis at district level. Regular epidemiological mapping of vector borne diseases to be
used to modify and plan strategies. The epidemiological surveillance strategy must have a
strong entomological component.
•
Diagnosis and treatment programmes to integrate with general health services at primary
care level, with specialised public health support at taluk, district and state level.
•
Training, regulation of prescribing practices and involvement in surveillance system of the
private practitioners. Drugs available under the programme may be given to them, on
condition they provide free treatment and record and report cases.
•
Evolve new partnerships with communities, NGOs, general practitioners, the private sector,
the educational network of schools and colleges and with various other inter sectoral
departments to enhance their involvement in the integrated vector borne disease control
programme.
•
Guidelines have been drawn up at country level for all these areas of focus by a policy
resource group based in the state (CHC) along with NAMP and WHO-SEARO. These need
to be operationalised in the state, in the districts where the magnitude of the problem is
greatest.
8
KYASANUR FOREST DISEASE
Kyasanur Forest Disease (KFD) is a haemorrhagic fever found in a restricted part of Karnataka
caused by KFD virus and transmitted to man by the bite of infective ticks. KFD was first recognized
in 1957 in Kannur village, Soraba taluk, Shimoga district of Karnataka State. Local inhabitants
called it the "Monkey disease" because of its association with dead monkeys. The disease was later
named after the locality – Kyasanur Forest – from where the virus was first isolated.
Epidemiological Features:
a) Agent: The agent KFD virus is a member of Group B Arboviruses (Flavivirus). The
monkeys are recognized as amplifying hosts for the virus. They are not effective
maintenance hosts because most of them die from KFD infection. Small mammals
particularly rats and squirrels are the main reservoirs of the virus. Deforestation due to dams
and commercial felling of trees has made the monkeys move out of their habitat and spread
the disease.
b) Vector: Transmitted by the hard ticks of genus Haemaphysalis, particularly H. spinigera
and H. turtura. The disease is transmitted by the bite of infectious ticks especially nymphal
stages. Cattle provide the ticks with a plentiful source of blood meals, which in turn leads to
population explosion among the ticks. Thus cattle are very important in maintaining tick
population but play no part in virus maintenance.
c) Host factors: Majority of affected cases are between 20 and 40 years with a greater attack
rate in males. The patients are mostly cultivators who visited forests accompanying their
cattle or for cutting wood. There is no evidence of man-to-man transmission.
The highest number of human and monkey infections occur during drier months, particularly
from January to June. This period coincides with the peak nymphal activity of ticks. Human
activity is at its peak in the forest at the same time i.e., until the onset of rains in June.
The Case Fatality rate has been estimated to be 5-10%. Diagnosis is established only after
detecting the presence of virus in blood and / or serological evidence. Currently the health
authorities are using animal inoculation techniques for confirmation of diagnosis, which
takes a minimum period of one month and is outdated. They should shift to latest methods
like ELISA for confirmation.
Situation Analysis
Earlier the disease was found to be limited to an area around the original focus (Shimoga district)
covering about 800 Sq.km. Currently the disease is restricted to four districts – Shimoga. Uttara
Kannada, Dakshina Kannada and Chikkamagalur covering over 6000 Sq.km.
The disease continues to be active in its endemic foci. The outbreak during 1983-84 was the largest
with 2167 cases and 69 deaths.
9
The reported number of cases and deaths due to Kyasanur Forest Disease from Karnataka State in
1991-2000 is shown in the table 5.5.
Table 5.5: Kyasanur Forest Diseases
Year
Cases
Deaths
1991
940
15
1992
1171
5
1993
699
3
1994
110
0
1995
174
3
1996
140
3
1997
75
4
1998
298
1
1999
159
2000
142
6
Surveillance
The Department of Health and Family Welfare has established field stations at Sagar, Honnavara,
and Belthangadi for carrying out disease surveillance. This is monitored by the Deputy Director,
Virus Diagnostic Laboratory, Shimoga and the respective District Health and Family Welfare
Officers. The surveillance programme includes human case detection, blood sample collection from
acute and convalescent cases, investigation of monkey deaths, entomological survey and virus
isolation.
Treatment
There is no specific treatment for Kyasanur Forest Disease. Treatment is symptomatic;
hospitalization and bed rest, correction of fluid balance, antipyretics, prevention of secondary
infection and blood transfusion in bleeding cases.
Preventive Measures:
1. Control of Ticks:
For control of ticks in the forest, application can be made by power equipment or aircraft
mounted equipment to dispense Carbaryl, Fenthion or Propoxur at 2.24kg of active
ingredient per hectare. The spraying must be carried out in "hot spots", i.e., in areas where
monkey deaths have been reported (within 50m around the spot of monkey deaths), besides
the endemic foci.
Since the heavy tick population in forest areas is attributed partly to the free roaming cattle,
restriction of cattle movement is thought to bring about a reduction in vector population. The
Health Department has been applying 50% Benzene Hexachloride on cattle once in a week
during the monsoon season. Cattle spraying have been stopped since 1997 because of the
harmful effects of BHC.
10
2. Vaccination:
The population at risk should be immunised with killed KFD vaccine. It is given in two doses at
an interval of 4 weeks by subcutaneous route. The dose is 1ml for adults and 0.5ml for those
below 8 years of age. Booster dose is given in 3rd and 5th year. The vaccine is currently
manufactured at KFD Vaccine Production Unit located in Mc Gann Hospital Campus, Shimoga.
Currently the vaccine production is around one lakh doses per annum. The existing
infrastructure and resources are unsuitable for vaccine production. Much attention should be
paid to quality testing, safety and potency of the vaccine.
3. Personal Protection:
Protection of individuals exposed to the risk of infection by adequate clothing and insect
repellants such as Dimethylphthalate (DMP) should be encouraged. They should examine their
bodies at the end of each day for ticks and remove them promptly. They should be advised to
have a bath and wash their clothes in hot water after returning from the forest. The habit of
sitting or lying down on the ground should be discouraged. People should be advised not to go
into the forest areas where monkey deaths have been reported.
Recommendations
•
Anticipatory vector control measures in the forest periphery and high-risk villages
especially from January to June. Regular insecticide dust application should be carried out
in the hot spot areas.
•
Restriction on movement of humans and cattle in the forest areas where monkey deaths have
been reported.
•
Strengthen the existing disease surveillance system for KFD so that every case of human
infection or monkey death is reported and investigated. Entomological, epidemiological and
serological surveillance should be undertaken in new areas bordering the affected districts.
•
Health education regarding the transmission and spread of the disease, restriction of cattle
movement, adequate personal protection through the Health Department and Panchayat
system.
•
Vaccination of the population at risk. Production of enough quantities of KFD vaccine and
timely supply through cold chain..
•
The latest methods for diagnosis like ELISA test should be introduced instead of the
outdated methods like animal inoculation. All the KFD field stations should have diagnostic
facilities.
11
5.4.2. TUBERCULOSIS
The evolution of the National Tuberculosis Programme (NTP)
Tuberculosis was recognised as a major public health problem by the newly independent
Government of India in 1947 and steps were initiated towards its control, given the knowledge
and technology of the time. The national BCG inoculation programme was launched given the
understanding that BCG would protect from infection, as well as from latent infection
progressing to bacillary pulmonary TB, which is the source of infection to fresh individuals,
most often children and youth. Shortly after, a prospective longitudinal study was established
under the ICMR to investigate the protective effect of BCG. This study, conducted in
Chingleput, Tamil Nadu, was reported in the late 1970s and showed that the assumption that
BCG would offer protection from infection or from disease progression was incorrect. In
summary, BCG has no role as a public health intervention as it does not protect against adult
pulmonary TB.
Recognising the immensity of the burden of disease and numbers of death due to TB, the
National TB Programme (NTP) was established in 1962 based on research proving the
effectiveness of domiciliary treatment and on sociological, epidemiological and operations
research which established the rationale of passive case detection, the efficacy of sputum
microscopy, the expected case load, and the need for integration of the programme into the
general health services. TB is widespread and distributed in both rural and urban communities
with a few patients (10-12) in every village. They need to access to services as close to their
homes as possible. Hence the need to develop adequate diagnostic and therapeutic services at
primary health centres. In fact certain core principles of the primary health care approach were
developed by the NTP. Several obstacles and competing interests adversely affected
implementation of the NTP in India. However, it was accepted by the WHO and implemented
successfully in several countries, including some developed countries.
In India it was a centrally sponsored program on 50:50 basis. The Central Government provided
all costs for drugs, and the State met the costs of implementation and administration. The
achievements of NTP included the establishment of 446 District TB Centres, 330 TB Clinics,
and over 47,000 hospital beds for TB. In 1992, a review of the NTP, supported by WHO and
Swedish International Development Association (SIDA), concluded that the NTP had not
achieved the desired impact on TB in India. The treatment completion rate was estimated to be
only 30%. This reiterated findings and conclusions of earlier evaluation by ICMR and by
reports from NTI and the TB Association of India.
Reasons for failure included:
•
•
•
•
•
•
•
•
inadequate budgets;
lack of coverage in some parts of the country;
shortage of essential drugs;
varying standards of care in various centres;
poor administration;
unmotivated and unevenly trained staff;
poor quality sputum microscopy;
focus on case detection without accompanying emphasis on treatment outcomes.
However, underlying political economy factors and policy process factors were not considered
by the largely techno-managerial approach.
Consequently, the Government of India designed a revised TB Control Strategy, in 1993. This
strategy was pilot tested in a population of 2.35 million, and was extended to cover 13.85
million, in 13 States. In these areas under study conditions, and with much national and
international attention, the diagnostic practice improved and cure rates more than doubled.
Based on this experience, the Revised National TB Control Programme (RNTCP) was formally
launched in India on March 26, 1997, with the plan to increase the area under coverage in a
phased manner. This was supported by a soft loan (USD 142.4 million) from the World Bank,
with a target to cover 102 Districts with 271.2 million people. The goal of RNTCP is to detect at
least 70% of sputum positive pulmonary TB cases and to cure at least 85% of them, for the
purpose of breaking the process of transmission. Treatment is by the Directly Observed
Therapy, Short course (DOTS).
The situation of TB control programme in Karnataka
In Karnataka, RNTCP was introduced in 1994 as phase 1 Pilot Project, in 3.5 lakh population in
Bangalore city, and expanded to cover the entire City Corporation (1998 October) and to the
entire Bangalore Urban District (1998 November). RNTCP was extended to one more district in
1998, and was expected to extend to seven more districts in 1999. The following Table 5.6 gives
the planned coverage of all districts, vis-a-vis RNTCP.
Table 5.6: Districts covered by RNTCP
1998
Bangalore (U)
Bangalore (R)
1999
Bellary
Bijapur
Bagalkot
Chitradurga
Davangare
Raichur
Koppal
2000*
Belgaum
Bidar
Dharwad
Gulbarga
Gadag
Haveri
Mandya
Kolar
Tumkur
2001**
Chikmagalur
D. Kannada
Udipi
U. Kannada
Hassan
Kodagu
Mysore
Chamarajnagar
Shimoga.
* yet to be covered under RNTCP
** The performance in Bangalore city in phase one was much below other pilots and with very
low case detection. The expansion to other districts is also at a slower pace than planned, and
Karnataka is currently placed as the second worst performer in the country in the RNTCP. Its
performance has been rated as unsatisfactory by the recent World Bank review.
Problems of TB control: national overview
The South East Asia Office of the WHO has published a monograph on TB in India, in 2000
(Research for Action. Understanding and Controlling Tuberculosis in India. World Health
Organisation, Regional Office for South East Asia Region, New Delhi, 2000). The situation in
India in general and in Karnataka in particular, is not satisfactory. The WHO has estimated that
the annual gross economic loss for India, on account of TB is about 13,000 crores of rupees. In
addition, TB patients spend, from their own resources, 645 crores of rupees, annually. Other
studies report indebtedness and impoverishment resulting from out of pocket spending for TB
treatment. Some 300,000 children lose both parents due to TB, and become orphans, annually.
The situation is rapidly deteriorating, on account of the increasing prevalence of HIV infection
and AIDS. To cite one representative study from a public hospital in Mumbai, the frequency of
HIV infection in patients with TB rose from 2% in 1988 to 16% in 1998. TB has been found to
be the most common major secondary disease in symptomatic HIV disease (otherwise, AIDS).
The widespread use of anti TB drugs in an inefficient manner, the continued transmission of
infection from partially treated patients and the combination of HIV and TB are all factors that
might contribute to the emergence of drug resistance in TB, making the future control of TB
even more problematic and very expensive.
India has an estimated 1,799,000 cases of TB, an incidence of 187 new cases per 100,000
population and 805,000 new total annual case burden. Yet, in 1997, only 7,708 cases were under
DOTS. We get an idea of the magnitude of our failure when we compare this last figure with
147,905 under DOTS in China, 19,492 in Indonesia, 25,871 in Bangladesh and 15,753 in
Ethiopia. It points to the urgent need for improvement in the health system, for better
supervision and for good leadership of TB control at national, state and district level! Apathy,
disinterest and non-performance in regard to TB care are widely prevalent. The following
paragraphs are quotations from the WHO SEARO publication, 2000.
"All too often, health providers fail to diagnose the disease correctly, thereby delaying the start
of treatment and perpetuating in the community. Many providers do not confirm their diagnosis
of pulmonary TB by sputum examination relying instead on just radiograph and thus often
incorrectly diagnosing patients to have TB. In one study in Bombay only 39% of doctors used
sputum examination to confirm the diagnosis in TB. Studies in Karnataka, Delhi and Tamil
Nadu revealed that, even after the multiple visits less than one third of patients had undergone
even a single sputum examinations, despite spending 1-6 months of their income. In rural areas
lack of effective diagnosis and treatment was even more pronounced ".
"Even when TB is diagnosed by private practitioners, prescribing practices vary widely. A study
of 100 Private doctors in Bombay found that there were 80 different regimens most of which
were either appropriate, expensive or both in the similar survey in Pune 113 doctors prescribed
90 different regimens (Uplekar and Shepard. Tubercle 1991; 72: 284). Private doctors seldom
felt that it was their duty to educate the patient about TB and never made attempts to contact or
trace patients who had interrupted treatment (Khatri. Indian Journal of Tuberculosis 1999;
46:157) virtually no individual patients' records are maintained by private practitioners".
"In one recent study, researchers interviewed several 100's patients and their families and found
that most patients felt uncomfortable talking about TB, several patients denied that they were
suffering from the disease are taking treatment for it, and some even refused to mention TB by
the name. Patients frequently attempted to hide their disease from their family and community
by registering under false names at TB clinics are by denying their identity when confirmed to
their interviewers"
" Estimates in India indicate that of every 100 infectious TB cases in the community, about 30
are identified in public sector, of which at most 10 are cured. Similarly about 30 are identified
in the private sector, of which at most 10 are cured. Hence not more than 20% of patients who
developed TB in Karnataka in each year are cured. Many of the remaining patients remain
chronically ill, or die slowly from the disease, infecting others with strains (of TB bacilli) which
may have developed drug resistance"
Problems of TB control: Karnataka
The WHO monograph and several studies and reports have identified the problems of poor
quality in diagnosis and treatment of TB in Karnataka. The health seeking behaviour of 'chest
symptomatics' is very interesting and illustrative.
The vast majority of patients with chronic cough seek care quite promptly, as shown in the Table
below.
Table5.7: The proportions of chest symptomatics seeking care in public or private
facilities.
Private provider
Government facility
Other
Total taking action
Not yet taking
action
Mysore
Rural %
Urban %
48
76
51
22
1
2
83
85
17
15
Raichur
Rural %
Urban %
93
74
5
25
2
1
90
85
10
15
That chest symptomatics seek treatment early was recognised by NTI studies in the early 1960s,
along with findings regarding the failure of the medical profession and the health system to be
able to diagnose TB early. While expansion of the private sector, and poor performance by the
public sector, has shifted care seeking behaviour to the private sector, the latter is equally poor in
rational treatment of TB and in achieving cure, though their services are more expensive.
Unqualified rural practitioners are the first point of contact for most rural patients. Many
patients, rural or urban, spend a great deal of time and money "shopping for health" before they
begin treatment. Very often, they do not receive either accurate diagnosis or effective treatment,
despite spending considerable resources.
The annual statistics of diagnosed pulmonary TB in Karnataka are presented in the following
table 5.8.
Table 5.8: Tuberculosis diagnosed in the State.
Year
No. of Sputum
tested
No. of TB cases
detected
TB cases as % of
sputum tested
1996
1997
1998
1999
243,405
241,590
314,671
261,756
81,785
80,028
71,666
66,976
33.6
33.1
22.8
25.6
Decline of TB case
detection since last
year (%)
2.1
10.5
7.5
The above table suggests that the annual numbers of new TB (pulmonary, bacillary) cases
detected through the TB control programme is in the range of 70,000-80,000. However, during
1997 (April) to 1998 (March) the total number of sputum positive cases under therapy was
174,594.
These numbers are underestimates of the total number of TB cases in the state because of the
following reasons:
• in many teaching and private hospitals, pulmonary TB is diagnosed using chest X-Ray,
without testing the sputum; these patients are not included in the state statistics because
they have not been classified as sputum smear positive;
• the RNTCP with emphasis on more intensive case detection is operational in only some
districts;
• TB cases diagnosed outside the TB control programme are not included in the statistics .
No conclusions can be drawn based only on routine statistics because of incompleteness and
issues of validity.
A deficiency under the TB control programme is the lack of assessment of the incidence and
prevalence of TB infection in childhood. Trends in the Annual rate of Infection indicate the
dynamics of the TB epidemic. One of the parameters of TB control status is the prevalence of
TB infection (as positive PPD reaction) of less than 1% at 14 years of age, though this was
arrived at entirely arbitrarily. However the current prevalence of TB infection at 14 years of age
has not been measured. The earlier assumption that BCG inoculation would be protective has
been disproved in the ICMR Chinglepet study. Widespread use of BCG of course affects
Mantoux testing and measuring of annual rates of infection.
From among the pool of infected children approximately 10% are estimated to develop bacillary
pulmonary TB during their adult age. The premise of TB control is that transmission of
infection to children and others will be drastically reduced if the majority (70%) of TB cases
particularly bacillary pulmonary TB are diagnosed and a majority of them (80%) are made
noninfectious by multi drug therapy. It has already been pointed out that there is delay in
diagnosing TB in symptomatic patients. Again in many cases there is delay of starting treatment
once sputum is found positive. These delays result in susceptible contacts getting infected with
TB bacilli.
The extreme urgency for effective TB control in Karnataka
HIV infection is spreading in the state. Currently it is estimated that 1% or more adults in the
sexually active age group are already infected. A majority of adults are already infected with TB
bacilli. HIV infection accelerates the development of disease due to TB. It is estimated that,
among HIV infected persons the annual risk of TB disease (among those latently infected) is
10% per annum, as against the lifetime risk of 10% among those without HIV infection. Thus
the prevalence of bacillary TB will increase due to the epidemic of HIV infection. Indeed there
is evidence to show that such increase has already begun in some parts of the country.
Another reason for the urgency is the increase in drug resistance recently being reported among
isolations of Mycobacterium tuberculosis. We have been warned that the " unknowingly we are
transforming an eminently treatable disease into one which is life threatening and exorbitantly
expensive to treat" (Jain.N.K. Indian J Tubercul, 1992;92:145-48)
Recommendations
•
The quality of implementation of the Tuberculosis control programme in all districts,
including urban areas, under both the National Tuberculosis Programme (NTP) and the
RNTCP needs to improve within the next year. All staff involved will need to be held
accountable for non-performance. The most important level of service delivery are the
primary health centres which should provide access to good quality TB care for all. For
this, it is necessary to have,
a.
b.
c.
d.
e.
f.
laboratory technicians, whose skills are updated and whose slides are cross
checked regularly;
microscope, stains, all records and registers;
uninterrupted drug supplies;
medical officers who are trained by the District TB officers regarding the
organisation and functioning of the NTP/RNTCP;
most important there is need for close supportive supervision from the taluk
health officer and DTC in particular with problem solving in the field;
all peripheral health institutions should be “implemented” under the NTP.
•
The District TB Centre should function as they were originally envisaged, with a
qualified person in public health or with a diploma in TB and chest diseases. DTOs
should undergo the training at National Tuberculosis Institute (NTI). Two medical
officers are required at the DTC – one to run the clinical service and the other to
undertake training in the field and to analyse reports etc. The DTC is the referral centre
for all aspects of the NTP/ RNTCP and should undertake orientation and training of
institutions and General Practitioners in the private, voluntary and public sector
regarding the programme. A medical college department cannot replace the DTC.
•
The state should work towards
a.
Increased case detection to 75% of expected cases. This will include cases
detected by the public, private and voluntary sector for which a system of
notification may be required. The expected number of cases may also have to be
recalculated based on recent epidemiological data. Targets should not be used.
b.
Early case detection, with a emphasis on sputum microscopy for diagnosis. The
use of x-rays should be rationalised to reduce over diagnosis and unnecessary
treatment. There should be an acceptable ratio between sputum positive and
sputum negative cases (1:1).
c.
Completion of treatment with cure rates (measurable in sputum positives) of at
least 85%. Two drug regimes should be discontinued.
•
Recording, reporting and analysis at DTC level to be used for monitoring and planning
the programme.
•
Paediatric dosage forms of drugs to be made available. Anganwadis could be centres
for follow-up of young children with TB.
•
Supervised or directly observed therapy to be used only when necessary. Active
involvement of patients and their families in the treatment process with adequate patient
education.
•
The State TB Centre to be a model centre that is also used for training and operational
research, including social science research into patients and peoples’ perspectives.
Networking and training with NGOs and the private sector to be facilitated by this unit
along with the Karnataka State TB Association.
•
The state should make greater use of the services and advice of the National TB Institute.
•
Given the co-infection of HIV and TB, training for physicians and health personnel
regarding specifics of presentation, access to treatment, developing working links with
the Karnataka State AIDS Society.
•
The State TB Society should include professionals and NGOs and regularly (annually)
review the implementation of the programme.
5.4.3 VACCINE-PREVENTABLE DISEASES
Introduction
It is well known that 'variolation' was practiced in India and China during the 16 th century, as a
preventive measure against smallpox. Two principles were inherent in this practice:
a) infection with the causative agent of Smallpox protected against subsequent occurrence of the
disease.
b) the inoculation of the smallpox agent through an 'unnatural' route (skin versus respiratory)
caused a mild disease, in most instances. However, variolation did cause full fledged smallpox
in a few cases. Obviously the seed of the concept of immunisation was present in our country
long before it was scientifically developed and promoted in other countries.
In 1798, Edward Jenner proved by experimentation, that cowpox inoculation prevents smallpox.
Using the Jennerian vaccination in a strategic manner, smallpox was eradicated globally, by early
1970's. The power of immunisation in public health was thus proven beyond doubt. Consequently
the World Health Organisation designed and promoted the Global Expanded Program on
Immunisation (EPI), in 1974, to protect the under-5 children of the world from six specific diseases
against which safe and effective vaccines were already available. They are BCG (against childhood
tuberculosis), Diphtheria, Pertussis, Tetanus (DPT) vaccine, oral polio vaccine (OPV) and measles
vaccine.
India adopted EPI in 1978 / 79 and made it a Centrally sponsored project. Either the Government of
India or donors, especially UNICEF, provided full funding for training of personnel, cold chain
equipment and procurement and supply of vaccines. Initially India accepted BCG, DPT and OPV in
EPI, but not measles vaccine. Instead, typhoid vaccine was included, but discontinued within a few
years. In 1985 India accepted measles immunisation making India EPI on par with global EPI.
In 1985 India modified the EPI plan under the name Universal Immunisation Programme (UIP).
Under UIP the target was set to cover 100% of infants with the 6 vaccines, as against the 80 or 85%
target under EPI. By 1990, all districts in the country came under UIP. In that year Karnataka also
adopted UIP in all districts.
Situation Analysis
The Universal Immunisation Programme, although a major success story, remains an unfinished
story. Under this programme, BCG (1 dose), DPT (3 doses in infancy and one in 2nd yr), OPV (3
doses in infancy and one in 2nd yr), Measles vaccine (1 dose in infancy), and DT (at 4-5 yr) are
given free of charge. Pregnant women are given TT (2 doses in first pregnancy and 1 dose for
subsequent pregnancy) in order to prevent neonatal tetanus. TT is also included in school health (2
doses at grades 5 and 7).
The official reports show over 100% coverage for all vaccines (Health Dept. Annual Report, 199899). Independent assessment indicates that Karnataka is in the bracket of 60-80% for fully
immunised children (BCG, DPT3, OPV3, Measles) in the 12-23 months age group and also in the
24-35 months age group (Government of India, MoHFW, Evaluation of Routine immunisation
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1997-98). The coverage for measles vaccine was assessed to be only 52% (Human Development in
Karnataka 1999, p25). The following data are quoted from the National Family Health Survey –2,
for the year 1998-99.
The immunization coverage data of the 4 southern States and Maharashtra are presented below in
the Table 5.9.
Table 5.9: Percentage vaccinated.
State
BCG
DPT 3
OPV 3
Measles
All
Maharashtra
Andhra
Tamilnadu
Kerala
Karnataka
93.7
90.2
98.6
96.2
84.8
89.4
79.5
96.7
88
75.2
90.8
81.6
98
88.4
78.3
84.3
64.7
90.2
84.6
67.3
78.4
58.7
88.8
79.7
60
Card available
48.9
41.3
45.8
63.2
41.2
It may be seen from the above Table that the overall performance of our State has been the lowest
among the cluster of the five contiguous States. It is worth reminding ourselves that in 1992, when
Karnataka adopted the ‘Child Survival and Safe Motherhood’ programme, the targets to be
achieved by 2000 included 100% fully immunized children. Again, in 1994, The State Programme
of Action for the Child accepted the following goals for the year 2000.
Immunisation
: 100% coverage for each antigen
Neonatal tetanus : complete elimination
Measles mortality : complete elimination
Polio
: OPV 3 coverage 100% and polio-free status throughout the State
Among the above goals, only the elimination of polio has been achieved, but it was not through
routine immunization coverage reaching 100%, but by the additional repeated annual pulse
immunizations. In 2000 there were only 5 wild poliovirus isolations in the entire State of Karnataka
and it is safe to assume that they were the very last cases in the State.
The percentages of antenatal women receiving two doses of Tetanus Toxoid in these States were:
Maharashtra 74.9; Andhra 81.5; Tamilnadu 95.4; Kerala 86.4 and Karnataka 74.9 (NFHS-2).
Having achieved only less than 70% measles vaccine coverage, and 75% coverage with Tetanus
Toxoid in pregnancy, it is most likely that the goals of elimination of measles mortality and
neonatal tetanus have not yet been achieved in Karnataka.
It must be pointed out here, that the vaccine coverage data represent only a measure of the
efficiency of the inputs. The actual output of the immunization effort, or its outcome, is the degree
of reduction of the incidence of target diseases, the so-called vaccine preventable diseases. This
deficiency in the system, namely the lack of monitoring of the incidence of the vaccine-preventable
diseases, needs to be corrected. Only in the case of polio vaccination for the eradication of polio,
has an excellent system of surveillance been built up. This system has two components. The first is
clinical; every case of acute flaccid paralysis is now being reported to the designated agency. The
second is virological; every case is investigated by collecting two sequential samples of stools and
sending them to a designated virus laboratory. The designated laboratory for Karnataka is the ICMR
laboratory in the Bangalore Medical College. Obviously, we need clinical surveillance for all
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vaccine-preventable diseases and also sufficient laboratory expertise and capacity to investigate
such diseases when they do occur.
As discussed in their respective sections, rabies and Kyasanur Forest Disease are also vaccine
preventable diseases. Both these vaccines are manufactured in Karnataka State and the State is selfsufficient in this regard. However, the rabies vaccine made and used in Karnataka is obsolete and
we must replace it with the more modern and safe rabies vaccine, like in other countries.
Newer vaccines and new developments in vaccines
Some newer vaccines have been available for quite some time, both in other countries as well as in
India, but we do not have a mechanism to assess their epidemiological need or priority for inclusion
in the immunisation programme. Such vaccines include mumps and rubella vaccines (combined into
one Measles-Mumps-Rubella vaccine, MMR), Hepatitis B, Haemophilus influenzae type b (Hib),
Hepatitis A, varicella (chickenpox), the oral and the Vi typhoid vaccines and the Japanese
Encephalitis vaccine. The old-fashioned whole cell killed typhoid vaccine is safe and effective, but
the Government of India has been discouraging its manufacture in India in order to promote the
importation of the oral vaccine and importation and indigenous manufacture of the Vi vaccine.
In the near future, sooner than later, there will be a global review of the choice between OPV and
the inactivated polio vaccine (IPV). A childhood vaccine against pneumococcal diseases
(pneumonia, meningitis, otitis media) has recently been licensed in North America and some
European countries. Studies are taking shape to evaluate two Indian strains of Rotaviruses as
candidates for vaccine. One of these is from Bangalore itself. Having realized that immunization is
a powerful tool of public health, for the prevention of an increasing number of diseases, which can
be reclassified as vaccine preventable diseases, we do need a practical and effective mechanism to
assess the epidemiological need, effectiveness, safety, cost-benefit and priority of each such
vaccine.
The Indian Academy of Pediatrics has included Hepatitis B vaccine and MMR in their
immunisation schedule recommend for children attending the private sector health clinics. IAP has
strongly recommended to the Government of India to include Hepatitis B vaccine in the Universal
Immunisation Program. Hepatitis B virus infection is very common, but silent in children.
Consequently, many infected children grow up as chronic virus carriers, contributing to the already
large pool of infected persons, estimated to be 45 million nationally and 2.7 million in Karnataka. A
recent study in Karnataka has confirmed the prevalence of Hepatitis B virus carrier state to be in the
range of 3-5% even in children (Indian Pediatrics 2000; 37:149). Most of the consequences of
chronic infection (chronic hepatitis, cirrhosis of liver, hepatocellular carcinoma) are manifested in
adults. While chronic hepatitis carries with it serious and disabling morbidity, once cirrhosis or
carcinoma sets in, the condition is almost universally fatal. Consequent to the large pool of
infection, acute infection continues to occur in children and adults. Acute Hepatitis B is a major
cause of acute fulminant hepatitis among adults. All these conditions are vaccine preventable.
The Indian Academy of Pediatrics has also recommended to the Government of India to abandon
the manufacture of sheep brain rabies vaccine and to replace it with the safe cell culture rabies
vaccine; to ensure the continued availability of the whole cell killed typhoid vaccine; and also to
establish an Advisory Committee on Immunisation Policies and Practices at the National level. All
of these issues are equally relevant in Karnataka State also.
-3-
Strengthening UIP for 21st Century
There are four issues to be addressed here, in the light of the statements above: first, to improve the
efficiency of the routine immunisation programme; second, to monitor the outcome of the
immunization efforts by disease surveillance; third, to evaluate the need and priority of newer
vaccines; and fourth, to evaluate the efficiency and quality of vaccine manufacture within the State.
The needed dialogue and deliberations over the above issues is not a one-time affair, but an ongoing necessity, for which a mechanism needs to be designed and established. A State level
Advisory Committee on Immunisation Policies and Practice is necessary to fulfill this need.
1. Improving the efficiency of UIP
Karnataka must aim to achieve near 100% coverage with the 6 EPI vaccines in all communities,
rural and urban. This requires special attention, planning and close monitoring of the UIP in all
villages, panchayats, taluka, Districts and cities. There is great potential for public – private
participation, with the UIP supplying vaccines to private agencies, who in turn shall return
beneficiaries list and utilization reports to the immunisation programme officer in the locality.
2. Monitoring outcome of Immunisation programme
The true outcome of our immunisation programme includes a sustained reduction in the incidence
of the target diseases, and also the creation of demand by the community for perpetuating the
programme. The former is not being measured; the latter has not been achieved as shown by the
difficulty in obtaining high enough vaccine coverage levels. Thus, a successful disease surveillance
system must include vaccine-preventable diseases, in order to measure the fall in disease incidence.
The occurrence of even one case of a vaccine preventable disease is to be investigated. Whenever a
vaccine preventable disease is reported anywhere, that information must be made available to the
health system. It could have been due to non-immunisation or due to vaccine failure. So we need to
know the immunisation history of the subject. Non-immunisation identifies inadequate coverage,
whatever the coverage statistics has been. Remedial measures must now be taken. Vaccine failure
indicates either poor quality vaccine or inherent property of that vaccine with lower than 100%
efficacy. Many cases of failure would suggest quality problem when we know the accepted vaccine
efficacy level. In such a situation, vaccine potency must be checked. In short, not to have a disease
surveillance programme is unacceptable from the viewpoint of management principles.
3. Evaluating and introducing newer vaccines
Regarding the introduction of newer vaccines, we must assess the actual need based on
epidemiology of the target diseases, and the availability and affordability of such vaccines. All
newer vaccines are relatively more expensive than the classical ones. That is partly because they are
the products of heavy investments in research, some patented. The production costs of newer
vaccines tend to be high, and the number of manufacturers are usually few, and their competition
low. Rich countries have been quick to introduce inspite of their high cost. Even for the classical
vaccines, the prices are higher there than in developing countries. So, they are able to absorb the
newer vaccines more readily as they understand the economic value of preventing diseases. In
poorer countries the newer vaccines tend to be private market vaccines. Therefore the companies
have to promote the products, stock them at their risk, market is not assured and for all these and
also for quick profit they are sold at very high prices. They must make their profit even when the
quantum sold is not very high. These are ground realities. So, when the government considers the
introduction of a new vaccine, it has to ponder over the financial implications very thoroughly.
-4-
There are two basic principles we must recognize. One, when the government assures a market, and
endorses it, the prices tend to crash. In 1984, measles vaccine was being sold at Rs 40 per dose.
When it was approved in the national immunisation programme, the price fell to Rs. 5 per dose.
Some neighbouring countries are purchasing HB vaccine for less than Rs. 30 per dose, while in
India the open market price is well above Rs. 70 per dose for multidose vials and over Rs. 100 for
single dose vials. In a State programme, with open tender, or UNICEF tender, we must be able to
get HB vaccine at Rs. 25-30 per dose. Fortunately there are a number of manufacturers of Hepatitis
B vaccine and there is a healthy competition in the market among several suppliers, including at
least two excellent Indian manufacturers. This same principle will apply to several newer vaccines.
The second principle is the question as to whether it is the Government’s responsibility to supply
free vaccines to all children, rich and poor. In public sector institutions they must be made free, or
heavily subsidized, for the coverage of the clientele that use these institutions for their health care
needs. Perhaps we can build a case for the Government not providing the newer vaccines to those
who can afford to pay for them. Thus, in private sector institutions these vaccines could be sold, at
market prices. It is possible that the vaccine prices may not fall so drastically if a large chunk of
private marketing is allowed side by side with free supplies. This dichotomous financing system for
vaccinations has to be carefully thought through by the Government economics experts alongside
with the health care experts.
As already highlighted, Hepatitis B virus infection is frequent, but children seldom suffer from
overt disease. Virus carriers with chronic infection develop chronic active hepatitis, cirrhosis or
liver cancer. Although we do not have quantified data on the burden due to these liver diseases, we
do know that 4-5% of the population are virus carriers and that the lion’s share of carrier state
begins in newborn period and early childhood. Thus, prevention with vaccine has to be addressed in
childhood, preferably starting in the newborn period. The Task Force recommends the inclusion of
HB vaccine in the State immunisation programme. This recommendation is actually an endorsement
of the recommendations already made by the Indian Academy of Pediatrics and the WHO.
4. Vaccine manufacture in the state:
There are two vaccine manufacturing units under the Karnataka government. They are Vaccine
Institute (Rabies vaccine unit) at Belgaum and KFD vaccine Unit at Shimoga. The quantities of
vaccines produced in these units are given in the table 5.10.
Table 5.10: Vaccines produced in Karnataka
Year
Rabies vaccine (ml)
1993
27,50, 640
1994
27,77,356
1995
22,13,700
1996
27,78,900
1997
32,62,460
*NA: not available
KFD vaccine (ml)
43,650
NA*
29,380
18,210
8,000
Some of the problems faced by these vaccine units is the lack of modernization and lack of
Research and Development. The sheep brain rabies vaccine is becoming obsolete and it will have to
be replaced with safe and effective cell culture vaccine. The Task Force suggests that the
-5-
Department of Health and Family welfare explores the possibility and potential of introducing all
vaccine manufacture, against rabies and KFD, with the Department of Animal Husbandry which
already has vaccine manufacturing activities for veterinary needs. A technical steering committee is
suggested for working out the details.
Rabies as a vaccine preventable disease
Rabies is also a vaccine preventable disease. A detailed account of rabies and its prevention is
given in section 5.4.7. The currently used vaccine, the sheep-brain grown, inactivated, rabies virus
vaccine is effective for preventing rabies, but it is not a safe product for human use. It is
manufactured in the public sector Rabies Vaccine manufacturing unit at Belgaum. Currently,
Karnataka is self sufficient for rabies vaccine for the needs of the public sector health care
institutions. However, most, if not all, private sector institutions give only cell culture vaccines.
There are several such vaccines available commercially.
The Task Force has explored the possibility of manufacturing cell culture rabies vaccine, either in
Belgaum or in Shimoga. However, neither centre has and R & D background, nor modern facilities
for cell culture or the leadership and expertise to develop these. Yet the Task Force wishes that
Karnataka remained self sufficient for rabies vaccine. The Task Force expects that the modern, safe
and highly effective cell culture vaccine will soon replace the old-fashioned sheep brain vaccine.
One realistic possibility is to join forces with the Department of Animal Husbandry which already
has good facilities for manufacturing vaccines for veterinary use. A Technical Steering Committee
may be appointed for an in-depth analysis and recommendations, to be ready within 6 months.
Karnataka's own vaccine-preventable disease - KFD
A detail account of Kyasanur Forest Disease is given in section 5.4.1. An infant–mouse-brain grown
and inactivated KFD virus vaccine was indigenously developed and is being manufactured in the
KFD unit in Shimoga.
The KFD unit in Shimoga also functions as a diagnostic centre, conducting virus isolation studies
and serology test.
The Task Force is of the opinion that the KFD unit in Shimoga deserves modernisation, especially
for improving the technology for diagnosis of human KFD.
Japanese Encephalitis
While the major plank of JE control is vector control, JE vaccine also has a role to contribute.
Currently JE vaccine is manufactured at the Central Research Institute, Kasauli, Himachal Pradesh.
When the control of JE is brought under the integrated vector borne diseases, a holistic approach of
the careful assessment of the need and the potential of using the JE vaccine may also be considered.
Cold chain for vaccines and other biologicals:
Fortunately, cold chain equipment has been provided to all relevant institutions, for holding their
vaccine stock under refrigeration.
• Use same for rabies vaccine
• Use same for anti snake venom sera
-6-
Recommendations
•
Review periodically the Immunisation Policies and Practices with the help of experts.
•
Establish Disease Surveillance System to measure the outcome of the Universal Immunisation
Programme. Any occurrence of vaccine-preventable disease, especially in a cluster of two or
more cases, must immediately attract public health attention, and improve vaccination
coverage locally
•
Include Hepatitis B vaccine under Universal Immunisation Programme for the immunisation
of children.
•
Production of vaccine in the State to be modernized using the latest technology, under
guidance of a Technical Steering Committee for a) Kyasanur Forest Disease b) Cell Culture
Anti Rabies vaccine and vaccines against typhoid, Japanese Encephalitis and other vaccine
preventable diseases in collaboration with the Department of Animal Husbandary .
•
Maintenance of cold chain and utilizing it for all drugs and vaccines that require cold chain.
-7-
5.4.4 FOOD AND WATER-BORNE DISEASES
Introduction
Food, water and substances of human sustenance, are also potential vehicles for the transmission of
pathogenic microbes. Human progress has resulted in organised production, collection, processing,
and distribution of various ingredients of food as well as of drinking water. By and large, such
organisation has improved the quality and safety of food and water, contributing to human health,
and prevention of food / water-borne infectious diseases. At the same time, if pathogens find entry
into such a volume distribution system for public consumption, then large numbers of consumers
are put at risk at once. There have been many instances of such food and water-borne outbreaks of
diseases in many countries in the world. Such experiences of detecting and controlling diseases
have helped in the growth and development of public health expertise and practice the world over.
In the context of Karnataka, water continues to be a common channel of infection, especially in
urban communities. Processed and ready-to-consume food is beginning to become commercially
available. Eating out of home, in hotels, restaurants, dhabas and roadside eateries etc., is already
widely practiced. It is important to ensure the safety of water and food for human consumption in
all communities. Not that these issues have been ignored in the past: checks and measures have
been made to ensure such safety. Rules and procedures do exist. However, their implementation
leads much to be desired.
Food and water provide a mechanism for direct person to person transfer of chemicals, toxins and
organisms causing infections and diseases, such as food poisoning (salmonella, staphylococci,
clostridia), typhoid fever, dysentery (shigella / amoebiasis), cholera, giardiasis, other diarrhoeal
diseases, Hepatitis E and Hepatitis A, tapeworms, nematodes and various flukes. The microbial
pathogens are exclusively human infectious agents and therefore all of them are amplified in human
gastro-intestinal tracts. Human faecal contamination of water or food is the critical step that sets off
the ensuing events to leading to outbreaks of food/water-borne infectious diseases
Situation analysis
In the absence of a functional disease surveillance system, no statistics on diseases is complete or
reliable. The available information is the cumulation of reports from the various levels of primary
and secondary health care system in the government sector. Therefore the data should be accepted
as indicative of the magnitude of the disease burden rather than representative of the magnitude.
Table 5.11: Reported numbers of cases and deaths in 1995 and 1996
Year
Disease
1995
1996
1995
1996
1995
1996
Ac. diarrhoeal diseases
including cholera
Enteric fever
Viral hepatitis
Number of
case
7,54,966
7,12,179
34,801
26,198
7,377
7,377
-1-
No. of deaths
426
348
19
24
69
49
The nature of the information available to the Health Department reveals several drawbacks. The
issue of incompleteness and lack of data from the private sector health care providers has already
been alluded to. Another glaring drawback is the fact that diseases are classified syndromically,
without data on aetiology, which is essential both for appropriate treatment and for taking
appropriate public health interventions.
There is very little information on the overall contribution of water and food in spreading infectious
agents. Every time there is a fairly large outbreak of diarrhoeal disease / cholera, especially one
which gets reported in the media, then the water supply comes under scrutiny. All too often, the
results of microbiological testing of drinking water show contamination with human
faecal.microbes (coliforms or actually E.coli). It is then surmised that the pathogen causing the
outbreak, whatever it was, was also present in the drinking water. Indeed, many anecdotes of
outbreaks of hepatitis are heard of but investigations for the delineation of the exact aetiology or its
transmission pathways are not undertaken.
Cities and towns do have rules and regulations dealing with hygiene and standards in food-serving
centres such as hotels / restaurants. However, this system of Inspection was established during
British rule and not improved upon in recent times. In many developing countries stringent
screening of food handlers, food components and food is implemented, by which food safety is
ensured.
The needed improvements and interventions:
In 1854 there was an outbreak of cholera in one part of London. The local administration was able
to supply to Dr. John Snow, a detailed map of the water distribution lines of two companies that
provided water to that area. John Snow saw the association of one of these two water supplies with
cholera cases and concluded that it was responsible for the outbreak. The hand pump of that water
supply point was removed and the outbreak was controlled.
In our country, urban development has gone on without the service components keeping pace.
While it is easy to say that clean and safe drinking water supply alone will result in the prevention
of a large proportion of gastrointestinal diseases and consequent deaths, it is not easy to set things
right without huge inputs of money and material. We cannot wait, to improve the situation, for the
engineering sector to modernise the water supply system. We must find ways of preventing
outbreaks of water-borne infections diseases, accepting the present system of water supply.
What is the role of the Health System in prevention and control of food / water – borne
infectious diseases?
The Health System must know about every outbreak of food / water – borne infectious disease, for
which purpose it must establish a systematic method to learn about its occurrence and its exact
etiology, and its exact mode of transmission. For this purpose, the Health System must have a
functional epidemiological disease surveillance system spanning across public and private sector
health care providers. In addition, the Health System must also have skills, personnel and
wherewithal to investigate outbreaks both epidemiologically and microbiologically.
-2-
The Health System must assume responsibility for regular periodic monitoring of the
microbiological safety of water, and food served in public places. While the standards of safety of
water are well established, namely the total absence of coliform bacteria, the standards of food
safety have not been adequately defined. Over the past several decades, our understanding of the
aetiological agents of food-borne infectious diseases has improved very much, but these have not
made an impact on our ability to monitor and prevent food-borne infectious diseases.
Recommendations
•
The Health System must establish a functional disease surveillance system and develop
epidemiological, microbiological and chemical analysis and expertise and facilities for early
outbreak control.
•
The health system must establish routine periodic monitoring of water for coliforms and
chlorine content. Each local area health authority must develop its own plan of action to
monitor water quality. At any point when coliform is found in supplied water, that information
must be immediately made available to the local government, the water supply agency and also
to the public (consumers). Health System will also provide technical advice for correcting the
deficiencies and to monitor progress.
•
The Health Department must review and revise the regulations and legislative measures
governing food safety. Regulations must include all food serving facilities including street
vending. They must check and prevent adulteration and contamination of foods at various
stages of production, processing, storage, transport and distribution..
•
The Health Department should develop guidelines for the health check-up and immunization of
food handlers against typhoid fever and hepatitis A.
•
Control measures recommended include, training and certification of food handlers in
restaurants, hostels, hotels etc.
•
Personal hygiene, adequate cooking of food – this needs to be part of the health promotion
package for children, women and the public in general.
-3-
5.4.5 HIV/AIDS, REPRODUCTIVE TRACT INFECTIONS (RTIs), AND SEXUALLY
TRANSMITTED DISEASES (STDs)
"And that was the day that we knew, oh! In the world there is a new disease called AIDS, I thought surely this will be
the greatest war we have ever fought. Surely many will die. And surely we will be frustrated, unable to help. But I also
thought the Americans will find a treatment soon. This will not be forever."
- Dr. Jayo Kidenya, Bukoba, Tanzania, 1985.
Sexually Transmitted Diseases (STDs) and Reproductive Tract Infections (RTIs)
STDs are a group of communicable diseases, transmitted predominantly by sexual contact. From the
earlier five venereal diseases (syphilis, gonorrhoea, chancroid, lymphogranuloma venereum and
donovanosis) they now comprise a group of diseases resulting from 20 causative organisms that
include bacterial, viral, protozoal, fungal agents and ectoparasites. Recent studies show that
prevalence rates of RTIs in women are fairly high, as are STDs in the general population. Routine
statistics greatly underestimate the problem. For reasons of privacy people prefer over the counter
medications or go to quacks and private practitioners. These never get reported and the
appropriateness and rationality of treatment are questionable from untrained health care providers.
Women suffer particularly because of feelings of shame and shyness to share about symptoms and
lack of access to health care services that are technically sound, humane and sensitive. However,
this particular problem of public health importance is another among those that have received
inadequate attention in provision of service and in public education in Karnataka, as in the country.
This is despite adequate funding in the RCH programme and the HIV/AIDS programme.
Three types of RTI’s need to be addressed appropriately:
•
•
•
Sexually transmitted diseases, e.g., Gonorrhea, Syphilis, Trichomonas, Chlamydia, HIV/AIDS.
Endogenous - due to overgrowth of existing bacteria, e.g., Candidiasis during pregnancy.
Infections caused by instrumentation, e.g., following a pelvic examination, septic abortion, etc.
STDs can be broadly classified as genital ulcerative (e.g. Syphilis) and genital discharge (e.g.
Gonorrhea)
Co-relation between STDs & HIV infection:
•
Presence of a genital ulcerative STD increases the chance of acquiring HIV infection by 10
times. Presence of an STD causing genital discharge increases the chance of acquiring HIV
infection by 4 times. Therefore prevention, early diagnosis and effective treatment of STDs is an
important targeted intervention for prevention and control of HIV/AIDS.
•
An underlying HIV infection makes STDs more severe and more difficult to treat.
Morbidity
RTI’s can cause pain, ulcers, discharge and infertility in males and females. They can lead to
prostatitis & epididymo-orchitis in males and dysmenorrhoea, or ectopic pregnancy following
pelvic inflammatory diseases, etc. in females. A large percentage of women are asymptomatic and
therefore are unaware of the presence of any infection.
Women are biologically more prone to infections than men because of a larger mucosal surface
available for entry of infecting organisms. Young girls are more vulnerable to RTI’s specially STD,
as are older menopausal women.
RTIs/STIs are supposedly dealt with through the RCH program. But the ineffective implementation
of this component, biological vulnerability to these diseases, the lack of power to negotiate
responsible behavior from their sexual partners and the non-availability of lady medical officers in
adequate numbers, all contribute to increasing incidence of these eminently preventable diseases
amongst women.
HIV/AIDS
Incidence & Prevalence
India has the largest number of people living with HIV/AIDS in the world. Latest reports from
NACO estimate the prevalence of HIV/AIDS in India at anywhere between 3.5 to 4 million cases.
The numbers per se may not be seen as large compared to other health- related problems. What is
alarming is the steady rise in incidence, with estimates that the numbers are doubling every three
years.
From the first HIV sero positive individual detected in 1988 in Karnataka the numbers have risen
dramatically and is estimated to be upwards of 0.15 million. Karnataka is now third among the
states with the highest prevalence, Maharashtra, first and Andhra Pradesh, second. Tamil Nadu
which was second on the list a few years ago has managed, with a concerted effort by TNSAPS and
NGO partners, climb down to the fourth position.
Six districts viz. Bangalore Urban, Mangalore, Udipi, Dharwad, Bellary and Mandya contribute to
73.3% of HIV positive cases in this State.
It is also no longer confined to the so-called “high risk behavior” groups. The infection is spreading
rapidly to the general population or the so-called “low risk” population of women and youth. The
National AIDS Control Organization’s (NACO) epidemiological data (1997-98) revealed that one
in every four cases reported is a woman with heterosexual transmission being the single largest
mode of transmission. Women are also getting infected at an earlier age. Karnataka sentinel
surveillance figures show an HIV infection level of more than 1% among antenatal women.
The association of two important diseases with HIV infection is known
There is a considerable increase in the incidence TB which is the commonest opportunistic infection
found among HIV patients in India. There are additional problems of drug reactions and drug
resistance in HIV patients.
STD - not only indicates risk behavior, but an underlying STD also increases the chances of HIV
infections by 15 to 50%.
Vulnerable populations:
The marginalised sections of our society are most vulnerable to HIV/AIDS and its consequences.
Though poverty is a factor, very often risk behaviour is related to other factors. Often the criminal
laws and the law enforcement agencies themselves lead to increased marginalisation and
exploitation of already marginalized groups.
Women: Biological (physiological), social, cultural, economic factors and gender inequalities make
women more vulnerable to STDs & HIV/AIDS.
Children: In the coming years, as HIV infections increase, large percentages of children will be
orphaned, or affected by HIV themselves. Opportunistic infections in children with HIV occur more
often and are likely to be more severe or difficult to treat.
Street children in particular are vulnerable. Sexual relations start at a very early age (10years or
even earlier) and are a part of the reality of street life- power struggles; as a payment for favours and
protection of older “God-Fathers”. This coupled with a certain fatalistic attitude to life, lead to low
impact, if any, of awareness and preventive intervention programmes.
Adolescents: Despite quite a high degree of awareness about HIV/AIDS, the knowledge is not
translated into responsible (sexual) behaviour because of misinformation and myths; and a feeling “This will not happen to me!”
Migrant workers and others who stay away from their homes and family for long periods of time
are vulnerable because of the high incidence of promiscuous and unsafe sex.
Others who are vulnerable for the same reasons are inmates of jails, boys’ hostels etc, especially
because of a high incidence of homosexual activity. Preventive interventions like distribution of
condoms amongst them is not possible as these are construed as “aiding and abetting” a criminal /
illegal act, under Section 377 of IPC, 1860, which criminalises “sexual intercourse against the order
of nature”.
STD infected have an increased risk for HIV infection. Addressing AIDS will be far more difficult
in a country like India, where leucorrhea and gonorrhea, which can be prevented and treated, have
not yet been successfully addressed.
Commercial Sex workers for obvious reasons are the most vulnerable. In Karnataka there is no
designated “Red Light district” for sex work like in some other cities. This and exploitation by the
police make it even more difficult to reach preventive interventions to them.
Alcohol abusers: Several studies in Karnataka and elsewhere have found a significant link between
alcohol use and abuse and sexual risk behaviour. Karnataka does not have a significant injecting
drug abuse problem, alcohol use and abuse though is quite high.
An evolving response to the HIV-AIDS epidemic in Karnataka.
The first AIDS surveillance centre was set up in Bangalore Medical College in 1987 with technical
guidance from the Indian Council of Medical Research. During 1989-94 the Blood Safety
Programme, assisted by Government of India, initiated the modernisation of the blood banking
system in Karnataka. The State AIDS Cell was established in 1992.
From 1992-1998, Phase I of the National AIDS Control Programme was implemented with World
Bank assistance. Under this program 10 zonal blood testing centres were established and 51 blood
banks (37 government, 15 private) were modernized. Sectoral surveillance was carried out through
7 STD clinics and one antenatal clinic. Three Voluntary Blood Testing Centres were set up.
Training of doctors and paramedical workers was conducted. Heath education and IEC programs
reached out to communities using a variety of media. STD clinics have been strengthened. The
Karnataka State AIDS Prevention Society (KSAPS) was registered.
Phase II of the AIDS Control Project was launched in December 1999 for a 5 year period till 2004,
with World Bank assistance and the overall objectives of keeping HIV prevalence rate below 3%;
awareness level of not less than 90% among the youth and those in the reproductive age group; and
achieving condom use of not less than 90% among the high -risk behaviour groups. It aims to
reduce the spread or transmission of HIV infection in the state and to strengthen capacity to respond
to HIV/AIDS on a long-term basis.
NGOs have been active, particularly in Bangalore. Three NGOs provide care and support to people
living with AIDS (PLWA’s) in Bangalore (one also has home based care program), one for women
in Chickmagalur while another is being established in Mangalore (February 2001). A well women
clinic is run by an NGO in Bangalore; two other NGOs work with CSWs in Bangalore and Belgum.
Other NGOs work with preventive education in schools and industries in and around Bangalore;
and with truckers in Raichur, Bangalore and Mangalore. Two networks namely the AIDS Forum
Karnataka (AFK) and the Karnataka Network for People Living with HIV/AIDS (KNP+) have been
formed. Another NGO network, CHAIKA has undertaken sensitization and training programs for
its member institutions (over 300) working in different districts. A few mission and private
hospitals provide testing and inpatient facilities for HIV positive patients who need medical care.
Training of Counsellors for HIV/AIDS is also carried out. Other NGO’s include HIV/AIDS work
as part of their overall health work. For instance HIV/AIDS awareness is part of women’s health
empowerment training program. The National Law School University of India takes an active part
in legal and ethical aspects of HIV/AIDS
Thus over the years a slow but sure response to the HIV epidemic has evolved in Karnataka.
Efforts are however inadequate and slow in respect of the rapidly increasing trends in infection
rates, the spread of the infection into the general community and evidence regarding growing
vertical mother to child transmission.
Several factors are responsible for this:
•
People, especially people at the helm of affairs, are not accepting the reality of AIDS- not
accepting the estimates; not accepting that promiscuity is wide-spread; not accepting that
preventive interventions should include discussions with adolescents on issues related to sex;
and so on.
•
•
•
•
The silence that surrounds the AIDS victim due to the associated stigmatisation and shame
make it that much more difficult for interventions to prevent further spread to reach them.
The HIV/AIDS prevention and control programmes have remained in a vertical mode, largely
independent of the Department of Health & Family Welfare activities. The department therefore
has not responded responsibly to this problem.
A majority of the interventions are Bangalore-based. This inequality needs to be addressed
especially in the high prevalence area.
Many issues related to acquisition and spread of HIV/AIDS is rooted in underdevelopment, as
also, the negative consequence of HIV/AIDS on development. Thus, HIV/AIDS policy and
interventions need to be integrated into general developmental policies that deal with raising
socio-economic and health status.
The action points should therefore cover the following
•
•
•
•
•
A “mapping” of prevalence of STDs and HIV with related socio-cultural and risk factors, to
enable specific needs based and local level interventions. Needless to say this has to be done in
a sensitive manner, keeping in mind the stigma, confidentiality etc.
A comprehensive media campaign for awareness utilizing professional agencies; which will
focus on prevention as well as strategies to reduce stigmatization
An equal emphasis on awareness among larger vulnerable populations in addition to targeted
interventions among “High risk groups”.
Involvement of PLWAs in the management of HIV/AIDS - design, implementation and
evaluation of KSAPS programs
A special cell to look at legal & ethical issues related to HIV/AIDS
Recommendations
I.
For STDs/ RTIs in general
•
Facilities for simple diagnosis and treatment of STDs/ RTIs in all PHCs and CHCs.
Necessary drugs to be listed in the essential drugs list and uninterrupted supplies to be
ensured. Treatment of partners or contact treatment is critical for control.
•
PHC and CHC medical officers to be re-trained through CMEs regarding management of
STDs/RTIs and HIV/AIDS. Patient feedback to be actively sought regarding quality of care.
Feedback should modify the functioning of the programme.
•
Educational and health promotional programmes for different groups in the community to
be sensitively developed in collaboration with NGOs, teachers, communication and health
promotion experts. Films, TV, theatre, street plays and folk media to be used. Prominent
sports and entertainment personalities to be brought into the campaign. Creation of peer
group programmes and sathis for adolescents.
•
STDs/ RTIs/ HIV to be part of the epidemiological diseases surveillance system.
II.
More specific to HIV/AIDS
•
Integration of HIV/AIDS programme with primary health care and all levels of services.
Special linkages with programmes for STDs/RTIs and tuberculosis.
•
Capacity building through training at various levels for PHC medical officers/ all allied
health workers, general practitioners and NGOs.
•
Developing Voluntary Counseling and Testing Centres (VCTs) in all districts. This will
entail making available diagnostic facilities in all district hospitals and subsequently taluk
hospitals. Training for maintaining of confidentiality will need to be undertaken. Caution to
be taken so that counselling does not become routine pre and post test rituals to meet
obligatory requirements.
•
Interventions to be undertaken to initiate and maintain behaviour change that decreases the
chance of HIV transmission. This would include messages regarding risk reduction
behaviour, safe behaviour, no anonymous or casual sex and faithfulness to one partner.
Work particularly with adolescents and youth. Strategies to relate to individual's behaviour,
educational levels, culture beliefs, ethnicity, gender, knowledge. Awareness and preventive
education among children, adolescents, women’s groups etc. The “men make a difference”
campaign attempting to make men more responsible in the control of the epidemic to be
supported.
•
Condom promotion within the state through a multisectoral collaboration involving KSAPS,
NGOs, condom manufacturers, market research agencies. Education on the correct use of
condoms, including that they are not 100% protective.
•
Shift emphasis of targeted interventions from “high risk groups” only to a larger vulnerable
population.
•
Home care counselling and support programmes to be encouraged with facilities for
treatment of opportunistic infections
•
Access to antiretroviral therapy is an issue that needs to be negotiated with the Government
of India, pharmaceuticals and international bodies. Provisions under WTO to be used for
indigenous production, which would lower costs. Care to be exercised in the rational use of
these drugs so that resistance does not develop. Drug therapy to be introduced only where
necessary investigations are possible.
•
Involvement of people living with AIDS (PLWAs) in the management of HIV/AIDS – design,
implementation and evaluation of KSAPS programmes.
•
Strengthen and establish state private sector collaboration with NGOs, private medical
institutions and professional bodies such as IMA, FOGSI etc and intersectoral coordination
within government departments and agencies.
•
KSAPS to play a nodal role, including advocacy with political leaders; resource generating
management; to promote district level action and to function with accountability. Create a
specialized cell to address legal and ethical issues.
•
Measures to prevent mother to child transmission - antiretroviral therapy, alternatives to
breast milk and support.
•
Blood safety to be strengthened.
•
Treatment and admission policy in all hospitals, not just one or two centres, including
routine treatment as well as treatment of opportunistic infections, particularly TB, ethical
and effective antiretroviral therapies.
•
Training and networking for home based care, including use of herbal medicine and other
systems of healing with backup support for referral hospitals.
•
Universal precautions and disposal of bio-hazard wastes in health care institutions.
-1-
5.4. 6 LEPROSY
National Leprosy Control
Leprosy Elimination - Declining prevalence but persisting incidence.
The detection and control of leprosy as a national programme is in a process of evolution. The
National Leprosy Control Programme has been renamed the National Leprosy Elimination
Programme with the goal of achieving the incidence of new leprosy, of less than 1 per 100,000
population. The target year for achieving elimination status was the year 2000. The method is
multi-drug therapy, especially of multi-bacillary cases, for a period of only one year, by which time
a total microbiological cure can be achieved. Consequent to this hope, currently the "vertical"
leprosy program is being integrated with primary health care. The disease burden of leprosy, as
detected by the leprosy Programme is given table 5.12.
Table 5.12: The situation under the Leprosy Elimination Program, Karnataka.
Year
1994
1995
1996
1997
1998
Target for Achievement %
Target for
detection
Achievement completion
of
treatment
20,000
26,465
132
40,000
18,000
24,019
133
30,000
9,000
21,978
244
26,000
8,000
19,589
245
23,000
6,000
17,761
296
19,320
Achievement %
Achievement
30,462
26,221
23,076
20,883
21,202
76
87
89
91
110
It is quite obvious from the above table that the target set for detection of new cases for each year
was unacceptably low, in comparison with the experience of the immediate past year. This resulted
in achievements of 200-300% of the target. On the other hand, the target set for completion of
treatment (one year for multibacillary and 6 months for paucibacillary) appears to be better guided
by year- to - year experience.
The table shows that from 1994 – 98, 21,000 to 30,000 patients had completed treatment annually
and were presumably microbiologically cured. However the incidence of newly detected cases
continued to be high. Accepting the yearly numbers to be 17,000 to 18,000 new leprosy cases
detected, the annual incidence (calculated on the denominator of 60 million in Karnataka) is in the
range of 28-30 / 100,000 population. The target for Leprosy elimination by the year 2000 was less
than 1/100,000 population. The Multi Bacillary cases cured / disease arrested during the 5 years
(1994-1998) were, 6348; 4517; 4355; 3829; and 13,763; respectively. These numbers do not show
a downward trend. The annual incidence of detected MB cases was about 7/100,000 during 1995 –
97 and 20/100,000 in 1998. Leprosy Elimination is thus not within grasp as yet in Karnataka. The
continuing high annual incidence rates of leprosy must be viewed with concern.
-2-
Integration of Leprosy programme with Primary Health Care
The Leprosy programme is in the process of integration with the primary health care system at all
levels. All PHC doctors and health workers are being trained in the diagnosis and treatment of
leprosy. The laboratory technicians are being retrained for skin snip smear examination for
detection Mycobacterium leprae. This phase of integration will have to be managed very carefully.
It is proposed that the Taluka Health Officer will be given the Supervisory role for Leprosy
detection, treatment, follow up and documentation. The Taluka Health Officers will be guided,
suggested and supervised, for the leprosy work, by the District Leprosy Officer.
The early signs of Leprosy are often without symptoms of discomfort and disfigurement. Therefore
there is a tendency for persons with early leprosy (skin patch, nerve thickening) not to seek health
care. Moreover since the primary health care system is heavily involved in the diagnosis and
treatment of serious or life threatening diseases, often accompanied with symptoms which force
people to seek health care, there is the probability that health care workers may not pay due
attention to the diagnosis of early leprosy. Under the Leprosy programme dedicated leprosy workers
actively searched out for early leprosy cases and brought them under treatment, continued their
follow up and documented data diligently. The importance given to Leprosy detection and
management should be continued without letup even when the programme is integrated with
primary health care.
The uneven distribution of Leprosy in Karnataka
Over the last several years the following districts have reported more than 2000 cases of Leprosy
each year: Bijapur, Bellary, Gulbarga, Raichur.
The following districts have been consistently reporting between 1000 – 2000 cases annually:
Kolar, Belgaum, Dharwad, Bidar, Mysore
The following districts have reported 500 – 1000 cases annually: Bangalore, Bangalore Rural,
Shimoga, Tumkur, U. Kannada, D, Kannada, Mandya.
Three districts Chikamagalur, Hassan and Kodagu have been reporting less than 100 cases annually.
Keeping this geographic pattern in mind it will be very important for the state health leadership on
the annual number of cases reported from the time of integration with primary health care. If any
district shows a fall in numbers since integration with primary health care, those districts must be
specially targeted for intensive studies to check if there has been any deficiencies in case detection
methodology.
Maintaining the state expertise in Leprosy
There are district leprosy offices in nearly all districts. The high prevalence districts have 2-4
Leprosy Control Centers while most others have one LCC each. The State has 677 Leprosy Sample
Survey-cum-Assessment Units, 6 reconstructive surgery units, 2 Leprosy training units, 3
Rehabilitation Centres and 14 Modified Leprosy Control Units. It is very important that these units,
centers and their staff are sustained for their expertise and interventions even after integrating
leprosy programme with primary health care.
-3-
Leprosy continues to be an important health problem in the State. It is not contagious, and its exact
mode of transmission remains unidentified. However, it is eminently treatable, especially when
detected early, particularly before any deformity has developed. Although the antimicrobial
treatment is well standardised, the diagnosis and management of neuritis, nerve damage, deformity,
ulcer formation, "reaction" states, etc. do require special skills and expertise, which is currently
available with the appropriate leprosy staff.
Even though a person may be declared
microbiologically cured, he/she requires long follow up to detect and remedy any of the above
complications, which may appear any time during the months to a few years after completing
specific treatment (of 6 months for PB and one year for MB cases). This "care after cure" is very
important in preventing the disfigurement so often associated with leprosy and which often leads to
social discrimination of persons affected with leprosy. For these reasons it is very important for the
health care system to continue to focus attention on early detection, treatment and follow-up of
persons with leprosy.
Recommendations
•
The Department of Health should maintain the expertise and skills developed and sustained
over the years in the detection and management of leprosy even after integration of leprosy
into primary health care.
•
The Leprosy incidence must be closely monitored so that under-diagnosis, if any, due to the
integration with the primary health care system, may be identified and rectified without losing
ground.
•
Rehabilitation of leprosy cured persons with disability to be taken up seriously.
5.4.7. RABIES
The situation
Statistics on rabies are unreliable. Official reports indicate annual numbers to be 1345 in 1990 and
1424 in 1993. However the reported numbers of death due to rabies in these years were only 40 and
34, respectively. Everyone knows that case fatality of rabies is 100%. On the other hand, in 1990,
the number of rabies patients admitted in Bangalore Epidemic Diseases Hospital alone was 65.
Post-exposure rabies immunisation after animal bites is given in at least 4 major Government
hospitals in Bangalore, and in one of them (Jayanagar General Hospital) the number of persons so
treated is about 3000 per year. Animal bites and rabies deaths are a serious, but preventable health
problem. The economic loss due to this problem has not been calculated. The major responsibility
of the Vaccine Institute, Belgaum, is to produce sheep brain (Semple) rabies vaccine (ARV). In
1998 (April – December), 1617 litres of ARV was produced; the expenditure of the Institute was
Rs. 62 lakhs. To this we may add transportation, storage, physician-time, injection equipment, work
time lost, human suffering and the loss of life.
Problems:
▪
Lack of an integrated approach to prevention of animal and human rabies.
▪
Several agencies involved, but not coordinated.
▪
Interference from animal rights people who put obstacles to dog control, but ignore the
thousands of sheep being slaughtered for preparing ARV.
▪
ARV is not safe for human use, although highly antigenic (effective). One person per 3000
–7000 vaccines get severe paralysis (allergic encephalomyelitis) due to the myelin in the
vaccine. About 10% of them die as a result. The rest of the world has given up its use and
replaced with either newborn mouse brain (no myelin) rabies vaccine (in very poor
countries) or one or another cell culture rabies vaccines or purified duck embryo rabies
vaccine. In India, one manufacturer makes chick embryo fibroblast cell culture vaccine and
another is apparently ready with a Vero cell culture vaccine. Imported Vero cell vaccine
and human diploid cell culture are also available. In the private market, cell culture rabies
vaccine costs over 100 rupees per dose, and 5 doses are needed per person bitten by an
animal suspected to have rabies.
▪
Strict quality assurance is lacking in management of animal bites. Anecdotally it is reported
that a large proportion of subjects are vaccinated without proper indication.
▪
Rabies immune globulin is not readily available. It is necessary for post exposure treatment
of persons bitten by rabid animals or those bitten on face, head, neck, hand or genital area,
by an animal suspected of rabies.
2iRabies.doc
-1-
Recommendations.
•
The responsibility of dogs on the streets belongs on the legally correct agency. The health
authority should immediately call a meeting of the relevant agencies: those who manage roads,
veterinarians, health personnel, local administration, Vaccine Institute, SPCA, animal activist
lobbies, ministry of environment etc. and prepare a comprehensive action plan, within 6 months,
defining responsibilities. The plan of action must be put to action.
•
Immediate action to train relevant personnel on rational use of ARV.
•
Decision to discontinue the use of animal brain rabies vaccine, and to replace with a cell
culture vaccine. Design the transition from animal brain ARV to cell culture ARV. Evolve a
method to give cell culture vaccine at no payment to poor people but leave the private sector
patients to purchase it. The price of cell culture vaccine may come down drastically, if bulk
orders are placed.
•
Explore manufacturing of cell culture vaccine in Belgaum Institute.
•
Ensure strict licensing and immunising of pet animals in every town and city. In rural areas this
may not be possible.
•
Educate the public on rabies.
•
Revise Public Health Act on rabies patient’s management in Hospitals. Shutting up in cells is a
gross violation of human rights and ethics.
•
Ensure that the responsibilities have been clearly defined and the respective agencies have
begun action (Corporation, highways, SPCA, Environment etc). If dogs cannot be killed, then
sterilization and rabies immunisation must become the responsibility of a defined agency.
•
Continuing Medical Education for correct management of animal bites to all registered
practitioners / hospitals etc. State Institute of Health & FW to be in charge. Material to be
professionally prepared.
•
Rabies to be included in the disease surveillance list.
2iRabies.doc
-2-
5.4.8 OTHER INFECTIOUS DISEASES
Introduction
There are a number of infectious diseases, other than those discussed above, that deserve our
attention as well as plans for intervention. Infection by a pathogen is the result of the following two
phenomena. One is the amplification of the pathogen and the second, the transmission of the
pathogen to the human hosts.
Amplication of the pathogen may occur in humans themselves, and transmission may occur directly
(person-to-person) or indirectly via biological vectors, via environmental vehicles such as food /
water. Some pathogens are amplified in vertebrates and humans get infected either by direct contact
(such as bite, for rabies, via milk for brucellosis) or indirectly (through mosquitoes as in Japanese
Encephalitis, via soil as in leptospirosis). Such diseases are called Zoonoses. There are pathogens
amplified in the environment (other than vertebrates or biological vectors), such as soil saprophytes
causing human disease include melioidosis and mycotic diseases. Guinea worm (Dracunculus
medinensis) is a nematode, with life cycle shared between fresh water crustaceans and humans. The
lesson to be learned here, is that a holistic understanding of the ecology of a region, including the
cataloguing of all potential human infectious agents, is essential for taking control over human
infectious diseases.
Recent decades have witnessed the appearance of new diseases in different regions (HIV /AIDS,
Ebola disease). Consequently the concept of "Emerging and Re-emerging infectious diseases" has
been formulated. They include:
• Previously unknown infectious diseases being recognized anew
• Recent trans-species transmission of pathogens
• Previously known agents now appearing in new geographical territories
• Re-appearance of diseases once under control
• Infectious diseases out of control (increasing incidence / prevalence)
• Increasing anti-microbial resistance of specific pathogens
Against the above broad-brushed backdrop, selected infectious agents and diseases will be
presented below in order to focus attention on them. However, the important lesson is that
infectious diseases are a reflection of the environmental factors – including degradation and human
invasion into the ecological balance of Nature. To illustrate this further, it may be pointed out that
there is no Department of Public Health in Singapore. All diseases are reported (under disease
surveillance) to the Department of Environment. Disease control measures are taken jointly by the
Departments of Environment and Health.
Draunculiasis (Guinea worm disease)
India has been declared free of Guinea Worm Disease as of Feb 2000. The last case had been
reported in 1996. During the past 5 years, Guinea worm disease was officially recognised only in
the state of Rajasthan. On the other hand the Annual Reports of the Department of Health and
Family Welfare, Karnataka continued to report “endemic status” of Guinea worm disease even in
1998-99 and 99-2000 in Raichur, Bijapur, Gulbarga and Bellary districts. Anecdotal information of
the continued occurrence of Guinea worm disease in Bellary district has been presented to the Task
Force.
The Task Force views this situation with concern and recommends that Guinea worm fact-finding
mechanism be established and the situation clamped within the next 6 months. All the districts in
which Guinea worm disease was known to occur in the late 1980’s and early 1990’s should come
under scrutiny.
Leptospirosis
Human Leptospirosis is increasingly being recognised and reported in the medical press, in different
parts of the State. Animal Leptospirosis has been widely recognised by the Department of Animal
Husbandry and modern and competent laboratory expertise has already been established.
On the other hand, laboratory diagnostic facilities for human leptospirosis is grossly deficient in the
health care system of the state. The Task Force desires that the Department of Health & Family
Welfare and Department of Animal Husbandry develop a coordinated mechanism for the laboratory
diagnosis, epidemiological investigations, health education and prevention and control of
leptospirosis.
In the proposed expansion of the expertise of the State Level Apical Laboratory for Public Health,
expertise for leptospirosis must be included. The State Laboratory will be responsible for the supply
of the required reagents for the diagnosis of leptospirosis at the district and other relevant hospitals.
Leptospirosis will be included in the laboratory manuals at the State and District Levels.
Brucellosis
From the medical literature of the recent decades, it is widely recognised that human brucellosis
occurs, not infrequently, in Karnataka. The infection is enzootic in animals (cattle and sheep/goats).
Humans get infected through contact with animals and through consuming inadequately treated
milk. The coordinated intervention of the Department of Animal Husbandry and the Department of
Health & Family Welfare is essential both for epidemiological definition of the problem, measuring
its magnitude and geographic distribution as well as for taking effective intervention for diagnosis,
prevention and control.
Anthrax
Although it is well known that animal and human anthrax occurs in Karnataka, its magnitude and
epidemiology remain unexplored. A coordinated approach, between the Departments of Animal
Husbandry and Health & Family Welfare is necessary to define the problem and for interventions.
Intestinal helminthoses and parasitic diseases
The common parasitic infections in Karnataka include hookworm, round worm, enterobiasis,
trichuriasis, tapeworms, systemic cysticercosis, hydatidosis, amoebiasis and giardiasis. The
prevalence of such parasitic infestations is inversely proportional to the level of the hygiene
standards of the people, general sanitation of the environment, safe disposal of human excreta, and
the safety of supplied water from faecal contamination. This has been discussed in the section on
water and sanitation.
As the laboratory network at various levels is being strengthened, there should be a mechanism to
collect and collate information generated in these laboratories. With such a mechanism in
operation, we should be able to obtain a geographic mapping of the relative frequencies of these
various parasitic infestations in humans.
Authenticated information must be translated into health education of the public – both for formal
education (schools and colleges) and informal education (media).
For example, we are concerned about the prevalence of cerebral cysticercosis even in vegetarians.
In this area also, coordination between Health Department and Animal Husbandry Department is
essential.
Plague
Even though human plague has been eliminated several decades ago, it is most likely that the
sylvatic foci of plague continue to exist in the forest areas of Karnataka. The Task Force
recommends that laboratory skills must be maintained in the state. Moreover, rodent surveillance,
and the examination of rat fleas must be systematically maintained.
Common skin infections and infestations
Scabies, pediculosis or lice infestation, pyodermas or purulent skin infections, tinea or ringworm,
superficial fungal infections of the skin, such as pityriasis, versicolor and candida, viral infections
such as molluscum contagiosum and warts are all common skin infections, requiring treatment,
which should be available in health centres as close to peoples homes as possible.
Otitis Media
Otitis media, both acute and chronic, is a common diseases of childhood. It is estimated that almost
every third child in a rural population has a discharging ear. It is linked to poverty, overcrowding,
poor sanitation and nutrition and inadequate medical care. Untreated it can lead to several serious
complications and sequelae, including hearing loss, which then affects the development of the child.
It is important to prevent the development of chronic suppurative otitis media and rupture of the
tympanic membrane.
Recommendations
•
Active search to be conducted in the erstwhile endemic districts with Guinea worm disease, to
ensure its complete elimination, and the result to be reported in the 2000-2001 Annual Report of
the Department of Health and Family Welfare.
•
The expanded laboratory in the Public Health System, at the State level, must develop expertise
in the microbiology of the following diseases and develop training, reagents and
standardisation of laboratory test for the District Laboratories; Leptospirosis, Brucellosis,
Anthrax, Plague.
•
After a disease surveillance system is established, a laboratory based information system must
be developed in order to pool and collate laboratory generated information in infectious and
parasite diseases. This will give the geographic prevalence of specific infectious diseases so that
intervention can be designed and applied.
•
A mechanism to coordinate public health activities between the Departments of Animal
Husbandry and Health and Family Welfare must be created. Such a mechanism will help in
epidemiological investigations, development of laboratory skills, vaccine manufacture and
development, health education, and preventive intervention.
•
All primary health centres and even sub-centres should be provided with simple drugs to treat
skin infections.
•
Provision of adequate quantities of water for washing and bathing, and health promotion
regarding personal hygiene are important, particularly in the younger age groups, when
personal habits are formed.
•
Provision of antibiotics at PHCs and referral facilities for other interventions at taluk hospital
level. Audiometry at least at district hospital level.
•
Train the village level health worker to manage acute infections of the ear, preventing rupture
of the tympanic membrane and the development of chronic suppurative otitis media.
5.5 DISEASE SURVEILLANCE
The need for epidemiological disease surveillance system
Public health cannot progress without surveillance systems. For example, the design, management,
tactics and final documentation of the eradication of smallpox or Guinea worm could not have been
achieved without high quality surveillance. Unfortunately, the surveillance established for smallpox
and fever with rash was too narrow in its target diseases to be sustained after smallpox eradication.
History is repeating with the efforts for the eradication of poliomyelitis, for which purpose, high
quality surveillance for one disease has been established in all communities in the country. After the
achievement and documentation of polio eradication, this surveillance will also decline. Thus
surveillance is an integral component of public health and disease control. It is not mere
collection of information for statistics.
On the other hand, it is information for
epidemiological analysis and action.
We have invested heavily in our universal immunization programme. Currently its success is
evaluated by immunization coverage, which is an inputs-monitoring criterion and not an outcome
measuring parameter. The outcome is the degree of disease reduction, which cannot be measured
without measuring the frequency of the target diseases.
Outbreaks of water-borne or vector-borne infectious diseases (IDs) are not infrequent in Karnataka.
Often such outbreaks come to the attention of the health system only after they have become large
and even the news media have reported on them. The Health Department then gets blamed for the
outbreaks, for no better reason than its ignorance of the outbreak in its early stage. Surveillance
systems are essential for the early detection of outbreaks and epidemics, so that effective control
measures can be applied in a timely fashion. Today it has also become obvious that surveillance is
imperative for the detection and interception of emerging and re-emerging infectious diseases and
also for understanding the pattern of risk factors and distribution of non-communicable diseases.
Situation analysis in Karnataka
Karnataka state does not have a working disease surveillance system. The existing rule for disease
notification is neither widely known nor practiced, nor enforced. The State-wide network of primary
health care centers are actually filing in monthly reports of communicable diseases, but these
reports are used only for passing on to the next higher level of hierarchy, for adding to the statistics,
without being made use of locally for any public health action. This information system has not
served the needs for a disease surveillance system as described above. Another source of
misunderstanding is that some consider the health management information system (HMIS) to be
sufficient for the purposes for which surveillance is needed. Disease surveillance is neither for mere
statistics, nor for management and administration, but for disease prevention and outbreak control.
It is an integral tool of public health.
In public health we need the identification of pathogens and the delineation of their transmission
pathways, in order to design and deploy preventive interventions. These modalities require the
services of functioning microbiology laboratories, and also staff competent in epidemiology. For the
identification of transmission pathways, the microbiology of food and water as well as the
bionomics of vectors will have to be monitored. Although much expertise does exist in the State, in
microbiology, epidemiology and medical entomology, these remain scattered and not integrated.
The State Public Health Institute is the ideal repository of all these technical expertise, but the
Institute is very inadequately equipped, funded and staffed.
The Karnataka Health Systems Development Project (KHSDP) has attempted to establish a disease
surveillance system, which has not been implemented. Its design is relatively complex and not userfriendly, with several reporting formats. A committee has been formed to develop this further and a
Memorandum of Understanding has been signed between the Directorate of Health and BPL
Innovision for the necessary software development. The National Institute of Communicable
Diseases has begun to encourage and fund a disease surveillance system in selected districts in
India; its design is also inadequate. In the latter, there is no provision to include the private sector
health care institutions in disease reporting. Thus, 60% or more diseases will be missed in this
system. There is also no provision for the rapid transmission of information from the periphery to
the central point. Both the Bajaj Committee report on Public Health (Planning Commission) and the
Ramalingaswamy report on the plague outbreak in Surat and Beed, commend the North Arcot
District Health Information (NATHI) model of disease reporting and surveillance as a potential
national model. Both the concept of district as the surveillance unit, and the postcard system linking
private and Government sector health care institutions, which are the cardinal qualities of this
system, have been described as appropriate for India. The NATHI model is currently being
replicated in the neighboring State of Kerala.
Remedial measures
1. The mission
The ultimate purposes of disease surveillance are: 1). to prevent preventable diseases
and to prove that diseases were actually prevented by intervention and 2). to recognise
every outbreak at the earliest possible stage and to take effective measures to control its
further spread and to prove that the intervention actually succeeded.
2. The Principles
Surveillance consists of three components, namely the recognition of the occurrence of
diseases under surveillance; the reporting of such cases; and the response to the reports.
The response includes epidemiological investigations, establishment of aetiology and
transmission pathways, preventive and control interventions, evaluation and
feedback.
3. The Starting Steps
Each District will function as the unit for disease surveillance. The District Health
Officer shall prepare a complete list of all non-government health care institutions in the
District. An institution with admission facilities (even with one bed) will be defined as
hospital. Other health care stations will be called clinics. The DHO shall send a first
circular letter informing and inviting all hospitals to join the surveillance network.
Hospital management will be requested to identify one liaison person and a back up
person to work with the system. Training workshops should be designed and conducted
in each town within the District, so that all personnel, governmental and nongovernmental, become aware of and familiar with, the entire system. The liaison and
back up persons from each hospital will be invited to the workshops. Thereafter the
reporting forms will be distributed and a date set to start reporting.
4. Time Line
It is recommended that this system be established in two districts to begin with (starting
by first quarter, 2001) and then expand to the remaining 25 Districts in a phased manner,
to be fully operational in the State by the end of 2002. Chikamagalur and Dharwad
Districts are recommended to commence the disease surveillance system. Preparations
by DHO: Jan. 2001. Circular letters: February first week. Training workshops:
February, March. Reporting starts: April 1, 2001. Computer training at District
headquarters April. May 2001: Begin the process in 5 selected Districts. By August 1,
2001, reporting should begin in them. Computer training, in September. September
2001: Begin the process in the remaining 20 Districts. By December 1, 2001, reporting
starts in them. Computer training in November- December. The Bulletin starts in June or
July, 2001, with the disease summaries of 2 Districts. In September or October, 2001 the
Bulletin will contain disease summaries of 7 Districts. By January 2002, the Bulletin
will cover statewide disease summaries.
5. Recognition of diseases
Sick people report to health care stations for help. They may be in the government sector
or non-government sector. To begin with, we will concentrate on hospitals as diagnostic
points for reporting. The health care worker, usually a physician, would make a working
diagnosis and either seeks laboratory evidence, or, more commonly, begin treatment
based on the presumed diagnosis. As the disease surveillance system is to be
superimposed on the present condition of the health system, we have to accept the
clinical diagnosis without laboratory confirmation, as a starting point of disease
recognition. However, each disease must be reported the same day as presumptively
diagnosed, as speed and sensitivity are more important than specificity in surveillance.
6. List of diseases for reporting.
All diseases cannot be and need not be under surveillance. Practicality demands the
minimum number and public health requirement demands the maximum number. A
balance must be struck, as shown below. The criteria for inclusion of a disease in the
surveillance list are: those against which already preventive intervention is being
applied; disease is outbreak-prone and outbreak control tools/measures are available. If
specific intervention tools are not available for a given disease, then it is not desirable to
include that disease in surveillance.
The suggested list of diseases for commencing disease surveillance include:
• Acute flaccid paralysis
• Malaria, falciparum / vivax
• Acute dysentery, Amoebic / Bacillary,
• Measles
• Cholera or cholera-like disease
• Meningitis, Pyogenic / Aseptic
• Diphtheria
• Rabies
• Encephalitis
• Tetanus
• Fever with bleeding tendency
• Typhoid fever
• Hepatitis, Acute viral
• Whooping cough
• Any other, to be specified
Reporting of diseases
All clinicians, in government and non-government sectors, must report these diseases as soon as
they suspect them, to make the system meaningful. The health care workers must understand that
their responsibility to the client is diagnosis and treatment, but their responsibility to the society
includes the duty to report diseases of public health importance. The reporting form and method
must be user-friendly and not cumbersome or time-consuming. Ideally disease reporting should be
by telefax or internet. However, a simple, self-addressed, post-paid, card would suffice, or may be
even better, since it is easily filled up in the examination room and mailed conveniently. It can and
must be so formatted that the information can be directly fed into a computer. If the list of diseases
is examined closely, it will be obvious that most, if not all, patients with any of them would attend a
hospital or a clinic of modern medicine, government or non-government. Therefore, for practical
purposes it would suffice if all hospitals and clinics of modern medicine reported cases of these
diseases as and when they see them. To be meaningful, therefore, the disease reporting should be
such that both government and private institutions must participate.
Response to reporting
The success of surveillance will depend entirely upon the response of the health system. In order to
be practical, timely and efficient for mounting the necessary response, the surveillance system
should be operative in a unit, which is sufficiently small but adequate. The District is the ideal unit
for this purpose. The District Health Office is situated in a town with communication facilities. The
reporting post card would reach the DHO’s office within a day or two of posting. A computer can
and must be installed at the DHO’s office for entering the data of reports on a daily basis. The
computerized data should be scanned on a daily basis to cull out duplicate reports and also to note
any unusual clustering of cases in time or space. If any clustering is noted, then it is an early signal
of an outbreak, now being picked up by the DHO’s staff, much earlier than any one else, either in
health profession or the media. Indeed, this capability will enable the DHO to initiate investigations,
through the local health staff, very early in the course of the potential outbreak. In other words, the
first response is to computerize, collate and interpret data. The second response is to investigate
suspected outbreaks. The third response is to control the outbreak by appropriate interventions. The
modus operandi of outbreak investigation and control interventions will be discussed later. The
fourth response is to give a feedback to all reporting stations. The suggested method of feedback is
through a monthly bulletin, published by the Health Department. One bulletin should suffice to
cover all Districts of the State participating in the disease surveillance system. It should be the
medium to give feedback, which should include the summary of reported diseases, the actions
taken, the outbreaks investigated, the results and the interventions and their effects. The bulletin
should also to provide any messages the Department wishes to address to all medical professionals
in the Districts, clippings of current medical news of relevance, and at least one continuing medical
education article per month.
•
Motivation of reporting physicians.
The interest of the reporting health care professionals can be stimulated and maintained by
visibility of the four responses listed above. This will give the reporting clinicians the sense
of satisfaction that their reports mean something to society, and not merely add to statistics
that are not useful to society. This feeling alone will sustain the sense of ownership by the
reporting institutions.
•
Integration of different lines of data
When surveillance data flow into the Health Officer's office, the information will be
computerized. At the same time the DHO will be receiving, at different paces, information
on communicable diseases from the PHC system. In addition, there will be data on TB,
malaria, leprosy and some others too. The Health Department officials must grapple with
the process of integrating all information for the purposes of 1. Outbreak recognition; 2. TB
control; 3. Statistics.
•
The staff, infrastructure and costs
The reporting post cards must be printed separately for each district, in sufficient quantities,
after obtaining the postal department clearance and the post paid system permit number.
The District level disease surveillance system is designed to be implemented by the present
staff contingent in the District, if necessary by redeploying them suitably, rather than by
adding to them. One deputy DHO must be designated to be in charge, answerable to the
DHO. There should be a computer and a person should receive and enter all cards on a daily
basis and scan them as mentioned earlier. At least two persons should be trained to do this,
so that work will continue even when one is on leave. And of course the supervisory staff
and the Deputy DHOs and the DHO himself/herself should be well versed with the whole
operation. The WHO EPIINFO software should be installed in the computer. The costs
have to be worked out. In the original model in North Arcot District, the cost including
Bulletin was about Rs 100,000 per year. It would seem to be adequate even today in each
District, if the Bulletin costs are borne centrally. The entire system should be supported,
directed and supervised by a State level Officer (?Jt Director) under Additional Director
(Communicable Diseases). A network of laboratories must be available, with one central
reference and special pathogens lab, a lab in each District (combining diagnostic and
epidemiological service) and labs at Taluka and CHC levels, feeding information into the
system. The State level expertise must also include competent epidemiological skills and
tools. Repeated CME for the District leaderships must be organized at the State level. The
Karnataka State monthly disease surveillance bulletin will be published by the JD, in
collaboration with the State public health laboratory.
Investigations following Reports
There are some basic principles to be understood about specific diseases. One case of polio is the
outcome of some 200 children infected sub clinically with poliovirus; thus one case is already an
outbreak. Similarly, one case of Japanese encephalitis represents about 500 sub clinically infected
children and thus an outbreak. Since cholera is the result of consuming a large amount of cholera
vibrios, it is an indication of the presence of the pathogen in a territory at a particular time. Thus,
the first case of these illnesses should elicit the response of immediate investigations. Haemorrhagic
fever may be caused by variety of pathogens and every case needs an etiological diagnosis, hence
investigation. In the case of vaccine preventable disease, herd effect is operative and even a single
case might be the indicator of insufficient immunisation coverage. If the child had not been
vaccinated against that disease, the point is proven. On the other hand, a case may be due to
vaccine failure, as shown by a fully vaccinated child developing the disease. This is reason for
immediately searching for other similar cases, and if found, may be an indicator of inadequate
vaccine potency. Here the vaccine lot has to be investigated. In the case of locally endemic diseases
(dysentery, viral hepatitis, malaria, meningitis, typhoid fever) one case does not mean anything
special. But, if a second case occurs within the incubation period of the disease, within the same
locality, then it is an indicator of an outbreak already in the initial phase. Thus, clustering of two or
more cases must elicit the response of investigation. Sometimes, the outbreak may break out so
rapidly that a fairly large cluster of cases might be reported more or less simultaneously. Immediate
investigations are called for. The purpose of investigation is to understand the exact mode of
transmission, so that it can be cut immediately. It is not enough to say water-borne, vector-borne,
food-borne etc., but, “Which source or supply of water? Which species of vector? Which food, from
where?” These specificities must be identified before intervention can be applied. It may be that a
particular ice cream or the ice used for frozen fish, or a part of piped water supply, or a well near a
sewage pipe, or eggs from a poultry farm, or an unusual mosquito species, or an insecticide resistant
vector, or water from a surface pond or whatever else, could act as the transmission pathway.
Unless it is specified and cut, the intervention may not change the course of the outbreak.
The health system also has to prove that the epidemic curve deviated downward from the normal
curve, coinciding with the intervention. Therefore, qualitative and quantitative information must be
gathered by investigation. Standard methods of outbreak investigation are available from textbooks
of epidemiology and public health and from the WHO. Strict adherence to ‘case definition’ is
necessary to ensure that we are not mixing up different diseases making an artificial outbreak.
Aetiological diagnosis would be needed in many instances, for which microbiological expertise
must be available nearby. Sometimes, epidemiological investigations may by themselves identify
the exact vehicle or mode of transmission without necessarily identifying the pathogen
microbiologically.
•
Microbiologic skills and expertise.
Some diseases such as polio, JE, cholera, malaria, typhoid fever, dysentery, meningitis,
measles etc. must be confirmed aetiologically, since many other diseases can mimic them. If
other diseases are also counted as cases, then the epidemic curve, the epidemiological
linkages etc. will be distorted. Modern medicine cannot be practiced conscientiously without
microbiological support service, at various levels. Thus, both for disease surveillance,
prevention and control, and for quality in health care, appropriate and adequate
microbiology must be available at various levels. In Karnataka, each District must have a
microbiology laboratory, serving both clinical diagnostic functions and also epidemiological
functions. This laboratory must be supervised by an MD in Microbiology. Human power
development in the State must take into account this need. They should be supported and
backed up by one state level public health laboratory which will also function as reference
lab, training center, external quality assessment station, and center for reagent and protocol
preparation, procurement and standardization.
Expanding disease surveillance to ‘public health surveillance’
Since the ultimate goal is to prevent and control infectious diseases, we must address the broad
channels of pathogen transmission under a comprehensive disease prevention programme. This
requires other parameters to be under vigilant watch. These elements can be clubbed together into 7
items of surveillance. They are:
1. Disease Surveillance.
2. Capturing data on computers in the Health Department, in each district, on death (as reported to
revenue/municipal agencies,) by age and perceived cause. This should be plotted for time trend.
3. Water quality assessment, regular periodic, by microbiology and chlorine content.
4. Vector bionomics, species, breeding, adult density, infection rate, insecticide sensitivity.
5. Food related infections or outbreaks.
6. Veterinary disease pattern, prevalence and rodent species and densities.
7. Antimicrobial sensitivity/resistance patterns.
The continuous generation of the above data, by District, will enable the DHO and his/her team to
take effective measures to monitor disease trends and to design and apply methods of
prevention/control of the spread of infectious diseases. Once theses are in place, then the system can
address issues like TB control, elimination of Salmonella typhi, prevention of vector breeding to
prevent all vector borne infections and other public health measures.
Conclusion and summation
Currently, much energy and efforts are already being deployed under the name of statistics
collection, time trend analysis or disease summary reporting. All these are essentially envisaged as
tools in management. What we need is a system in which information is used not merely for
statistics or for administrative planning and budgeting, but for disease prevention and control of
outbreaks. For these purposes, a dynamic, effective and efficient, participatory and result oriented
disease surveillance system must be established. The data generated by it will suffice for statistics
and management of administration. In short, we must re-establish the principles and practice of
public health in disease control, as designed by ourselves, appropriate for our conditions, and
supportive of the existing infrastructure and institutional networks. The district level disease
surveillance seems to fit this need. The proof of the surveillance system can be had only after
tasting its results.
Recommendations
•
An epidemiological disease surveillance system to be initiated in two districts in 2001 and then
progressively expanded to cover the entire state over a period of two years. The purpose of the
system is for public health action.
•
The State Public Health Institute (PHI) will be adequately staffed and equipped with the State
and District public health laboratories reporting to it.
•
Recording, reporting and communication systems will need to function with accuracy and speed
and lead to decision-making and response at the district level. This will require epidemiological
skills at district and state level. A monthly bulletin will communicate information and analysis
from the system.
•
Training of staff to be planned and undertaken.
•
The private and voluntary sector to be included in the coverage by the surveillance system.
•
List of diseases and conditions included in the surveillance system to be reviewed and modified
at intervals.
DISEASE SURVEILLANCE - ORGANISATIONAL CHART
State Disease Surveillance Office
(Under Epidemiology Wing of Public
Health Institute)
District
Surveillance Office
Government
Sector
District
Hospital
Government
Sector
*
/*
/ *
Taluka
Hospital
City Corporation
Surveillance Office
*
Private
Sector
*
Within
District
All Private
Hospitals
Within
City
Within
City
All
Hospitals
Urban Health
Centres
/*
CHC
/ *
PHC
Sub
Centre
*
Reporting by post card
Reporting / communication by means other than post cards
Note: All medical college hospitals to report by post cards to district
or city surveillance office
STATE AND DISTRICT LEVEL ADMINISTRATIVE & TECHNICAL OFFICERS FOR DISEASE SURVEILLANCE, AND
LABORATORY SERVICES
DGHS
Director
Public Health
Director
Medical
STATE LEVEL
Addl. Director (CMD)
State Surveillance Officer
Joint Director
Laboratory Services
Deputy Director
Disease Surveillance &
Publication of Bulletin
District Health
Officer
District Medical
Officer
District Surveillance
Officer
District Laboratory
• Microbiologist
• Pathologist
• Bio-Chemist
Entomologist
Statistical Officer
DISTRICT LEVEL
5.6. NON-COMMUNICABLE DISEASES
An early definition of non-communicable chronic diseases was that they included an impairment of
bodily structure and /or function that required modifications in the patient’s normal life and which
persisted over an extended period of time. They often cause residual disability and require a long
period of supervision, observation and care.
Most of these diseases cannot be cured but have to be relieved and managed lifelong. There are no
reliable data available at present, regarding the prevalence of these diseases in the community in
Karnataka. There is inadequate planning either to prevent or manage these diseases. The basis of
our strategy should be to develop preventive strategies regarding the risk factors and to treat patients
at or near their homes with proper referral systems for complicated cases.
5.6.1 DIABETES MELLITUS
Situation analysis: Burden of the Disease
There are only few surveys in Karnataka indicating the burden of the disease. The crude prevalence
rate of Diabetes Mellitus Type II in Bangalore City is 13.2% between the ages of 20 to 80 years.
(part of national diabetes survey). The Karnataka Rural Diabetic Survey conducted by Diabetic
Club, Bangalore at B.R Hills, Sringeri, Hariharpura and Udupi, between the age groups 20-85 years
gave a crude prevalence rate of 7.77% and age adjusted rate of 6.42%. The prevalence in men and
women (7.83% & 7.71%) is almost the same.
Table 5.13: Prevalence of Diabetes Mellitus
Place
B.R. Hills
Sringeri
Hariharpura
Udupi
Crude prevalence for women
Crude prevalence for men
Age adjusted prevalence
N
1288
1380
479
500
Prevalence
2.95%
7.65%
14.6 %
11.8 %
7.83%
7.71%
6.42%
This survey is an ongoing survey and subjects will be followed up for 3 years duration.
Apart from the large number of diabetics requiring treatment, it must be remembered that diabetes
mellitus and high blood pressure are risk factors for coronary artery disease. Further, inadequate
and improper treatment may result in complications like renal failure, cardiac failure, gangrene of
the legs and retinopathy leading to blindness. The state or individuals/ families have been spending
large amount of money for managing these complications, and hence primary and secondary
prevention assumes great importance.
-1-
Prevention and care strategies: A population strategy aims to prevent the emergence of risk
factors. Health education should particularly promote maintenance of normal body weight, through
healthy nutritional habits and physical exercise. In the high-risk strategy, persons at risk would be
advised to avoid alcohol that indirectly increases the risk further; avoid diabetogenic drugs like oral
contraceptives; and reduce factors promoting atherosclerosis, like smoking. Secondary prevention
measures recommended include good management of diabetes with patient education and self care.
Recommendations
•
Epidemiological surveys may be undertaken in rural, and urban areas to understand the
"burden" of diabetes mellitus and for proper planning for control and prevention of diabetes
mellitus. The survey may be confined to the 20-90 year age group, using fasting blood sugar
levels above 126mg/dl as the criterion. Surveys of hypertension, coronary artery disease and
stroke may be undertaken along with diabetic surveys.
•
Laboratory facilities: It is essential to provide minimum facilities to diagnose diabetes mellitus
even at PHC level. This includes a colorimeter, glucostrips or Benedict's solution. The
colorimeter is not costly, and the expenditure for glucose estimation is not more than Rs.2/-.
The instrument may also be used for estimating blood urea and creatinine.
•
Constant supply of essential drugs like insulin and oral hypoglycemic compounds are
necessary. The conventional insulin may be used instead of costly ones like purified / human
insulin except in certain special circumstances.
•
Continuing Medical Education (CME) and other training programmes: Diabetes being a
common disease, it is necessary that doctors / nurses and technicians are exposed to CME
programmes regarding the early detection, treatment and preventive measures. The course may
be of 3-5 days duration.
•
Referral System: It is practical that most patients are treated at PHC level. Occasionally
patients need to be transferred to the CHC / Taluka hospital for specialist opinion and
treatment. The cases with emergencies like diabetic coma and gangrene should be transferred
to higher levels of care. Other cases with chronic complications may be referred or specialist's
visits may be organised at PHC's on regular basis. Some guidelines may be formed for referral
/ treatment (See Appendix).
•
Health Education: Health education regarding early symptoms, complications, foot care, diet,
exercise and prevention of diseases and their complications is required. There is a need for
orientation courses for health workers / IEC staff regarding various aspects of diabetes mellitus
with special emphasis on the above.
•
In view of the burden of the disease, it is necessary to develop district diabetic control
programme. To start with, one Medical Officer for all non communicable diseases at the district
may be designated to supervise detection, drug supply and health education programmes.
-2-
Appendix
DIABETIC CARE
Treatment by Diet,
Exercise, Oral
Hypoglycaemic drugs
& Insulins
PRIMARY CARE
PHYSICIAN
Detection of DM facilities for Urine
examination
/Blood glucose
(PHC'S & PRIVATE CLINIC)
HEALTH
EDUCATION
TRAINING – by
CME, Workshops
Specialists
visits
Emergencies &
Complications
CHC / Taluka Hospital
TERTIARY
CARE
for
complications:
Dialysis,
transplant & Retinal Treatment
5.6.2 CARDIOVASCULAR DISEASES (CVD)
Among all the non-communicable diseases, cardiovascular diseases taken together are the leading
cause of morbidity and mortality. India and Karnataka are currently in the rising phase of an
epidemic of cardiovascular diseases, propelled by a shift in the population distribution of risk
factors. It would be prudent for the state to initiate measures to prevent cardiovascular diseases.
The cost of diagnostics and therapeutics is high, with treatment being required on a long-term basis.
This is unaffordable for most people. It would therefore be appropriate to spend resources on
primordial and primary prevention, namely, avoiding or reducing and modifying risk factors
associated with CVD. Attention should also be given to Rheumatic Heart Disease that is still
widely prevalent in the country/state.
5.6.2.1 Coronary Artery Disease (CAD)
Situation analysis: Coronary heart disease is becoming a major health problem in India, reaching
almost an epidemic proportion. However, there is no national programme on prevention in the
offing. As per the current estimates at least 50 million patients are suffering from CAD. A
population survey gave a prevalence rate of 10.9% in urban and 5.5% in rural males between the
-3-
age group of 35-64 years. The corresponding figures for females are 10.2% and 6.4% for urban and
rural respectively (Reddy K.S. Cardio-vascular diseases in India-World Health Statistics 1993).
Reliable measurements of prevalence may be difficult. There could be coronary artery disease
without symptoms and ECG changes; ECG changes may be false positive for coronary artery
disease. The hospital-based statistics especially from tertiary care hospitals may not represent the
true picture.
It is realistic to survey coronary artery disease risk factors and design prevention measures. The
non-lipid risk factors include diabetes mellitus, high blood pressure, smoking, positive family
history, gender, body mass index, waist-hip ratio and life style. Lipid risk factors include total
cholesterol level, triglycerides level, low HDLC and high LDLC levels.
The management and treatment of coronary artery disease is costly and may end up with costly
investigations & management, like echocardiography, coronary angiography and coronary artery
bypass surgery. Prevention of coronary artery disease is the need of the day and there has been a
consistent decline in coronary artery disease in USA using preventive measures.
Recommendations
•
Epidemiological sample surveys regarding the prevalence of risk factors in Karnataka need to
be conducted especially for diabetes mellitus, high blood pressure, positive family history,
smoking etc., which will help developing prevention strategies. However preventive measures
may be initiated now itself based on available data.
•
Case detection and emergency management of ischaemic heart disease, to be done at PHC /
general practitioner's level. The patient has to be transported to CHC / Taluka Level Hospital
for confirmation of diagnosis and further management.
•
Essential drugs like Nitroglycerine Tab, Pethidine, Morphine, parenteral diuretics, oxygen etc
must always be available. Well-equipped ambulance services to shift the patient to referral
centres should be available.
•
Preventive measures: To achieve the goal of preventing coronary artery disease it is important
to avoid major risk factors which is the basis of "success stories", in USA and other western
countries.
(a)
Controlling intake of salt, saturated fats and calories. Smoking is one of the most
important risk factors. Smoking is seen in 75% of those with coronary artery disease
and 80% of smokers have CHD. Community surveys conducted with urban and rural
populations suggest that 50-55% of adult males smoke. Smoking control measures
include increase in government taxes on cigarettes & beedies, ban on smoking in work
and public places, ban on advertising and sponsorship of sports and games and cultural
events by tobacco companies, limitation of tobacco crop subsidies and support for crop
conversion to other crops and community education programme. (See section 5.10 for
details).
-4-
(b)
Increasing leisure time physical activity & practice of yoga and regular exercise.
(c)
Increasing consumption of "heart healthy" food such as fruits, vegetables, high fibre
cereals, oils containing poly & mono-unsaturated fats, (eg. mustard-rapeseed oils, soya
bean oil and avoiding hydrogenated oils)
• Proper control of diabetes, high blood pressure and lipid levels:
Use of lipid lowering agents are proved to be beneficial. However, the need for life long treatment,
with high cost of drugs makes it difficult for government or the patients to afford them.
Health education/ health promotion programmes have to be strengthened with special training for
health staff on DM, HBP and CAD. Co-ordination with NGOs and private sectors is essential.
5.6.2.2 Hypertension
Situation analysis: Hypertension is a major contributor to cardio-vascular morbidity and mortality
in India. There is paucity of large, authentic epidemiological studies in India, involving the age
group of 18-80 years from different parts of the country. The prevalence rate varies from 1.24 to
11.59% in urban and 0.52 to 7% in rural areas. These studies have lot of shortcomings, in terms of
differing examination techniques and diagnostic criteria employed. The study conducted by
Diabetic Association of Karnataka in rural areas, involving the age group of 20-85 years, gives a
crude prevalence rate of 16.35% and 18.12% for women and men respectively.
The cardio-vascular & cerebro-vascular complications in untreated hypertension are significant and
management of these complications is costly. Hence there is need for proper guidelines and
policies regarding the detection and management of the disease. Health education regarding
prevention of disease and its complications is an essential part of health management.
Recommendations
•
There is need for multiple sample surveys to be conducted, to have some idea of the "burden" of
the disease, for proper planning of our strategy for management of hypertension. There is need
to take support of NGO's and specialist organisations. Estimation and recording of blood
pressure must be a part of routine examination by the doctor.
•
There is need for uniform method of taking blood pressure, criteria for diagnosis, evaluation of
the patient and guidelines for management. A protocol for diagnosis and management may be
suggested for all doctors working at various levels. (Tables I –IV). As majority of
hypertensives are mild, they should come under the purview of primary health care either in
urban or rural areas.
•
Facilities: There is a need for well maintained standard mercury sphygmomanometers and with
standard cuff in all centres. There is no need to buy any other type of sphygmomanometers.
Routine investigations of urine and blood should be done in all PHC's. For investigations like
ECG and chest X-ray the patients may be referred.
-5-
•
Constant supply of anti-hypertensive drugs must be maintained. Less expensive drugs with
minimum frequency of dosage are preferred which increases the patient's compliance (Table 4).
•
Health education programmes are very essential for both primary and secondary prevention.
Special stress on control of smoking, restriction of salt, saturated fat intake and reduction of
weight has to be laid.
•
There is need for conducting frequent continuing medical education programmes for doctors
and health education workers.
Table 5.14: Classification and criteria for hypertension
CATEGORY
SYSTOLIC (mm Hg)
DIASTOLIC (mm Hg)
Normal
<130
<85
High normal
130-139
85-89
Hypertension:
Stage 1
140-159
90-99
Stage 2
160-179
100-109
Stage 3
> 180
> 110
(Based on: 2-3 blood pressure readings taken at least on two visits after initial screening.)
Table 5.15: Measurement of Blood Pressure
1.
Instrument
2.
Aneuroid
Sphygmomanometer
Measurement:
3.
4.
5.
To refrain from smoking /
drinking coffee 30 min before
measurement.
Position:
Standard mercury Sphygmomanometer
cuff: Bladder – 12 cm x 35 cm
Bladder should cover 2/3rd of length of the arm.
Accuracy to be checked against standard mercury
sphygmomanometer.
First appearance of the sound – systolic BP
(Korotkoff)
Disappearance of sound – Diastolic
Supine or Sitting
To keep the arm at the level of the heart.
Measure the B.P in both arms
and take the higher reading.
-6-
Table 5.16: Management – Protocol
Hypertension
Stage I & II
Stage III
Life style changes
Repeated BP examination
for 3 months
Normal
No change
Continue Nondrug Therapy
Drugs
DRUGS
Life style changes
1. Life style changes include stoppage of smoking, alcohol intake, reduction of obesity,
Low salt and fat diet, exercise and relaxation.
2. If there is target organ involved, drug therapy instituted.
3. Refer: when there is secondary hypertention, resistant cases and emergencies after
initial treatment.
Table 5.17: Drugs
First line:
Thiazide diuretics
Beta-blockers
Calcium Channel blockers
Alpha blockers
ACE – inhibitors
to be available at the Primary Health Centre.
may be considered in referral centres.
Other Drugs
Alphadopa
Hydralazine
Clonidine
Reserpine
-7-
5.6.2.3 Rheumatic fever / heart diseases
Prevalence: A reasonable estimate regarding the prevalence may be made by survey of Rheumatic
Fever (R.F.) and Rheumatic Heart Disease (R.H.D.) of hospital admissions and survey of school
children. The All India Collaborative study of school children of 5-16 years of age in 1970 suggests
a prevalence rate of 0.56%. A pilot study from Vellore showed a prevalence rate of 5.4 / 1000 and
6.0/1000 in rural and urban pupils respectively.
The antecedent Streptococcal pharyngitis causes rheumatic fever that may lead to rheumatic heart
disease. Once the heart disease is established, patient has to be treated surgically or by other
interventions and financial burden increases. Bacterial endocarditis may complicate the RHD with
dental and other surgical procedures.
Repeated attacks of R.F. may lead to R.H.D. Primary prevention includes use of penicillin to
prevent streptococcal infection and Benzathine Penicillin 12 lakhs once in 3 weeks is advised.
Antibiotics prior to and after surgical or dental procedure are to be used as bacterial endocarditis
propylaxis.
Recommendations
•
Rheumatic fever may be detected at PHC level and may be treated.
•
Benzathine Pencillin should be supplied to PHC's for Rheumatic fever prophylaxis programme.
(The duration of prophylaxis is controversial, but it is advisable to give penicillin upto 25yrs of
age).
•
Patients with R..H.D.s are referred to specialist / tertiary care hospitals for special
investigations, surgery and other interventions.
5.6.2.4 Thrombo angitis obliterans (Berger's disease)
The disease is characterised by occlusive disease of the small and medium size arteries occurring in
males in the age group of 20-40 years. Lower limb is usually involved. The symptoms and signs of
occlusive disease will be present and gangrene of legs/toes are common. The exact cause of the
disease is not known, but use of tobacco seems to an important cause.
Treatment entails giving up of smoking, which prevents the disease. Use of vasodilators and
lumbar sympathectomy may give temporary relief of symptoms. Gangrene of toes and legs needs
amputation.
Recommendations
•
Discourage use of tobacco as a definite measure to prevent jthe disease.
-8-
5.6.3 CHRONIC BRONCHITIS AND ASTHMA
Diseases of the respiratory system form one of the common causes for OPD treatment and inpatient
admission. Chronic bronchitis and bronchial asthma form major contributors for morbidity.
Reliable data regarding the prevalence are not available.
Bronchial Asthma:
India alone has 20 million asthmatics; this is increasing every year. A survey conducted in
Bangalore (1991) between ages of 15-65 years gives a prevalence rate of 2.99% (Omprakash and
S.Rao) In majority of people, the disease starts at a young age. There are a number of precipitating
factors that are responsible for the attack of asthma.
(a)
(b)
(c)
(d)
(e)
(f)
Inhalation of cold air – seasonal
Respiratory tract infections
Allergens: House dust, Pollens, Moulds etc.
Environmental pollution: Cigarette smoke, fumes of petrol, vapours and strong scents &
perfumes.
Exercise
Drugs – NSAIDS especially Aspirin
Situation:
An acute attack of asthma is being treated mostly on an outpatient basis with administration of
parenteral bronchodilators / steroids in most of the clinics with occasional admissions. The use of
Ephedrine is very much reduced and metered dose inhalers (MDI) are not popular yet, especially in
the rural areas. Nebulisers to treat the acute attack are not available in most of the rural centres.
The patients are maintained on bronchodilator tablets. Preventive measures like avoiding allergens
like pollen, chemicals, dust and food allergy and drugs are often discussed on individual levels.
Recommendations
•
Every health centre / practitioner must have the drugs and facilities always available to treat
asthmatics. Drug supply should include injections of Deriphylline, Aminophylline, Adrenaline,
Steroids and tablets of Salbutomol, terbutaline.
It is desirable to supply pressurised aerosol nebuliser in every health centre, so that an acute
attack may be relieved, even at subcentre levels.
•
Preventive measures and health education may be addressed individually. Lowering
environmental / industrial pollution should be taken up as a part of wider health issues.
-9-
Chronic bronchitis:
Chronic bronchitis is the commonest lung disorder after tuberculosis and equally prevalent in rural
and urban areas. The various factors causing this condition are:
•
•
•
•
•
Smoking: It is the most common single factor leading to chronic bronchitis. Hooka and
beedi smoking is as harmful as cigarette smoking.
Occupational exposures: to organic and inorganic dusts or noxious gases.
Air pollution: Industrial effluents, smoke from wood fires
Infections: Recurrent viral infections
Rarely, genetic and familial conditions
The condition is usually recognised even at the peripheral centres and clinics. Chest X-ray is
occasionally prescribed to rule out associated pulmonary tuberculosis.
Recommendations
•
Every primary care doctor / medical centre must be able to handle cases of chronic bronchitis
and its acute exacerbations. There must be a constant supply of drugs like bronchodilatiors
(injections & tablets), Nebulising solutions / nebulisers, antibiotics and oxygen.
•
Preventive measures, health education regarding smoking and control of air pollution are
important from individual / community’s point of view.
- 10 -
1
5.6.4 CANCER
Situation Analysis
With the increase in life expectancy and increasing exposure to certain chemicals, cancer has
become a public health problem. Cancer is a major cause of death in India. Nearly 45,000 new
cases of cancer are detected in Karnataka every year. It is estimated that the prevalence is about 1.5
to 2 lakh cases.
The common cancers in women are cancer of the cervix and breast cancer. With increasing tobacco
use in the form of smoking and use of gutka, especially by men, oral, oesophageal and lung cancers
are more commonly encountered.
There is need for looking at the problem of cancer in Karnataka in a broader perspective
encompassing prevention, early detection, access to treatment and utilisation. Presentation of
cancers often occurs in advanced stages due to a combination of lack of awareness, poor economic
condition, fear of disease and inadequate diagnostic facilities.
Presently only one third of cancer patients receive treatment in specialised centres. There is need to
establish more cancer treatment centers with low cost, high quality care. Involvement of the nongovernmental agencies is very crucial.
Plan of Action
•
The Director, Kidwai Memorial Institute of Oncology has prepared comprehensive
recommendations for Karnataka State cancer control programme, which is quite selfexplanatory and practical and should be acted upon (Annexure – 1).
•
However, this booklet covers only government departments catering to oncological care. A
general view must be taken to encourage non-profit oncological institutions. Private-for-profit
institutions must also be taken into confidence as they also cater to sizable part of the
population.
•
Government should consider exemption from taxation on anti-cancer drugs and certain
sophisticated oncology equipments such as Telecobalt units.
•
The government of India under the cancer control programme gives some grants to establish
radiotherapy centers and cancer detection centers in government hospitals, medical college
hospitals and non-profit medical establishments. Karnataka has not fully utilized this share.
This must be utilized to the maximum extent, as it will help to have detection and treatment
centers in all district head quarters. District cancer control programmes should be
developed.
•
Oncology care should be comprehensive. Patients in their terminal stages need close nursing
attention and an empathic treatment. The concept of hospices must be encouraged in all
divisional centers with the help of voluntary organisations. The Government should help them
in granting the required land and also financially assist these centers.
2
•
As half of all new cancers diagnosed are tobacco related. The government should discourage
tobacco production, manufacture of tobacco products and sales, through education and
legislation. (see 5.10).
•
It is advisable to encourage the use of well-established non-allopathic methods such as
ayurveda, homeopathy, siddha, yoga and naturopathy, at least in the centers of excellence
established for oncology care. This can be done scientifically with a research approach and
documented. However, the exploitation of gullible people by quacks for these chronic
diseases must be disallowed.
•
With this multi faceted approach, and through imparting oncological concepts at primary &
secondary health care levels, along with establishing few zonal centers of excellence, one can
work towards satisfactory cancer control and care.
•
The cancer registry is doing good work and must be further developed.
•
The programme should have a strong component regarding prevention of exposure to risk
factors and to early detection.
Cancer control among women
Special attention is needed, as women tend to seek treatment late and come in advanced stages of
the disease. Health education, early detection and management of the more prevalent cancers such
as cancer cervix, breast and oral cancers by trained health personnel should be taken up as an
integrated programme. In addition, women can be taught to conduct self-examination of the breast.
1. Health education programmes regarding commonly occurring cancers, and their aetiological and
risk factors, such as tobacco and alcohol use; poor reproductive hygiene; techniques for
prevention and importance of early detection should be undertaken. Health promotion should
facilitate safe hygiene practice, safe sex practice and also encourage women to demand visual
inspection of the cervix from the trained health workers.
2. Screening and early detection programmes for cervical cancer as recommended by KMIO
should be effected by ensuring the following:
promote early detection and down-staging through appropriate screening methods.
target women 35-64 years of age groups.
maintain a cancer registry
referral and follow up services.
3. Women health personnel (both health workers and lady medical officers) should be responsible
for and trained to perform visual inspection of the cervix and triaging of its appearance into
normal, abnormal and suspicious of malignancy; and make appropriate referrals
They should be trained to sterilize the gloves and specula. They should be provided with a
torch, sufficient specula and gloves, and for those performing cytology with slides, a slide
box, a glass marking pencil and fixative solution.
The screening can be performed at the PHC, Primary Health Unit, and the village school
or at the homes of the women.
3
4. For further investigations samples required (Cervical smear / Fine Needle Aspiration Cytology)
can be drawn at the PHC and sent to district laboratories for investigations. Surgeries and
chemotherapy can be performed at FRUs. Only cases requiring radiation need referral to
specialized centers.
5. Prior to the launching of public health efforts to prevent and downstage cervical cancer, it is
critical to ensure the availability and accessibility of therapeutic services- early detection,
treatment, referral networks, and palliative care. It is no use empowering women, if diagnosis,
referral and treatment are not guaranteed.
6. Treatment of early stage cancer is not less expensive, or less technology intensive, than late
stage disease; however, it is more effective because of higher rates of survival and cure.
Bleeding and foul-smelling discharges which occur in late stages can be avoided.
7. Palliative care can ensure that unacceptable, unnecessary suffering can be avoided. Nearly 8090 per cent of pain can be managed using drugs, which cost less than aspirin. Early stage disease
can be successfully treated by either surgery or radiation therapy, but in the advanced stages,
only radiation therapy and palliation are useful.
8. Public-private partnerships in all these areas are essential. Eg. Specialists to augment services of
government doctors; radiation therapy totally free or at minimal costs by using the facilities of
private institutions at nighttime or during other lean periods / holidays.
Recommendations
•
Primary prevention
Health promotion programmes in schools and colleges to reduce use of tobacco.
Intensive anti-tobacco campaigns by doctors, nurses, paramedicals, teachers, social worker
and anganwadi workers and voluntary organsiations
Orientation programmes in the problems of tobacco use for all people's representatives and
other decision makers.
Legislation to reduce tobacco use
•
Secondary prevention
Have cancer detection camps with the help of voluntary organisations to create awareness
and detect cancers at early stage.
Have cancer detection units in hospitals
•
Tertiary prevention
Have multidisciplinary treatment facilities at Kidwai and other identified centers: surgical,
medical, radiation oncology and supportive systems
•
Palliative care for terminally ill cancer patients.
•
Have a District Cancer Control Programme, consisting of a field unit and a clinical team, with
staff trained at Kidwai Memorial Institute of Oncology and located at the District Hospital.
4
Appendix I
KARNATAKA STATE CANCER CONTROL PROGRAMME PROPOSED
COMPREHENSIVE INTEGRATED MODEL
I.
Preamble
The need for early detection of carcinoma cervix in India in order to decrease mortality is well
known. No significant progress has been made until now, probably due to lack of a suitable model
for India. Inspite of extensive work done in several parts of the country, conventional models have
failed to produce the desired results. Hence there is a need for innovative methods to suit our socioeconomic conditions.
The Conventional Models
1.
Opportunistic Screening: This type of screening is unlikely to succeed in the Indian
scenario as most of our rural population are illiterate and have no access to such screening
facilities.
2.
Organised Population Based Screening: WHO recommends this project for developing
countries – atleast once in a lifetime screening for women between 35 & 60 years and
covering atleast 80% of the population.
3.
Visual Inspection Method: This method was studied in KMIO in a ICMR – WHO project
using the existing health infrastructure. There were many problems encountered.
a.
b.
c.
II.
The existing health infrastructure is already over burdened with National and State
health projects. Hence the personnel were very reluctant to accept any more additional
programs. The cancer control projects need commitment in terms of time and
dedication.
To improve efficiency, NGO's were involved to educate the people and motivate them to
"demand service" from the existing health infrastructure. Unless the NGO's involved are
totally dedicated and committed, it would not be practical to apply the programme all
over Karnataka. NGO's are ready to involve themselves in a time bound programme
only.
Many women were very reluctant to undergo visual inspection. The compliance rate
was very low.
The Problems With Existing Models
I. Efficiency
COST
No. of tests (each taluk)
Cost per PAP smear at
Total cost for one taluk
Total cost for one district of 6 TQ
Detection rate @ 40/100,000
PAP TEST
40,000 women
Rs.20 (minimum cost)
Rs.8.0 lakhs
Rs.48 lakhs
16 patients / taluk
Effective cost per patient for single pap test only: Rs.50,000.
Other expenses: Staff salary + additional TA & DA, transport etc
Impression of ICMR studies: This method is unacceptable on cost effective basis.
5
11. Logistic Problems
(For the detection of 16 patients of carcinoma cervix in a year)
Total number of population to be examined in a taluk
@ 50% compliance rate for examination
Effective working days
No. of patients to be examined per day
No. of doctors needed on duty (@ 4 pts per hr.
40,000
20,000
220
91
3
Other requirements:
Nurses, survey team, education team, attenders, drivers,
Cyto-technicians
Transport?
Stay?
Organisation of camp site?
Salary burden of entire team?
Repeat visit team?
Putting together dedicated team of KMIO, PHC's and NGO's etc
III. Ethical problems
With organised screening programme less than 3% are expected to have dysplasias,
where immediate treatment may not be necessary, but they need to be followed very
scrupulously. For a population of 40,000 eligible female population, 1200 persons are
expected to have dysplasias. This burden increases every year. After 5 years this would
become an unmanageable load. This would lead to an ethical problem because we have
created a "fear" that some thing is not normal and cannot provide the adequate treatment
facility at the same time. We would have created a population with "worry", who
otherwise would be living happily.
Summary: All trials based on Existing Models have been unsuccessful in India!!.
It has lead to only intense and prolonged scientific discussion with almost no benefit to the
community.
6
III. PROPOSED COMPREHENSIVE-EDUCATION, EARLY DETECTION AND
TREATMENT-INTEGRATED MODEL FOR KCCP.
This model is comprehensive because it encompasses the concepts of education for cancer
awareness and prevention of disease; specified, regular, fixed timeplace cancer detection clinics for
early detection; and provision of cost-effective treatment as near to patient's home as possible.
It is integrated because it involves participation of existing Government health infrastructure,
Panchayathi Raj system, NGO's and KMIO.
It is in a way incorporation of practical features of various models, that are described earlier, to suit
our set up.
A.
The basis of concept
"The answer for all our national problems-the answer for all the problems of the world-comes from a single word. The
word is education."
-Lyndon B. Johnson.
"You can only cure retail, but you can prevent wholesale."
Main theme is "Population based systematic health education with early detection clinics". This is
significant paradigm shift from "ACTIVE INTERVENTION" TO "ACTIVE MOTIVATION and
SELF EMPOWERMENT". With this model primary thrust is motivation in order to make people
take measures to prevent cancers (and other diseases by "bystander effect") and come soon for
examination resulting in early detection. The message that will be conveyed to the person in the
remote village – "you are responsible for your health".
Power of Panchayati Raj System:
Karnataka Panchayati Raj Act of 1993 has a provision which says that gram panchayats may
also carry measures which are likely to promote health, safety, education or social and
economic well-being of its inhabitants.
Subsequent notification of July 1994, listed schemes for Zilla and Taluk panchayats with
transfer of funds to specific areas. Forty two schemes have been identified under the Zilla
Panchayats, one of which is cancer control.
July 1994 notification also brought PHC's under the control of Zilla Panchayats.
B.
Components:
I.
FIELD UNIT AT DISTRICT CENTRE + DISTRICT HOSPITAL (ZILLA PANCHAYAT LEVEL)
a.
Education Team: The team would be located at the district hospital and would be
minimum of two in number. But the operational level of the unit would be at the taluk
panchayat level, which is 6-8 in number, under each district. The team will visit each
taluk under the district, 2 days every month. Each taluk panchayat will have 40-50
Gram panchayats. From each gram panchayat 1 person per day, will attend the
educational session. The person would be a health worker / Anganwadi worker / school
teacher / Agricultural extension worker / NGO's / social worker / elected member as
decided by the particular gram panchayat. Those who attend the education camp would
be given simple pictorial pamphlets to be given to the village person. The next batch
will give the feed back about the action taken by the previous batches. This will set in
place an effective feed back system to assess the effect of cancer control programme.
7
The mode of education would be group type. The time of education can be coincided
with existing taluk level programs for the gram panchayat members. In addition bus
exhibition, one to one interviews, flip charts, pamphlets, encouragement of "word of
mouth", media (news paper, radio, TV etc.) would be employed.
One education team will have 1 person from KMIO to co-ordinate the whole operation
and 3 persons from Zilla panchayat.
b.
II.
Clinical Team
This team will be formed from the existing staff of district hospital, who would be given
training at KMIO if necessary. The other facilities to be organised from the existing
infrastructure of District Hospital are:
• Facilities for detailed clinical examination of oral cavity, breast and cervix and
Pap smear.
• Other investigations (based on symptoms).
• Treatment facility for diagnosed cases.
1. Radiotherapy at PCC's
2. Surgery by district hospital surgeons trained at KMIO.
3. Chemotherapy by trained staff.
4. Active Pain relief measures by trained staff.
5. Referral to KMIO if absolutely necessary.
• Dysplasia and leukoplakia clinic to keep the patients on follow-up.
• Computer network to co-ordinate the programme instantly.
EARLY CANCER DETECTION CLINIC (ECDC): The team made of district and taluk hospital
personnel will attend cancer detection camps at taluk level in order to "Reach the Unreached".
The duration of camp could be 1-2 days every month depending on the response at each taluk
under the district. The concept is – provision of clinical facility for the persons who re
motivated by the education, who otherwise do not know where to go or what to do. Once the
education process is initiated, it is obligatory to provide such a facility. No attempt
should be made to have organised screening procedure that has ethical implications and
opportunistic screening which is not cost effective.
The purpose of the ECDC team
a) Provide early detection facility for the village individual at a reasonable distance;
b) Act as reinforcements and catalysts to activities of PHC's and taluk hospitals. The
ECDC camp can be coincided with the visit of education team camp.
III.
RANDOM SURVEY TEAM: This is done at selected places in random fashion, covering the
Gram Panchayaths, villages and PHC's / Taluk hospitals, to monitor the effect of control
programme. Already existing Management Information Evaluation System (MES) of Govt. of
Karnataka can also collect the feedback information.
IV. ADVISORY COMMITTEE AND WORKING COMMITTEE: These committees will help in
providing finances, organisation of education and ECDC camps.
8
V.
GRAM PANCHAYATS: The individuals from the Gram panchayats who have been trained will
educate the other personnel of gram panchayats. They in turn will educate the village
individuals. The personnel who can undergo the educational training are:
a) health workers
b) anganwadi workers
c) school teachers
d) agricultural extension workers,
e) elected members
f)
NGO's decided by the gram panchayats.
VI. PHC's AND TALUK HOSPITALS: Taluk hospital will be a nodal point for education and ECDC
camps. Both PHC's and Taluk hospitals will provide the visual inspection and PAP smear
facility to the individuals who seek clinical examination. The PAP smears will be then sent to
the cytology lab at district hospital. ECDC's will act as reinforcements and catalysts to the
activities of PHC's and taluk hospitals.
VII. BASE UNIT AT KMIO: The Base Unit at KMIO will initiate, monitor, analyse and coordinate
the programme and train the personnel. Network of computers will facilitate the acquisition
of data.
VIII. DIRECTOR KMIO: The Director of KMIO will be in charge of the entire programme and
report the progress to the Government of Karnataka.
IX. HEALTH SECRETARY TO GOVT. OF KARNATAKA: Secretary, Health and Familk Welfare,
Government of Karnataka will help to co-ordinate Government Health infrastructure with
KCCP. He will also coordinate between the feedback information received from KMIO and
MES.
C.
METHODS:
Three-pronged strategy will be adopted.
1) Education to use proper food items and personal hygiene: Fresh vegetables and fruits
decrease the incidence of cancer very significantly. Effective slogans will be coined to
convey the message.
2) Anti-tobacco education programmme: Enough experience has accumulated by KMIO
regarding this. Existing Anti-Tobacco Cell at KMIO will be used to organise this. Anti
tobacco education in Kolar District spanning over 3 years, has shown significant decrease in
the use of tobacco.
3) WHO warning signals: Symptomatic persons, especially having Persistent and Progressive
Symptoms need to attend the PHC / Taluk hospital / field unit at district centre for
examination. Awareness encourages people to come in the beginning of symptoms resulting
in Early Detection.
D.
•
•
ADVANTAGES
Cost would be phenomenally minimal versus other methods.
Logistically easy to maintain a team in one permanent place.
9
•
•
•
•
•
•
•
•
E.
The field units of District centres can be established immediately with minimum personnel and
cost, at all the districts of Karnataka to cover the entire 5 million population.
Cumulative salary burden and overheads would be low.
Can be started simultaneously in strategically different places with very large population
coverage.
No ethical problems since people come on their own and are advised follow-up.
Can be easily duplicated in any other place and disease.
Will reduce the patient load at KMIO.
By "bystander effect" there will be influence on incidence of:
Cardiovascular disease due to anti-tobacco and diet education,
AIDS due to sexual hygiene education
Nutritional and infectious diseases due to diet education.
Once this model is established all over Karnataka, it will form a template for engraftment of any
other control programme to be implemented in Karnataka.
IMPLEMENTATION
The model is suitable to be implemented over entire Karnataka. But it is desirable to take this as a
pilot project at 3 or 4 places such as Mandya, Gulbarga, Kanakapura, Chikkamagalur. Since these
places have treatment centers and population based programs, it is easy to implement at these
centers. After 6 months to 1 year, it can be extended to entire Karnataka in a phased manner.
5.6.5 OTHER NON-COMMUNICABLE DISEASES
5.6.5.1 ENDEMIC FLUOROSIS
Endemic fluorosis is chronic fluoride intoxication caused mostly by ingestion of water containing
high concentration of fluorides. It is a well-defined clinical entity characterised by dental and
skeletal changes.
The safe level fluoride of potable water in India is between 0.5-0.8ppm; 1 ppm is the maximum
permissible limit. When fluoride content is high the fluoride gets deposited in the teeth and
skeleton.
Epidemiology
The disease is prevalent in 17 out of 25 states in India, 200 million people are afflicted and more
than 400 million are exposed to the risk of developing endemic fluorosis. In Karnataka, it is mostly
found in north Karnataka districts, Kolar and some parts of Tumkur district. In a house to house
survey conducted at Mundargi Taluka of Dharwar District (presently Gadag district) above the age
of one year the crude prevalence rate was as high as 75% for dental fluorosis and 45% for skeletal
fluorosis. (Maiya M., Hande H.S. et al JAPI 1977). The three villages surveyed are hyperendemic
and fluoride concentration of well water varied from 5.4-8.74 ppm.
The disease is common in hot and dry climate and higher prevalence is noted with higher
concentration of fluoride in water, longer duration of exposure in males and hard manual workers.
The hardness of water protects the population from the disease.
Dental fluorosis
Popularly known as "mottled enamel" is the earliest and easily distinguishable sign of fluorosis,
especially in children. It is taken as an index of endemicity. The teeth show chalky white deposit,
brownish discoloration, pitting of enamel with chipping of edges and teeth may fall prematurely.
Skeletal fluorosis
It may be asymptomatic or may present with vague symptoms like joint pains, pain in the neck and
back. It may be mistaken for rheumatoid arthritis. The well-established cases show postural
defects, limitation of movement of the spine and exostosis easily appreciated in the tibia and spine.
Recently, genu-valgum deformity and secondary hyperparathyroidism are described. Fluorosis of
spine may compress the spinal cord and various neurological deficits like, radiculopathy, paraplegia
or quadriplegia may disable the patient.
Radiological changes are diagnostic and seen in the vertebral column, pelvis and forearm as
osteosclerosis, osteophyte formation and calcification of ligaments
Management
There is no specific treatment; preventive aspect of endemic fluorosis is of paramount importance.
The effective measure is to provide the rural population with water not containing more than 1 ppm
of fluoride (preferably 0.5-0.8 ppm)
There is a fundamental requirement for surveying and mapping areas with a high content of fluoride
in water in the dug wells or bore wells throughout the state, so that appropriate preventive measures
may be undertaken. Many such surveys are conducted by Geological survey of India in various
parts of the country.
Surface water supply
Usually surface water contains less fluoride than ground water. The water may be supplied to the
village from rivers, dams or canals. This scheme was executed near Nagarjuna Sagar Dam in
Andhra Pradesh. In Mundargi the water from nearby Tungabhadra river is utilized (fluoride
concentration 1 ppm.)
Deep bore drinking water technology
By increasing the depth of the well, the fluoride content of water will be maintained at 1 ppm. The
technology of deeper tube well is the most practical, cost effective and acceptable to the people
(Teotia, Indian J. Med. Research 1987).
Defluoridation of drinking water, using various chemicals is not cost effective.
Calcium is the strongest antagonist of fluoride toxicity. The individual who is exposed to high
fluoride water should receive a minimum of one gram of calcium per day; this may be increased to
2 grams to lactating mother.
Recommendations.
•
Survey and map the dug wells and bore wells in suspected areas for the fluoride content.
•
Make available drinking water with less than 1 ppm of fluoride to the people living in areas
where the fluoride content is more than 1 ppm. Surface water (rivers, dams and canals) has less
content of fluoride.
Deep bore water also has less of fluoride content.
•
Individuals exposed to high fluoride content of drinking water may be given one gram of
calcium per day (2 grams to lactating mother).
5.6.5.2. HANDIGODU DISEASE
Handigodu Disease is a peculiar disease of the osteoarticular system, which is geographically
restricted to Shimoga and Chikkamagalur districts in Karnataka. Besides the geographic
localisation, the disease predominantly affects the Chanangi and Chalwadi sections of the Harijan
community.
The disease was first identified at Handigudu village in Sagar Taluk of Shimoga district in January
1975. 362 persons have been affected in Shimoga district (until 1997) and 349 persons in
Chikkamagalur district until Sept. 2000, since the first appearance of the disease.
Handigodu disease is a genetic disorder inherited mostly in an autosomal dominant pattern affecting
the skeletal system with basic defect of dysplasia of epiphyses at the spine, hips, knees and other
sites on the long bones. Affected heterozygotes are usually present in arthritic and dysplastic forms
and segregate in the same family. Besides the genetic aetiology, there is a strong nutritional,
metabolic, endocrine and bone histomorphometric evidence that, deficient dietary intakes and
associated secondary hyperparathyroidism had aggravated the disease. A study carried out
indicated a marked deficiency in the intake of dietary calcium in the population surveyed.
Clinically and radiologically the earliest onset is 5-10 years of age. At this stage the disease is
largely asymptomatic but on specific examination, difficulty in sitting cross-legged and squatting is
observed. Majority of the patients present in young age. The disease has a gradual onset and a
progressive course. In late stages secondary osteoarthritic changes in hips and knees lead to
incapacitation and patients develop flexion deformities of the hip and spine.
. The Sagar General Hospital has a 10-bedded ward for treating Handigudu Syndrome patients.
Rehabilitation measure has been undertaken in Shimoga district but the same is not available for
those affected in Chikkamagalur district.
Treatment and Prevention
Cases having mild to moderate disability are treated with analgesics, steroids and rest. Those with
severe disabilities need surgical correction. The quality of life after operative procedures is poor.
Physiotherapy should be provided to the affected individuals.
Genetic counseling regarding marriage, child bearing, risk estimates on the basis of pedigree
analysis should be provided. The affected should be advised about dietary supplementation with
calcium.
Recommendations
•
Early detection, physiotherapy and surgical correction facilities are to be provided to all the
affected people.
•
Genetic counseling regarding marriage, child bearing, risk estimates on the basis of pedigree
analysis should be provided
•
Vacancies in the Handigodu Disease Unit at Sagar Hospital to be filled up and made fully
functional along with the mobile unit. Disease surveillance system should be introduced.
•
Patients with Handigodu Disease should be provided with supplementary calcium in dietary
and tablet forms.
•
Socio Economic rehabilitation of the people disabled due to Handigodu Disease.
1
5.7 ORAL HEALTH
Oral health constitutes a major component of the health care system. However, with
inadequate recognition it still receives relatively low priority in health planning and financing,
in the country and state. This is mainly due to the following reasons:
•
•
Lack of awareness among the public and health policy makers about the high
prevalence, severity or consequences of oral diseases.
Oral diseases are not life threatening or severely debilitating initially. They are not
regarded as serious health problems by the government and community.
There is no State level survey of oral diseases but, based on scanty reports, the following
diseases are commonly seen:
• Periodontal disease: found in 90% of the population resulting in early loss of teeth.
• Dental caries: seen in 70% children upto 12 years.
• Oral cancers: prevalent in 18-20 per 1,00,000 population (dealt with separately).
• Fluorosis: seen mostly in north Karnataka districts, Kolar and Pavagada.
Facilities available and situation analysis
Oral health services are offered by the government, private and organised sectors, like industry
and military establishments.
Government Sector:- The Department of Health and Family Welfare has established Dental
Clinics in District and Taluka headquarters. Recently the Government has published new draft
rules, in which it proposes to redesignate the above posts as follows:
Existing designation
Assistant Dental Surgeon
Deputy Dental Surgeon
Dental Surgeon
Proposed designation
Dental Health Officer
Senior Dental Health Officer
Chief Dental Health Officer
The number of sanctioned posts for dental doctors is only 201, for service at various levels
from district hospitals to PHCs. Equipment for dental work is inadequate, for example, there
are dental clinics without dental chairs. Most equipments require repair and maintenance.
Services rendered are primarily dental extraction and minor oral surgical procedures. Even
where facilities for permanent restoration and prophylaxis are available these are not offered to
the public due to nonfunctioning of units and irregular supply of permanent restoration
materials. Preventive measures, including oral health education, are not given any importance
in government clinics.
There is no full time person at the Directorate of Health Services in charge of coordinating the
organisation and development of oral health care services and dental education.
The number of private dental practitioners is increasing with the large number of graduate turn
over from 41 colleges in the state. The figure of dentist: population ratio of 1:44056 of 1980's
has been changing fast, though we do not have the exact figures for 1990's.
2
More than 80% of dentists serve 30% of the population based in the urban areas. The people in
the rural areas have no access to oral health care. The "out of pocket" spending especially from
middle class / poor is a matter of concern as dental treatment in private sector is expensive.
1.
The organised sectors like industrial houses and military establishments have dental
clinics managed by Dental Surgeons.
2.
Dental Colleges
(a) There are 41 dental colleges in the State of which 40 are private. Most of them
offer BDS and some offer MDS degrees. The total intake of students is 1552
annually. The facilities and staff provided by colleges are not always adequate; they
are under review by Dental Council, University and the Government. Trends in
recent years show that a proportion of dental seats remain unutilized, indicating
excess of supply over demand. The quality of many colleges needs to improve
(b) Auxiliary training for Oral Hygienists and Dental Laboratory Technicians is offered
by the Government Dental College and also some private colleges. The course is of
2 years duration.
(c) Mobile Dental Units / Ophthalmic Units: There are 4 units mostly concerned with
school health programmes for each zone. These are not effective.
3.
Dental Manpower Planning: In spite of the large number of dental colleges and dentists
in Karnataka, the oral health care picture in rural areas has not changed much over the
years. The situation is mainly due to unwillingness of dentists to go to rural areas and
biases in training. Students are trained in curative, individual oriented approaches rather
than in community oriented, preventive education methodologies.
The human resource strategy must address the following:
• Oral health needs and demands of the community.
• Proper distribution and utilisation of manpower to effectively serve the population.
The great majority of people report to dentists/ hospitals for relief from pain, extraction of teeth
or simple restoration and prophylaxis. Do we need highly trained personnel for this? It is time
to think in terms of primary dental health care workers, hygienists and dental nurses for
effective coverage of oral health care in the community.
Primary dental health workers or auxiliary health care workers are permitted to carry out
certain treatment procedures to relieve pain and suffering for common oral emergencies. They
are an integral part of the health team and are suitably trained for one or two years. As utilising
their services involves creation of additional posts, currently it may be more practicable to train
the primary health care doctor for a short period in simple skills. Utilizing auxiliaries may be
considered in the longer term.
Since 42% of the population is children, it is worthwhile developing school dental health
programmes. There is need for school dental health nurses.
3
Services at various levels:
All vacancies of dental surgeons and supportive staff at various levels are to be filled.
I.
PHC Level: At this level, procedures like simple extraction of shaking teeth, temporary
restoration and oral prophylaxis can be done. It is practicable to train the primary care
physician in the above mentioned procedures. Dental clinics are to be run by auxiliary
dental health personnel (dental hygienists with expanded function later).
Equipment:
• Dental Chair – Portable Dental chair which is used often in "camps" is sufficient (cost
about Rs.5,000).
• Dental Kit containing extraction forceps, local anesthetic spray, clove oil and
temporary dressings.
• Education materials like Posters / Slides: Oral health education should be used as an
integral part of the duty of auxiliary dental health personnel.
II.
Taluka Level: This is a referral centre for PHCs and school health dental programmes.
The personnel should include a dental surgeon and a dental technician / dental hygienist.
The services of an oral surgeon may be obtained on payment basis to take care of trauma
and orofacial problems.
The centre should be able to provide all services including specialist services and Oral health
education. The dental surgeons must be able to supervise the work at PHC's.
III.
District Level:
•
•
•
Equipment and personnel: Dental clinics should have all equipments and facilities
to render all specialised work apart from routine work. It should possess all facilities
for management of maxillo-facial injuries, prosthetic and restorative services. Dental
surgeons with post-graduate qualification are to be posted apart form District Dental
surgeon (Chief Dental Health Officer). The specialists include conservative dentists,
orthodontists, periodontists and oral surgeons etc. The Government may consider
appointment of private dental specialists, if necessary, on a payment basis.
Training centres: The hospitals should also function as training centres for dental
auxiliaries and primary dental health education.
Referrals: It should serve as specialised centre for all special work.
IV. Directorate Level: A designated post to be incharge of dental service and education who
could supervise the oral health of the state and also dental education.
V.
School Dental Health Programmes: It is worthwhile to develop a school dental health
programme. For this purpose a school dental health nurse is to be trained to look after
nearly 2000 children. A training programme will have to be designed. The nurse must
have a minimum qualification of matriculation with training of not less than 2 years. Her
work is supervised by dental surgeon.
Payment plans: Collection of user fees only from patients who can afford to pay. School
children to get free treatment.
4
Private sector: Private dentists are mostly located in the cities and Taluka Levels. The "out of
pocket" spending may be minimised by social insurance facilities.
Maintenance of dental equipment: Many equipments are not utilised for want of repair
work. It is necessary to study the cost benefits of annual maintenance agreements with the
suppliers, as against having a maintenance department.
The suggested organisational pattern of Dental Health Services (Govt)
State Level
- Deputy Director in charge – Dental Health Services and Education
District Level - District Dental Officers (Senior Dental Health Officer)
Taluka Level - Dental Surgeons (Dental Health Officer)
PHC
1. Dental Auxiliary Personnel (In future)
2. School dental nurse (In future)
To start with, the primary care physician may be trained to look after the function of the above
personnel
Prevention:
• Oral Health Promotion Programmes at all levels with posters, slides and cassettes etc.
This may be a part of the health education programme.
•
It is necessary to create awareness about use of locally available material for oral
hygiene eg., neem sticks may be used for brushing. Supply of cheap brush / toothpaste
/ tooth powder by removing sales tax may promote brushing of teeth.
•
Prevention of fluorosis is possible by supplying potable water from flowing river water,
defluoridation, and supplying water from wells that do not contain high fluoride.
Research: There is a need for surveys of dental diseases in the state and Research projects
may be undertaken for dental caries, oral cancer, fluorosis and periodontal disease. Research in
dental health may be part of the medical and public health research body that is to be created.
Recommendations
•
Introduce oral health promotion as an integral part of health promotion at every level of
health care and as part of the school health programme.
•
All vacancies of dental health officers to be filled up by suitably qualified persons.
•
All dental clinics should have the necessary equipment and facilities, which should be
maintained in good working condition.
•
A designated post of Deputy Director to be in charge of Dental Health Services and Dental
Education, at the Directorate.
5
•
Train PHC medical officers in simple dental procedures; expand the number of auxiliary
dental health personnel trained and increase their utilization in the field in a phased
manner. Trained health workers on awareness, detection and referral of dental health
services.
1
5.8. OCCUPATIONAL HEALTH
Occupational health deals with measures to make all work related activities and the environment
safe and free of hazards to health. It is the science and art devoted to the anticipation, recognition,
evaluation and control of health hazards arising out of work and work environment.
Regional Occupational Health Centre (South)
Karnataka is fortunate to have the Regional Occupational Health Centre (South) of the Indian
Council of Medical Research located in the Bangalore Medical College Campus. It is upto the State
to make full use of the facilities of the Centre to carry research into the occupational health
problems of the State and find appropriate solutions, so that the quality of life of the workers will be
improved.
Types of occupations
The occupations vary; so also the health hazards. Majority of our people are engaged in agriculture
and the hazards related to agricultural work must be anticipated and dealt with effectively. There is
an increasing number of industries and factories (large, medium and small) dealing with different
processes and products. They employ large numbers of people, who are exposed to the
environment within the factory and its surroundings. The people living nearby, though not working
in the factory, are also exposed to the environment, which is affected by the activities of the factory
by way of fumes and gases and other effluents.
Agricultural labourers
Agriculture is the primary source of employment in Karnataka. Apart from the usual causes of ill
health affecting all people, especially the poor, the use of chemicals (fertilizers and pesticides)
produces toxic effects. Pesticide exposure related problems are increasing as with resistance
developing, larger doses of pesticides are applied. The pesticide residues remain in food, water, soil
and fodder. Adverse effects are seen not only in people involved in the manufacture, formulation
and application of pesticide but also in the general population as the pesticide enters the food chain.
Aerial spraying of organophosphorous insecticides can affect the eyes and other parts of the body
(systemic). Repetition of spraying should not be done in the same area within a few weeks to avoid
cumulative effects.
Carbamate insecticide used in cotton cultivation can cause cardiotoxic effects with changes in
electrocardiogram.
Agricultural tobacco workers, growing or curing tobacco, may develop a symptom complex known
as "green tobacco sickness". The signs and symptoms are headache, nausea, vomiting, giddiness,
weakness, fatigue and fluctuations in blood pressure and heart rate.
Agriculture and accidents
Agriculture workers are prone to many accidents. Mechanisation of agricultural processes has
increased the incidence of accidents. Threshers, for example, can lead to loss of fingers, hands or
arms. Whenever machinery is introduced, it is necessary to train the workers in the safe working of
the machines.
-1
-
2
Table 5.18: Use of pesticides in agriculture
Insecticides
Fungicides
Weedicides
Others
:
:
:
:
75%
15%
6%
4%
100%
Table 5.19: Use of pesticides on different crops in India
Crops
Percent pesticide
Share
Cotton
Rice
Fruits and Vegetables
Plantation
Cereals, millets, oilseeds
Sugarcane
Others
52 – 55%
17 – 18%
13 – 14%
7 – 8%
6 – 7%
2 – 3%
1 – 3%
Pesticides are used for health programmes such as the malaria and filaria control programmes.
Sometimes pesticides may be used for committing suicide. Accidental poisoning can also occur.
Apart from the effects of pesticides, the use of traditional tools in agriculture can cause ergonomic
problems.
Sericulture
Karnataka is the major silk producing State. Sericulture is an agriculture based cottage activity. It
involves mulberry cultivation, silkworm rearing, silk reeling, silk weaving and finishing.
Chemicals like formalin and bleaching powder are extensively used. Smoke from cocoon cooking
basins (using firewood) can affect the workers. The workers in sericulture may develop breathing
disorders, including bronchial asthma.
Poultry
Poultry farming has become a highly commercialized agri-business. India stands fifth in egg
production; Karnataka has its share in it. The occupational problems arise from physical, chemical
and biological hazards. Allergic alveolitis occurs in workers who are hypersensitive to feathers,
feather dust and faecal material. Cough, dyspnoea and fever might be seen. If continued, decrease
in lung capacity may be seen. Noxious gases, such as ammonia, carbon dioxide, carbon monoxide,
methane or hydrogen sulphide, can cause adverse effects. Chemicals and antibiotics can cause
dermal allergies or transfer antibiotic resistance.
Bacterial, viral and parasite pathogens can occur with faecal waste. The common bacteria are
salmonella, E.coli and Chlamydia.
-2
-
3
The poultry farmers and their families and employees in poultry processing plants are
predominantly at risk. The general population also is at risk from the infectious agents.
Industries and factories
There is large scale increase in the number of industries and factories. Considerable improvement
can be effected in the reduction of health hazards. The design of the work place should be such that
there is no or only minimal hazard to the health of the worker. It should be ensured that harmful
agents are eliminated. The manufacturing process itself may have to be changed or toxic agents
substituted by harmless or less toxic agents.
Industrial accidents, accidents at construction sites and occupational diseases must be avoided. So
also, it is necessary to ensure that women and children do not work in industries that are specially
harmful to them. Child labour should be abolished progressively and children must be at school.
Among the industries in Karnataka, apart from the large industries where protective measures are
usually taken, are electroplating, foundry, castings, dyeing, pharmaceuticals and others.
Electroplating industry caters to making of automobile spare parts and others in which Zinc, Nickel,
Chromium, silver etc are used. These can produce nasobronchial allergy and contact dermatitis.
Similar problems can be found in dye factories.
Silicosis
Quarrying, granite industry, cement industry, grinding of metals, iron and steel foundries, silica
mining and tunneling can cause silicosis. The problem is attributable to the inhalation of silicon
dioxide (silica). The lungs are affected. Persons having silicosis are more prone to be attacked by
tuberculosis. The symptoms are dyspnea on exertion, cough and symptom complex resembling
chronic bronchitis. Vital capacity of the lungs is reduced.
Asbestosis
Asbestos is used in many products. Continued inhalation of asbestos particles causes a lung disease
known as asbestosis. There is gradual obstruction to airway and damage to the lungs. It is banned
in many countries.
Asbestos contains magnesium silicate, iron, calcium, sodium and other minerals. It is silky and
fibrous in nature. It is available in nature in several varieties, the common ones being white
asbestos and blue asbestos. Asbestos dust can become impacted in the respiratory bronchioles and
alveoli. It causes thickening of the walls of the alveoli, making them inelastic. Asbestosis leads to
progressive breathlessness and decrease in capacity to work. There may be chronic bronchitis.
Thickening of pleural sac is seen commonly. The major consequences are lung cancer and
mesothelioma of the pleura.
Agarbathi
Agarbathi industry is a cottage industry concentrated in the city of Bangalore and present in other
parts of the state. In 1999, Bangalore city had over 300 agarbathi manufacturing units, of which 134
were registered under the Factories Act. The industry involves persons of all age groups. There is
need for dust control measures. The rooms must be well ventilated. Dust masks may be used while
making the chemicals, which liberate the aroma. Gloves and aprons will be useful.
-3
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4
Tea
The processing of tea involves plucking of leaves, withering, rolling, drying/firing, sifting and
packing. Heat, humidity and noise can produce health hazards. The field worker and factory worker
must be protected.
Beedi rolling
Men, women and children must be engaged in beedi industry. tender leaves, tobacco and thread
must be used. The problem is due to suspended particulate matter and tobacco, which produces the
adverse effects due to nicotine.
Legislation
There are a large number of laws governing the health of the workers in the industries. They are not
adequate nor are they implemented effectively. The main laws are:
•
The Factories Act, 1948 and amendments 1976 and 1987.
Workers are to be protected from the harmful effects of dust and fumes. Safety and health
surveys are to be carried out. The Act provides for availability of drinking water and toilets.
The Act gives a number of notifiable diseases. The government can declare any manufacturing
process as hazardous and order its closure. The Act gives the right to information to the
workers and the people living around the factory. There is an Inspectorate of factories and
boilers under the Chief Inspector.
•
The Mines Act, 1952 and amendment, 1983.
The Act requires the constitution of a committee to advise the Government on the rules and
regulations to be framed regarding the health and safety issues of the workers. Silicosis and
pneumoconiosis are notifiable. There is an Inspectorate of Mines under the Mines Inspector.
•
The Plantations Labour Act, 1951
It regulates the conditions of labour in plantations – tea, coffee, rubber and others. It provides
for the availability of drinking water, medical care, education of children, crèches and housing
for plantation labour. There is a Chief Inspector of Plantations.
•
The Beedi and Cigar Workers (Conditions of Employment) Act, 1966.
It covers all the processes in the manufacture of beedies and cigars. It makes provision for the
availability of drinking water, washing facilities, ventilation and cleanliness.
•
Employees State Insurance Act.
It provides for benefits to the worker and family in case of sickness and employment injury.
•
Workmen's Compensation Act, 1923
The law provides for compensation in case of occupational injuries and diseases.
•
All the Acts and Rules regarding prevention and control of pollution, Central and State, are
applicable to the industries, to control pollution of water land (e.g., dumping of waste), air
(e.g., dust) and noise.
-4
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5
In order to implement the laws effectively it is necessary to work out the standards for industries,
including standards for protective equipment. There have to be adequate number of trained staff for
inspection. Workers should be involved in decision making with respect to health and safety
measures.
Sexual harassment as an occupational hazard
Sexual harassment can occur anywhere but it is now being recognized as an occupational hazard.
This is particularly so in the case of the health workers such as ANMs who may be called to render
help (sometimes bogus) at any time of day or night. There is need to ensure protection and safety of
women health personnel. The relationship between 'boss' and 'secretary' or between 'contractor' and
'worker' is also occasionally open to sexual harassment or abuse. Child workers are particularly
vulnerable.
Health Care and Occupational health
People working in hospitals, nursing homes and other health care institutions are open to hospital
acquired (nosocomial) infections, as are the patients admitted to these institutions. Care has to be
exercised when dealing with patients with infectious diseases. HIV infection can be acquired from
needle stick injuries. All persons working in these institutions must adopt universal precautions to
prevent infections.
Basic approach
The basic approach in occupational health / hygiene is the identification and monitoring of exposure
to harmful physical, chemical and biological agents (going beyond the permissible limits) and
removal of these hazardous agents. It also involves taking necessary precautions and safety
measures to avoid health hazards, including the wearing of gloves, masks and goggles. There is
always need to make the work place hygienic with good ventilation, lighting and housekeeping.
Moving machine parts and equipment (unless protected) can be harmful. Evaluation of exposure
levels should be carried out carefully, using appropriate technology. The Inspectorate of factories
has an important role to play.
Objectives
•
Protect the health of employees
•
Recognize, evaluate and control health hazards
•
Counsel employees on health hazards and the need to take precautions to avoid the adverse
effects.
•
Ensure that the employers respect the advice and report findings of the Inspectors and take
action on the recommendations.
Occupational health services
Occupational health services should include
a)
Pre-placement assessment: A pre-employment medical check-up is a must. This would
include physical examination and laboratory, radiological and other tests to assess health
status. This could form the basal data; any deviation due to work / work environment can be
found out.
b)
Periodic check-up: This would enable the medical inspector and others to find deviations
in the health status of the individual at the earliest and take appropriate steps. These check-5
-
6
c)
d)
e)
ups should focus not only on the physical condition but also on mental health, as there can
be psychosocial stresses.
First aid and emergency services: Necessary equipment and materials should be available
at all times to give first aid and emergency care to any employee who might require them.
It is also necessary to train workers in first aid.
Measures for continuous improvement of working conditions and environment must be
undertaken.
Health Education: It is necessary to educate workers and the public on possible adverse
effects on safe work practices and to take immediate action in cases of accidents or
otherwise.
Recommendations
•
The use (abuse) of pesticides must be reduced to the minimum. The effects of pesticides must be
studied. Only such insecticides as are found to be not harmful within the dosage should be
allowed to be manufactured / imported and used. Cumulative effects should be considered.
Monitor continuously the effect of the use of pesticide. If found harmful, withdraw it.
•
Occupational health services exist in large industries but this must be made mandatory and
expanded. Smaller industries can pool their resources and have effective centers with qualified
and trained persons. The quality of service of the Employees State Insurance (ESI) Scheme
should be improved. Pre-employment and periodical health check-ups of all workers should be
conducted.
•
Workers in the unorganized sector are the vast majority in India and include agricultural
workers, quarry workers, beedi rollers, agarbathi rollers, vendors, domestic workers, among
others. Their access to quality health care to be covered by social insurance schemes. Safety of
equipment, work processes and work environment to be progressively improved. The
responsibility of employers to be delineated.
•
Implement pollution controls – environment; air, water and soil. Ensure that standards are
worked out periodically and that the permissible levels are not violated. This will be through
intersectoral coordination with the State Pollution Control Board.
•
Suitable modifications to legislation be enacted to ensure good health of all workers, after
consulting workers, experts, and professional bodies in occupational health.
-6
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5.9. CONTROL OF BLINDNESS IN KARNATAKA
Introduction:
It is estimated that about 12 million people in India are blind that is with a visual acuity of less than
6/60. The magnitude of the problem is listed Table 5.20 below:
Magnitude of Blindness in India and Karnataka
Population
Prevalence
Blindness
VA<6/60
VA<3/60
Bilaterally blind
persons
VA<6/60
VA<3/60
Cataract blind
persons
VA<6/60
VA<3/60
Cataract blind
Eyes
VA<6/60
VA<3/60
ICMR Survey
(1971)
WHO / NPCB
Survey (1986)
Estimated
(1993)
586,572,852
762,893,474
876,205,384
42,939,775
1.38%
0.54%
1.49%
0.70%
1.49%
0.70%
1.62%
0.70%
8,112,303
3,167,493
11,399,917
5,316,605
13,093,137
6,106,275
728,079
394,407
6,084,227
2,375,620
9,131,334
4,258,600
10,487,603
4,891,127
498,101
266,226
15,450,329
8,033,115
22,845,750
13,100,283
26,239,009
15,046,057
1,614,535
1,056,318
Table 5.21: The leading causes of blindness in India are:
Cause of Blindness
Cataract
Aphakia
Refractive errors
Trachoma
Other infections
Xerophthalmia
Corneal opacity
Glaucoma
Small Pox
Injuries
Others
ICMR (1971)
WHO-NPCB (1986)
55.5%
80.10%
4.69%
7.35%
0.39%
5.00%
15.00%
2.00%
0.5%
3.00%
1.50%
18.00%
1.52%
1.70%
4.25%
Karnataka
(1995)
National Programme for Control of Blindness in Karnataka
The National Programme for control of Blindness (NPCB) is a centrally sponsored programme
managed by the Ministry of Health and Family Welfare (MOH&FW) in operation since 1976. An
estimated 80% of the blind is due to the curable cause of 'senile cataract'. This curable cause
provided focus for the programme in the last decade, which was to reduce the backlog due to
cataract, both in terms of quantity of cataract surgery and also on quality of visual outcome. The
number of cataract surgeries performed each year, both in the public and private section is
increasing from 1.2 million in 1989 to over 3 million in 2000. The overall objective is to reduce the
prevalence of blindness from 14 per 1000 to 3 per 1000. The estimated prevalence is above 4.5
lakhs in Karnataka.
DANIDA has supported the NPCB since 1978 in three phases. The present third phase covers a
period from 7th Nov 97 to 6th November 2002, which has since been extended to November 2003.
This phase is expected to be the last phase. The emphasis is on consolidation, internalization and
sustainability.
To improve the quality and coverage of eye care services a gradual shift in strategy as follows:
1. From an out reach eye camp approach to in-reach base hospital approach
2. From providing standard 10+ glasses to individual corrected glasses.
3. From Conventional Cataract surgery to IOL surgery.
To tackle this aspect following infrastructure was developed.
Infrastructure
A. STATE OPHTHALMIC CELL (SOC)
The State Ophthalmic Cell as per the Govt. of India guidelines has been created to plan, monitor
and evaluate the programme with the following staff.
• Joint Director (Ophthalmology)
• Assistant Statistical Officer
• Accountant
• Stenographer Grade – J
• Second Division Assistant
• Driver and a Group 'D' staff
The SOC is supported by the CSS under Government of India. A national consultant, who is a
retired Govt. joint director of Health is also appointed for the state from the 1st December 2000.
B. DISTRICT BLINDNESS CONTROL SOCIETIES (DBCS)
Karnataka is one of the first states to start the DBCS in the country with DANIDA support in
1990. The pilot district was in Tumkur. In the year 1999-2000, all the 27 districts had a fully
functional DBCS and a DPM. The district leprosy officers who are also in charge of the district
leprosy control societies replaced the contractual district programme managers of the DBCS in
all the districts from the 1st September 2000. This is in accordance with the revised policy of the
GOI. The DBCS provide the external support that is required for the effective functioning of the
programme at district and sub district level.
C. REGIONAL INSTITUTE OF OPHTHALMOLOGY (RIO) – MINTO OPHTHALMIC HOSPITAL. (MOH)
A multi-specialty Ophthalmic Hospital, Bangalore attached to Bangalore Medical College has
been upgraded as Regional Institute of Ophthalmology as per GOI norms to provide advanced
eye health care to community and training to eye surgeons. The RIO is over 100 years old and is
a premier postgraduate training institute of ophthalmology in the state. The institute is a base
hospital for the surrounding districts of Bangalore urban and rural.
D. MEDICAL COLLEGES
Karnataka has 23 medical colleges. Five medical colleges have been upgraded to provide high
quality training and clinical ophthalmic service. Qualified Super specialists are working in these
institutions they are
a. Government Medical College, Mysore
b. Government Medical College, Bellary
c. Karnataka Institute of Medical Sciences, Hubli
d. JJM Medical College, Davangere
e. J.N. Medical College, Belgaum
E. DISTRICT HOSPITALS
22 of the 27 district hospitals in Karnataka have been developed to provide surgical / clinical
ophthalmic services with Ophthalmic surgeons and Paramedical Ophthalmic Assistants
(PMOAs) as per GOI norms. Of the remaining five, Koppal and Haveri are newly formed
districts and the district hospitals area to be upgraded under the NPCB. The districts hospitals of
Mysore and Davangere are attached to the medical colleges respectively. Bangalore urban
district has no district hospital. These District Hospitals have been provided with a separate
operation theatre funded by KHSDP and are being provided with equipment for high quality,
high volume service delivery. Those districts that are not provided equipment by the KHSDP
are being provided for under the DANPCB.
F. GENERAL HOSPITALS
Seven general hospitals in the state which are over 100 bedded are to be upgraded to provide
clinical and surgical ophthalmic services to rural communities with an Ophthalmic Surgeon and
Paramedical Ophthalmic Assistants. They are located in Jayanagar, Bangalore (Urban),
Chennapatna Bangalore (rural), Sagar – Shimoga district, Kolar Gold Fields – Kolar district,
Hospet – Bellary district, Holenarsapur – Hassan district, and Jevargi – Gulbarga district.
G. DISTRICT MOBILE OPHTHALMIC UNITS (DMU)
31 District Mobile Ophthalmic units are functioning in the State to provide curative, promotive
and surgical facilities to rural and tribal communities by adopting hitherto a camp approach.
Each Mobile unit has an Ophthalmic Surgeon, a Health Education Officer, Staff Nurse,
Paramedical ophthalmic Assistants, Driver and a Group 'D' staff. The District Mobile
Ophthalmic units are instructed to operate not only in those fixed centers that have upgraded
operating theater but also assist in the district hospital.
There are four districts with an extra mobile unit located in
Gokak – Belgaum district.
Yadgir – Gulbarga district,
Hospet – Bellary district and
Tiptur – Tumkur district.
Posting of doctors other than ophthalmologists to the mobile units defeats the purpose of such
units e.g. Bagalkot, & Chamarajanagar
H. PRIMARY HEALTH CENTRES
416 PHC's were developed with creation of one ophthalmic assistant post to give primary eye
health care facilities to the rural community. An extra 99 posts for ophthalmic assistant was
created for the general and taluk level hospitals. There at present a total of 515 posts for PMOAs
and 385 posts are filled of which 316 PMOAs are in the PHC's.
I.
EYE BANK
Three eye banks are functioning at RIO Minto Ophthalmic Hospital, Bangalore, K.R. Hospital,
Mysore and District Hospital, Belgaum. There is also the Lions West Eye Hospital and Cornea
grafting center in Bangalore and one eye collection centre in Hospet, Bellary. There is a need to
upgrade the same so as to improve the Eye Banks standards.
MANPOWER AND TRAINING
a. Ophthalmic Surgeons:
The state has over 670 eye surgeons in all sectors combined. Though there are a few dedicated
tertiary eye care hospitals; almost all districts have on average 2 eye surgeons in the
Government Sector. Under the quality improvement programme for microsurgery in IOL, 64
Government Eye surgeons have undergone IOL training up to December 2000. This is inclusive
of those in the Govt. Medical Colleges.
b. Para-Medical Ophthalmic Assistants (PMOAs)
Under National Programme for Control of Blindness, Paramedical Ophthalmic Assistants
training has been started in four Government Medical Colleges. They are Minto Eye Hospital,
Bangalore, K.R. Hospital, Mysore, KIMS, Hubli, VIMS, Bellary. In each training school 15
students are trained. The syllabus was revised and adopted by the State Govt. Para Medical
Board.
The following problems have been identified in Karnataka:
• Effectiveness of NPCBs state level functions as perceived by districts has only marginally
improved.
• The NPCB focuses on the major cause of Blindness which is cataract; other causes of blindness
such as glaucoma, Refractive errors, Vit. A deficiency, Diabetic Retinopathy require more
emphasis.
• The high turnover of state progrmme officers and inadequate support staff in SOC is a major
concern.
• Lack of integration and ownership at state and district level have been responsible for NPCBs
poor performance.
• Inadequate capacity utilisation at the medical colleges and district hospitals has resulted in poor
quality of care and coverage of services.
• Trained ophthalmic manpower has been maldistributed at medical college, district hospitals and
various other levels.
• The infrastructure and trained manpower have not been optimally utilised, leading to inadequate
coverage and quality of service.
• Manpower training of Ophthalmic Surgeons, PMOAs and ophthalmic Nurses has been far from
satisfactory
• There have been delays in procuring equipment and setting up IOL microsurgery centres at
district level
•
•
•
•
•
Networking with the NGO and voluntary sectors is far from satisfactory.
Micro-planning and implementation have not been achieved in most of the districts.
Output and visual outcome of cataract surgery are inadequate in most of the base hospitals and
outreach surgical camps.
There have been delays in providing GOI funds to DBCSs during 1999-2000, probably due to
accounting and auditing problems.
The Department of Health & Family Welfare and DBCS, IEC budget are not fully utilised.
Strategies
I. To improve the performance of the programme in the State
State Ophthalmic Cell must be strengthened by
• The long term continuity of the Joint Director, at least for a period of two years
• The posts of Assistant Statistical Officer and Accountant need to be filled with qualified
staff.
• An additional post of Deputy Director should be created and filled with dynamic, young and
focused public health specialist or ophthalmologist.
Manpower utilization:
• Trained ophthalmic manpower should be appropriately distributed at medical colleges,
district hospitals and various other levels.
• Accountability of the ophthalmic units,specially the ophthalmologist. The number of
cataract surgeries performed against the total expenditure on the unit per year will give the
cost per cataract surgery incurred by the government.
• All teaching institutions in the state especially those utilizing government facilities (district
hospitals) to be made responsible so as to participate in the programme.
Information Education Communication (IEC):
• The Government of Karnataka should develop an IEC strategy that strongly emphasises
area-specific approaches and community participation in the dissemination of IEC.
• The IEC strategy needs to be gender – sensitive and also address the marginalised groups.
• The Government of Karnataka should issue clear guidelines for utilisation of IEC resources
(financial and technical) in the districts and at the state level.
• The decentralised approach needs to be further strengthened, so that the districts are able to
develop their own modified IEC strategies.
• The IEC should address the new service access options in particular by informing
marginalised groups who have otherwise less access to information.
• The state must integrate intensively the IEC work with the health system. At district level, the
district health education officer will liaison with DBCSs and will be in charge of the IEC
activities.
Management Information System (MIS)
• There is the need for an MIS trained person to assist the district programme fo the DBCS.
• The second generation of MIS with segregated data must be implemented
• The MIS from the service provider to the State Ophthalmic Cell must be uniform in the state.
• Feedback in terms of performance and accountability must be given to the concerned
officials.
School Eye Screening (SES)
• The SES must be integrated with the regular check up of the school children. This is possible
by including the Deputy Director of Public Instruction (DDPI) and the Reproductive and
Child Health Officer in the DBCS and making them responsible for the implementation of
the programme.
II. Specific Causes of Blindness
1.Cataract
An estimated 80% of blindness is due to the curable cause of 'senile cataract'. This curable cause
provided focus for the programme in the last decade, which was to reduce the backlog due to
cataract, both in terms of quantity of cataract surgery and also on quality of visual outcome. To
improve the cataract surgical coverage in Karnataka the following measures are recommended:
• All Medical Colleges Eye departments should take up in-reach base hospital programme.
• All taluk hospitals upgraded by the KHSDP should be made base hospitals for conventional
cataract surgery and be allotted a fixed area and target.
• All districts should have atleast two Govt. base hospitals where IOL surgery is available
• The Divisional Joint Director for their effective utilisation should coordinate and depute the
available surgical manpower to fixed surgical centres on the operation days in the districts.
• All post-operative patients should be given individually corrected spectacles.
• All fixed surgical centres should strictly follow the guidelines laid down by the Govt. of India for
conducting cataract surgical services.
2. Glaucoma
The prevalence of glaucoma in India as stated by the WHO / NPCB survey (1986) was 1.7% of the
cases of blind. It is the third cause of blindness in the country. The blindness due to glaucoma may
be because of congenital glaucoma, chronic open angle glaucoma or primary angle closure
glaucoma. In India data related to glaucoma in the general population is not readily available. To
prevent blindness due to glaucoma the following strategies must be adopted.
Primary Level:
• Health education on glaucoma
• Screening of those at risk, by the health worker
Secondary Level:
• Case finding or evaluating those that are referred.
Tertiary Level:
• Confirmation of the diagnosis and management, either medical or surgical
This may be conducted as follows:
Screening in the community by the health worker to identify and refer persons at risk of developing
glaucoma. The persons to be screened are:
•
All people over the age of 50 years.
•
•
People with a family history of glaucoma
People with a history of high Myopia and diabetes.
Those people referred by the health worker should be evaluated by the ophthalmologist for
• Intra ocular pressure using Schiotz tonometer.
• Cup disc ratio.
• Ophthalmoscopy
Those that are suspected of having glaucoma should have:
• Visual field tested
• Gonioscope examination for angle estimation
These persons must be referred to a tertiary level institution for confirmation of diagnosis and
management, that may be surgical or medical.
3. Blindness due to corneal opacity
The WHO / NPCB survey listed blindness due to corneal opacity as the fourth cause of blindness
accounting for 1.5% of the blind. The common causes for corneal opacities are Vit A deficiency,
Trauma and corneal ulcers.
Thus the strategies to be adopted are:
Primary Level:
• Health education on causes and prevention of corneal opacities.
• Vit. A supplementation, strengthen the ICDS programme.
• Measles Immunisation.
• Promotion of Eye Donation.
Secondary Level:
• Early diagnosis and management of causes of corneal opacities.
• Eye collection centres: The development of eye collection centres in each district hospital with
the information available to the community as to the personnel available and the procedure for
collection of eyes.
Tertiary Level:
There is need to develop an eye bank of high standards and expertise for corneal grafting for the
four health divisions at the following centres.
• Regional Institute of Ophthalmology. Minto Ophthalmic Hospital, Bangalore.
• K.R. Hospital, Mysore Medical College, Mysore
• Karnataka Institute of Health Sciences, Hubli.
• Vijayanagar Institute of Health Sciences, Bellary.
4. Diabetic Retinopathy
It is estimated that about 2.5 million people in the world are blind from diabetic retinopathy. In
India, data related to diabetic retinopathy in the general population is not readily available. It is
however estimated that 2% of the general population are diabetics and 16% of them will develop
diabetic retinopathy.
Thus the strategies to be adopted are:
Primary Level:
• Health education on diabetes mellitus and its control.
• Early detection of diabetes mellitus and its management.
Secondary Level:
• Early diagnosis and management of diabetic retinopathy.
• Train general physicians on early detection and risk factors for diabetic retinopathy.
• The availability of the equipment necessary for the early diagnosis of diabetic retinopathy in
each district hospital with the information available to the community.
Tertiary level:
• There is need to develop the expertise of vitreo retinal units for the four health divisions at the
following centres.
Regional Institute of Ophthalmology. Minto Ophthalmic Hospital, Bangalore.
K.R. Hospital, Mysore Medical College, Mysore.
Karnataka Institute of Health Sciences, Hubli.
Vijaynagar Institute of Health Sciences, Bellary.
• Rehabilitation of the blind (visually impaired).
Recommendations
•
Improve effectiveness and outcomes of the programme by strengthening the State Ophthalmic
Cell filling up vacancies with qualified dynamic staff, and long term continuity of Joint
Director.
•
Ensure accountability of the ophthalmologist and ophthalmic units regarding number and
quality of cataract surgery. The epidemiological surveillance system to include ophthalmic
conditions.
•
Improve access to information regarding availability of services, especially for the
disadvantaged sections. Area specific health promotion regarding eye care, with community
participation.
•
Integrate school eye screening with health check-up of school age children.
•
All Medical College Eye Departments should take up in-reach base hospital programmes.
•
All taluk hospitals (upgraded by KHSDP) should be made base hospitals for conventional
cataract surgery and be allotted a fixed geographical area.
•
All districts should have at least two government base hospitals where intraocular lens (IOL)
surgery is available. All postoperative patients should be given individually corrected
spectacles.
•
The District Medical Officer should coordinate and depute the available surgical manpower to
fixed surgical centres on the operation days in the districts.
•
Screening the community by the health worker to identify and refer persons at risk of developing
glaucoma, to ophthalmologists for evaluation and management.
•
Prevention, early diagnosis and intervention in persons liable for corneal opacities causing
blindness. Develop eye collection centres, eyebanks and expertise in corneal grafting for the
four divisions in government medical college hospitals.
•
Establish speciality clinics: glaucoma, vitreo-retinal and corneal grafting centre.
•
Improve networking with the voluntary and private sectors.
1
5.10 TOBACCO CONTROL
Tobacco consumption in smoked or chewed form has been proved harmful to health over the past 34 decades. Extensive epidemiological and medical studies have provided evidence that over 25
serious diseases are associated with tobacco use. These chronic disabling diseases reduce life span
by as much as fifteen years in long term users and result in great suffering and economic loss. The
strong addictive nature of nicotine is now more widely known. This was however known to the
industry in the 1950s and kept hidden. Much evidence has been generated as a result of the cases
against leading tobacco multinationals in the United States Courts of Justice. Chemical
manipulation of cigarettes, with ammonia and other substances, is resorted to for increased nicotine
absorption. Simultaneously, advertising and marketing efforts focus on young consumers from 10
years of age onwards, because given the addictive nature, once a consumer there is a strong
probability of becoming a consumer for life. In India and Karnataka, tobacco use has been
increasing over the years even among younger children and women, especially chewed tobacco.
Tobacco consumption is commonplace among all economic strata in both urban and rural areas.
Irrespective of age and sex men, women and children use tobacco in both urban and rural areas. It
is the production of tobacco, availability of tobacco and the role model of adults in the community,
which perpetuate and reinforce this habit pattern.
WHO and its member country governments including India have been signatories to 18 resolutions
over the past 20 years, endorsing the need for initiating tobacco control measure.
Every eight seconds a person dies of a tobacco related disease and almost as quickly another victim
is recruited. With current smoking patterns, about 500 million people alive today will eventually be
killed by tobacco use, more than half of these are now children and teenagers. By enabling efforts
to identify and implement effective tobacco control policies particularly in children, different
organisations would be fulfilling their missions and helping to reduce the suffering and costs of
smoking.
A six-year prospective study by the Indian Council of Medical Research has shown that in India, the
health care costs of tobacco related illnesses by government medical institutions far outweighed all
the revenue accruing from taxation, excise, export earnings, etc. This is an underestimate as costs
borne by the person / family in the private sector are not included. The study included major health
consequences requiring hospitalization. If outpatient and over the counter treatment were included,
the costs would go up even further.
One million Indians die every year from tobacco related disease, this is more than the number of
deaths due to motor accidents, AIDS, alcohol and drug abuse put together say the Indian Medical
Association (IMA) and the Indian Academy of Pediatrics (IAP) (reported in The Hindu edition date
31-10-1998 under the caption "smoking kills 10 lakhs").
Epidemiological and experimental evidence has identified smoking as the primary cause of lung
cancer, chronic obstructive pulmonary disease (COPD) and a major risk for heart disease; smoking
has been also associated with other cancers, cerebro-vascular and peripheral vascular disease and
peptic ulcer disease. Cigarette smoke consisting of particles dispersed in gas phase is a complete
mixture of thousands of compounds produced by the incomplete combustion of the tobacco leaf.
Smoke constituents strongly implicated in causing disease are nicotine tar in the particulate phase
-1-
2
and carbon monoxide in the gas phase. Smokers have a 70% higher mortality than non-smokers.
The risk of death increases with the amount and duration of smoking and is higher in smokers who
inhale. Lung cancer has been the leading cause of cancer death in men. Since 1950
epidemiological studies have shown an association between smoking and cancer of bladder,
pancreas, stomach and uterine cervix. The coronary disease death rate in smokers is 70% higher
than in non-smokers.
Tobacco cultivation in Karnataka
In Karnataka, as elsewhere, the special variety of Virginia tobacco has attracted the fancies of
farmers. Government of Karnataka is also inclined to encourage its production, as it increases the
revenue to the exchequer and has kept target of production at 30 million kgs with awards to farmers,
("Awards presented to four state tobacco farmers". Deccan Herald, October 2000).
Tobacco cultivation in Karnataka during the year 1989-90 and 1990-91 was 50.5 and 46.1 thousand
hectares, of these 18.1 & 19.2 thousands hectares were under Virginia tobacco.
Tobacco consumption
There is a wide consumption of tobacco in the various forms like cigarettes, cigars, beedi, hukka,
Gutka, Panparag. Tobacco consumption pattern in India is as follows: 50% beedi, 30% gutka or
chewed tobacco and 20% cigarettes.
The number and percentage of tobacco users in Karnataka is given by the International Journal of
Tobacco Control – 1995, Vol. 1, No. 3 Page 202. It gives the type of habit (use of tobacco in
different forms) in the rural and urban areas, as also the users below 15 years of age and those
above 15 years.
Passive Smoking
Non-smokers exposed to passive smoke are vulnerable to irritating coughs, sore throats, dizziness
and headache. Exposure to passive smoke worsens pre existing health problems like allergy,
asthma, and bronchitis as well as heart and lung disease. In children passive smoke causes higher
incidence of cough, wheezing, asthma and respiratory infection. Babies born to mothers who
smoke have lower birth – weight, face greater risk of respiratory disease and die of sudden infant
death syndrome.
Non-smokers involuntarily inhale the smoke of nearby smokers, a phenomenon known as passive
smoking. Wives, children, workers and friends of smokers are highly risk prone group. This
pointed out that India hospital admission rates are 28% higher among the children of smokers.
Maternal smoking during pregnancy has also been linked with higher rates of spontaneous abortion,
fetal and maternal death.
When smoking occurs in enclosed areas with poor ventilation such as in buses and conference
rooms high levels of smoke exposures can occur. In recent studies on non-smoking women, those
married to smokers had higher lung cancer than those married to smokers.
Damages of passive smoking are real, broader than once believed and parallel to those of direct
smoking.
Environmental tobacco smoke (ETS) also contributes to respiratory morbidity of children.
-2-
3
Every year one million tobacco related deaths take place in India (The Hindu, dated 8-1-1998). An
estimated 65% of men use tobacco and in some parts a large proportion of women chew tobacco.
About 33% of all cancer is caused by tobacco. About 50% of cancers among men and 25% among
women are tobacco related.
Prevention of tobacco use through tobacco control measures
Prevention of tobacco use and abuse is urgently required for promotion of health and economy in
Karnataka and other parts of India.
To do so the following strategies are of prime importance.
1. Awareness education programmes in educational institutions and with community groups,
particularly with children and the youth.
2. Health education and tax increases.
3. Legal measures regarding direct and indirect advertising, sponsorship, sales restrictions, ban
on smoking and spitting in public places, curbing of smuggling and unregistered beedi
production.
4. Decreased production of tobacco.
5. Support to the international public health treaty, the “Framework Convention for Tobacco
Control” (FCTC) initiated by WHO, based on the mandate of member countries, including
India.
Although both national and international agencies have been engaged to restrict use of tobacco for
promotion of health, still it is not enough to control this habit. Hence there should be public arousal
and cooperation at the individual level, family level and community at large, in addition to the
execution of strategic efforts.
Often paradoxical evidence are observed in media, which should also be screened and modified for
example "smoking is injurious to health" is written in microscopic size at the unnoticeable corner
of a huge colourful attractive advertisement with alluring statement like "live like a King " or "
relax with a puff of smoke" etc. Therefore moderation of such advertisements with warning labels,
which would catch the perception of individuals properly, would be of help.
Recommendations
I.
Ban on tobacco consumption
•
Complete ban on tobacco consumption in public places such as:
(a) Hospitals and all other health care facilities
(b) Educational institutions (schools, colleges, university).
(c) Transport facilities:
i.
Air travel (domestic)
ii. Buses
iii. Trains: Separation of smoking and non-smoking compartments.
(d) Waiting areas: Segregation of smoking areas from non-smoking areas
i.
Airports.
ii.
Hotel lobbies.
(e) Theaters / Cinemas
(f) Restaurants
(g) Sports
-3-
4
(h)
II.
Ban on tobacco sale
•
•
III.
IV.
Museums, libraries and closed areas of tourist interest: total ban on consumption
at work site and to provide segregated area for smokers at recreational / eating
facilities.
Ban on sale to minors (below 18 years of age)
Ban on sale in the immediate vicinity of educational institutions
Ban tobacco advertisement / promotion
•
All hoardings / poster advertisements to be banned, including in / on all transport
facilities.
•
Radio and television ban on tobacco advertising should be continued.
•
Advertisements in cinema halls / videocassettes / audio.
•
Ban on advertisement in the print media (desirable).
•
Health warning should accompany at least 20% area of advertisements on the topside.
The health warning must be rotated periodically and must have a graphical display e.g.
skull and bones as a sign of danger; a picture of a cancerous lesion or a warning that
impotence is also a side effect.
•
Point of sale advertising should be prohibited. Warning symbols and health warning
should be prominently displayed at the point of sale.
•
Ban on all forms of sports, arts and entertainment sponsorships or linkage with sports
goods / accessories should be effected. This ban should apply to all tobacco products
and to other products with the same brand name. Indirect sponsorship through setting
up of trusts, etc., should be banned.
•
All promotional activities for any tobacco product such as free distribution, mailings,
discount offer etc., should be banned (Mandatory)
Statutory warning on packaging / nicotine and tar content notification:
•
Notification of nicotine and tar content on all packages of the cigarettes and beedies
should be made compulsory.
•
Statutory warnings should be extended to all forms of tobacco
•
Size of the statutory warning should be as large (in letter size) as the brand name
•
Statutory warnings should be periodically rotated.
•
Statutory warnings should be placed in the local regional language (Desirable).
-4-
5
V.
•
Graphic danger symbols such as skull and bones must also be printed on the packaging
in addition to the statutory warning.
•
Nicotine and tar content of cigarettes should be progressively reduced, in a specified
time frame. This may need to be introduced for beedies as well.
•
A national nicotine-testing laboratory should be set up by the central government, to be
used as a licensing and monitoring center. The requisite funds for this center may be
derived from the tobacco industry through special taxation measures (Desirable).
Taxation
• Taxes on all tobacco products should be increased (Desirable)
•
VI.
VII.
A specified percentage of the tax revenue from tobacco should be set aside for health
education on tobacco related diseases (Desirable)
Incentives
•
Farmers who change over, from tobacco, to alternate crops should be provided
incentives for three years (Desirable).
•
Government must establish tobacco cessation clinics and programmes in government
health facilities (Desirable).
•
Promote diversification of tobacco industry into other industries such as information
technology (Desirable).
Environmental legislation
•
Environmental legislations to provide for a targeted compulsory compensatory
reforestation programme by tobacco producers and industry to make up to a tobacco
curing related deforestation. A specific tax may be levied for this purpose with penalties
for noncompliance.
VIII. Joining international effort
•
IX.
Support the Framework Convention for Tobacco Control (FCTC) initiated by WHO, by
discussion at government level with legal experts.
Miscellaneous
•
Improve working condition of beedi workers. Industry must provide for medical care of
the workers.
•
Have alternate employment for beedi workers and labourers now working in tobacco
growing, curing, etc.,
-5-
6
•
Investment of public sector funds in the tobacco industry should be stopped.
-6-
5.11 ALCOHOL AND HEALTH
Ethyl alcohol, the intoxicant & depressant present in alcoholic beverages, is a product of
fermentation & distillation. Methyl alcohol is a contaminant found in many “illegal &
spuriously” produced beverages and causes morbidity including blindness and death.
Alcohol use and abuse and the attendant problems have risen many-fold in Karnataka in the past
decades. Alcohol abuse must be seen as a major public health problem and a socio-economic
issue. Karnataka has to take responsible action towards the prevention and control of this
problem.
Constitutional provision
Article 47 of the constitution of India says: "The State shall regard the raising of the level of
nutrition and the standard of living of its people as among its primary duties and in particular the
State shall endeavour to bring about prohibition of the consumption except for medicinal
purposes of intoxicating drinks and of drugs which are injurious to health".
The Governments of different states had attempted to bring about prohibition, total or partial,
but gave up those efforts due to a variety of reasons, loss of revenue, cost of policing, corruption
of enforcement machinery, illicit, distillation, 'hooch' related deaths and above all, lack of
political will.
Revenue
The alcohol industry contributes a major part of the revenue of the States. In 1997 it was
estimated to be about 17,000 crores of Rupees, in the form of taxes and levies. The liquor
consumption in the country was growing at a steady 15 percent annually.
Types of alcohol
•
Toddy, obtained by fermenting the sap from various species of palms, especially palmyra
and coconut. The production of toddy has been restricted in the State.
•
Country liquor, produced by distillation. Arrack is the common name; it is widely
available, and distributed usually in small sachets.
•
"Indian made foreign liquor": Different varieties like whisky, brandy, rum and gin are
available.
•
Illicitly distilled liquor:
house made for personal use
house made for sale in the neighbouring areas
made for sale in a wide area, including cities and towns.
Production, sales and consumption
We have no accurate figures regarding the production, sales or consumption of alcohol for
drinking. Consumption of alcoholic beverages is increasing. It is spreading to younger people.
High School students are becoming regular users of alcohol. Pub culture is spreading in the
State especially in the cities.
Health Problems
Alcohol consumption produces a large number of problems, affecting adversely almost every
organ in the body. Gastritis is an early symptom which brings the patient to the doctor. Alcohol
can cause fatty liver, alcoholic hepatitis and cirrhosis. Alcohol uses frequently present with
malnutrition; deficiencies of B group vitamins can occur. Alcohol impairs blood sugar
-1-
regulation. Control of blood sugar by antidiabetic medication is impaired. Drinking can affect
blood pressure control. There is increased risk for cerebral haemorhage and stroke and for
cardiac failure. Alcohol can cause polyneuropathy. Alcohol withdrawal produces unpleasant
physical and psychological symptoms. Serious complications include delirium tremens and
hallucinations. Depression and anxiety are more common among drinkers.
Many medications can interact with alcohol. Alcohol can reduce the metabolism of many drugs.
Alcohol can magnify the effects of drugs like sedatives and narcotics. Many drugs such as
analgesics, antihistaminics, and antibiotics, antidiabetics and hypnotics have significant
interactions with alcohol.
Social Problems
Alcohol causes family disruption and marital discord. Its use leads to family violence, wifebeating and physical assaults. There is neglect of family responsibilities. Alcoholism in the
parent affects the educational performance of children and leads to deviant behaviour. The most
demeaning effect is the loss of self-esteem among family members
Financial Problems
Alcoholism is more common amongst poorer sections of the society: Schedule casts, landless
labourers, daily wage earners etc. Money been spent for alcohol leads to deprivation of the basic
needs of the rest of the family members. 15 to 40% of family income is wasted on alcohol. If
we compare the regular uses of alcohol and the non-drinkers, the non-drinkers spent 8% more on
food, 30% more on clothing, 168% more on health care and 300% more on children education.
Industrial Workers
Absentees is much more common among alcohol users. There is also lowered productivity,
maladjustment at work place and increased accidents. Non-drinkers, on an average, took home
about 50% more money than the habitual drinkers.
Crime and Violence
There is increasing in crime and violence as a result of use of alcohol. Increasing all kinds of
violence, sexual abuse, rape and murder is seen with increase use of alcohol.
Pattern of drinking
Alcohol consumption is an accepted social and traditional norm in many countries. Among
developing countries especially, this was predominantly by males, very rare among women &
children, and even then low in terms of numbers and quantity consumed.
Today there is substantial evidence to prove increasing levels of consumption, and growing
numbers of users among adults as well as children. The norms are also changing- there is
societal acceptance to drinking- no excuse needed for it like religious rituals or festivals. Peer
pressure, social pressures, association of drinking with a “Macho” image which is perpetrated &
promoted by cinema & other media and advertising are some factors responsible to for this.
"Social" drinking is considered to be synonymous with "moderate drinking". While this is so in
the context of a traditional "wet" or alcohol using cultiure, this is not necessarily so in the
context of a "dry" culture as in India where there are no traditional norms pertaining to alcohol
use.
Moderate drinking refers to patterns of drinking where people drink no more than 2 drinks a day
in case of males and one in case of females and those over 65 years. Never more than 4 drinks
at any given sitting (3 for women). The assumption is that the person has at least 2-3 dry days in
-2-
a week. (One unit drink refers to half a bottle of beer, one 30ml.peg of spirits or one-third sachet
of arrack)
However in a "dry" culture the predominant pattern of use or "social drinking" is drinking to
intoxication. This leads to harm from drinking in inappropriate situations (e.g. drinking and
driving) or heavy drinking likely to cause physical, psychological and social problems.
The large number of such users account for a significantly greater proportion of medical
problems, social costs and economic losses to the state compared to that from the much smaller
population of those addicted or dependent on alcohol.
In the context of Karnataka, while about one third of the adult male population uses alcohol; one
out of two people who drink develop significant problems related to drinking.
Alcoholism
Alcohol dependence is a recurrent and relapsing illness which affects one in four drinkers. It is
characterized by increasing intake of alcohol to get the desired effect, a compulsion to drink,
unpleasant physical and mental symptoms on withdrawing from the substance, loss of control
over intake, a preoccupation with seeking and taking of the substance, consequent impairment in
physical, social and psychological functioning and continuing to drink despite knowledge of
such harm.
Alcoholism is a disease which needs intense medical and psycho-social interventions for the
alcoholic as well as his family. Treatment consists of detoxification (medically supervised to
minimize withdrawal symptoms) abstinence and training to prevent relapse.
Certain people may be especially susceptible to developing alcohol dependence and genetic
(heritable) factors might account for around 60% of such susceptibility. However, like any other
complex medical disorder, environmental factors play a major modifying role in determining the
expression of this illness.
As a Public Health issue however, the medical, social and economic costs generated by the
significantly larger population of people with heavy or hazardous use (not just the alcoholics)
are immeasurably greater. Also, Early stage alcohol problems are more amenable to treatment.
Early detection and intervention of alcohol related problems offer the best outcome.
The lax implementation of regulations and laws is leading to increased production & wide
availability of alcohol. This stems from a perceived loss of income to the exchequer from
production and sale of alcohol, and compounded by pressure from liquor lobbies. Unfortunately
this does not take into account the health spending and economic loss due to alcohol- related ill
health.
A ten –year study by NIMHANS between 1988 to 1999 reveals some shocking facts.
• Karnataka’s instilled capacity for beverage alcohol is one of the highest in the country. The
production has gone up by 150%, and per capita consumption by 114%, i.e. average
consumption by an average drinker has gone up from 9 bottles of whiskey per year to 20
bottles.
• People are beginning to drink at an earlier age (average age- dropped from 25 to 23years),
drink larger quantities, and develop health problems earlier (mean age dropped from 35 to
29years).
• More than 50% of all drinkers have problem drinking patterns and associated morbidity.
• Early alcohol related health problems is under recognised by Primary health care physicians.
Although a large proportion of patients were reporting potential alcohol related symptoms
-3-
•
•
•
only 1.4% to 2.3% were asked for history of alcohol intake and none advised to stop alcohol
use.
Heavy drinkers far outweigh chronic alcoholics in numbers and also account for
substantially more medical, social and economic problems.
The problem is larger and more serious in rural than urban Karnataka.
The Karnataka Government’s alcohol related health expenditure and loss due to alcohol
related industrial losses was Rs.975 crores more than the earning from excise on beverage
alcohol.
How to tackle the problem?
Prohibition has almost been given up. Where it has been tried, it has not been a success. Hence
the present thinking is to reduce the problem. This can be done in three ways:
1.
Supply reduction: Alcohol related problems are caused by the availability of alcohol.
Various methods are used to reduce the supply:
(i) Increase in taxes: It is considered that there is an optimum level of taxation of
alcoholic beverages. Beyond a certain level, increasing in taxation may lead to more
spurious liquor being made available are there may be an increase in smuggling
One suggestion has been to proportionately increase the taxes and duties on hard
liquor compare to beer and wine with lower content of alcohol. But there is
possibility that youngsters who start with beer or wine may 'graduate' to the spirits
with larger alocohol concentration.
(ii) Increase the minimum age for legal purchase fo alcohol. Even when there is such a
law, it is often violated.
(iii) Reduce the number of alcohol outlets. This is effective.
(iv) Restrict the sale hours. This is also effective.
(v) Restrict the sale of alcoholic drinks on certain days. This can be tried.
2.
Demand reduction: There are different strategies
(i)
School based prevention strategy: Imparting knowledge about the adverse effects
of alcohol consumption, particularly the hazards to health may create awareness,
which can lead to action. Often students take to drinking because of peer pressure.
This can be reduced
(ii) Community based preventive strategy: Community groups can mount campaigns
against drinking and particularly against illicit distilling and distribution. The use of
mass media, and particularly folk media, can give dividends. The voluntary
organisations and religions institutions can play a important role in reducing the
demand
(iii) Family focused prevention strategy: If family is strengthened, problem drinking
can be reduced.
(iv) Reduction of advertisements: demands are created by advertisements. If
advertisements, direct and indirect, are stopped, there will be substantial reduction in
demand.
3.
Harm reduction: The harm caused by drinking alcohol can be reduced to extent by
following certain principles.
(i) Do not drive after drinking. Accidents caused by drinking after driving can be
reduced if breath analyzers are used and punishment given when alcohol
concentration in the breath is above a certain limit.
-4-
(ii)
Do not drink in an empty stomach. When food is taken before drinking there is
slower absorption. It is then assimilated and detoxicated more effectively in the
liver.
(iii) Drink only beverages with less concentration of alcohol and limit the number of
drinks at any time.
Alcohol use and abuse is associated with violence, especially against women and children. It is
important to actively look for history of violence in drinkers and conversely, history of alcohol
abuse in family members of women and children who present with unexplained and repeated
physical injuries. The abuser may require anti-psychotic drugs in addition to other therapeutic
interventions.
Alcohol abuse has a definite association with other risk behaviour e.g. unsafe sex, and therefore
with STDs & HIV/AIDS.
Recommendations
•
Training of all Medical Officers and especially at the Primary Health Care level on
screening the patient for alcohol abuse problem with a simple questionnaire, early detection
and interventions for alcohol-related health problems including discontinuation of drinking.
•
The training should include sensitization regarding association of alcohol use with violence
in the family, and association with STDs & HIV/AIDS.
•
Referral centres for treatment of alcoholism should be identified or set up at district levels.
The treatment programme should include detoxification, treatment of withdrawal symptoms,
psychological therapy and long- term relapse-prevention programmes to ensure abstinence
•
Referral to local self-help groups like Alcoholics Anonymous should be encouraged as part
of the relapse prevention programmes for treatment of alcoholism.
•
The model of “camp-approach” for treatment of alcoholics which is being successfully
implemented by TTK Hospital, Chennai, in some centres in Tamil Nadu could be tried in
Karnataka. The essential element for the success of this model is involvement of the local
community in the relapse-prevention programme. This should be ensured.
•
The Government should treat the alcohol problem as a major public health problem and
socioeconomic issue.
•
The departments of Excise (Finance), Health, Education, Social Welfare and Police
department should work together to implement and enforce the existing regulations and
measures applying to production, sales, retail, taxation and advertising of alcohol.
•
A differential Tax structure with a higher taxation on liquors than on beer or wine will help
in discouraging the drinking of beverages with higher alcohol content.
•
A general awareness about “drinking and driving” should be undertaken by the Transport
department. This should specify the type and amount of drink over which the person should
not drive, explained in lay terms and not as percentage of alcohol. The laws against drinking
and driving should be strictly implemented and exemplary punishment must be awarded to
offenders.
-5-
•
Measures to prevent production and trade of illicit liquor should be enforced.
•
Health education programmes for children and adolescents should include substance abuse
as well as Life Skills Education.
•
Community level interventions by Government and by NGOs should include community
awareness, Health Education, social support for battered women and children, vocational
rehabilitation for reformed alcoholics, etc.
•
Advertising agency and media should be encouraged to self-regulate and avoid even covert
messages.
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5.12. HEALTH ASPECTS OF DISASTER MANAGEMENT
Introduction:
The Indian subcontinent is prone to disasters caused by natural phenomena. The sub continental
techtonic plate is continuing to shift in a northern direction, giving rise to seismic activities and
phenomena consequently there have been earthquakes, mild to severe in different parts of the
country. The recent major earthquakes affecting the Latur district in Maharashtra and BhujAhmedabad belt in Gujarat are still fresh in our memories. Due to the long coastline and due to the
geographic features of the land mass and ocean, the coastal regions if India are prone for cyclones
and sudden flooding by rise in sea tides. The recent disastrous Orissa cyclone is also still fresh in
our memory.
The immediate effect of a disaster is loss of human life and injuries. The health impact is
compounded by uprooting of human habitations and disruption of social organisation. In the
aftermath of such disasters large populations are housed in overcrowded camps, which make them
prone to outbreaks of diseases. Every developed country has a contingency plan of disaster
management in general and for emergency health care in particular. The Government of India has
recently formed a national disaster management council with members having cabinet rank.
Karnataka State must develop a multi hazard disaster management plan for all districts. The
Department of Health must take the leadership and develop a plan for preparedness to face the
health aspects of disasters within the state.
Can disaster strike Karnataka?
Yes, natural disasters could occur in areas of our state. Hazard maps have been documented by
agencies in terms of risks for cyclone and wind hazards, earthquake and floods. Based on Hazard
maps, Karnataka has:
• Coastal areas of Moderate Damage Risk Zones for Cyclone and Wind Hazards,
• Coastal areas of Low Damage Risk Zones for Earthquake Hazards.
In addition there are the likelihood of disasters on account of:
• Krishna and Cauvery flowing through both the north and south of the state, with the
likelihood of floods,
• Long-term slow disasters like Drought,
• Human made disasters such as riots and conflicts,
• Fire accidents, major industrial accidents,
• Road, rail or plane accidents.
In 1998, Karnataka had sought central assistance to the tune of 13,521.3 million rupees as a part of
National Calamity Relief. In 1998-99, floods and rains affected accounted for 10339 villages
affected, 8.549 million Habitat Population, 310 lives lost, 9,562 animals lost, 1,28,402 houses
damaged. Disaster Preparedness and reduction means appropriate development planning.
-1-
Role of medical teams in disasters:
One of the primary impact areas of disasters is health, both physical and psychosocial. Medical
teams would be required during the early phase of resuscitation following rescue, in terms of care
for injuries and other life- threatening medical problems.
In the next phase when displaced populations develop health problems, typically seen due to
crowding, poor sanitation and hygiene, inadequate nutrition and safe drinking water, medical teams
have major roles in disease prevention, outbreak control and treatment of diseases. In addition
psychosocial counseling and assistance play very important role in successful rehabilitation.
In post disaster progress towards normalcy, children and women, particularly among the poor,
remain vulnerable to deprivation and exploitation. The health teams have a major role to prevent or
mitigate such problems.
Resources available in Karnataka
o NGOs: Numerous major NGOs like OXFAM, Action Aid and Community Health
Cell already exist here in Bangalore and have been involved in "Bangalore
Responses" to major disasters in different parts of the country. Oxfam has an
Emergency Fellow who has an Oxford published India Disaster Report.
o Armed Forces: The services have a contingency plan for disasters and have always
been the most organized and efficient unit where we have had the opportunity to
work with in the past.
o St. John’s Disaster Relief and Training Unit: The only one of its kind among
Medical colleges in India, with a seven disaster experience and motivated volunteers
they could be a boon to coordinating, training and organizing any rapid disaster
response team. The medical college hospital has an Emergency Medicine
Department. They have an excellent ability to improve upon an already existing
Disaster Relief and Training Unit. This institution has lead the Bangalore response in
seven disasters since 1971 Refugee camps.
o NIMHANS: The experts in Post Disaster Stress and Psychosocial consequences are
available with dedicated volunteers.
o HAMs: There are a large number of people who are linked with HAM radio
broadcasting and receiving in the state.
The broad framework of a district level multi hazard disaster management plan
A group of competent persons must be identified for preparing a Karnataka state multi hazard
disaster plan for all districts. The Department of Health must give leadership. The group may obtain
and study the The India Disaster Report (Oxford), the Maharashtra State Disaster Management
Plan, the UNDP led Orissa cyclone rehabilitation activities and other relevant experiences and
reports.
-2-
The group may consider the following items in drafting a plan document.
▪
Institutions and protocols. Identify all relevant institutions including district
hospitals, teaching hospitals and private institutions to be oriented to face
mass casualties. There should be in place clearly defined protocols in case of
a disaster to allow minimum response time and rapid activation of the system.
Members of these centers should receive basic training to be resourceful in a
mass casualties situation.
▪
Manpower: Volunteers identified, classified according to skills, trained and
oriented, updated and with contact numbers/addresses.
▪
Finances: Potential sources and available funds must be identified.
▪
Supplies: Sources, storage areas, WHO essential drug list modified, bulk
instead of samples, labeled, packaged and classified.
▪
Communication: Facilities such as HAMs and Cellular phones are essential
for any disaster.
▪
Transportation: Identification of rapid transportation of personal, equipment
and supplies to sites of need and mobility in the field of action.
▪
Need assessment teams: Personnel identified as specialists able to assess
needs of populations displaced in the field.
▪
Team support and needs: Teams need survival shelter, food and water for
themselves to avoid becoming a burden in the populations they serve.
▪
Coordination: Identification of Coordinators and regular updates between
potential teams. Identification of nodal persons in each district.
▪
Network: Liaison between Government agencies, NGOs, Armed Forces and
Medical Institutions with Relief Team capabilities is a must to effectively
coordinate activities.
▪
Training: Training of all concerned in disaster preparedness and relief is
essential to sensitise volunteers and organizers to the needs of people in
distress. Also survival techniques for self-preservation of team members.
▪
Advocacy: Appropriate advocacy would go a long way in raising issues and
support for not only relief but also preventive measures.
Recommendation
The Government of Karnataka will commission a competent group of expert administrators and
policy makers including those in the field of human health, to prepare a multi hazard plan for all
districts in the state of Karnataka. This Plan should be completed before the end of the year 2001.
-3-
-4-
6. MENTAL HEALTH AND NEUROSCIENCES
6.1 MENTAL HEALTH
The World Health Organisation has defined health as a state of complete physical, mental and
social well-being. The components of Primary Health Care (Alma-Ata declaration) has
promotion of mental health as one of the eight specified areas. While the physical well-being
has been receiving attention, mental health has been largely neglected. Many individuals are
unable to enjoy life because of mental illness or personality disorders. The quality of life
suffers. Such persons can benefit from early psychotherapeutic and social interventions. Recent
developments in therapy have enabled many persons to be integrated into the society as a result
of judicious use of drugs and other modes of treatment; these persons would otherwise have
been incarcerated in the 'asylums'. Early detection and intervention are needed.
Mental disorders
Mental disorder is defined as a clinically significant behaviour or psychological syndrome or
pattern that occurs in a person and that is associated with present distress or disability or with a
significantly increased risk of suffering death, pain, disability or an important loss of freedom.
Karnataka Situation
Karnataka has been in the forefront of mental health care in India and developing countries.
Bangalore Mental Hospital was one of the first mental hospitals for the mentally ill persons
without an outside boundary wall. The first psychosurgery for treatment of chronic mental
illness in India was carried out in Bangalore Mental Hospital in the early 1940s.In Independent
India, the National level institution for the training of psychiatrists, clinical psychologists and
psychiatric nurses, namely All India Institute of Mental Health was set up in Bangalore in
1954.In the 1970s and 1980s Karnataka pioneered the integration of mental health with general
health services and provided the district model for mental health care in the whole country.
Currently the Bellary model of organising mental health care with general health care has been
accepted for national level mental health planning. The state has the opportunity to develop
further programmes at the state level to promote mental health, prevent mental disorders and
provide care for the persons with mentally disorders
Scope and importance of mental health
The scope and importance of mental health ranges from care of the ill to the promotion of
mental health. One of the earliest Indian psychiatrists and from Bangalore, to clearly outline this
was Govindaswamy (1948) as follows:
"The field of mental health in India has THREE objectives. One of these has to do with mentally
ill persons. For them the objective is the restoration of health. A second has to do with these
people who are mentally healthy but who may become ill if they are not protected from
conditions that are conducive to mental illness which however are not the same for every
individual. The third objective has to do with the promotion of mental health with normal
persons, quite apart from any question of disease or infirmity. This is positive mental health. It
consists in the protection and development of all levels of human society of secure, affectionate
and satisfying human relationships and in the reduction of hostile tensions in the community."
The above three levels of activities continue to be relevant at the beginning of the new century.
Mental disorders are more common than most people believe them to be. A number of
epidemiological studies have been conducted in various parts of Karnataka (the first general
1
population epidemiological study in India, was planned in 1956 in Bangalore) and India to find
out the prevalence of mental disorders. These studies have shown that mental and behavioural
disorders are present among about 10 to 15% of the general adult population. About 1% of the
general population has serious forms of mental disorders requiring urgent care. AFR-bout 1015% of those attending general health facilities suffer from common mental disorders
Burden of mental disorders
Epidemiological figures show the enormous burden of illness resulting from psychiatric and
behavioural disorders, both in the community and in primary care. Even so, the burden is grossly
under represented by conventional public health statistics, which until now have tended to focus
on mortality rather than morbidity or disability.
With the development of the new health indicator, the Disability Adjusted Life Year (DALY),
an instrument is now available for calibrating the public health significance of mental disorders,
providing a tool for comparative assessment in a general health context. The DALY is a
composite outcome measure designed to assess the amount of ill health, including premature
death and disability, due to specific diseases and injuries. It adds, for each disorder, life-years
lost due to premature death, and life-years lost due to living in a disabled state. Using the DALY
as a measure, the WHO-World Bank study in 1993 revealed the magnitude of the long
underestimated impact of mental health problems.
Types of mental disorders:
Persons with mental disorders experience psychiatric problems, psychological stress and social
dysfunctioning. Some of them have genetic origin, they have changes in the nervous system:
neurochemical or structural. Others reflect breakdowns of vulnerable people in response to
social and environmental pressures. These different types, biological and social, require
different strategies for management.
Mental disorders with biological origin like schizophrenia, manic-depressive disorder and
organic brain disorders account for 1-2% of the population at any given time. There is need for
early recognition of the problem, sensitisation of the family and the community to their needs,
provision of psychiatric help and provision of a caring environment.
Classification:
There are different ways of classifying mental disorders. The International Classification of
Diseases (ICD 10) is the one now followed. This includes a simplified classification for use in
primary care. It has broad categories such as dementia, delirium, eating disorders, acute
psychotic disorder, chronic psychotic disorder, depression and bipolar disorder. The main
categories of mental disorders included in ICD 10 are based on a mixture of symptoms and
causation. Some of the disorders of individual and public health importance are described
below.
1.
Depressive disorders
Depression is the most common “treatable” mental disorder. It is characterised by
sadness of mood, loss of interest in activities and decreased energy. Other symptoms
include loss of confidence and self esteem, inappropriate guilt, thoughts of death and
suicide, diminished concentration and disturbances in sleep and appetite. A variety
of somatic symptoms may also be present. Though depressive feelings are common
especially after experiencing setbacks in life, depressive disorder is diagnosed only
when the symptoms reach a threshold and last at least two weeks. Depression can
vary in severity from mild to very severe and is most often episodic but it can be
recurrent or chronic. Depression is commoner in women in the ratio of 2:1.
2
Treatment of depressive disorders: The goals of therapy are early recognition and
diagnosis, treatment with drugs and psychological methods to decrease the
symptoms, and continuation of therapy to prevent relapses.
2.
Schizophrenia
Schizophrenia is a severe disorder that typically begins in late adolescence or early
adulthood. It is characterised by fundamental distortions in thinking and perception
and by inappropriate emotions. The disturbance involves the most basic functions
that give the normal person a feeling of individuality, uniqueness and self-direction.
The behaviour may be seriously disturbed during some phases of the disorder,
leading to adverse social consequences. Delusions, strong belief in ideas that are
false and without any basis in reality are another feature of this disorder.
Schizophrenia follows a variable course, with complete symptomatic and social
recovery in a proportion of cases. However, schizophrenia can follow a chronic or
recurrent course with residual symptoms and incomplete social recovery. Individuals
with chronic schizophrenia constituted a large proportion of all inmates of mental
institutions in the past as well as at present, wherever these institutions still exist. A
substantial number of individuals with schizophrenia attempt suicide sometime
during the course of their illness.
Treatment of schizophrenia: The goals of care are to identify the illness as early as
possible, treat the symptoms, provide skills to the family to cope with the situation,
maintain the improvement over a period of time, prevent relapses and reintegrate the
ill person in the community to lead a normal life. The treatment of schizophrenia has
three main components. First, there are medications to relieve symptoms and prevent
relapse. Second, education and psychosocial interventions help patients and families
cope with the illness and its complications, and help prevent relapses. Third,
rehabilitation helps patients reintegrate into the community and regain educational or
occupational functioning.
3.
Substance Use Disorders
Use of psychotropic substances causes a number of health and social problems.
Mental and behavioural disorders due to psychoactive substance use include
disorders due to use of alcohol, opioids (e.g. opium, heroin) cannabinoids (e.g.
marijuana), sedatives and hypnotics, cocaine, other stimulants, hallucinogens,
tobacco and volatile solvents.
Though the use of substances (and associated disorders) varies from region to region,
tobacco and alcohol are the substances that are used most widely and also cause the
most public health consequences. Alcohol also causes a high economic cost on
society. Communities spend more money on taking care of alcohol problems than
they earn by alcohol taxes.
4.
Disorders of childhood and adolescence
Contrary to the popular belief, mental and behavioural disorders are common during
childhood and adolescence. However, attention given to this area of mental health is
grossly inadequate. During the last one year a general population study of children in
the rural and urban areas around Bangalore has been completed.
3
5.
Suicide
Suicide is the result of an act deliberately initiated and performed by a person in the
full knowledge or expectation of its fatal outcome. Suicide is now a major public
health problem. Though only about half of all individuals who complete suicide
have mental disorders, behavioural and psychological factors are important for all.
On an average about one in ten of all suicide attempts result in death. The most
common mental disorder leading to suicide is depression, though the rates are high
for schizophrenia also. In addition, suicide is often related to substance abuse –
either in the person who commits it or within the family. A proportion of suicides
by women are believed to be caused by alcohol dependence among men, though
clear evidence on the extent of this is not available. Against a national rate of 11/100
000 of population, Bangalore city suicide rates are twice that rate.
There are many approaches to Suicide Prevention. These are:
a. acceptance of normalcy of suicidal feelings by the general population;
b. life skills programmes for children and adolescents;
c. enrichment of family life;
d. community institutions for crisis support;
e. crisis help centres;
f. care for people with chronic illnesses;
g. early treatment of mental disorders;
h. help for suicide attempters to prevent repeat attempts;
i. support to families with suicide experience and
j. social policies relating to alcohol, family life.
MENTAL HEALTH CARE IN KARNATAKA
State Level Mental Health Resources:
The mental care resources in the state consist of NIMHANS, Bangalore, Institute of Mental
Health in Dharwad, departments of psychiatry in the medical colleges, private psychiatric
hospitals/nursing homes in major cities like Bangalore, Mysore, Hubli, Davanagere and services
provided by voluntary organisations. Karnataka is fortunate to have a number of organisations
like the Medico Pastoral Association, Richmond Fellowship, Family Fellowship, Cadabams
which provide short and long term care and rehabilitation services. In addition agencies like
Viswas, Helping Hand are involved in suicide prevention. Another important initiative is the
families coming together to develop support to each other like the Association for the Mentally
Disabled (AMEND). There are a number of Institutions for the care of the mentally retarded
individuals. There are a few facilities for the care of the persons with drug and alcohol
dependence. Many professionals have used the newspapers, magazines, radio, TV and movies to
educate the general public.
National Institute of Mental Health and Neurosciences, Bangalore
Karnataka is fortunate to have NIMHANS, though the State lost the Mental Hospital, Bangalore
when it became the All-India Institute of Mental Health and later it became NIMHANS. It is
now a deemed University and reputed National Institute in the forefront of Service, Teaching
and Research. Karnataka must make maximum use of this Institute, particularly in the areas of
organizing the services and training of the health professionals. The Institute can be major
source for conducting surveys and research into mental health problems in the State and the
country.
4
Dharwad Mental Hospital:
This hospital needs considerable improvement on the lines suggested in "Minimum standards of
Care in Mental Hospitals", published by NIMHANS. The Hospital is utilized for the training of
medical students of Karnataka Institute of Medical Sciences. While it should cater for such
training, it should remain as a State Institute with better facilities. There is no other large
institute under State control.
Medical Colleges:
The Medical Colleges and affiliated teaching hospitals should have full-fledged psychiatric units
for teaching, service and research.
It is necessary to integrate mental health with primary health care. Hence the health
professionals and workers at the peripheral health units (e.g. the primary health centre) should
be capable of detecting and managing common mental disorders.
Innovative approaches:
Karnataka has pioneered the development of community mental health programmes. This
approach started with the Sakalawara programme (1975-1980) followed by the Solur
programme(1981-1984) which demonstrated the feasibility of integrating mental health with
primary health care. This was followed by the Bellary District Mental Health Programme.
The results demonstrated the feasibility to integrate mental health with general health services
by choosing priorities and developing proper training programs for the health personnel. This
requires
• the commitment of health authorities to include mental health as part of Primary Health
Care;
• provision of adequate drugs
• availability of support and supervision from the PHC doctors and
• further crystallisation of knowledge regarding the treatment schedules to be used in the
community without daily and continuous supervision of specialized staff.
The National Mental Health Programme (Government of India, 1982) was formulated with
the following objectives:
•
To ensure availability and accessibility of minimum mental health care for all in the
foreseeable future, particularly to the most vulnerable and underprivileged of the
population,
•
To encourage application of mental health knowledge in general health care and in social
development and
•
To promote community participation in mental health services development and to
stimulate effort towards self-help in the community.
During the last few years, the District Mental Health Programme (DMHP) has been launched at
the national level. The DMHP was launched in 1996-1997 in four districts, one each in Andhra
Pradesh, Assam, Rajasthan, and Tamil Nadu, with a grant assistance of 22.5 lakhs each. A
budgetary allocation of Rs.28.00 crores has been made during the Ninth Five Year Plan period
for the National Mental Health Programme.
5
The current programme envisages:
" A community based approach to the problem, which includes
• training of the mental health team at the identified nodal institutes within the State;
• increase awareness in the care necessity about mental health problems;
• provide services for early detection and treatment of mental illness in the community
itself with both OPD and indoor treatment and follow-up of discharged cases, and
• provide valuable data and experience at the level of community in the state and Centre
for future planning, improvement in service and research. The training of trainers at
the State level is being provided regularly by the National Institute Of Mental Health
and Neurosciences, Bangalore under the NMHP"(GOI,2000)".
The DMHP was extended to 7 districts in 1997-1998, five districts in 1998 and six districts in
1999-2000.Currently the programme is under implementation in 22 districts in 20 states.
Action Plan
The state has the responsibility and opportunity to create environments that will promote mental
health, implement measures to prevent mental disorders and organise services so that the ill
individuals recognised early in the illness, receive appropriate care and integrated into the
community.
Towards these goals the following actions are needed.
a. Promotion of Mental Health:
Mental health promotion implies the creation of individual, social and environmental
conditions that enable optimal psychological and psycho-physiological development. Such
initiatives involve individuals in the process of achieving positive mental health and
enhancing their quality of life. The evidence on the health impact of mental health
promotion interventions shows that a significant preventive answer could be given to the
growing mental health problems.
There are two priorities that can be initiated in this area. First of these is to understand the
strengths of the socio-cultural /religious aspects of the community and strengthen those
beliefs and practices that are positive for mental health (e.g.: childrearing practices,
support in crisis, family life). The second is the life skills programs. The life skills
program aims to provide the school age children with skills related to their understanding
of the self and handling their developmental crises, interpersonal relationships and coping
with stress. The widespread use of the school level life skills programs could address the
needs in the area of mental health promotion. NIMHANS and voluntary organizations in
Karnataka have developed pilot programs in this area. These programs should become part
of the school system all over the state.
b. Prevention of mental disorders:
Mental disorders are caused or precipitated by a number of preventable causes. The most
important steps for immediate intervention are adequate antenatal, natal and postnatal care,
immunisation , early intervention for low birth weight babies , treatment of epilepsy and
iodinisation of salt and prevention of foetal alchohol syndrome.
6
c. Head Injury
Crash Helmets can save lives and prevent severe brain damage. Wearing of crash
helmets when riding two wheelers is mandatory in many countries. It was so in our State
also but now it has been removed.
The incidence of head injury was in the range of 120-160 per 100,000 populations with a
mortality of 14-20 per 100,000 populations. Most of them are due to traffic accidents
(62% in Bangalore, 1995). Many factors contribute to traffic accidents: careless driving,
bad condition of the roads, heavy and disorganised traffic. Those who survive the traffic
accidents may suffer from brain damage causing paralysis, loss of mental faculties or
become a mere 'vegetable'. A crash helmet can give a good deal of protection. It could
decrease two wheeler head injuries by about 30-50%. (The highest number of head
injuries occurs in the age groups of 20-29 years (27%) and 30-39 years (19%), the highly
productive age groups). This is a substantial number. Action can and should be taken to
prevent the tragedy of death and disability to the extent we can by the use of crash helmets.
Barriers to mental health care programmes
There are many barriers to mental health care, the promotion of mental health and prevention of
mental disorders. These include the low priority given to mental health in general health policy,
the negative attitudes of community toward mental disorders and limited human and financial
resources. In addition, mental health faces competition from other priorities such as infectious
disease, malnutrition, and infant mortality.
Five initiatives could be employed to tackle these barriers:
•
Organizing services in an accessible and affordable way;
•
Supporting families caring for the mentally ill;
•
Educating people to remove stigma and discrimination;
•
Using community resources through nongovernmental organizations;
•
Formulating mental health policies and financing systems;
Organizing services
There are four ways of organizing services in the state, even with limited resources, so that
those who need them can make full use of them.
The first of these is to humanise the Dharwad mental hospital, reducing the stigma associated
with the mental treatment by converting it into a centre of active treatment and rehabilitation,
and lowering barriers to admission and discharge. This requires improvement in the buildings
and living facilities, enhancing the treatment facilities and increasing the professional staff, as
has been done in NIMHANS, Bangalore.
The second approach is to integrate mental health care with primary health care, which is the
best setting for the care of most mentally ill people.
7
Successful integration requires policy decisions to include mental health in primary care,
adequate staffing, supplies, and training of personnel. It also needs the support and supervision
of mental health professionals as part of a monitoring system. Primary health care personnel
need to be given additional skills of mental health care through brief training programmes,
which should be boosted and reviewed periodically. Essential neuro psychiatric drugs
(chlorpromazine, amitryptyline, fluphenezine decanoate, phenobarbitone, trihexyphenidyl) must
be provided to all health care facilities on a continuous basis. . Including mental disorders in
health reporting systems will enable the monitoring of programmes. Integration with primary
health care does not make mental health professionals redundant. They should regard supporting
and supervising primary care personnel as part of their work.
The Bellary model of mental health care should be extended to all the districts. This requires that
each district has a mental health team both at the level of the district hospital and at the district
health office.
The teams should consist of one psychiatrist, a clinical psychologist, a psychiatric nurse and a
psychiatric social worker. The District Hospital unit should have 10 inpatient beds. Facilities
must be available for all forms of treatment.
The third approach is to enhance the mental health skills of all doctors. All doctors need to
know about the psychological problems and psychiatric disorders of the patients and families
they encounter in the practice of their speciality. This is particularly so for general practitioners,
as they will encounter large numbers of patients with the less severe forms of psychiatric
disorders and psychological problems.
Developing human resources to support mental health programmes is urgently needed and can
be achieved through enhancing the training of psychiatry at the
undergraduate and
postgraduate levels. Undergraduate courses in behavioural sciences for all medical students
would enable them to develop an understanding of the relationships between mind, brain and
body, and to recognize patients' psychological problems and psychiatric disorders.
The medical colleges should be strengthened by creating full complement of staff in the
departments of psychiatry. The duration of training in psychiatry should be two months during
the clinical period in the MBBS course.
The fourth approach is to develop a wide variety of community based rehabilitation facilities
like day care centres, halfway homes, hostels and long stay facilities. This can be jointly
developed with the involvement and support to voluntary organisations.
Supporting families
Families are the primary care providers in the State. Having a mentally ill person in the family
puts a great strain on the members of the family. The caregiver may have to forego his or her
occupation and social life. The members of the family may need training to cope with the
situation. Family therapy is an approach being used now. Families need support from the state
and society in a number of ways, including financial support. They also need an understanding
of the illness in question, and to know how to encourage medication compliance, recognize early
signs of relapse, ensure swift resolution of crisis and reduce social and personal disability. They
can be supported by visiting community nurses and other support staff, and encouraged to form
networks of self-help groups. State should facilitate these initiatives by
8
(i)
(ii)
providing financial support such groups of families,
offering public places in the community for their meetings and organisation of day
care activities,
(iii) developing visiting nurses to support families (at least one nurse for 100 families); a
(iv) involving them in the planning of the mental health programmes.
Employment
People with mental disabilities face numerous barriers in obtaining equal employment
opportunities. Finding work or returning to it after treatment for mental illness is often difficult,
largely due to stigma and misunderstanding of the recovery process.
Multisectoral support is needed for the rehabilitation of the mentally ill persons. The most
important other sectors directly related to mental health are education, social welfare,
employment, justice and the media. An urgent need of the recovered patients is employment.
The reservation of 3% available for the disabled should be implemented and include the
mentally ill persons.
Educating the public
Stigma is a significant barrier to people seeking mental treatment or wanting to feel included in
their communities. The effects of stigma include discrimination, access to housing, employment
and health care, restricted social activity and unwillingness to seek medical help.
While there is no obvious panacea for stigma, there are three specific interventions that can be
taken up in all communities and countries. Firstly, to disseminate accurate information about
mental health, human behaviour, and the real nature of mental disorders; secondly, education in
schools with the same objectives; and thirdly present mental health fairly in the media.
Public education using the mass media and traditional methods of communication is important
to change the community attitudes and beliefs. Myths relating to chronicity of
mental disorders, non- treatability, association of violence with mental disorders and other
myths should be corrected. The mental health education should form part of all public health
education programmes. The existing leaders in mental health education should be brought
together to develop a state level long-term mental health education plan.
The Zilla Panchayat and the local level administration should be charged with the responsibility
of mental health initiatives. The available channels of administration at all level from village to
the state level should be utilised to educate the public and mobilise the local resources.
Nongovernmental Organisations
Nongovernmental organisations are a valuable community resource for mental health. They are
often more sensitive to local realities than are centrally driven programmes, and are usually
strongly committed to innovation and change. In the state they have already shown their value in
the areas of suicide prevention, rehabilitation and community education.
The state should support these initiatives by
•
bringing together the experiences of the voluntary organisations and disseminating the
information for wider use;
9
•
developing funding support for specific initiatives by the voluntary organisations.
Mental Retardation
Mental retardation is a condition of arrested or incomplete development of mind characterised
by impairment of skills and overall intelligence in areas like cognition, language, motor and
social abilities.
Mental Retardation is estimated to occur in 0.5 – 1.0 percent of all children. The degree of
mental retardation varies and used to be classified as mild (IQ 50-70), moderate (IQ35-49)
severe (IQ20-34) and profound (IQ less than 20). Classification on the basis of IQ alone is
outmoded. Mental retardation means a condition of arrested or incomplete development of the
mind, which is characterized by subnormal intelligence. The prevalence of 'severe' mental
retardation was found to be 3 - 4/1000 in a survey of 3 villages in Bangalore District (1981). In
another study in two villages in Bangalore district (1983), the prevalence rate in a sample of
1498 children aged 3-4 years was found to be 27.4/1000. 65.8 percent were mildly mentally
retarded. The male: female ratio was 2:1.
Neurologically disabled children often have multiple deficits – intellectual retardation,
spastically, tremors, difficulty in focusing eyes, articulation problems and voice disorders. Such
children need special educational services. The problems of being slow in hearing, maladaptive
behaviour, inadequate social interaction and associated problems would require special and
expert handling by trained teachers. For the mentally retarded, the focus has to be in personal
care and development of social and vocational skills.
Rehabilitation
The objectives of rehabilitation include improving social skills, being socially adjusted and
accepted in their families and in the society and becoming economically productive. Chronic
mental illness can wreck individual lives, destroy families (unable to cope with the situation)
and create tensions within the community. Rehabilitation avoids these from happening. We
also need to change our attitude to people with mental illness or retardation. It has been said: It
is the society that needs to be rehabilitated.
Recommendations:
•
Train the medical officers and others at the Primary Health Centres to recognize mental
health problems early, manage them effectively or refer them wherever necessary.
•
Have District Mental Health Programmes in all districts on the model of Bellary District
Programme.
•
Ensure availability of essential drugs for the management of mental disorders.
•
Have counseling centers with qualified and trained personnel.
•
All district hospitals to have mental health units with qualified psychiatrists and other
trained staff and facilities for outpatient and inpatient care of the mentally ill persons.
•
All medical colleges to have qualified psychiatrists and facilities for teaching medical
students and for outpatient and inpatient care of mentally ill persons.
10
•
Upgrade the Dharwad Mental Hospital, converting it into a centre of active treatment in a
humane way.
•
Encourage community based rehabilitation of persons with mental disorders, who have
recovered from acute illness.
•
Encourage community based rehabilitation of persons with mental retardation, integrating
them into the society.
11
6.2. NEUROLOGICAL DISORDERS
Among the cluster of non-communicable disorders, prevention and control of neurological
disorders are increasingly being recognised as major health challenges. In Bangalore UrbanRural Neuro-epidemiological study (BURN) of 1,02557 population 3206 individuals had some
neurological disorders, providing a crude prevalence rate of 3126 per 1 lakh population. The
neurological disorders prevalence rate is twice as frequent in rural areas. The commonest
neurological disorders are headache, epilepsy, febrile convulsions, cerebrovascular disorders and
mental retardation in the order of frequency (TABLE-I) (Report of ICMR Research Project. A
neuro epidemiological Survey in urban and rural areas: A prevalence Study 1995).
Table 6.1
Proportional distribution of neurological disorders in urban and rural Bangalore.
Sl.
No.
PLACE
URBAN
RURAL
TOTAL
DISEASE
(N)
%
(N)
%
(N)
%
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
Epilepsy
Febrile Convulsion
Syncope
Headache
Cerebrovascular Disorders
Mental Retardation
Dementia
Parkinsonism
Tremors
Involuntary Movements
Cerebellar Disorders
Demyelinating Disorders
Speech Disorders
Cranial Nerve Disorders
Facial Nerve Disorders
Spinal Cord Disorders
Anterior Horn Cell Disorders
295
102
12
508
71
54
6
9
28
3
7
0
6
1
18
5
27
26.2
9.0
1.1
45.0
6.3
4.8
0.5
0.8
2.5
0.3
0.6
0.0
0.5
0.1
1.6
0.4
609
238
12
640
84
91
7
25
193
6
12
0
4
5
49
14
86
29.3
11.5
0.6
30.8
4.0
4.4
0.3
1.2
9.3
0.3
0.6
0.0
0.2
0.2
2.4
0.7
4.1
905
340
24
1,148
155
145
13
34
221
9
19
0
10
6
67
19
113
26.4
9.9
0.7
33.4
4.5
4.2
0.4
1.0
6.4
0.3
0.6
0.0
0.3
0.2
2.0
0.6
3.3
18
19
Peripheral Nerve Disorders
Disorders of Neuromuscular
Junction
Disorders of Muscle
Posttraumatic Disorders
Postencephalitic / Meningitic
Sequelae
Intra Cranial Lesions
Other Neurological Disorders
26
0
2.4
2.3
0.0
39
5
1.9
0.2
65
5
1.9
0.1
50
50
11
0.4
0.4
1.0
6
15
26
0.3
0.7
1.3
11
20
37
0.3
0.6
1.1
8
13
0.7
1.2
9
38
0.4
1.8
17
51
0.5
1.5
1,221
100.0
2,213
100.0
3,434
100.0
20
21
22
23
24
TOTAL
("NEUROEPIDEMIOLOGICAL SURVEY IN URBAN AND RURAL AREAS: A PREVALENCE STUDY")
1
6.2.1. EPILEPSY
Epilepsy is a common neurological problem. Nearly 50 million people suffer from it world over
and one fifth of them live in India alone. The prevalence was 12 per 1000 in rural areas
compared with 6 per thousand in urban area, with an average of 8.8 / 1000 across both the
population. In absolute terms, there are 16-20,000 persons in a district seeking care of epilepsy
(BURN-study). Hence epilepsy is a significant public-health problem, in terms of burden of
disease nature of illness, and its impact on individuals and families. It also poses a serious
problem in terms of stigma attached with the illness, resulting in limited employment
opportunity, education, marriage and quality of life.
Diagnosis
It is the history from the patient and / or the eyewitness that is very crucial and the vast majority
is diagnosed by careful history. The diagnosis is supported by electro-encephalographic details
though it has its limitations. The universally accepted and useful classification is shown in Fig1.
Understanding the cause of epilepsy is the key issue for preventive programmes. The
commonest type is idiopathic (50%). Causes include, birth trauma, neuro-infection, brain injury,
alcohol, tumors, and metabolic conditions.
Figure - 1
Primary Seizure
1. Simple Partial Seizure with motor, sensory
and automatic or psychic signs
2. Complex Partial Seizures
3. Partial
seizure
with
secondary
generalizations
1.
Primary generalized seizure
Absence (Petitmal)
2.
3.
Tonic-clonic (ground level)
Tonic
4.
5.
Atonic
Myoclonic
Classification of Seizures
Unclassified seizures
Status Epilepticus
Management – Problems:
A major area of concern is delay and failure of regular treatment. In the recent BURN' study it
was noticed that nearly 25% and 10% of urban and rural subject respectively had not received
treatment. An examination of utilization of service revealed that general practitioners were the
major care providers in rural areas. Hence a decentralized management by a trained primary
care physician with trained para-medical worker is the key to the success of epilepsy control
programme.
It has been well acknowledged that epilepsy can be managed effectively with minimum drugs at
community level. Several studies from NIMHANS satellite clinics and community mental
2
health clinics indicate that the improvement rates vary from 60-80% depending on the
compliance of the patient.
The treatment can be given with well established, cheap and effective drugs like phenobarbitone
and phenytoin; though there are other well established drugs like carbamazapine and valproate
which are costly. Ensuring a "seizure free" life improves the quality of life, which requires,
continuous supply of drugs, and compliance of the patient.
Status epilepticus is an emergency in an epileptic. Intravenous diazepam is the drug to be
given immediately and if not controlled the patient has to be referred.
Epilepsy is known to affect number of social (employment, education, marriage, day to day
living) areas.
The stigmas attached, exert significant psychological and behavioural
consequences on the patient. It was noticed in one study that 39% had difficulty in progress of
studies, 9% had work related problems, and 39% had personality adjustment problems. Nearly
15% of individuals had concealed their illness from employers. 22% of urban and 32% of rural
believed in "supernatural" causes for the illness.
Recommendations:
•
Epilepsy Education: It is a key area that needs immediate attention. These programmes
should aim at relieving stigma, and improving the compliance of the patient in taking drugs.
It must also highlight DO's and DONT'S and focus on positive outlook on epilepsy. Involve
voluntary and private sectors. Awareness should be created on Hot Water Epilepsy
particularly in Chamarajanagar, Mysore and Mandya Districts.
•
The primary care physicians (both PHC doctor and private practitioner) and auxiliary staff
have to be trained by a short-term course, regarding diagnosis, treatment, epilepsy
education record keeping and monitoring.
•
Establish and strengthen epilepsy services at district hospitals through out-patients clinics
with adequate supply of drugs. The district medical officers, physicians and paediatricians
may be trained by a short course as it is done at NIMHANS under epilepsy control
programme.
There must be a continuous supply of anti-epileptic drugs.
•
Have a District Epilepsy Control Programme for planning, implementing, supervising and
evaluating, epilepsy services. The programme officer may be incharge of all noncommunicable diseases.
•
Epilepsy and Law: The existing laws need finer modifications with regard to employment
and driving have to be modified.
•
The primary prevention is to be achieved by improved disease control programmes, better
mother and child health care services and measures to prevent accidents.
3
6.2.2 STROKE
The W.H.O. defines stroke (cerebro-vascular disease) as "rapidly developing clinical signs of
focal / global disturbance of cerebral function with symptoms lasting 24 hours or longer or
leading to death with no apparent cause other than vascular origin". In epidemiological studies,
the diagnosis of stroke is chiefly based on clinical observation (e.g. hemiplegia) though in
clinical practice confirmation of diagnosis is by CT Scan. It may not be feasible in India as CT
scan is available only in major cities.
Causes: The major causes of strokes are:
(1) Ischaemic variety resulting in cerebral infarction / ischaemia, due to thrombosis
following atherosclerosis and embolism following rheumatic and ischaemic heart
diseases.
(2) Haemorrhagic variety where bleeding occurs into central nervous system due to
ruptured aneurysm in the young or due to hypertension in the old. The risk factors
involved in cardiovascular disease is almost the same as that of atherosclerosis and
hypertension like smoking, diabetes, sedentary habits, and hyperlipidaemia
Prevalence:
Stroke is a common neurological disorder and ranks fifth in the list of neurological disorders
(ICMR Research project 1995).
The available data from community surveys from different regions of India (both urban and
rural) for hemiplegia presumed to be due to stroke indicate a crude prevalence rate of about 200
per 100,000. A house to house survey conducted at Gowribidanoor taluk by NIMHANS,
suggested a crude prevalence rate of stroke of 52 per 100,000 population.
The clinical diagnosis is accurate in 70-80% cases in trained hands without the help of CT Scan.
Only a few cases might have to be referred to secondary / tertiary centers. It is also necessary to
have some guidelines for reference (See Appendix). In general, any case which is unconscious,,
suspected sub-arachnoid haemorrhage or subdural haematoma has to be referred urgently. In
case of TIA, atrial fibrillation, syncopal attacks, the case has to be referral for evaluation and not
as an emergency. The management strategy is outlined in appendix.
The prevalence rate of stroke above 40 years will be several times (3 to 15 times) more than that
of below 40 years of age. The anticipated costs of rehabilitation of stroke victims will pose
enormous socio-economic burden on our meagre healthcare resources. Hence prevention of
stroke should be our main strategy.
The goal of treatment is to avoid development of cerebral infraction, and if present already to
prevent its progression or recurrence.
Phase I – measures to save life and speeding recovery by maintenance of vital signs,
ventilation, reduction of high blood pressure and cerebral edema
.
Phase II – Rehabilitation and gainful employment
Phase III – Prevention of recurrence by management of risk factors.
4
Recommendations
•
Control of hypertension, discouraging smoking, reducing intake of saturated fats, and
control of obesity are important measures to be instituted at all levels of health care.
•
Antiplatelet drugs like aspirin 100-325mg are prescribed, to prevent further attacks. It may
be used as primary prevention in a person who has a strong family history and risk factors.
•
Nearly 80% of stroke may be managed at PHC level and certain specific cases to be referred
to secondary / tertiary level as an emergency (See Appendix)
•
Training programmes for the management of all causes of neurological disorders to be
instituted at NIMHANS for primary care physicians, both private and public. The training
should be practical and should include physiotherapy.
•
As the principal goal is to prevent the occurrence of stroke, a survey of prevalence of "risk
factors" may be undertaken along with that of Diabetes, hypertension and coronary artery
disease.
Appendix
Stroke – Management at the peripherals
Is it stroke or non-stroke?
1.
2.
3.
4.
5.
Gradual onset and progressive symptoms
History of head injury, ear infection
Persistent head-ache / vomiting
Presence of neck stiffness
Age less than 45-50years
YES
YES
or
No
NO
Non stroke – Refer to centre with CT
scan facility
Likely stroke
Unconscious: refer
Secondary / Tertiary Centre
No improvement after 4-5
days
5
Conscious
Evaluation by
physician. Investigate
Blood sugar, Urea,
Sugar examination
Start Aspirin, Oral
glycerol, control of
HBP, DM
6.2.3. NEUROLOGY AND NEUROSURGERY SERVICES IN GOVERNMENT
MEDICAL COLLEGES
Introduction
The prevalence rate of Neurological and Neurosurgical disorders in the community (excluding
head injuries) is approximately 40 per thousand population. Based on this prevalence rate, in the
State of Karnataka the number of people with neurological and neurosurgical disorders is
estimated to be 2 million. The rapid developments in science and technology have made it
possible to accurately diagnose a variety of neurological disorders and to offer improved
methods of treatment and alleviate the suffering of patients.
Neurology and Neurosurgery services in the southern States – Andhra Pradesh, Kerala
and Tamil Nadu.
In Andhra Pradesh, Kerala and Tamil Nadu, all the Government medical colleges have units of
Neurology and neurosurgery (unit being defined as three faculty members, inpatient ward and
out patient clinics, diagnostic and treatment facilities). Therefore the low-income group people
are provided these speciality services. Each of these states in addition to the facilities in the
medical colleges also has major regional apex centres: Nizam Institute of Medical Sciences in
Andhra Pradesh; Sree Chitra Tirunal Institute of Medical Sciences in Kerala; Madras Institute of
Neurology in Tamil Nadu. There was a parallel development of the regional apex centres as
well as neurology and neurosurgery services in the government medical colleges.
Neurology and Neurosurgery services in Karnataka.
•
The All India Institute of Mental Health, and the Mental Hospital were merged together
and National Institute of Mental Health and Neuro Sciences was established in 1974
funded by Government of India and Government of Karnataka. NIMHANS is
considered as one of the premier institutions in Asia. The Institute is a Deemed
University.
•
Private Medical Colleges / Hospitals
Neurology and Neurosurgery are well developed in private medical colleges at Manipal,
Mangalore, Belgaum, Davanagere, St.John's Medical College, Bangalore, Ramaiah
Medical College and Hospital, Bangalore etc. There are super speciality private
hospitals, which provide quality services. These services are utilized mainly; by affluent
people; people below the poverty level and middle income group find it difficult to
afford the services.
•
Government Medical Colleges
Except in the Bangalore Medical College where skeletal services of neurology and
neurosurgery are available, these services are not available in any of the other
government medical colleges in Mysore, Bellary and Hubli. Even in Bangalore Medical
College, there are no special diagnostic facilities, advanced neurosurgical facilities or the
requisite number of specialists.
Problems of the public in utilizing neurology and neurosurgery services:
Since facilities are not available in the Government Medical Colleges, a large number of patients
have to travel long distances to NIMHANS for treatment with considerable inconvenience. This
often leads to delay in diagnosis and institution of prompt treatment. The resources at
NIMHANS in terms of manpower, diagnostic facilities, drugs and inpatient beds are stretched
beyond the limits and it is not possible to cope up with large number of patients. Inspite of best
6
efforts by NIMHANS the needs of these patients cannot be satisfactorily met. Therefore there is
a need to establish neurology and neurosurgery in the Government medical colleges.
Recommendation
•
The Government of Karnataka must initiate immediate and energetic steps to establish
Neurology and Neurosurgery services in all the four government medical colleges. The
requirements for a Neurology unit and Neurosurgery unit are given in annexures 1 and 2
•
Train physicians and general surgeons at taluka and district hospitals to manage
neurological disorders and head injuries and refer patients, when necessary to the Medical
Colleges / NIMHANS, Bangalore.
Annexure – 1
REQUIREMENT FOR ESTABLISHING NEUROLOGY UNIT IN MEDICAL COLLEGE
1.
Staff
(i)
Consultant Neurologists
-3
(1 Senior, 1 middle level and 1 junior consultant Neurologist. The consultants must
possess superspeciality degree of DM Neurology, with experience of a minimum 7
years for senior consultant, 4 years for middle level and 1 year for junior consultant
after completion of DM degree in Neurology).
(ii)
Residents / House Surgeons
(MD Med./ MBBS)
-6
(iii) EEG Technician
-1
(iv) Adequate ward Staff
2.
Special equipments
(i)
(ii)
3.
Electroencephalograph machine (16 channel)
Electromyography machine (2 or 4 channel)
-1
-1
Inpatient services
25 beds for providing inpatient services
(10 for men, 10 for women and 5 for children)
4.
Outpatient services
Outpatient services should be made available on at least two or three days a week.
5.
Neuroradiology and Imaging equipment
(i) X-ray
(ii) Myelogram
(iii) CT Scan
7
Annexure – 2
REQUIREMENT FOR ESTABLISHING NEUROSURGERY UNIT IN MEDICAL COLLEGE
Neurological unit to have 30 beds with 10 beds for trauma, 5 beds for ICU and 15 beds for
elective cases.
1.
Staff
(a)
(b)
2.
-2 Nos.
-4 Nos.
Nursing:
1) Wards
-12 nurses
2) ICU
- 8 nurses
3) OT
- 8 nurses
Adequate group D staff:
Operation theatres:
1)
2)
3.
Medical
1) Consultants
2) Residents
Elective surgery
Emergency available for 24 hours
-1 OT room
-1 OT room
OP Equipments
1)
2)
3)
4)
5)
6)
7)
Microscope with micro instruments
Controlled suction
Unipolar and Bipolar coagulator
OT table with facilities for adjustable positions (either manually or electrically)
Radio frequency lesion generator
Surgical instruments for craniotomy
-3 sets
Laminectomy
-2 sets
Blood gas analyzer
ICU (5 Beds)
Equipments – ventilators – 3 numbers
ICU Monitors – 5 nos. with facilities for invasive blood pressure, temperature, pulse
oxymeter, ECG, invasive pressure monitoring equipment.
8
6.2.4 HEAD INJURIES AND TRAFFIC ACCIDENTS
Road traffic accidents are among the leading causes of mortality and morbidity in our state. The
estimates of the number of people killed, suffering and disabled exceed the problems of curable and
preventable diseases. With the changing economic reforms, industrialisation and modernisation
accidents are bound to increase over a period of time increasing death and disability. Studies reveal
that the percentage of head injury due to road traffic accidents in Bangalore is 62% (Gururaj G
Neurology India Suppl; 43:95-106). There is enough evidence that indicates the increase in head
injuries due to accidents after the withdrawal of the helmet rule.
Head injury from all causes in Bangalore was found to be in the range of 120-160 per 1,00,000 with
a mortality of 14-20 per 1,00,000 population. Head injury due to traffic accidents forms nearly 2062% of them; the highest is in Bangalore. (Gururaj G. Neurology, Indian Suppl. 1995). Further, the
NIMHANS study at Bangalore suggested 68% of death due to head injuries are due to road
accidents.
Consequences: Damage to brain due to head injury may lead to death, serious brain injury or longterm psychosocial and neuro-physiological problems. These include immediate manifestations like
concussion, contusion, laceration, internal haemorrhage and post-traumatic epilepsy. The long term
effects include, chronic haematoma, personality problems, dementia, intellectual defects, headache,
speech problems and behavioral disorders.
Whenever head injury occurs, it affects the person, family, and society. The cost of management is
shared by the family, the hospital and the insurance company. If the person survives with disability,
the family is burdened both economically and psychologically. Further the cost of death of a young
productive individual, his treatment and rehabilitation is enormous.
Helmet use by Two Wheeler riders
There are many contributory causes of traffic accidents like careless driving, bad roads, heavy and
disorganized traffic and poor vehicle maintenance. The study conducted by NIMHANS on
epidemiology of head injuries in Bangalore, reveals many interesting facts about the two-wheeler
and helmet.
1.
On an average, 60-80 two wheeler riders (including pillion riders) meet with head injuries
every month out of which 6-8 succumb to death. It forms 48% of road accidents, leading to
head injuries. Out of the head injury admissions nearly 10% die during the hospital stay.
2.
Deaths among those who were not wearing helmets was 2 times more as compared to those
with helmets. The severity of head injuries was more and skull fracture was 1.2 times more
among those without helmets.
3.
Use of crash helmets by riders of two wheelers would decrease head injuries by 30-50%
(Status report on head injuries, NIMHANS 1993).
Crash Helmet: Amongst the several preventive strategies suggested for prevention of head injuries
wearing of helmet is one of them. The NIMHANS study and several other studies from abroad
suggest that helmets offer protection and reduce severity, disability and fatality in head injuries.
The amendment made by the State Government, in exercise of the powers conferred by Section 129,
138 R/W section 212 of Motor Vehicles Act 1988 is unfortunate. Because of this amendment if we
go back to section 230 of the Karnataka Motor Vehicles rules 1989, the effect is that the driver or a
rider of a motor vehicle having 11 B.H.P and less than that is not legally required to wear a helmet.
It is known beyond doubt that the maximum BHP of any two-wheeler is 10.5, only barring certain
types of motor vehicles that are not commonly used. (Status report on head injuries and helmets,
NIMHANS, Bangalore.)
After examining the various aspects of head injuries due to road traffic accidents the Task
Force on Health & Family Welfare is of the firm opinion that compulsory wearing of helmets
must be reintroduced in Karnataka. This opinion is in the interest of the public and also the State
exchequer. In a wider context it would enable the safety of the citizens, prevent tragic loss of life
and improve the quality of life.
Controversies: Several spurious arguments are put forth by those who oppose helmet laws. These
are: helmets are unsafe, cause hair loss, increase sweating and discomfort, diminish hearing and
range of vision. There is also an argument that helmets cause strangulation and neck injuries that is
not based on facts.
There is no validity in most of the arguments, when one compares the hazards of not wearing a
helmet. However, there is a need for an improvement in quality of the helmets.
Recommendations
•
Helmets are essential to protect the two wheeler rider and pillion rider from severe, disabling
and total head injury. The law regarding compulsory wearing of crash helmet by riders and
pillion riders of two wheelers must be re-introduced.
•
It is essential to educate the public regarding the road safety measures and benefits of wearing
the helmet. Education and enforcement are complementary.
•
The collective observation from the legal and epidemiological point of view demonstrate a need
for making amendment in the existing act and compulsory wearing of helmets by the riders of
two wheelers must be reintroduced.
•
It needs to be ensured that sufficient quantities of quality helmets are available in the market.
•
A combination of education and enforcement measures is required for promoting helmet usage
in public.
•
An Integrated approach to road accident prevention and control will yield long term benefits.
Frequent changes and amendments in legislation will have a negative result as seen elsewhere.
Bringing about policy changes on a scientific basis will give a firm foundation and rationale for
the proposed changes.
7. NUTRITION
There is rampant malnutrition in Karnataka, inspite of average availability of food being
relatively adequate. This has not assured nutrition security. Progress in health requires good
nutrition.
Percentage distribution of children (12-71 months) according to nutritional grade:
Gomez classification, 1996 - 97
Percentage
Normal (>=90%)
9.4%
Mild malnutrition (75-90%)
39.0%
Moderate malnutrition (60-75%)
45.4%
Severe malnutrition (<60%)
6.2%
Total
100.0%
Source: NNMB Rural, 1999
Status
The issues relating to nutrition, as a parameter that impact on health status of the population
are:
1. Nutrition issues relating to the vulnerable groups: infants pre-school children, school
going age children, expectant young mothers and elderly people;
2. General nutrition issues that relate to the population as such – these include the efficacy
of the public distribution system (PDS), purchasing power of the people; nutrition
education of the public and in medical schools and nursing schools for doctors and
nurses.
3. Monitoring of nutrition, data requirements, reporting and evaluation systems and
feedback for policy formulation and management for enhancing the nutrition status of
the population.
7.1 Issues relating to vulnerable groups
In the case of newborns and infants, the improvement of survival rates depends on the health
of the mother and proper breast feeding practices. The fact that the infant has to be breast fed
soon after birth and why this is necessary is not sufficiently known. Only about 5% of the
newborn are put to breast immediately after birth (within 1 hour). Another 18% start breast
feeding within 24 hours of birth. Majority of mothers (67%) squeeze out the colostrums before
beginning to breastfeed. The benefits of colostrum must be emphasized.
All mothers should be encouraged to have breastfeeding exclusively for the first 4-6 months.
At present, exclusive breast feeding is only 69% for infants in the age group of 0-3 months.
Breast feeding should be continued as long as possible. A majority of women do continue
breast feeding till about 2 years.
The weaning period (after exclusive breastfeeding) between 6 months and 18-24 months is
critical. Semisolid foods must be introduced progressively, while continuing breast feeding.
-1-
Rampant malnutrition exists during this period. Mother is often away at work, usually in the
unorganised sector and breast feeding and supplementation of food do not take place.
Pre-school and school going age children also need greater attention.
Adolescent girl: With inadequate nutrition, discrimination and loss of blood during periods,
there is gross under nutrition, with pronounced anaemia.
Pregnant mother: With increasing demand by the growing child there are unmet nutritional
needs. It is often compounded by certain beliefs and behaviours. Periodical weighing of the
pregnant mother to note weight gain and action should be taken to maintain the weight gain
optimally.
Delivery: There is loss of blood, which can be substantial.
Lactating mother: There is greater need for wholesome food to provide for the growing child.
Nutrition of the elderly is an issue of concern. This is especially so in the case of the widowed
elderly. Their nutritional needs may not be met adequately.
During all these periods, government and the people must assure good nutrition (available,
accessible and affordable) and if necessary, provide free or concessional nutritious food to the
poor.
7.2 Integrated Child Development Services
The ICDS and the school-feeding programmes need to be improved. The ICDS programme,
which has 185 projects, including 10 urban projects, caters to the young children and young
mothers. The coverage and adequacy of the inputs need to be studied. Often the coverage is
only of children of 3-6 years. It is not geared to cater to children below 2 years of age. It would
be necessary to obtain further information and discuss these with the officers concerned. A
major problem has been in growth monitoring. Many of the balances available are defective
and need to be replaced. Associated concerns are:
•
Is the ICDS sufficiently spread out for adequate area and age coverage, accessibility
and training of staff? What kind of restructuring is needed?
•
Can the school feeding programme be enhanced by the use of local raw materials and
with the establishment of local small scale entrepreneurs, to reduce too much
centralisation with consequent management problems of timely distribution, storage and
the like?
•
Can additional nutrients be added – CFTRI formulae?
•
Operationally, can a variety of mixed food items be introduced, including sprouted
horse gram/green gram, rice with amaranths, kidney beans and the like? Can a
reasonable choice be provided, taking into consideration regional availability and
preferences?
•
The ICDS and the school-feeding programme should preferably be based on the
principle of local raw materials, local production and local distribution.
-2-
•
Micro-nutrients such as iron, iodine and vitamin A in the school feeding programmes
must be ensured. The sufficiency of use of oil in these programmes would need
examination.
•
Can we have better empowerment of the people, through improved information?
•
Can we address non-nutritional problems that lead to malnutrition, e.g., safe drinking
water (prevention of gastro-intestinal disorders) and better sanitation?
In the case of young mothers and pregnant women, the possibility of making available ready
and nutritious food mixes to them through the PDS or through local women's organisations
may be considered. The mechanisms of doing so would have to be worked out. In this case too,
the principle of local raw materials, local production and local distribution should apply.
Dependence on food substances from abroad should be discouraged since it generally tends to
distort food habits and introduces foods which are not necessarily better. Soya imports are a
case in point. Similarly, palm oil cannot be considered better than gingelly oil – even if cost
wise it is cheaper. It is said to be more difficult to digest.
It would seem useful to consider further the concept developed by Dr. Swaminathan of a
"Nutritional Garden" consisting of drumstick plants (including use of the leaves), papaya,
gooseberry, etc. There may be regional variation in the composition of the varieties.
Anaemia
Anaemia is a major problem at all ages and particularly among children.
Percentage of children with anemia by age
Haemoglobin grams / decilitre
Age in months
<12 months
12-23 months
24-35 months
Total
>11
43.8
21.9
37.8
34.2
10-10.9
20.8
20.2
16.4
19.2
7-9.9
33.7
48.7
36.8
40.1
<7
1.7
9.2
9.0
6.6
Only 34.2% of the children below 3 years have normal percentage of haemoglobin. Anaemia is
a major problem in pregnant mothers. It can be tackled by the micronutrients intake of iron rich
food and iron and folic acid. Among the other micronutrients, vitamin A (to prevent blindness
in children and infections) and iodine (to prevent goitre in goitre prevalent districts) are
important and adequate intakes must be assured. One dose of 100,000 IU of Vitamin A is given
at 9 months and 200,000 IU given at six-month intervals to children below 3 years. The need
for iodine is being met by the use of iodised salt.
School age children
Children of school going age may be in school or out of school. The nutrition of school
children can be ensured in collaboration with the Department of Education. It is estimated that
over 94 lakhs of children are enrolled in classes 1 to 10 for the academic year 2000-2001. Apart
from nutrition and health check-ups, deworming can be carried out at least once a year.
-3-
The school curriculum can be used for nutrition and health education. The teachers need
training to handle these subjects effectively. The children need help in self-learning to handle
these subjects effectively. The children need help in self-learning for improving their own
health and nutrition.
Out of school children need special attention. The Department of Health and Family Welfare
Services can collaborate with the Panchayat Raj institutions to ensure better nutrition of these
children.
Prevalence of anaemia in women (percentage) – NFHS-2, 1999
Age in years
15-24
25-34
35-39
Severe:
Moderate:
Mild:
Mild
29.3
25.4
25.8
Moderate
16.4
12.5
12.2
Severe
1.7
2.4
2.7
Total
47.4
40.2
40.7
< 7 g/dl
7-9.9 g/dl
10-11.9 g/dl
7.3 The Public Distribution System
The PDS is important since it seeks to establish a minimum degree of distributive justice in
access to food. PDS serves the larger proportion of the poorer population. Its purpose is to
enhance access to food to those whose purchasing power does not permit ready access to the
open market. There are two groups – the below poverty line and the above poverty line. The
emphasis has to be on the below poverty line. The system would need consideration from the
health point of view with regard to:
quality and quantity of food grains including ragi, oil and sugar made available;
presence of micro toxins in the grain available from PDS;
accessibility, timely availability;
management of the distribution system to prevent malpractices;
making available ready and nutritious food mixes to pregnant and young mothers through
the PDS;
other nutritious foods, such as red gram, that could be distributed through the PDS.
Organisational Issues
The involvement of the community in the PDS in the local area and in the nutrition
programmes is essential for ensuring quality, adequacy and good management. The
establishment of Women's Co-operatives for Food (as a Self Help Group) and the involvement
of the women members of the Panchayats would need consideration. Similarly, with the
agreement of government, well established NGOs could also be inducted in this system of
community involvement. The NGOs could, in fact, help in training the local women's groups
in their rights and responsibilities.
Food handling
Street foods need attention. It is necessary to ensure hygiene both with regard to the food
served and the water that is used/drunk. In this context, courses in food handling would have
to be considered. Street vendors could be trained in local areas, compensating them for the loss
-4-
of a day's returns. Such training would also be useful for employees of the hotels, fast food
outlets and the like.
General Issues and data needs
The nutritional status of the population, particularly in the rural areas and of the vulnerable
groups such as the poor women and children, is dependent on the purchasing power,
availability of food and ability to access the PDS in areas where the latter is prevalent. The
socio-economic status of the household often determines its access to sufficient food, its
requirements being conditioned by the work the members of the household do and its
demographic composition.
The nutritional status varies over regions in the State. In particular, the morbidity patterns
reflect the nutritional status.
There are other dimensions to the issue – the diet patterns of sections of the population vary,
there is inadequate education on nutrition and there is an absence of social marketing in this
sector. Even if food is available, the mix would be important, including oils, pulses and green
leafy vegetables.
Malnutrition is widespread and it is reflected in deficiencies in eyesight, insufficient growth
and development and other signs. It is in this context that the possibility of social marketing of
cheaper infant mixes and mixes for pregnant women become important. The shelf life of such
foods is generally small and therefore local production and distribution would become relevant.
For a reasonably efficient programme of reduction in malnutrition, the data on nutrition status
and its parameters would need to be adequate and timely and mechanisms for evaluation of
these data would have to be in place. For Karnataka State, the NIN has carried out the nutrition
survey.
The assessment of deficiency of micronutrients in children, of anemia among younger women,
would need particular attention. The prevalence of hookworm and iron deficiency would also
need to be determined. Morbidity profiles of local areas, particularly of rural areas, would have
to be developed. Such data would be particularly important for the rural areas where the
problem of malnutrition is pronounced. The available data, the reporting systems and the use
to which this data are put would bear examination.
Nutrition education must be introduced in medical education (all systems) and nursing
education. Nutrition education of all the people is necessary.
It would also be useful if an interface is established between local agricultural and horticultural
programmes and practices and nutrition programmes so that the former cater to the local
nutritional needs, based on sound data of the nutritional profile.
Nutrition and Immunity
There is direct relationship between nutrition and immunity.
Breast milk contains
immunoglobulins, which protect the breast fed babies from infections. Diarrheas, measles,
acute respiratory infections and other infections are more common in those who are
undernourished.
-5-
Nutritional Security
Karnataka is fairly self-sufficient with respect to cereals but there is mild and moderate
malnutrition of a high order. We have to eliminate malnutrition to improve physical and mental
development and to assure a better quality of life.
Multi-sectoral co-operation
To reduce malnutrition, a multisectoral strategy is needed: Food, agriculture, health education,
rural development, public distribution, and co-ordination committee can help.
Nutrition Education
Even when the food availability is assured, there can be malnutrition. There is need for
massive nutrition education. It is necessary to ensure the proper use of food by the people.
Nutrition Policy
Policies for combating malnutrition must be based on food rather than "drugs"; farms rather
than pharmacies. There has to be linkages between agricultural research and nutrition research.
So also, there is need to tackle social causes of malnutrition. Malnutrition has peak and lean
periods. It is possible to withdraw feeding and to augment feeding based on the peak and lean
periods. Most importantly, there is need for full involvement of the people and for the political
will.
Recommendations
We must have a holistic approach to solve the problem of malnutrition. The purchasing power
of the poor must be increased.
•
Supplementary food supply to pregnant mothers be increased, based on the need; this can
be assessed based on the gain in weight, after excluding other causes..
•
Breast feeding to commence soon after delivery, to use the highly beneficial colostrums.
Exclusive breastfeeding during the first 6 months. Breastfeeding to continue for 18-24
months (Method: education of the mother).
•
Semisolid weaning (supplementary) food, adequate in quantity and quality, be given to the
infant under the ICDS scheme. In the case of the poor, weaning food be supplied free to the
infants above 6 months (Department of Health Family Welfare services with the help of the
departments of Women and Child Welfare and Food Supplies).
•
Growth monitoring to detect growth faltering, based on weights taken by anganwadi
workers, with well-calibrated balances; follow-up action by the medical officers of PHC. If
malnutrition is severe, admission and management.
•
Prevent infection. If infection occurs, treat promptly.
•
Free mid-day meals (nutritious) to poor school children. (Department of Education).
•
PDS must be strengthened. More foods like ragi, other pulses and oil to be supplied to the
green card holders (Food and Civil Supplies).
•
Encourage the use of green leafy vegetables.
-6-
•
Ensure supply of iron-folic acid to pregnant mothers. Ensure vitamin A prophylaxis.
Calcium tablets to be supplied if indicated, to lactating and older women.
•
Nutrition and Health Education (Health and Family Welfare Services, Medical and
Nursing Colleges and schools, University departments of Nutrition and Home Sciences);
Nutrition education of the public.
•
Improve access to health care of infants, children and pregnant mothers to PHCs and
CHCs with the help of Paediatricians and Obstetricians and Gynaecologists.
•
Safe drinking water and improved sanitation to prevent diarrheas and worm infestation.
•
Periodical (once in a year) deworming.
•
The District Nutrition Officer will co-ordinate the nutrition programmes in the district.
•
Every house to have a kitchen garden. The Department of Horticulture to help with supply
of seeds, seedlings, etc and promote the development of kitchen (nutrition) garden with
drumstick plants, green leafy vegetables, etc. Every PHC to consider possibility of
developing a demonstration plot.
•
Constitute an interministerial co-ordination committee (Health, food and civil supplies,
agriculture, education, rural development and social welfare) to tackle the problem of
malnutrition.
-7-
8. WOMEN AND CHILD HEALTH
8.1.WOMEN'S HEALTH
Why the need to look at Women's Health as a separate agenda • Consequences of poor health of women, as against those of men, are far greater since their poor
health translates into poor health of families, particularly the children who represent the future
generation. A mother’s death has twice the impact of a father’s death on child survival. "Women
- Days- Lost" due to ill health therefore includes many hidden but critical factors which impact
on the family and in the larger context on the health of the community and the nation.
• Also, gender related factors impact negatively on all issues related to women, including health.
Health status of women in Karnataka
The overall health and developmental status of women in Karnataka has improved over the past
several decades. But, the improvement does not compare favourably with that of States like Kerala,
Tamil Nadu, Andhra Pradesh, Maharashtra etc.
There is considerable disparity between Rural & Urban Karnataka, between males & females and
regional disparities with the districts of Raichur, Koppal, Gulbarga, Bidar, Bellary, Bijapur and
Bagalpur characterized as category C due to poor health and other developmental indicators.
Some Health Indicators of Karnataka:
Infant Mortality Rate (IMR)
The IMR is 51.5 according to NFHS-2, and 58 according to SRS 1998. IMR is 70 for Rural and 25
for Urban areas and varies from 29 in Dakshina Kannada to 79 in Bellary.
The Maternal Mortality Rate (MMR) according to UNESCO is 450. But recent estimates by SRS
(1998) places it at 195 per 100,000 live births.
Life Expectancy at Birth (LEB)
The International Conference on Population Development had resolved to target LEB of 70 by 2005
and 75 by 2015. Karnataka has only reached 62. LEB of women was higher than that of men
throughout the State, but the difference ranged from the highest of 9 in Kolar and Hassan and only
0.62 in Bangalore (Urban).LEB was highest in Dakshina Kannada with 68.82 and lowest in Bellary
with 57.12years.
Developmental Indices of Karnataka - HDI & GDI
The Gender-related Development Index (GDI) measures the overall achievements of women and
men in three dimensions of the Human Development Index (HDI) -life expectancy, educational
attainment and adjusted real income and takes note of inequalities in development of the two sexes.
The methodology used imposes a penalty for inequality such that the GDI falls when the
achievement levels of both men and women in a country go down or when disparity between their
achievements increases. The GDI is therefore the HDI discounted for gender inequality.
Though the GDI and HDI are not comprehensive and do not cover all aspects of human
development they serve to highlight disparities within the State as well as the consequences of
gender discrimination.
According to the 2001 census the Gender Ratio in Karnataka is 964 women for 1,000 men, a small
improvement over the previous decade. This is worse than in Kerala, Andhra Pradesh, Orissa and
Tamil Nadu. The Gender Ratio is unfavourable to women in most districts except in Udupi,
Dakshina Kannada & Hassan. The IMR for females is 72, and highest in Dharwad, Bellary &
Bidar. Age specific mortality rates indicate that 26% of deaths of women occurred between 15 –
34years of age as against 15% among men (1991 Census). Also there is a startling decrease in the
sex ratio in the 0-6 years age group according to 2001 census.
Reasons for the poor health status of women in Karnataka:
•
The efforts taken to address women's issues have been inadequate, distorted, vertical, top-down
and have rarely emerged out of women's priority concerns. Gender disaggregated data is often
not collected on women's morbidity, suffering and pain.
•
Health seeking behavior of women: The ingrained gender insensitiveness in society has led to
women themselves relegating their own physical and mental health, emotional and social needs
as their last priority, if at all.
•
The health needs of women are addressed by the RCH programmes, which are restricted to the
reproductive phase. Very little systematized attention is being paid to their other health needs
and much less to their emotional needs.
Factors for consideration:
Gender
Gender is the different meanings and roles that societies and culture assign to people, based on
whether a person is male or female. It is a strong, but often unacknowledged, part of what we learn
as we grow up, for example, how we treat each other and ourselves.
This means that men are expected to behave in a particular manner, women in a different manner
and transgendered persons in another manner. These divisions and roles are not equal between men
and women, and women are usually given restricted roles to perform. This also means that the
impacts of social phenomena are different on the different genders. These roles change with
changing times as well as within communities from time to time due to factors like improved
literacy, higher economic status etc.
Gender Discrimination
From the time of conception the girl child is discriminated against all her life. This includes being
subjected to foeticide and infanticide and sexual abuse; being weaned from breast feeds earlier than
male babies; her nutritional, health, emotional and other needs being given the last priority; having
restricted access to education- either not sent to school at all or if sent, not allowed to complete her
education in order to look after siblings or do household and other work; and are often married off
during adolescence.
The woman is required to meet the needs of her family before her own needs and acquires
recognition as a family member only after she bears a child, and more specifically a male child. She
has very little decision-making power and issues concerning her are marginalized.
When gender discrimination has been socialised and internalised, it is no longer visible to the
gender insensitive. Unfortunately, religion, health care, education the legal system, employment and
the media, reflect and promote gender discrimination. Men continue to control decision-making,
limited family resources, women's sexuality, freedom of movement, access to the world outside
home, etc.
Gender sensitivity
Gender sensitivity is an understanding and consideration of different needs of women and men
arising from their unequal social relations and that a policy or programme can thus benefit women
and men differently.
Gender sensitive indicators
Gender sensitive indicators are required to measure the integration of gender sensitivity into any
given programme. They will point out changes in the status and roles of women and men over time,
and therefore measure whether gender equity is being achieved.
Gender issues related to health care:
Even when available, health care services are underutilized by women:
• They are occupied all day with work related to childcare & household tasks, and work outside
the house, and often neglect illnesses in the early stages.
• Health services available are insensitive to women’s needs. They are staffed with male workers;
privacy is ignored; the timing is inconvenient and long waiting periods result in lost wages.
• Access to health care facilities is inadequate. These include factors like long distances; lack of
transport and even when available an inability to pay for it; a lack of independence that prevents
them from leaving their homes alone and restricts them from using their own income or savings;
the expenditure incurred even in the supposedly free health care facilities etc. This is especially
critical when emergency care is required and is a major factor resulting in high maternal and
neonatal mortality.
• The health needs other than those associated with their reproductive capacity are neglected.
• Their awareness of available facilities tends to be lower than that of men.
• They are also not aware of their rights and often do not think they have any.
In addition to specific actions taken to tackle gender issues in the Health Services, InterSectoral participation is also essential.
•
•
•
•
Access to adequate water, privacy while bathing, toilet facilities, etc. should be ensured.
Gender sensitization of all government functionaries of all departments should be ensured, and
institutionalized within government training systems at the entry and in-service levels.
Women's issues and perspectives must be part of every sectoral plan/programme and not be
limited only to the department of women and child development.
Every department should prepare a women focused action plan. Gender analysis and gender
audit of all plans, programs and policies both before and after should be made compulsory.
Institutional capacity should be created within all ministries to ensure implementation and
independent mechanisms, which include participation of women activists, for monitoring this.
•
•
•
Laws pertaining to Inheritance and ownership of land and other assets may need to be changed
to give fair and equal rights to the women. Necessary mechanisms to ensure their
implementation should be set up, including awareness building.
There should be advocacy for equal wages for men & women.
The Gender Empowerment Measure (GEM) looks at the level of participation of women in the
economic and political life in comparison with men through four indicators- the percentage of
women in Parliament, as administrators and managers, as professionals and technical workers
and the share of women in national income. The GEM and other gender indicators should be
used as the basis for improving interventions and programmes to achieve Gender equity.
Poverty and illiteracy
Poverty coupled with Gender bias and poor socioeconomic status of girls and women limits their
access to education, good nutrition as well as money to pay for health care and family planning
services.
Though the enrolment in primary schools exceeds 8.2 million; percentage of children in age group
6-14 attending schools is 65.3 (rural) & 82.4 (urban) and drop out rates have declined from 69% in
1950 to 16.5%, still 2.6 million children (28%) in 6-14 age group are out of school. Girls
participation has gone up from 44.5 in 1980 to 48 in classes 1to 4 and from 39 to 45 in classes 1 to
7and the drop out rates has declined from 73% to 17%. But still there is need for improvement.
Literacy programmes are not sustained despite good work in the early years. So the literacy rate is
56% for Karnataka but rural female literacy in Raichur is a dismal 16.48%
A low level of Female Literacy is a major factor resulting in high rates of maternal and infant
mortality, female foeticide, skewed sex ratio and dowry deaths. Some reasons for girls not being
sent to school are- to care for younger siblings, housework etc., for economic reasons, fear of sexual
harassment and sexual abuse, far off locations, an overwhelming number of male students and a fear
of not being able to get a groom with higher educational qualification than the daughter.
Women and Work
Wage earning empowers women in decision-making. Non-wage earners do not have this advantage
and their contribution is not even recognized. The downside to this is the fact that very often women
do not have control over their earnings. Also, work outside the home places an additional demand
on the women who are already burdened with household work; reproduction and child rearing; and
family demands- both physical and mental.
Girls start working earlier than boys, work longer and harder throughout their lives. The energy
consumption in mere survival tasks of fetching fuel, water, fodder, care of animals; washing;
cleaning-which are exclusively women’s responsibility, results in negative nutritional balance and
calorie deficit. The situation worsens when women also have to perform hard labour for wages.
They walk long distances to fetch water and fuel, especially in hilly areas; take care of large
extended families; caring of children, elderly, sick husband and animals is done by women alone
with little or no help.
All the above domestic work is unpaid work and is considered unproductive work. Even when
women work outside the house, they do not get equal wages for equal work and are made to
perform unskilled jobs that are poorly paid, more hazardous and demanding. They face various
occupational health hazards. Rural women cooking in poorly ventilated huts using wood and cow
dung cakes as fuel are exposed to 100 times the acceptable level of smoke particles. This is
equivalent to smoking 20 packs of cigarettes a day and can cause Chronic Obstructive Pulmonary
Disease. Women forced to earn their living as commercial sex workers are prone to infections like
STDs, HIV, etc. from their male clients.
Malnutrition
Though the incidence of severe malnutrition has declined to negligible levels, problems due to
milder levels of protein -calorie malnutrition, and deficiency of iron, iodine and vitamin A are seen
among a majority of women & children in India.
Denial of adequate food to girls, partly due to non-availability and partly due to gender
discrimination, results in the lower nutritional status of women. The height for age data shows that
girls are more malnourished than boys in Karnataka indicating the influence of this inequality. This
has life-long consequences for girls and their growth and development is jeopardized especially
during the growth spurt associated with puberty and onset of menstruation. Early marriage and early
pregnancy further deplete their inadequate reserves.
Other than the direct ill health caused, malnutrition and especially anaemia in adolescent girls
shapes the nutritional status of women during pregnancy and lactation, and contributes to mortality
and morbidity in infants and children. (Please see chapter on nutrition)
Post-Menopausal problems
Age-related and hormone related problems in women aged around 45 years or above, range from
bleeding per vaginum / prolapse / Uro-genital problems /cancer / Cardiovascular risk / Alzheimer’s
disease / depression / etc.
Osteoporosis, leading to fractures and resulting problems like life long immobility following hip
fractures for instance, is silent and caused by trivial injuries and even minor physical efforts like
coughing, sneezing, lifting buckets etc. Bone Mineral Density test or Densitometry is a scan which
provides a quick, painless and accurate measurement of bone density, but is accessed by very few.
Osteoporosis is eminently preventable with adequate Calcium intake especially during the teens and
early adulthood.
Psychological and psychiatric problems
Depression due to a variety of causes is seen in varying degrees from the milder Pre-Menstrual
Tension to the most severe kind with suicidal tendencies. Postmenopausal depression is a problem
in a large number of women but is not adequately diagnosed and therefore not documented
especially at the PHC level. Often milder degrees of depression get exacerbated when the woman is
subjected to violence. Conversely, underlying violence could present as depression. This co-relation
of depression and violence is not perceived by health care workers and Medical Officers.
Tuberculosis
TB kills more women annually than all causes of maternal mortality combined. It is the leading
cause of healthy years lost among women of reproductive age group [8.7 Million DALYs lost (TB)
2.5 Million (STD) 3.6 Million (HIV)]. This loss added to the cost of treatment, perpetuates poverty.
And now, HIV and drug resistance is increasing the burden of TB especially in productive years.
Although the prevalence of pulmonary tuberculosis is lower in women, the progression from
infection to disease is higher because of the delay in access to medical care. This is due to
underlying problems of ill health, malnutrition, repeated childbirth; burden of work & childcare;
fear & stigma etc. Children are more likely to be infected if their mother has TB than if their father
has TB. Thus, not only does TB affect women more, women with TB have a greater negative
impact on society.
Reproductive Tract Infections / Sexually Transmitted Infections:
RTI’s can cause pain, dysmenorrhea, discharge, infertility, ectopic pregnancy following pelvic
inflammatory diseases, etc. A large percentage of women are asymptomatic and therefore are
unaware of the presence of any infection until complications ensue.
Prevention, control and management of these diseases amongst women form part of the RCH
programme. But the ineffective implementation of this component, biological vulnerability to these
diseases, the lack of power to negotiate responsible behavior from their sexual partners, all
contribute to increasing incidence of these eminently preventable diseases amongst women.
HIV/AIDS
Incidence & Prevalence:
NACO estimates the prevalence of HIV/AIDS in India at anywhere between 3.5 to 4 million and in
Karnataka upwards of 0.15 million. More than the numbers per se it is the trends, which is alarming.
This includes the steady rise in incidence, with estimates that the numbers are doubling every three
years, and the spread to the “general population” of women and youth. The sentinel survey data
show 1% positivity among antenatal women. Women are also getting infected at an earlier age than
men.
Gender and HIV/AIDS
Lack of responsible sexual behaviour in men is clearly due to the gender roles. Women have fewer
choices and little or no decision-making power, both within the private and public spheres. For
many women, questioning the extra-marital sexual behaviour of their husbands, negotiating condom
use or asking them to get contraceptive pills, means inviting violence.
Other Gynaecological problems:
Abortions
Medical Termination of Pregnancy (MTP) has been legalised under the MTP Act of 1971, under
certain conditions, i.e. only prior to 12 weeks; and thereafter performed if there is documented
evidence and recommendation as a life-saving measure by two doctors.
The spiraling numbers of abortions reflect the increase in the number of inflicted, unwanted
pregnancies which women have to bear. The majority of abortions are almost a substitute for family
planning, as they are sought by married women, some being multigravida. Some are related to
prenatal sex determination & foeticide.
Women also have to bear the consequences of the abortion, be it death due to bleeding or sepsis
following abortion. 20% of maternal mortality is due to abortion-related causes. Despite availability
of legal abortion services, a number of illegal abortions are still being performed by untrained
people, using methods that are not medically approved leading to a high incidence of morbidity and
mortality. The lack of awareness about the services; or a sense of shame and guilt, especially when
it involves young unmarried mothers are some of the causative factors for this.
Infertility
Infertility is a medical as well as major social problem. There is a need to change public opinion and
attitudes towards childlessness of women. Even if the problem is structurally or functionally in the
male partner, it is the women who is labeled and not treated in society with empathy and
acceptance.
Uterine Prolapse
Heavy work at construction sites, walking long distances on steep hills in search of water or fuel, or
climbing 2-3 storeys up a narrow staircase with buckets of water, certain childbirth practices, such
as pressing the abdomen during labour to hasten delivery also leads to prolapse of the uterus,
especially if this is associated with a poor perineal muscular tone due to frequent pregnancies and
malnutrition.
Cancer
Magnitude of cancer problem in Karnataka
Magnitude and patterns of cancer in Karnataka are well documented by both Population Based
Cancer Registry and Hospital Based Cancer Registry of Kidwai Memorial Institute of Oncology
(KMIO).
About 35,000 new cancers are estimated to occur in Karnataka. The average annual age adjusted
incidence rate of cancer from 1982 -1991 was 113 per 100,000 in males and 138 per 100,000 in
females. The higher incidence of cancer in females is due to the greater proportion of cancer of the
cervix and breast. PBCR data shows these two sites of cancer constitute over 40 percent of all
cancers in women, accounting for over 11,000 cancer cases in Karnataka in 1994. It is estimated
that by year 2000, there will be 5447 new tobacco related cancer cases in Karnataka among males
and 3507 among females.
Factors leading to this high incidence include changing life-styles; high incidence of risk behaviour
- both sexual as well as substance abuse; lack of personal and reproductive hygiene etc. Lack of
clean water; poverty, gender inequality etc. are other indirect factors.
In terms of prevention of cancer, whether by primary or secondary prevention, over 60 percent of
all cancers in males and nearly 40 percent of cancers among females fall into this category. But, as
per the HCR about 85% male patients and 90% of female patients present when the disease has
spread beyond the site of origin. It is difficult to give one single reason for this phenomenon.
A combination of factors like lack of awareness, economic conditions, inadequate access to proper
diagnostic facilities, fear of the disease and poor knowledge of the outcome of treatment could
possibly contribute to the advanced stage of presentation.
Cancer Cervix
It is estimated that by year 2000, there will be 5503 new cervical cancer cases in Karnataka.
The study conducted between 1980 and 1986 by the Department of Oncology, Kidwai Memorial
Institute of Oncology found that, cancer cervix formed 40% of female malignances and 88.47% of
all gynecological malignances. About 84% of these women were between the ages of 35 & 64
years; only 0.32% of cases presented for treatment at stage 0 and in the majority (97.1%), cancer
had spread beyond the cervix at the time of diagnosis.
Reasons for delay in seeking treatment were: lack of awareness of the symptoms of cervical cancer
(57.6%) and inadequate advice by medical personnel to whom they had reported their symptoms
(33.7%)
Early Diagnosis of Cancer Cervix
Since treatment of pre-invasive cases markedly reduces cervical cancer mortality and prognosis
declines considerably as the stage of the disease advances, the primary goal of public health efforts
should be to promote early detection through screening programmes.
Cytology-based screening in India is not feasible due to the scale on which it is required (and the
concomitant level of resources), and the lack of quality control. An ICMR study in 1986 estimated
that even with a 12-fold increase in cytology services only 25% of women at risk could be covered
by the year 2000 AD.
But screening by visual inspection of the cervix " downstaging cancer cervix" if used can detect
early stage disease in about 50% of cases compared with the current 5%. A number of women
below the age of 35 years have cervical dysplasia, but only a very small proportion will develop a
malignancy. Thus, for a cost-effective screening programme, screening should have a high coverage
of women above 35 years, and should have a low frequency.
Breast Cancer
It is estimated that by year 2000, there will be 2949 new breast cancer cases in Karnataka, many of
them presenting at late stages for treatment. A study conducted in Bombay points to an increasing
incidence of breast cancer among the urban women, especially among the elite due to factors such
as increased age at first pregnancy, fewer children, decreased lactation etc. This is in contrast to the
incidence of cancer cervix, which is seen more among the rural as well as urban poor due to poor
reproductive hygiene; higher incidence of STDs, numerous pregnancies etc. Infection with the
Human Papilloma Virus (HPV) is also implicated as a causal factor.
Early detection of these cases can be implemented by awareness about self- examination of the
breast by women as well as annual examination by a medical officer. Mammography is also
recommended but is not affordable by the majority of women.
Violence against Women
Violence against women covers the whole gamut of domestic violence, sexual violence, sexual
harassment, rape and sexual abuse, marital rape, forced prostitution; dowry related violence; abuse
of children, neglect of widows and elderly women, etc. It has been recognised as a major public
health and women’s health problem, and occupational health hazard.
Despite a history of law reforms and increasing visibility around sexual violence, violence against
women has continued unabated in India. A first-ever study in India conducted by the International
Centre for Research on Women found that 45% of the women interviewed were victims of domestic
violence. These figures are an underestimation according to researchers, as women were not
willing to talk about it.
According to a research carried out in 1997-98 by RAHI, a support centre for women survivors of
incest, 76% of 600 women interviewed had been sexually abused in childhood or adolescence. 80%
of rapes are perpetuated by relatives or men known to the women; 24% of rapes involve young
girls, less than 16 years of age.
Domestic Torture constituted 30.4% of the total crimes committed against women in 1996, rape
formed 12.8% of the total reported crimes against women in India. Humiliation through verbal
abuse and forcing women to work like servants are extremely common.
A study conducted by Sakshi, an NGO working on women’s issues, in March 1996 revealed that
72% of women respondents had heard or encountered sexual harassment at the workplace.
The number of "missing women per 1,000 men" is an indicator of the increasing violence against
women. This according to Census of India 1991 is 73 for the country and 40 in Karnataka.
Violence against girls and women is prevalent among all-social classes and castes in India, touching
women at every stage of life and linked to their low social status within a patriarchal society.
Violence has its roots in the way men have been socialised to exert social and economic control
over their wives and other females in the household. Control over women’s sexuality is an integral
component of this process, where men believe they have the right to have sex with their wives
regardless of whether or not their wives consented and justified wife beating as appropriate
discipline when their wives refused sex. In a discussion by researchers with men in a Tamil Nadu
village, the justification for violence was "A cow will not be obedient without beatings". When
couples are unable to produce children, it is the woman who is blamed, ostracized and abused,
regardless of which partner is infertile or the cause of infertility.
Violence has a strong bearing on some of the most intractable reproductive health issues - unwanted
pregnancies, forced abortion, HIV and other sexually transmitted infections and other complications
of pregnancy. Clearly then, its implications on policies on issues like AIDS prevention, population
control and ensuring reproductive health rights are immense.
Gender based violence leads not just to physical injuries, but also to psychological problems
including depression and suicidal tendency. Mental cruelty by men with low self worth especially
against women who perform better than them at work, jealousy towards wives are examples of
violence.
Alcohol related Violence
Several studies show that that there is a strong co-relation between substance abuse and domestic
violence. It is also seen that violence during relapse is only during drinking. Failure to address
domestic violence issues among substance abusers interferes with treatment effectiveness and
contributes to relapse.
Woman’s response to violence is limited by the choices available to her. Women prefer to suffer
silently and believe that men are justified in beating them; a way to survive in the marriage and
protect her children and herself.
Though women with better education reported less violence, their economic independence does not
seem to matter much when it comes to resistance.
The very nature and functioning of the present system of redressal is such that women would not
want to approach it for succor till the situation seems to threaten their lives or more importantly,
that of their children.
For the majority of women, there is no safety valve at all. Though some pick up courage to register
complaints with police, the latter refuse to accept, dubbing them as "domestic problems that ought
to be settled within the family itself". They are directed by the police to undergo a medico-legal
examination/ report. Even when there are obvious injuries, in the absence of a fracture these are
recorded as only 'simple injuries' in which case minimal action will be taken. This kind of
minimalisation leads to a lack of clarity regarding the violence suffered, as well as of their rights.
In 1989 the Supreme Court of India passed a judgement in which it used the moral character and
conduct of a minor victim to reduce the sentence of two policemen who were convicted of gang
rape. Expressions describing the minor as "lewd and lascivious"; criticism that she had taken seven
days to report the crime; reflected in the judgement. Despite India's constitutional promise of gender
equality, judgements like this demonstrated how gender bias, stereotypes and myths in dealing with
the phenomenon of violence against women, impact on judicial decision-making.
The need of the hour is to change the irrational prejudices in society and myths and stereotypes that
impact on the mechanisms of redressal available. There is a vital need for gender-sensitizing the
police, lawyers and judges through an interactive educational forum to enable them to understand
violence as women experience it.
Laws pertaining to women like laws related to rape, sexual abuse, sexual harassment, divorce,
marital rape, domestic and other violence etc. have to be changed to empower women. This should
also include changes in the legal procedures and processes to enable the women to have easy access
to justice.
Child sexual abuse
Child sexual abuse is highly prevalent in our society, most of it hidden for obvious reasons. Even
the best studies are only able to elicit history of sexual abuse from a small percentage of the total.
Sexual gratification is seen as a normal need in males, but not so for females; is associated with a
“Macho image”; an aggressiveness that is acceptable. Therefore most sexual acts by men, whether
normal or deviant, and whether within legal and ethical boundaries or not is accepted and is
forgiven. These are some reasons why in India, statistically more girl children than boys are
abused.
With such emphasis on virtue and virginity in girls in our culture, sexual abuse in any degree is all
that more traumatic. History of violence of other sorts in the family should alert the Health worker
and Medical officer to the possibility of child sexual abuse in the family. Long-term effects include
behavioral problems; inability to cope with ordinary everyday situations and relationships long after
the abuse has stopped.
Female foeticide and infanticide
Biologically, 105 boys are born for every 100 girls. In the first year of life, through higher death
rates among boys, these figures even out. Logically, there should be 1000 women for 1000 men.
But Indian population statistics reveal a consistent and alarming decline in the population of women
and, more importantly, girls right through the century.
The sex ratio in Karnataka in 2001 is 964 females for every 1,000 males. There is a decline in the
number of children below 5 years. Whether the sex ratio is less in the group is not clear. One
possible reason for this decline could be female foeticide/infanticide, due to deep-rooted gender bias
in all sections of our society.
The reason for this is that daughters are perceived as an economic and social burden on the family
because of the dowry system, their dependency on males and therefore a lower status of women and
of course the son obsession in our patriarchal society. Most women feel that it is better for a female
to die in the womb than to be ill treated later. On the other hand, the son is perceived as an asset, a
breadwinner, capable of supporting himself and the rest of the family, a person who will continue
the family lineage, perform funeral rights and support parents in old age. If unchecked, foeticide
and infanticide will permanently damage the demographic balance in India. This will lead to an
increase in sexual crimes against girls and women.
Prenatal Sex Determination
Prenatal tests like Chorionic villous biopsy, Amniocentesis and Ultrasonography, which should be
used for detection of abnormalities in the foetus, are widely misused for sex determination by
doctors. Ultrasonography, a non-invasive method done during 14-16 weeks of pregnancy, is
presently the most sought-after, and has a success rate of 96%.
Moreover, doctors have been promoting female foeticide at the cost of woman’s health through life
threatening second trimester abortions. The use of pre-pregnancy sex selection by X-Y Separation
is also increasing.
The Abortion Issue
The subject of selective female abortion is a highly complex issue raising many ethical and moral
questions. The justification for liberal abortion laws in India is for health and humanitarian reasons
and individual entitlement to an abortion by a woman. The government gave licenses to only trained
doctors, some hospitals and nursing homes to conduct abortions on humanitarian grounds under
aseptic conditions. It certainly did not give a license to kill at random and by no means on gender
bias.
Legal aspects:
The first law in India banning infanticide was enacted in 1870 during British rule. The Central
government has begun to regulate prenatal diagnostic techniques. But the nexus between some
doctors and private ultrasound clinics that help determine the sex of the foetus have led to a virtual
epidemic of female foeticide.
Enacting laws regulating the conduct of the medical and paramedical fraternity alone will not check
this deep-rooted social evil that originates from gender bias. Awareness about its dangerous
consequences will help catalyse the evolution of a broad social movement against foeticide and
infanticide.
Violence against women and girls at societal and household levels should be eliminated through
strengthening of institutional capacity, involvement of women, and review of certain existing legal
provisions.
A. Health Sector
1. Domestic violence
•
Guidelines for addressing domestic violence should be incorporated into the national health
policies.
•
•
•
Diagnostic and treatment guidelines for domestic violence and emergency room policies and
procedures for dealing with abuse victims should be developed.
Privacy is essential when interviewing clients about domestic violence and this should be
ensured.
Health personnel should be trained adequately and sensitively to recognize signs of violence, to
do early medical check-ups for trauma & give legal advice and counseling,
The health care giver should be trained to actively look for physical injuries, especially patterns of
untreated injuries to the face, neck, throat, and breasts.
Other indicators may include inconsistent explanations for injuries and evasive answers,
complications in pregnancy, stress related symptoms such as headache, backache, chronic pain
gastrointestinal distress, sleep disorders, eating disorders and fatigue; anxiety, palpitations,
hyperventilation, panic attacks; sad, depressed affect; or talk of suicide. The interviewer should be
trained use concrete examples and hypothetical situations when asking about violence rather than
vague, conceptual questions. They must also be familiar with common excuses used. For example"I only pushed her," " She made me so angry, I didn't know what I was doing." " pressure of
work”….
2. Substance abuse
• Substance abuse treatment programs and domestic violence programs should be linked and
should include specialized counseling; a relapse prevention plan etc.
• All substance abusers should be screened for current and past domestic violence, including
childhood physical and sexual abuse.
• Families have to be counselled to break the cycle of “violence - honey mooning - violence” that
the abuser inflicts on them. It is extremely important to convey to the family that there is no
justification for the battering; that substance abuse is not the real reason for the violence though
it is often used as an excuse.
3. Child sexual abuse
• The Health care personnel should be trained to recognize signs of child sexual abuse which can
include psychiatric problems, abnormal or inappropriate sexual behaviour, physical signs like
genital / anal injuries / bleeding, staining of underwear, pain while passing urine or stools; sores
/ ulcers in and around genitals, anus or mouth, STDs etc.
• Long term psychological support for sexually abused children of a trained counseller /
psychologist / psychosocial worker / psychiatrist should be identified within the Health system.
4. Female foeticide and infanticide
Unless we actively look for female foeticide and infanticide, we will not find it.
• Gender disaggregated data on children born, as well as percentage of female foetuses aborted
should be gathered and studied for trends which can specifically point to particular doctors /
hospitals / nursing homes / ultrasonography clinics where female foeticide is being practiced.
• Information should be collected to estimate the incidence as well as to understand some of the
causes. Religious leaders could be urged to spread awareness about gender issues, violence
against women and the evil nature & consequences of female foeticide & infanticide.
IMA and other professional associations should:
• Disseminate information about Prenatal Diagnostic Techniques Act, 1994 among doctors on a
war footing.
• Sensitize doctors on the gravity of the situation caused by selective female foeticide.
• Socially boycott known offenders.
B. Social support
•
•
•
•
Mechanisms to help women and children in immediate danger from a batterer, including referral
to women's shelters should be available.
Legal, social and rehabilitative support for children abused by a close relative should be ensured
through W&C department.
For long-term support rehabilitation centres, community linkages, professional services
including counseling, legal aid, social security and training in income generating skills, a
directory of information on available support services are also necessary.
The above services if provided by NGOs should have the active support of the Government.
C. Legal and judicial issues
•
•
•
•
•
Police, lawyers and judges should be gender sensitised through workshops and training sessions,
which would make them aware of the nature of violence against women, in particular domestic
violence, sexual violence (including child sexual abuse) and dowry offences.
The language employed in official court correspondence, decisions and oral communication
when referring to women litigants, witnesses and lawyers should be gender sensitive and not
derogatory to women, perpetuating traditional myths about women's roles.
An advisory body of judges, legal activists and women's rights/human rights organizations
should be constituted under the auspices of an autonomous body like the National Judicial
Academy to review past judgements to highlight cases of gender bias, as a starting point of
gender equality education
Certain existing legal provisions and laws regarding rape, dowry etc. may need to be reviewed
and changed.
Implementation of the 1994 law against female feticide & infanticide.
The Karnataka government was most active in the first two years in implementation of the law.
Thereafter the Appropriate Authority has lost interest and has not even met since 1998. They have
refused to register ultrasound machines because of opposition from ultrasonologists.
•
Urgent steps should be undertaken to correct the above to implement the law both in letter as
well as in spirit.
•
To effectively implement the law, criminalisation of female infanticide and victimization of
people involved should be avoided. Otherwise we will not be able to reach out to these already
marginalized women and backward social groups.
Empowerment
The management and monitoring of the basic health services that a community is entitled to by the
community itself would go a long way to ensuring availability, accessibility and quality. The
community should be capable of determining their basic health needs, evaluating the local health
situation and the services that exist and improving upon them. In other words, to ensure that the
peoples health is the people's hands.
Empowerment of the community, especially women, adolescents, the poor and the marginalized to
make informed choices in issues relating to their health, amongst other important decision-making
issues is the single most important factor that needs to be addressed if the health status of the
community has to improve.
Empowerment will enable them to demand and get the services they are entitled to. A strong and
active Panchayat will be able to help achieve this empowerment.
Health education
While the provision of primary health care services (like immunisation; control of diarrhoeal
diseases, acute respiratory infections, malaria, tuberculosis; and provision of antenatal and postnatal
care) are important in the short run, interventions that focus on the underlying causes of ill-health
are much more significant in the long-term. Continued emphasis on the curative approach had led to
the neglect of the preventive, promotive and public health aspects of health care. Health Education
will form part of the empowerment process and therefore will have to be addressed as a long-term,
separate, planned activity.
Recommendations
While general recommendations regarding Nutrition, STD & HIV/AIDS; Cancer control among
women etc. are incorporated in the specific chapters; some specific issues are emphasized here.
1. Recommendations to tackle gender inequality:
•
A department headed by an Additional / Joint Director should be designated to tackle the
impact of gender inequalities on health. Needless to say the head should have a thorough
understanding of gender issues. This department can implement the following recommendations
and also co-ordinate inter- sectoral action, as given earlier.
•
All Health -care personnel should be sensitized on issues relating to gender inequalities. The
curriculum for Medical Education and for training programs for health care personnel should
include gender perspectives.
•
Gender disaggregated data and gender sensitive indicators to evaluate gender equity should be
integrated in all plans & programs. Examples of gender disaggregated data would include birth
and death details, actual consumption or otherwise of the food and micro-nutrients supplied to
pregnant women through the RCH / ICDS programmes; admissions & attendance at schools,
hospital in-patient & out-patient records, immunization details, salary patterns for the same
jobs and so on.
•
This department should support research on women’s health needs and the shortfalls in
fulfilling them.
•
The village level committee should ensure gender equity of all plans and programmes at the
grass roots level.
•
Awareness programmes for the community should ensure responsible behaviour by males.
2. Recommendations to address Violence against women:
Violence against women and girls at societal and household levels to be eliminated through
strengthening of institutional capacity (especially Health, Police and Judicial Sectors);
involvement of women, and review of certain existing legal provisions as detailed earlier.
Health Sector:
•
Diagnostic and treatment guidelines for domestic violence and emergency room policies and
procedures for dealing with abuse victims should be developed.
•
Privacy is essential when interviewing clients about domestic violence and this should be
ensured. The hospitals should be made women friendly.
•
Health personnel should be trained adequately and sensitively to recognize and treat signs of
domestic violence, sexual abuse & violence associated with alcohol abuse; give legal advice
and counseling.
•
Long term psychological support for sexually abused children of a trained counseller /
psychologist / psychosocial worker / psychiatrist should be identified within the Health system.
Female foeticide and infanticide:
•
Unless we actively look for female feticide and infanticide, we will not find it. Gender ratio at
birth and other indicators to show trends, underlying causes etc should be used for communitylevel control programmes. Female foeticide being seen almost exclusively amongst Hindus,
Religious leaders can be used to strengthen the programme.
•
The Prenatal Diagnostic Techniques Act, 1994, should be enforced strictly.
•
IMA and other professional bodies should be encouraged to sensitize doctors on the legal and
ethical aspects; self-regulate and socially boycott known offenders.
8.2 CHILD HEALTH
Preamble:
The ages and stages in a child’s life:
In 1999, the Indian Academy of Pediatrics (IAP) defined the age range of children, for the
purview of Child Health and Pediatrics, as from birth to 18 years. This is a revolutionary
concept in India, which had traditionally accepted the cut-off of 12 for pediatrics, from the days
of the British Raj. Usually children from 13 years are taken to adult medical departments for any
health problems. Since childhood is characterised by growth, maturation and development, at 13
it is too early to count a child as an adult. The Rights of the Child document of the UNICEF
also defines the child as a minor, according to the law of each country. In India, voting right is
given to all those who have become 18 years of age.
For convenience, both conceptually and practically, the different stages of a child’s life may be
divided as follows:
•
•
•
•
•
•
•
•
Prenatal
New born / neonate
Infant / infancy
Preschool child
School age
Teenager / teenage
Adolescent /adolescence
Youth
Before birth
0-28 days
Below 1 year of age (First year of life)
Below 5 years of age (First 5 years of life)
5 to 16-18 years of age
13 to 19 years
13 to 18-20/21 years
10 to 24 years
Issues of concern in Child Health:
Child survival
The early part of childhood, especially the neonatal, infancy and even preschool age are a
vulnerable period for many illnesses and adverse outcomes. Thus, child survival, especially
survival with no damage to the processes of growth, maturation and development, is of prime
concern in the preschool age period.
In many rich nations of the world, only less than 10 children are lost by death, during the first 5
years of life, among 1000 infants born alive. On the contrary, in India more than 100 would die
before the fifth birthday. Of these, about 70-75 deaths occur in the first year of life (infant
mortality). From the time of independence our infant mortality rate (IMR) has fallen reasonably
steadily, but relatively slowly, from about 140/1000 live births to about 70-75 today. However,
during the last 5 years, the IMR has not declined. In Karnataka, the estimated IMR was 81 in
1981 and 74 in 1991. More recently, the IMR estimate in 1998 by the Sample Registration
Scheme (SRS) was 58. There is gross urban-rural disparity in IMR. The urban IMR is 25, while
the rural rate is 70. This is a pointer to the deficiency of access to health care in the rural
communities. The National Family Health Survey 2 (NFHS-2) has given the IMR as 51.5 in
Karnataka. For comparison, the IMR in Kerala is 14 (SRS, 1999).
We do not have wholesome data on IMR based on registration of all births and deaths. On the
other hand we collect information during decennial censuses, and in between by SRS and by
NFHS. We must strive towards achieving complete registration of births and deaths in all
communities, as early as possible. This is necessary not only for equity and quality in primary
health care and in public health, but also for good governance in general. In this age of
information, storing and analyzing data are easy, but the collection of primary data is what the
Government must now concentrate on. The decentralized administration is an ideal set up for
achieving this.
Approximately one half of deaths during infancy occur in the first 4 weeks of life. This is
referred to as neonatal mortality. High neonatal mortality is a clear signal of inadequate access
to, or utilization of, health care services. Unless neonatal mortality rate (NMR) is reduced,
we will not be able to substantially reduce IMR. Universally, the demographic indicator of
the total fertility rate (TFR, reflecting the complete family size) and IMR are inversely
correlated. In other words, we must further reduce our IMR not only for the benefit of our
children, but also for reducing our population growth. Similarly, we must reduce our TFR
to improve child survival with quality.
Table 15.1: Childhood Vital Statistics: Karnataka (NFHS-2)
Childhood Vital Statistics
Perinatal mortality rate
Neonatal mortality rate
Post-natal mortality rate
Infant mortality rate
Under-5 mortality rate
Karnataka
:
:
:
:
:
Urban
:
Rural
Breast feeding within one hour of birth
:
Exclusive breast feeding for first 6 months :
Low birth weight
47.8 / 1000 live births
37.1 / 1000 live births
14.4 / 1000 live births
51.1 / 1000 live births
69.8 / 1000 live births
27-56%
33-41%
5.4%
3.2%
Interventions for child survival: The unfinished agenda.
Several child survival interventions had been applied in India over several decades. The
expanded programme on immunisation (EPI) was established in 1978, and upgraded to the
universal immunization programme (UIP) during 1985-1990. Since then there have been several
national programmes like control of diarrhoeal diseases (CDD), control of acute respiratory
illness (ARI), growth monitoring, oral dehydration, breast feeding, immunization, integrated
child development scheme (ICDS), child survival and safe motherhood (CSM), integrated
management of childhood illnesses and reproductive and child health (RCH). In spite of all
these, childhood mortality continues to be high. The EPI /UIP has been a major success story,
but it still remains an unfinished story. While the official reports in Karnataka show 100%
coverage for all vaccines (Health Department Annual Report 1998-99), independent assessment
indicates that the coverage of full immunization is in the range of 60-80% (Government of India
Ministry of Health and Family Welfare. Evaluation of Routine Immunisation, 1997-98). The
coverage of measles immunization has been assessed to be only 52% (Human Development in
Karnataka 1999, p25).
Although we have been able to reduce the incidence of gross protein energy malnutrition, iron,
iodine and vitamin A deficiencies, mild to moderate undernutrition, growth retardation and
stunting continue to be highly prevalent. Optimum nutrition is a major positive factor for child
survival. Infectious diseases tend to be milder in well-nourished children, while they tend to be
more severe and cause death more frequently in undernourished children. Repeated infectious
diseases tend to cause negative nitrogen balance and induce undernourished state of physiology.
Prevention of diarrhoeal diseases
• Exclusive breastfeeding upto six months
• Complementary feeding with fresh low cost weaning foods at 6 months along with
breastfeeding upto 2 years.
• Personal hygiene (handwashing after defaecation, before feeding and before preparing
meals).
• Provision of safe drinking water and good sanitation.
Training of mothers to use house available foods, oral rehydration solutions and recognition of
danger signs.
Reducing neonatal mortality
There is urgent need to address the high neonatal mortality in Karnataka and to take remedial
measures. For a large proportion of rural women, delivery is conducted at home. Trained birth
attendants, or Dais, assist most such deliveries. The Dai assists in the delivery of the baby and
then continues to look after the mother until the placenta is expelled and the mother is stable.
During this time, women from within the household or the neighborhood handle the baby. They
are not trained to care for the newly born. The infant has to be watched during the first 60
seconds for the establishment of breathing (usually heralded by the cry). Some infants do not
breathe spontaneously, and are prone to develop birth asphyxia. Immediate interventions, by
way of clearing the throat by suction, physical stimulus, or bag and mask ventilation, can make
all the difference between a normal baby or a brain-damaged baby. This simple but crucial skill
can be imparted by training, to women of ordinary intelligence. A second birth attendant, trained
to receive and resuscitate the newly born baby, will be an asset to our health care system.
Interventions that can reduce neonatal morbidity and mortality
• Antenatal care: Diagnosis and treatment of anaemia, UTI / RTI / TB, TT immunisation.
• Intrapartum care: Preventing prolonged labour, management of complications, clean
delivery, clean cutting of the cord.
• Post partum care: Optimal care of the cord, early and exclusive breast feeding.
• Case management protocol for community care of sick neonates.
• Training of TBA, AWW and village level health workers in the identification and
management of high-risk babies.
Additional advantages of the availability of an advocate for the infant
The availability of a trained second worker, either a local volunteer, or a functionary of the
primary health care system or the ICDS, will provide further opportunities to care for the new
born and improve neonatal survival. For example, she could be trained to keep the baby dry,
recognise and correct hypothermia, establish early breast feeding and provide support for the
mother for breast feeding – exclusive breast feeding – for at least 4 and no more than 6 months.
She can also help introduce supplementary (weaning) feeds in a correct and clean manner. She
could monitor the weight gain of the baby frequently, she could identify sickness or sepsis very
early and either start therapy or immediately seek medical attention. She could continue
counseling the mother on good immunisation practice, and on hygiene in food preparation. The
same second health worker could be made a skilled resource person for oral hydration during
diarrhoea, and for the early detection, management and referral of infants with pneumonia.
Improving immunisation services
Immunisation can be used for achieving further reduction of childhood morbidity and mortality,
provided two issues are taken into account. The first is to improve the efficiency, coverage and
effectiveness of the current immunisation programme, with the traditional vaccines. It has been
noted that the high immunisation coverage levels are not being sustained. The literacy level of
people is an important factor in parents themselves understanding the value of immunisation and
taking responsibility to sustain high coverage levels. The second functionary, as described
earlier, would be a source of information and support for the mothers of infants, guiding them to
the correct schedule, helping them to go to the health centers and to be available in case of fever
or local inflammatory reaction at the injection site. This approach is most likely to improve
immunisation coverage levels in the community.
The success of an immunisation programme is to be measured not only by coverage evaluation,
but also by two outcomes, namely the reduction of the incidence of the target diseases and the
creation of demand by the parents for sustained immunisation services. The incidence of
diseases is not being monitored, and this needs to be rectified by establishing a disease
surveillance system for vaccine-preventable diseases. A disease surveillance system, for
vaccine preventable diseases, must measure the incidence of target diseases and to measure
the success of immunisation by way of reduction in their incidence. Such a surveillance
system will also act as an important survey of the quality of immunisation programme in general
and specific vaccines in particular. The second issue to be addressed is to systematically assess
the need, the costs and the benefits of introducing newer vaccines in the universal immunisation
schedule. The safety, efficacy and epidemiological need for newer vaccines must be assessed
periodically by an expert group, for which purpose, there is need to establish a State Advisory
Committee on Immunisation Policies and Practices.
Newer Vaccines
All newer vaccines are relatively more expensive than the traditional EPI vaccines. This is partly
because most of them are the products of heavy investments in research, some even patented.
Production costs are high and the number of manufacturers are few and market competition
relatively low. Rich countries have been quick to introduce several newer vaccines as they find
them cost-beneficial. In countries like ours, these vaccines remain in the private market,
companies having to promote the product by advertisements, incentive for practitioners, and
maintain stocks at their own risk and cost. For all these and for profit reasons, the prices remain
high. The Government sees this price structure and shies away from considering them for
routine use. The prices are likely to crash if the Government directly purchases such vaccines or
obtains them through global tender purchase through the UNICEF. Even if the Government can
purchase newer vaccines at lower costs, it may not be necessary for the Government to incur the
entire expenses for disease prevention by immunisation. As long as the availability of free or
subsidized vaccines for the low income families is ensured, the rich may be left to obtain
their immunisation in the private health care system, at no cost to the public sector health
care system.
The need to include hepatitis B vaccine in the routine schedule
Hepatitis B virus infection is common, but silent, particularly in children. The chronically
infected pool is high. A recent study in Karnataka has confirmed the prevalence of carrier state
in the range of 3-5% even in children (Indian Pediatrics 2000;37:149). Most of the
consequences of chronic Hepatitis B virus infection, such as chronic hepatitis, cirrhosis and
cancer of the liver are seen in adults, but these are mostly due to infection acquired in early
childhood. A large proportion of acute fulminant hepatitis is due to HB virus. The State
Government may consider a policy to introduce Hepatitis B vaccination in our universal
immunisation programme.
Other vaccines for urgent consideration by the Advisory Committee:
There are several other newer vaccines already licensed in India for use in children. They
include the measles-mumps-rubella (MMR) vaccine, Haemophilus influenzae type b (Hib)
vaccine, chickenpox (Varicella) vaccine, hepatitis A vaccine, three kinds of typhoid fever
vaccines, and Japanese encephalitis vaccine. While the proposed Advisory Committee may
examine the need for these vaccines in general, the two diseases typhoid fever and Japanese
encephalitis deserve to be counted as major public health problems for designing special control
measures including systematic immunisation.
Child nutrition
Since the nutritional status of exclusively breast fed infants is excellent during the first 6 months
of life, it is important to ensure that such breast-feeding is ensured in all communities. However,
growth faltering begins usually from the seventh month of age, indicating the inadequacy of
complementary / weaning diet of the infant. What matters more is the quantity of food offered to
infants, rather than what type of food is offered. Mothers tend to assume that the infant cannot
digest foods and offer diluted food items, which often leads to deficiency in total calories. The
infant can be given most of the food items eaten by older children and adults. A close watch on
growth monitoring during the second 6 months of life is very important. If the velocity of
growth is to be maintained, then mothers need counseling and support and this function can best
be served on a one to one basis, by the infant’s advocate described earlier. Literacy and mother’s
educational level also is another factor in good nutrition of the infant.
Table 15.2: Nutritional Status of Children in Karnataka NNMB Survey, 1996
Nutritional Status of Children in Karnataka
NNMB Survey, 1996
Nutrition Status
Rural
Tribal
Urban
Normal
Moderate malnutrition
Medium malnutrition
Severe malnutrition
9.5
38.6
45.5
6.4
2.3
15.1
49.1
32.9
2.5
37.7
53.3
6.3
Early child nutrition has implications beyond the child’s own growth and development. Low
birth weight of newborn infants is a major contributing factor in high neonatal mortality rate.
Undernourished girls grow up as short women and tend to give birth to small for date babies.
This inter-generational effect of early nutrition is an important factor for child survival in the
next generation.
Vitamin A deficiency in its severest form leads to blindness. It is necessary to ensure vitamin A
supplementation to all children below 3 years of age. Colostrum, rich in vitamin A should be fed
to all newborns. Nutrition education and linkage with the Horticulture Department for locally
growing vitamin A rich fruits and vegetables should be part of the strategy.
Adolescent population
There is an increasing adolescent population with specific needs, which are not met by the
present health and social structures. India's adolescents (10-19 years) population is estimated at
21.8%, and married adolescents at 20 per 1000 population. 6% urban and 21% rural woman
aged 15 to 19 years married before the age of 15 years.
Adolescence is a period of transition from childhood towards adulthood. The body grows and
acquires maturity in sexual characteristics and functions. The processes of growth, maturation
and development span across the body, mind and spirit. It is a period of intense self-awareness
and the development of personal identity. Yet, this is also a neglected period from the point of
availability of care and guidance.
A majority of adolescent girls have nutritional inadequacies including under nutrition; stunting;
iron deficiency and anaemia; deficiencies of other micro-nutrients like iodine, vitamin A;
calcium, zinc and folate. This results in malnutrition during pregnancy and therefore to maternal
and infant mortality and morbidity.
Adolescent fertility is estimated at 17% and contraceptive practice is very low. Unmarried
adolescents (who constitute a sizable proportion of abortion seekers), often delay their abortions
until dangerously late because of ignorance or fear of social stigmatization.
Two problems of adolescents stand out in our society. One is increasing prevalence of HIV
infection in youth. Sexual behavior patterns which set in during adolescence can lead to sexual
and reproductive health problems; RTIs & STIs; HIV/AIDS; the majority of new infections
occuring in the age group of 14-24years. The second is increasing frequency of stress-related
problems, the culmination of which manifests as suicide, attempted or completed.
Other issues related to adolescents are sexual abuse, prostitution, street children, violence,
suicide and substance abuse. It has been found that in the six major cities of India, 15% of
prostitutes are below 15 years and 24% between 16-18 years of age.
Adolescents are capable of responsible behaviour and can take the right decisions if empowered
with information and the freedom to do so.
They need health information and services particularly with regard to nutrition, sexuality and
reproduction. There is need to promote reproductive health among adolescents. Right to factual
information to maintain good health must be met, because in reality, peers and parents often give
misinformation, pass on dangerous beliefs and practices or transmit a dis-empowering mind-set
regarding sex and sexuality.
There is the urgent need and the opportunity to design and implement adolescent care and
educational programmes. Family life education, basic understanding of sexuality, genital
hygiene, interpersonal relationships and conflict-resolution, coping capacities for the stresses of
increasing responsibilities and expectations of parents, teachers and peers and many such issues
are the needs for authentic information for the growing adolescent.
Special training of pediatricians for establishing and running teenage clinics is one remedial
measure. Including family life education in school curriculum is another. In both settings,
counseling facilities should be made available.
Child labour
The challenge before us is to eliminate child labour by an integrated, multi-sectoral plan of
action, which would cover rehabilitation, education, health care and vocational training. Public
opinion has varied from total ban to prohibiting child labour in hazardous industries and
regulating and improving working conditions in other industries. But the time has now come to
ensure that all children of school going age are studying in school and their physical, mental and
social development assured.
Children in especially difficult circumstances like street children and rag pickers need our
attention. They are exposed to all kinds of hazards and infections. They are abused, physically
and sexually, neglected and abandoned. Concerted efforts are needed to improve the quality of
life of these children.
Recommendations
•
Have an additional health worker trained to receive and resuscitate the newly born along
with other duties to be appointed by the Gram Sabha. This may be done as an experimental
measure in the 7 northern districts found to have lower health status and extended, if found
useful.
•
Institute a disease surveillance system for vaccine preventable and other important
communicable diseases.
•
Establish a State Advisory Committee on Immunisation Policies, Practices, Monitoring and
Evaluation.
•
Tackle the major childhood problems of diarrhoea (leading to dehydration) and acute
respiratory infections.
•
Develop Indira Gandhi Institute of Child Health as per the apex body for training, service
and research in child health.
Recommendations for improved services for adolescents:
•
Health education for children and adolescents should be the responsibility of the Health as
well as Education department. This should be integrated into the formal school system and
should include nutrition; sanitation; reproductive health, RTI/STI; HIV/AIDS; substance
abuse etc. Apart from this values & life skills; gender issues; etc. should be emphasised to
ensure responsible behaviour. Alternate mechanisms to reach school dropouts should be
identified.
•
Provide access for teenagers to health service delivery points such as PHCs, subcentres and
CHCs, ensuring privacy and confidentiality.
•
Provide lab-diagnosis based treatment & counseling for RTI/STI; safe MTP services to all
married/unmarried adolescent girls irrespective of age.
8.3 REPRODUCTIVE & CHILD HEALTH PROGRAMME
Reproductive health is the preventive, curative & promotional aspects as pertaining to the
reproductive system and its functions in men and women.
Reproductive health should address the following aspects at all stages of people's life:
1. Sexual and reproductive rights
2. Information on, and interventions for, responsible reproductive & sexual behaviour.
3. Access to safe prevention and management of infertility.
4. Access to effective, affordable, and acceptable methods of fertility regulation of their choice
5. Elimination of unsafe abortion;
6. Appropriate health care services that will ensure safe pregnancy and childbirth
7. Effective control of reproductive tract infections and sexually transmitted diseases.
8. Prevention and treatment of malignancies of reproductive organs.
Factors that impact reproductive health include gender inequality; nutrition; infant and child health;
adolescent health and sexuality; lifestyle, environmental; social and cultural behaviour. In
Karnataka, as in most of India, there is minimal communication between husband and wife about
their sexuality & sexual relations. Men generally have greater influence than women, in all family
decisions, especially those related to reproductive intentions - contraceptive use, planning of
pregnancies, number of children etc.
It is also important to note that though both men and women have problems related to the
reproductive system, the suffering of women due to reproductive health problems is far greater.
This is due to the fact that women alone are at risk for complications of pregnancy and childbirth;
potential side effects from most contraceptive methods; consequences of unwanted pregnancy & its
prevention & management including unsafe abortion; increased vulnerability to RTIs & STIs etc.
Maternal Mortality
WHO defines maternal death as “the death of a women while pregnant or within 42 days of
termination of pregnancy, from any cause related to or aggravated by the pregnancy or its
management, including abortion”. 40 per cent of pregnant women develop one or more life
threatening complications. Of these five main causes: post-partum hemorrhage, unsafe abortion,
sepsis, eclampsia and obstructed labour account for 85% per cent of all maternal deaths due to lack
of rational management of high-risk mothers and of those needing emergency obstetric care.
Indirect causes such as anaemia and malaria account for about 15 per cent of maternal deaths. For
every women who dies during childbirth, around 18-20 women survive complications, for example,
cervical lacerations, pelvic inflammatory diseases, anaemia, uterine or bladder prolapse, vesico
vaginal or recto vaginal, infertility, etc. Since it is not a matter of demographic concern, reliable
figures regarding these complications are not easily available.
It is often forgotten that women also suffer from communicable and other diseases during
pregnancy with attendant morbidity & mortality in the mother and the child. These include malaria,
Viral hepatitis, Tuberculosis, Rheumatic heart disease, diabetes, etc. Malaria in pregnant women is
associated with intrauterine growth retardation, spontaneous abortion and stillbirth. In the neonate
congenital malaria presents within 48-72hr after delivery.
Parasitic infections like Amebiasis, Giardiasis, Malaria, Nematodes etc. interfere with the nutrition
of women and result in a worsening of the already critical nutritional status with resultant impaired
fetal growth.
Medical complications during pregnancy also affect the child, which increases foetal and perinatal
death as well as morbidity like premature birth, low birth weight and infection among children.
Nutritional insults during the first trimester may set a low fetal growth trajectory and once set, the
potential for later catch up in growth or functions appears to be limited.
Health and Family Welfare Policy
In the past, India’s Health and Family Welfare Policy focused on meeting contraceptive “targets”.
The programmes virtually ignored women who were not of child bearing age (adolescent girls,
single women, women with infertility and post-menopausal women). Even among child- bearing
women, only sexually active women, especially those who had not yet “completed their desired
family size” were targeted for reproductive care interventions. They failed to address the root causes
of women’s poor reproductive health status, and consequently did little to improve their general
well being over the long term.
The International Conference on Population Development, held in Cairo in 1994, and The Fourth
World Conference on Women, held in Beijing in 1995, emphasized the need to empower women to
access services relating to all aspects of their health. It asserted that improvements in women’s
health needs should be met through the availability of affordable, comprehensive, integrated and
holistic care, within easy geographical reach of women. Reproductive health and primary health
care programmes are expected to address these gaps in health service delivery, mainly by dealing
with the comprehensive health problems of women and incorporating gender equity concerns into
their programmes.
Following this, the Government of India’s Health and Family Welfare Programme changed to
a more comprehensive Reproductive and Child Health (RCH) Programme offering the
following:
a. Prevention and management of unwanted pregnancies and family planning services including
spacing and sterilisation as also providing services for MTP to women who choose this option in
order to avoid incidences of unsafe abortion.
b. Safe motherhood (ante natal, natal and post natal) services:
• Antenatal care and identification and referral of high risk pregnancies to the first referral
units.
• Immunisation with 2 doses of Tetanus toxoid
• Prevention, detection and treatment of anaemic pregnant women with Iron Folic Acid (IFA)
tablets.
• Natal Care
• Delivery as far as possible, in institutions under the care and supervision of trained qualified
personnel or assisted by LHVs, ANMs or trained birth attendants. Emergency obstetric care
services for high-risk labour cases
• Postnatal Care - for 42 days after delivery of the placenta
• Advice and guidance to the mother about breast-feeding, nutrition, hygiene, care of the
newborn and immunisation.
•
Referral for immediate emergency obstetric care in case of fever foul smelling discharge,
bleeding, abdominal pain, painful breasts, pain while passing urine and abnormal behaviour.
c. Diagnosis and treatment of RTI & STI
d. Child survival – care of new born
• immunisation
• management of diarrhoeal diseases and acute respiratory infections.
• Vitamin A prophylaxis
RCH programmes in the rural areas
The RCH programmes in the rural areas are implemented through the Primary health care facility
network of Sub-Centres and Primary Health Centres. The Community Health Centres (CHCs) and
Taluka Hospitals are the First Referral Units (FRUs).
The ANMs play the major role in these programmes and are assisted by traditional birth attendants
who also provide antenatal and delivery services. The ICDS programmes of Women & Child
Department, through Anganwadi workers are responsible for ensuring access of the health care
services for children up to 6 years of age. The Male Health Workers are supposed to focus on
motivation of males to access family planning and other health care services.
RCH Programmes in the Urban areas
Urban RCH programmes are within the ambit of the City Corporations or Town Municipalities.
In Bangalore for example the Bangalore Mahanagara Palike has 30 maternity homes, 37 Urban
Family Welfare Centres (UFWCs) and 55 health centres. In addition there are 25 dispensaries and
some Ayurvedic clinics for general ailments under the BMP.
The IPP centres and UFWCs focus on routine out patient RCH activities, with field staff and link
workers residing in the slums, who motivate mothers to utilise facilities and services for antenatal
care, delivery, family welfare, immunisation etc. These centres act as referral units for the maternity
homes which focus on delivery; medical termination of pregnancy (MTP) and laboratory tests in
addition to providing antenatal / postnatal care, family planning, non-surgical care for children
needing specialists attention and minor gynecological procedures. All the services at all these
facilities are supposed to be provided free of cost but there is corruption, bribes being demanded for
the services. The IPP VIII programmes are being extended to other urban areas.
•
•
Specialised facilities, staffed with trained gender sensitive health care providers of both sexes,
were expected to provide the full range of reproductive health services to both men and women.
Sub Centre plan: Unmet needs for Reproductive Services were supposed to be identified &
quantified which, along with demographic data for that area and the previous years
performance, would form the basis for the planning of the programme.
Unmet need is defined on the basis of women’s response to survey questions. The unmet group
includes all fecund women who are married or living in union and thus presumed to be sexually
active, who either do not want any more children or want to postpone their next birth for at least
another two years, but not using any method of contraception.
However, at the field level, this paradigm shift has not become a reality, the target based
functioning is still very much in practice and the programme still targets mainly women.
Health indicators
It is apparent from the some of the health, developmental and other indicators that the RCH
programme is not as effective as envisaged. This is true of Karnataka as also of most other states in
the country.
The IMR is 58 according to SRS 1998. IMR is 70 for Rural and 25 for Urban areas and varies from
29 in Dakshina Kannada to 79 in Bellary. The IMR for females is 72, and highest in Dharwad
Bellary & Bidar.
The Maternal Mortality Rate (MMR) according to UNESCO is 450. But recent estimates by SRS
(1998) places it at 195 per 100,000 live births.
Family Welfare:The then Maharaja of Mysore created history when he started the first official
family welfare clinics (birth control clinics) in Victoria and Vani Vilas Hospitals at Bangalore and
Krishnarajendra Hospital at Mysore in 1930.Since then the Family Welfare programme has come a
long way. The couple protection rate increased from 12% in 1971 to 48 % in 1993 and to 57% in
1995-96. This varied from 41% in Raichur to 73% in Mandya
But the emphasis of the programme is on sterilization (40% in 1993) and not on spacing (9% in
1993). Another disquieting fact is that over the years the participation of men in family welfare has
reduced. The proportion of vasectomies in the total sterilizations in Karnataka increased from 43%
in 1958-59 to 59% in 59-60 and to 95% in 67-68. It was 52% in the emergency year of 1976-77.
But this fell to 0.1% in 1993-94, 94-95 & 95-96.1992-93 figures also showed that fewer men (1.7%)
than women (6.8%) adopted spacing methods.
The Second National Family Health Survey, 1998-99, showed that in the preceding 4 years:
• The emphasis on sterilization and that too among women was apparent from the 51.5% of
married women being sterilized.
• Mothers received antenatal care in 86% of births, though mothers in rural areas were less likely
to visit an allopathic doctor.
• Only 51% of live births took place in a health care institution but 70% were attended by doctors
and 15% by dais.
• Nearly 25% of mothers did not receive even one dose of Tetanus Toxoid.
• 75% of mothers were given Iron & Folic Acid tablets but it is anybody’s guess as to how many
actually took them.
• Immunisation for BCG, DPT & Polio was good but for Measles it was only 67.3%.
• Nearly 42% of children with diarrhoea were not given Oral Rehydration Therapy of any sort.
Issues of concern in implementation of RCH programs:
Inadequacies in terms of infrastructure and delivery of services:
• The aim of the RCH program to attain 100% institutional deliveries may be a laudable one. But
the inadequate capacity both in terms of numbers and the quality of services has led to a low
proportion of institutional deliveries.
•
Shortfalls in staffing requirements, especially lady medical officers, ANMs and trained birth
attendants has lead to sub-optimal implementation of RCH programs. Large vacancies are
aggravated by cumbersome recruitment procedures; unauthorized absence and indiscipline in
work force.
•
The role of the Traditional Birth Attendants or Dais is very crucial especially in providing
natal services. It was surprising to note therefore, that the Dai training program was abruptly
stopped without ensuring functional alternatives.
•
The Disposable Delivery Kit program also has been abandoned without insights into its
functioning or the need for alternate measurements.
•
Training of birth attendants: Initial and periodic reorientation training for all birth attendants
are essential to ensure quality. There should also be periodic evaluation and up-gradation of the
training programmes.
Some elements that should be included in this training are elaborated which would enable
them to:
a) Understand the CNA methodology, assess the "Unmet Needs", work out a realistic plan
based on actual preferences of couples instead of top-down, unrealistic targets; promote
spacing & follow up and monitor people using contraception including referrals if necessary,
and condom promotion.
b) Achieve 100% registration in the first trimester;
c) Enable trainee ANMs & Dais to perform a sufficient number of normal deliveries in the
field.
d) Take care of the newborn: Delay ligation of umbilical cord till it stops pulsating; ensure that
breast feeds start within the first hour after birth, promote exclusive breast feeding till the
baby is 6 months old.
e) Perform "Visual Inspection" for down-staging of Cancer Cervix; carry out examination for
Breast & Oral Cancers.
f) Elicit information regarding STI/RTI (including history of risk behaviour from the sexual
partner), refer to PHC, do follow up and counselling regarding responsible behaviour,
condom use etc.
g) Develop communications skills to elicit community participation; and leadership qualities to
perform the specific functions that are expected of them at a sub-center.
h) During delivery, while the birth attendant looks after the birth component, the crucial needs
of the newborn is ignored. This can lead to complications like asphyxia, hypothermia,
infections etc. This is one reason for the increased incidence of neonatal and infant
morbidity and mortality.
i) The nutrition needs of the child between 6 months to 2 years does not get the attention it
deserves. ICDS does not adequately cover this age group, leading to high rates of
malnutrition amongst them. This leads to increased incidence of infections, delay in milestones and retarded physical & mental growth.
j) Maternal nutrition: Weight gains of less than 4.3kg by 14 weeks of pregnancy
approximately doubles the risk of "small for gestational age newborns" as well as incidence
of preterm delivery regardless of total weight gain.
Therefore strategies aimed at improving the nutritional status of pregnant women, who are usually
seen only after 14 to 16 weeks under RCH now has to look at pre-pregnancy nutritional status and
correction of Iron & other micro-nutrients deficiencies.
Inadequate attention to quality
The quality of care framework developed by Judith Bruce (1990) uses the following indices to
assess the quality of care received by clients:
Accessibility and availability of services; availability of basic facilities and essential supplies,
choice of methods; information to users; technical competence; client-provider interaction;
continuity of services; and appropriate constellation of services, including treatment for sexually
transmitted diseases and MCH care.
In terms of these indices it is seen that the quality of services is poor. Lack of discipline,
accountability and a lack of adequate training and motivation among the health care givers at all
levels are factors that lead to the poor quality.
Often even the basic common courtesies are not extended. A telling evidence is the treatment
meted out to the women at tubectomy camps, where numbers score over the entitlement of the
people. The undignified and very uncomfortable posture the woman is made to assume on the tilted
“laproscopy tables” is also a case in point.
There is no Quality Assurance system in place and therefore no norms or bench-marks for quality;
no standardization of procedures etc. This leads to arbitrary changes, e.g., change from a double
puncture to a single puncture laproscopy that did not take into account the field level problems
associated with the procedure. All changes in the procedure, equipment specifications, new
techniques etc. should go through a specified evaluation process before being accepted for
implementation.
An important indicator of quality is the number and cause of maternal and infant deaths. Periodic
auditing will help in improving quality and instituting preventive strategies.
Poor quality of care and client satisfaction in the RCH services is reflected in lower levels of client
satisfaction, a poor image and general distrust of public sector system. This in turn results in weak
commitment among the RCH staff.
Several Indian studies have reported that the rude behaviour of health staff has been a major reason
why women have not liked or used the government health services and compelled them to go to
private doctors.
Government health functionaries usually blame the lack of equipment and supplies for the poor
quality of their services. Ramasundaram (1994) has however observed that even when equipment
and supplies were made available, clients continued to receive poor quality of care. He attributed
this to the attitudes of health workers, who showed little respect for clients, particularly if they were
poor, illiterate or from lower social strata. Some health workers even believed that because the
government provided free services and also gave cash incentives for sterilization operations, the
clients had no right to demand good-quality services.
Corruption - A major barrier to quality care for the poor:
People are not aware of their rights to health care and the facilities that are available. Though the
services are free at the Government health care facilities, several studies have proved that corruption
at many levels ensures that unaccounted charges are collected even from the poorest.
In a study by Jagadish C. Bhatia (1995) on the " Constraints to service quality in Rural Karnataka",
all categories or workers have cited the issue of widespread corruption during the in depth
interviews and focus group discussions. The Auxiliary Nurse Midwives (ANMs) complained that
their bills, arrears, and other claims were inordinately delayed unless they agreed to pay a portion of
their claims as "speed money".
Following are some highlights of the comments made by an LHV with more than two decades
which is a telling tale of how deep rooted corruption is in the area of public service delivery:
"In the past, although we had much less manpower, logistic support, service prerequisites, housing
etc., you will be surprised to learn that we used to work well. However overtime the working
standards deteriorated with the gradual erosion in the ethical standards of immediate supervisors
and higher officials, which paved the way to the institutionalization of corruption in the health
department. Today, to be corrupt is no longer considered reprehensible. Drugs and equipment in the
health facilities are misused without any hesitation. The doctors are interested only in private
practice and amassing wealth".
A World Bank initiated study in 1999 confirms free access to quality health care services at the IPP
health centers, but not in the maternity homes being run by BMP. None of the services like MTP,
sterilization, delivery were being provided free of cost and an "informal / unofficial user fee" (=
bribe) was demanded in almost all cases. The desperate condition of the patient and the their
families in a medical emergency is being exploited to the maximum.
A study by the Public Affairs Centre published in May 1998 on "Bangalore Hospitals and the
Urban Poor- A Report Card " revealed that:
• About 89% of the respondents interacting with BMP maternity homes admitted having paid
bribes (speed money) to access better services.
• There are distinct differences in service quality between maternity homes and IPP health
centres. While maternity homes do not score that well on cleanliness and hygiene, IPP health
centres do. Basic medicines that are to be given free are not being given to a large proportion of
poor patients at Maternity homes, while at IPP HCs more people get free medicines.
• The differences in quality of service are also indicative of poor discipline and responsiveness
among the staff at maternity homes
• The practice of corruption is far more entrenched in maternity homes than in IPP health centres.
Bribes are being demanded and paid for almost every service being provided at maternity
homes.
• The staff are not ready to accept the prevalence of corruption leave alone trying to tackle it.
Distortions in Primary Health Care
There is lack of integration of the RCH programme into the general Health System. This emphasis
as a separate vertical program results in ignoring the basic health aspects and diseases not addressed
under the RCH program, including menopausal and other gynecologic problems, cancers etc.
Community participation and ownership of the programme by the community is lacking. This can
be seen by the fact that even the Sub Centre plans are still made on the basis of the previous year's
"targets". A household survey and assessing "Unmet Needs" is not being done.
Partnerships with the NGOs and the private health sector are not adequately explored
Lack of Equity:
a. Regional inequalities:
The poor quality of services is worse in the Northern districts and gets compounded by poor social
structures, poverty and low literacy levels. All this leads to even lower access to whatever services
are available.
b. Gender inequality:
The programme is insensitive to the gender inequality factor and therefore does not address it
adequately.
• When women are not allowed to make choices about their life, they are hardly in a position to
make choices about contraceptive methods, ‘negotiate’ with their partners to use condoms or to
respect their reproductive rights, their feelings and their emotional needs.
• Male Responsibility: The issue of male responsibility in matters of contraception, STD, AIDS;
sexual violence, growth of red light areas, trafficking of women, spread of pornographic
literature and blue films, growing market for aphrodisiacs and male potency drugs, need to be
addressed. The role of male sexual behavior, gender relations, sexual and gender responsibility,
role of the ‘Y’ chromosome from the male partner in determining the gender of the child, etc.
must also be addressed.
• In the name of empowerment, contraceptive responsibilities have been transferred to the
women. In health programmes and policy planning, it should be ensured that pregnancy is made
a matter of male concern also.
Gender sensitive indicators
The indicators used to assess RCH programmes focus on general reproductive health aspects. They
are not useful to measure the impacts of the gender sensitive policy on the field level situation. So
there is a need to develop gender sensitive indicators to specifically measure the integration and
outcome of gender sensitivity at the programme level and subsequent changes at the community
level.
Gender sensitive indicators that may be used to assess RCH programmes are:
• Average attendance of men and women at meetings with the community.
• Number/percentage of couples who participate equally in decisions regarding reproductive
issues and sexuality.
• Number of women who negotiate with their partners for the use of condoms.
• Number/percentage of men using condoms.
•
•
•
Number/percentage of the total pregnant women who report that the present pregnancy was not
planned/unwanted and who are able to take a decision themselves to undergo MTP.
Number/percentage of men who think that use of family planning method is the wife’s
responsibility.
Number/percentage of sterilizations that are vasectomies.
Men have to be sensitized to this gender perspective and influenced to assume responsibility for the
consequences of their sexual behaviour and reproductive roles; and share household work and child
rearing. They have to actively promote gender equity, girl’s education and women’s empowerment
within their families, communities and work places.
Gender perspective of health care providers
The work of health care providers is divided along gender lines and tends to be inequitable for
female providers. The ANMs are completely responsible for MCH, family planning and outreach
work, while male health providers focus on prevention and control of infectious diseases. This
makes male health care workers insensitive to reproductive health issues.
ANMs are overburdened; lack logistical and administrative support, travel long distances alone at
odd hours of the day for home visits, risking their own personnel safety and security; and receive
abusive and biased treatment by virtue of working at the bottom rung of a male dominated
hierarchy. Lady Health Visitors do their own work as well as that of the male workers.
Recommendations
Quality of service
•
The general quality of service should be improved; a Quality Assurance programme should be
developed and implemented.
•
Any changes in the procedure, equipment specifications, new techniques etc. should go through
a specified evaluation process before being accepted for implementation.
•
The patient’s comfort and dignity are of first consideration. So the tilted laproscopy tables and
other such inconsiderate methodology should not be used.
•
The attitude of doctors and other staff should be positive and helpful. This can be ensured
through periodic internal audits, patient satisfaction studies and accreditation system with an
external audit.
Periodic auditing of maternal and infant deaths should be implemented to institute preventive
strategies.
•
While tobacco use and passive smoking, adversely affect everyone, the health hazards on the
fetus and newborn should be recognised. Every effort should be made to check this, including
Health Education; enforcement of Anti- Tobacco legislation; social boycott of tobacco use etc.
•
Referral for high-risk pregnancies to the FRUs, should include facilities for transport; 24-hour
delivery and emergency obstetric services should be ensured at FRUs.
•
Sterilizations, MTPs etc should be carried out only at FRUs (Fixed-Day strategy) and not at
camps.
•
Availability of safe abortion (MTP) services for married and unmarried women should be
ensured.
•
A female relative / attendant of the patient may be allowed to be present during delivery. This
will improve accountability and decrease corruption.
Infrastructure-Staff
•
The system of deliveries by Dais should be supported, with enhanced training.
•
To solve the problem of safety and timely attendance of ANMs: as far as possible, ANMs should
be posted in their home villages; given loan facility to buy a two-wheeler. Their workload needs
to be rationalized- less paper work and better use of their expertise and talent
•
Training of birth attendants: Initial as well as periodic reorientation training for all birth
attendants to ensure quality should be implemented. There should be periodic evaluation and
up-gradation of the training courses. Some elements that should be included in this training
have been elaborated earlier.
•
Ensuring availability of trained staff: Government may consider introducing approved, training
courses to provide services in the absence of a Medical Officer, such as:
a. Nurse-Obstetrician Practitioner at the PHC level
b. Short-term (6m to 1yr) training in anaesthesia for Medical Officers at the CHC level.
The details of the course, feasibility etc. should be worked out by an expert team.
•
A second village level functionary to take care of the newborn, may be considered.
•
Posting two Medical Officers at PHCs one of whom is a Lady MO will improve the quality of
services. The services of Lady Medical Officers should be made available at all levels, if
necessary with support from the private sector, especially in North Karnataka districts.
The following should be made available at the field level:
•
Disposable delivery kits with good quality cost effective components - with the expectant
mothers.
•
Subsidised menstrual cloth /pads may be supplied to the poor. This will promote personal
hygiene and should be supported with awareness programmes to ensure correct usage. Longterm sustainability, familiarity & preference of use and biodegradability etc. should be
considered before implementation.
To promote gender equity of RCH programme:
Women patients as well as female health workers face considerable gender discrimination. This
should be corrected.
•
Gender sensitive indicators as given earlier, should be used to assess and improve equity.
•
Privacy during examination and availability of clean toilets should be ensured.
•
Male Health Workers should be given adequate training and skills to tackle gender issues and
to ensure male participation through individual counseling as well as community education
programmes.
•
Gender inequalities among male and female health workers must be reduced by ensuring equal
representation of men and women in managerial and supervisory roles, equal distribution of
work and responsibilities, equity in pay etc.
(Specific recommendations with regard to family planning services are elaborated in the chapter on
Population Stabilization).
9. POPULATION STABILIZATION
That action is best which procures the
greates happiness for the greatest numbers.
- Francis Hutcheson
In the recently announced National Population Policy 2000, it is explicitly stated that the
stabilising of population is an essential requirement for promoting sustainable development with
equitable distribution but this has to be within the context of enhancing outreach of primary
education, enhancing essential amenities such as sanitation, drinking water, health care,
employment and empowerment of women. This policy would be implemented through the
States and it would, therefore, be necessary to consider the mechanisms of doing so and the
elements that are of particular importance to Karnataka. In other words, it would be necessary to
consider the formulation of a population policy specific to this State.
The Population Policy will be an important and integral part of the comprehensive State Health
Policy. The Government of India has separate policies for health and population. The advantage
in the formulation of separate policies would be that the emphasis on the different elements will
not be diluted. But there is greater merit in having an integrated comprehensive policy. There
have to be close linkages between health services and population issues. It is recognised that the
implementation of the population policy would not be the sole responsibility of the Health and
Family Welfare Department. Considerable inter-sectoral co-ordination is necessary.
The demographic goals for Karnataka, taking into consideration current levels of the indicators
have been estimated as follows 1:
Goals
1998
Total
Fertility
Rate
2.5
Crude
Birth
Rate
22
Crude
Death
Rate
8.0
2000
2.4
21
8.0
53
60
52091
2005
2.1
19
7.5
42
64
55425
2011
1.8
17
7.5
30
69
59815
2016
1.6
14
7.0
30
75
63007
2031
-
-
-
-
-
69836
Year
Infant
Couple
Mortality Protection
Rate
Rate
58
58
Population in 000s
50983
The population replacement level is expected to be achieved when the TFR is 2.1. It is estimated
that Karnataka would have to achieve this TFR by 2005, in which case the other parameters
would have to be at the levels indicated in the table above. Once the TFR of 2.1 is achieved, the
rate of growth of population would decline over time till the population stabilizes. In the State,
the population is likely to stabilize at 69.8 million in 2031.
From a paper “Perspective Demographic Goals for Karnataka” by Bhattacharjee, Prakasham and Gopal,
Population Centre and Directorate of Health and Family Welfare Services, Bangalore 1999. These differ slightly
from the assumptions and estimations of the Registrar General, India.
1
-1-
It would be noticed that the parameters in 1998 are very close to those required to achieve a TFR
of 2.1 by 2005 in the State. It would seem well within possibility to achieve TFR of 2.1 by 2005
provided that there is no slowing down in the family planning efforts and that a conscious plan is
adopted for achieving this goal. In this context, it is clear that a uniform approach all over the
State would seem inappropriate at this point of time when the State is poised to achieve a TFR
of 2.1. The elements of the services provided to achieve this demographic goal would have to be
tailored to meet the specific requirements of a sub-region. Three important factors that influence
fertility are (a) the age at marriage of girls as reflected in proportion of girls married below 18
years, (b) birth order 3 and above which would indicate need for limitation of family size (d)
proportion of safe deliveries and (d) unmet demand for family planning services.
The Table 9.1 indicates the districts ranked by the first three factors. The districts in which the
Table 9.1: Marriage and Child bearing
Marriage and Child bearing
% girls
married
below 18
years
Birth order
3 and above
% of safe
delivery
D. Kannada
Udupi
U. Kannada
Shimoga
Bangalore (R)
Kodagu
Tumkur
Chitradurga
Davangere
Kolar
Dharwad
Gadag
Haveri
Bangalore (U)
Chikkamagalur
Mandya
Bellary
Gulbarga
C.R. Nagar
Mysore
4.50
4.50
15.00
16.50
21.50
22.00
27.10
30.50
30.50
33.50
36.50
36.50
36.50
37.00
37.00
37.00
44.20
47.70
47.90
47.90
Bangalore (R)
Kodagu
Hassan
C.R. Nagar
Mysore
Bangalore (U)
Chikkamagalur
Mandya
U. Kannada
Tumkur
Kolar
D. Kannada
Udupi
Chitradurga
Davangere
Belgaum
Dharwad
Gadag
Haveri
Bagalkot
16.40
18.80
19.70
23.90
23.90
26.10
26.10
26.10
27.20
27.30
29.70
32.00
32.00
34.40
34.40
36.70
37.40
37.40
37.40
43.00
Gulbarga
Koppal
Raichur
Bijapur
Bidar
Chitradurga
Davangere
Bellary
Kolar
Mandya
Tumkur
Dharwad
Gadag
Haveri
Belgaum
C.R. Nagar
Hassan
Mysore
Chikkamagalur
Bangalore (R)
47.70
48.00
48.00
50.10
52.50
53.80
53.80
54.00
59.20
60.40
63.50
65.30
65.30
65.30
68.60
69.70
69.70
69.70
78.00
79.10
Belgaum
Koppal
Raichur
Bagalkot
Bijapur
Bidar
Karnataka
55.80
57.10
57.10
64.80
64.80
67.60
39.45
Bijapur
Bellary
Koppal
Raichur
Bidar
Gulbarga
Karnataka
43.00
48.60
52.80
52.80
52.90
53.70
34.96
Kodagu
Shimoga
U. Kannada
Bangalore (U)
D. Kannada
Udupi
Karnataka
79.40
83.00
86.10
90.60
91.50
91.50
70.15
Source: Letter D.O. No.27 / 2000 NCP dated 21 December 2000 from Member Secretary,
National Population Commission, Government of India, to Chief Secretaries
-2-
services would have to concentrate on these three issues are clearly distinguishable. It is in these
districts that the family planning services would need to be enhanced both in reach and quality.
The recent NFHS – 2 indicates that there is an unmet need for family planning services in the
State of 11.5 per cent. It is this unmet need that would have to be serviced effectively and
efficiently, even while maintaining and improving the current level of services in all the
districts.
The achievement of a TFR of 2.1, as a consequence of achievement of the attendant parameters,
would have to form the demographic core of the population policy of the State. However, the
policy would have to recognise and give equal importance to the socio - economic factors that
influence decisions on family size and adoption of family planning. These include elements in
both the health and social sectors.
Elements within the health sector
The family planning services would have to be based on the premise that the services that the
people want should be available, that they have options of choice of methods based on
information and advice, and that quality is assured. The health services would, in particular,
have to improve, enhance and efficiently implement programmes relating to RCH and family
planning. Priority would have to be given to meeting the unmet need for family planning
services.
Intensive IEC efforts would be necessary regarding the advantages of postponing the second
child and limiting the children to two. The fact that the male partner is the main determinant of
the sex of the child would need emphasis. The emphasis on spacing methods would need to be
intensive. This would have to be accompanied with prompt availability of services.
The family planning programme must maintain gender equity in evoking participation.
Enhancing male participation in the family planning programme is vital. Such participation
should be ensured through specially directed IEC efforts. Previously announced fixed days could
be designated in CHCs and Taluk Hospitals for vasectomies, to enhance such participation.
Accessibility and quality of services
The acceptance of family planning is dependent on the quality and accessibility of reliable
services. The services offered should be available through out the year. The quality and
availability in terms of choice of safe and effective family planning services must be improved
and maintained. The choice of temporary or permanent methods should be available and there
should be no compulsion. In particular, the quality of services relating to tubectomy and
laproscopy would have to be assured. The health services would have to continuously monitor
these aspects if the demographic goals are to be attained and if family planning acceptance has
to be enhanced.
Acceptance should be voluntary and there should be no compulsion with regard to either the
adoption of family planning or any particular method. The services should motivate acceptance
through IEC, so that acceptance of family planning is based on informed choice. In particular,
there should be no concerted efforts that seek to pressurize women to adopt such measures
through “camp” or “pulse” approach.
There should be access to safe abortion (MTP) services for both married and unmarried women,
with rights of privacy.
-3-
There has to be regular and effective follow up of acceptors after they adopt any of the family
planning methods to ensure that complications, if any are attended to expeditiously. Such follow
up would also encourage the increasing acceptance of family planning.
New technology
New technology should be adopted only after very careful evaluation, including public reactions
to its use. Such new technology should be adopted only after due consideration of the ethical
aspects, safety issues and cost effectiveness.
The focus of IEC would have to shift to the younger age groups, particularly the adolescents.
Even with the implementation of the law relating to minimum age at marriage, there are likely to
be cases of marriages in which the partners are below the legal age. In such cases, from the point
of view of the health of the mother and child, counseling for family planning should be
available.
Elements within the social sector
Conscious efforts for inducing a change in social attitudes regarding enhancing the age at
marriage must be made. The role of women’s groups and of the panchayat bodies in this effort is
most important. In this context, the introduction of legislation for registration of all marriages
could be considered. The strict enforcement of the law that prohibits marriages below specified
ages for boys and girls would go a long way, along with other efforts. Registration of marriages
would also assist in enhancing outreach services of family planning.
There would be need for a strong IEC programme regarding the health hazards and social ills of
early marriages and the need to raise the age at marriage. The basics of health and reproductive
behaviour would have to be introduced in school programmes – in particular for adolescents as
prospective parents.
With near replacement levels likely to be achieved with the enhanced efforts suggested, it is
important that the population policy is centred around the perceptions of the community
regarding this issue. This would imply that the community, through its representatives,
particularly women, is fully involved in both consultative and operational terms. There would
have to be facility for informed choices, with the health aspects receiving the greater emphasis.
Elements of a population policy:
The population policy for the State would have to include all parameters that impinge on
population dimensions, including health and social issues. The main elements of the policy
would include the following:
1.
2.
3.
4.
Recognition of regional disparities and need for regional / district focus with necessary
variations in emphasis depending on such disparities. The parameters would include those
that relate to health, RCH, the education and social sectors. Such an analysis would guide
decisions regarding location and scale of health services;
Based on the evaluation of the current status of the family planning programme and taking
into consideration the parameters indicated above, prioritization of the districts for
enhancement of the services and more intensive action on related measures;
Recognition that population issues are an important part of the health package would
include encouraging spacing methods, offering alternatives, combined with RCH, while
recognizing the need for continued emphasis on family planning;
Enhancement of availability, accessibility, quality of services;
-4-
5.
6.
7.
8.
9.
10.
Enhancement of male participation in acceptance of family welfare through intensive IEC
and also by designating fixed days in CHCs and Taluk Hospitals for vasectomies;
Enhancement of services to meet the unmet demand for family planning services, with a
strong IEC component regarding the advantages of postponing the second child.
Assignment of a clear role to the Panchayat institutions.
Developing a mechanism for ensuring coordination in implementation of schemes by
departments in closely associated sectors such as education, social welfare, nutrition and
the like;
Recognition of the importance of social parameters such as age at marriage for both girls
and boys and educational levels for enhancement of health status of the family.
Introduction of the basics of health and reproductive behaviour in school programmes – in
particular for adolescents as prospective parents.
Implementation
It would be relevant to note that even after the achievement of replacement level of TFR 2.1, the
family planning efforts should not de-emphasized. It would be important that these efforts are
maintained at the enhanced levels suggested herein even thereafter for obvious reasons, but the
emphasis would change over time to social and health issues, with particular emphasis on the
latter.
It is recommended that an Expert Committee, including non-official experts, be constituted by
Government to look into the Population Policy. The policy could also suggest the administrative
mechanisms for coordination between associated departments and for high level monitoring, so
as to achieve the parameters as soon as possible.
The draft Population Policy should be widely publicised for eliciting public and professional
opinions. The Policy would take into account the projections till 2011 which would indicate the
needs in terms of organisation, staff and training needs, recruitment procedures, equipment, and
enhancement of RCH particularly with regard to IMR, neo-natal deaths and female mortality.
Many social and development issues are associated with population issues. It would be desirable
that these issues are considered together. At the level of Government, therefore, the following
mechanisms for coordination are suggested:
1. A single Committee on Social and Population Issues could be constituted at the official level
with the Development Commissioner / Chief Secretary as Chairperson. Membership could
include the Permanent Secretaries of Finance, Health, Education, Social Welfare, Women
and Child Development, with others being co-opted, if necessary. This Committee could
consider all coordination issues between the various social sectors, including health; and
2. A Commission on Population and Social Development at the Cabinet level could be
constituted for consideration of all coordination, policy issues and covering all Departments
relating to social sectors of development, including health.
It is suggested that the Expert Committee be constituted very early so that the population policy
is adopted as early as possible and the operational efforts and organizational arrangements that
the policy may recommend are commenced urgently.
Recommendations:
•
The unmet need for family planning services should be met, with options of choice and
assured quality;
-5-
•
Information, education and communication activities should be enhanced to convey
messages of the advantages of postponing the second child, of a two child norm, and of the
health and familial advantages of spacing births;
•
Gender equity must be maintained in evoking acceptance of family planning. Male
participation in the programme would have to be increased through special efforts,
including IEC activities;
•
The quality and availability in terms of choice of safe and effective family planning
services, both temporary and permanent, must be improved, to enhance voluntary
participation;
•
There has to be regular and effective follow up of acceptors after they adopt any of the
family planning methods to ensure that complications, if any are attended to expeditiously.
Such follow up would also encourage the increasing acceptance of family planning
•
There should be no element of compulsion or pressure, particularly through camps or
“pulse approach”. The services should be such that their quality and availability, with
regularity and at all times, with choice encourages voluntary adoption of family planning;
•
New family planning technology should be adopted only after careful consideration of the
ethical aspects of use of such technology, safety issues and cost effectiveness;
•
Safe abortion (MTP) services should be available for married and unmarried women, with
right to privacy;
•
The focus of IEC and of counseling would have to shift to younger age groups, particularly
of adolescents;
•
Even with the implementation of the law relating to minimum age at marriage, there are
likely to be cases of marriages in which the partners are below the legal age. In such
cases, from the point of view of the health of the mother and child, counseling for family
planning should be available.
•
The introduction of the legal requirement of registration of marriages for all is necessary.
This would enable the stricter application of the law relating to restriction of age at
marriage and assist in organizing out-reach services;
•
IEC programmes should emphasize the health hazards and social ills of early marriages
and the need to raise the age at marriage;
•
The basics of responsible reproductive behaviour should be introduced in school
programmes for adolescents;
•
The community, particularly women’s groups, should be closely associated, in consultative
and operational terms, with family planning programmes to reflect the perceptions and
needs of the local community
•
The Population Policy for the State as part of Integrated Health Policy should be drafted.
The draft policy would have to be widely publicized for public awareness and response,
before it is finalized;
-6-
•
Districts may be prioritized on the basis of evaluation of the current status of the family
planning services available and related social criteria, for enhancing the scale of the
programme;
•
For ensuring inter-sectoral coordination and monitoring of the programmes relating to
family planning and related sectors, a Committee on Social and Population Issues may be
established at the official level, while at the Cabinet level a Commission on Social and
Population may be established.
-7-
-8-
10. FOCUS ON SPECIAL GROUPS
10.1 PERSONS WITH DISABILITIES
Disabilities rob the basic rights of an individual to physical, mental, spiritual and social wellbeing. A person with disability is one who has a functional limitation or an activity restriction.
Disabilities include among others, locomotor disability, visual impairment; hearing and speech
impairment; mental illness, mental retardation, multiple disability etc; learning disabilities,
usually neglected, are seen in an estimated 5-10% of school children.
Locomotor disability accounts for nearly 60% of physical disabilities (excluding mental
retardation and illness). The rehabilitative services include corrective surgery, physiotherapy,
occupational therapy and fitment of aids and appliances. The largest cause of visual impairment
is cataract, which is curable through surgery and use of intraocular lens. Rehabilitation of
persons with communication disability (speech and hearing) needs various procedures like use
of hearing aids, surgery, etc. Mental retardation and mental illness are widely prevalent.
Multiple disabilities are more difficult to tackle; the most common occurrence is in persons with
cerebral palsy.
It is estimated that 3 to 4% of the population in India have some form of moderate to severe
disability. The 1991 survey of the Government of Karnataka showed a lower figure of 1%
(3,55,819 persons with disability) Action Aid surveys showed a rate of 2 to 3%. These figures
may have included only the severe cases, those that the families and community perceived as
being disabled and needing interventions. They did not include mental illness. 76% of the
disabled are in the rural areas and 24% in urban areas. Males form 58% of the disabled
population. There are regional variations in the numbers as well as the types of disability. The
2001 census includes enumeration of people with disability. There is need for Karnataka –
Specific epidemiological studies and a registry, disaggregated with respect to rural – urban,
gender, age and region (districts).
A recent (2000) Survey of Bangalore City has shown the following distribution of persons with
disabilities.
Distribution of disability groups (Bangalore)
Disability
Locomotor & poliomyelitis
Others
Learning
Epilepsy
Speech and hearing
Visual
Multiple
Total
Percentage
32.5
16.0
6.5
4.5
9.5
4.0
27.0
100.0
(The mentally ill was not included in the survey; epilepsy was included.)
-1-
Age distribution of the above groups:
Age in years
1-5
5 - 10
11 - 15
16 - 25
26 - 55
> 55
Total
Percentage
17.5
26.5
23.5
17.5
14.5
0.5
100.0
Gender distribution
Males
Females
Total
52.5
47.5
100.0
Nearly 10% of disabilities in developing countries are caused by conditions, which are
preventable. Second-degree consanguinity marriages can lead to a high percentage of cases of
disability; pre-marital counseling can help. Prevention of brain injury by use of helmets by two
wheeler users is well documented. 60% of deafness is due to otitis media, which is easily
treatable.
Globally, programs for the Persons With Disability, which were earlier institution based and
expensive, have now become Community Based Rehabilitation (CBR).
"Community Based Rehabilitation is a strategy within community development for the
rehabilitation, equalisation and social integration of all people with disabilities. CBR is
implemented through the combined efforts of disabled people themselves, their families and
communities and the appropriate health, education, vocational and social services." – ILO,
WHO, UNESCO, 1994, The Joint Declaration, Geneva.
CBR seeks to promote the principles of universal coverage of services for Persons with
Disability, at a cost that is affordable along with the promotion of integration, active
involvement of Persons with Disability, their families and communities in the process. It seeks
to enable persons with disabilities to become productive and contributing members of society,
thereby reducing the burden of families, communities and nations with fragile economies.
Multi-sectoral collaboration between health, education, labour, vocational training, housing,
welfare, sports an agriculture, NGOs, Disabled Peoples Organizations (DPOs) and religious
leaders within the community is imperative. The interventions to achieve this include
prevention services; early detection and stimulation; discussing the child's capacities and
problems and training the mother on how to stimulate the child; inclusive education; ways to
integrate the persons with disability into daily activities of home life; self employment and
income generation activities; formation and support of self help groups of disabled persons, who
help in identification of other disabled, training of parents of the disabled, formation of income
generating co-operatives, etc.
-2-
The Government of India launched 11 District Rehabilitation Centres, one of which is in
Talakadu, Mysore District. In Karnataka, the Directorate of Welfare of the Disabled is part of
the department of Women and Child Development.
The health care professionals and workers can play an important role in the prevention, early
detection, intervention including corrective surgery and physiotherapy; immunisation, vitamin
A, and better nutrition can prevent many disabilities.
The other concerns include:
• The data in the areas of identification, classification, records of progress and evaluation are
not comprehensive and complete. The recording systems vary widely, thereby making
comparison difficult.
• There is need for change in the attitude of people with disabilities towards themselves and
the attitude of other people to people with disabilities.
• Handicaps, such as barriers in access to building and transport vehicles, must be avoided.
• Community Based Rehabilitation methodology is still not implemented adequately;
rehabilitation measures are still institution oriented.
• Most of the programs are carried out by NGOs who tend to be urban-based and cater to
single disabilities.
• Networking is unsatisfactory.
• Identification of persons with learning disability, severe emotional problems and
hyperactivity is not satisfactory.
• Availability of trained manpower for Community Based Rehabilitation is low.
• Existing training curricula and programs are biased towards institution based programs and
are not standardised.
• The latest developments in Community Based Rehabilitation are not available to people at
the grass roots level.
• Technical aids in rehabilitation are often not appropriate to Indian conditions and needs,
particularly the rural.
• There is a need for co-ordination of activities of health, education, vocational training and
welfare sectors.
Inclusive Education
Community Based Rehabilitation and inclusive education complement each other to enrich the
lives of all children. CBR implies the full participation of children with disabilities and their
families within the community. The attendance of children with disabilities into their regular
neighbourhood schools is a natural extension of this inclusion. Separation from regular
schooling (as by special schools, disability wise) contributes to negative attitudes in society. It
perpetuates segregation.
Legislation
The "Persons with Disabilities Act" and "the Rehabilitation Council of India Act" are in force
but not implemented effectively. Jobs are reserved for persons with disabilities but these are not
filled.
Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act, 1995:
According to this Act, every State Government shall constitute a State Co-ordination
Committee to serve as the State focal point on disability matters and facilitate the continuous
evolution of a comprehensive policy towards solving the problems faced by persons with
-3-
disabilities. The specific functions of the co-ordination committee are also spelt out. These
include,
•
•
•
•
•
review and co-ordination of the action of all Governmental and non-governmental
organisations dealing with matters relating to persons with disabilities;
develop a State policy to address issues faced by persons with disabilities;
advise the State Government on the formulation of policies, programmes, legislation and
projects with respect to disability;
ensure barrier free environment in public places, work places, public utilities, schools and
other institutions; and,
monitor and evaluate the impact of policies and programmes designed for achieving equality
and full participation of persons with disabilities.
The Act asks the Governments and local authorities to,
• undertake surveys, investigations and research concerning the cause of occurrence of
disabilities;
• promote various methods of preventing disabilities;
• screen all children at least once in a year to identify "at risk" cases;
• provide facilities for training to staff at the primary health centres;
• sponsor awareness campaigns and disseminate information for general hygiene, health and
sanitation;
• take measures for pre-natal, prenatal and postnatal care of mother and child;
• educate the public through pre-schools, schools, primary health centres, village level;
workers and anganwadi workers;
• create awareness amongst the masses through television, radio and other mass medial on the
causes of disabilities and the preventive measures to be adopted.
The Act provides for education, employment, affirmative action, non-discrimination, research
and manpower development for persons with disabilities.
A recent plan for Community Based Rehabilitation Programme has the following
objectives:
• Make all basic rehabilitation services available at the community level.
• Develop equal opportunities in all health, education, social welfare, rural development and
other programmes.
• Increase participation of people with disabilities in community life.
• Develop appropriate technology to enhance participation of people with disability in
mainstream programmes.
• Protect the rights of people with disabilities.
• Promote empowerment of people with disabilities.
• Remove physical, psychological and social barriers.
• Enable persons with disabilities to be productive members of the society through gainful
employment.
• Have inclusive education for children with disabilities, to the extent possible.
• In the case of persons with profound disabilities, have special schools, hostels and other
arrangements so as to promote independent living.
-4-
The plan envisages having
• local facilitator at the Gram Panchayat or equivalent level in urban areas;
• multipurpose rehabilitation worker at Taluk level;
• District Technical rehabilitation coordinator;
• State level department of Disabled Welfare.
There will be inter-departmental co-ordination, education, women and child welfare, health,
rural development, social welfare and labour. It is proposed to have District CBR Societies,
registered under Karnataka State Trusts / Societies Registration Act.
Recommendations
•
Establish the role of the Health department in Disability Prevention, Early detection,
Intervention, corrective surgery and physiotherapy. Sensitise health-care workers on
identification, classification, records of progress and evaluation, referral and home-based
stimulation training. Staff from Leprosy control programs may be trained first.
•
Utilise Media to create awareness and training of parents and other caregivers on specific
disabilities.
•
Shift from institutional approach to a Community Based Rehabilitation-home-(parent) based
approach; and from single to a multi-disability approach.
•
Networking initiatives – Get all people, Government as well as NGOs, from all sectors to
meet at a common platform and plan out strategies.
•
Have an orthotic and prosthetic centre at every district hospital (as in Tamil Nadu).
•
•
Develop and implement a policy of inclusive education. Change teacher training curricula,
physical environment of school and learning materials.
Train teachers for early detection and management of learning difficulties.
•
Make the wearing of helmets by two-wheeler users mandatory.
•
Ensure implementation of the provisions in the "Persons with Disabilities Act."
•
Include evaluation and management of speech and hearing and other impairments in school
health programmes.
•
Make provision for the manufacture, distribution and repair and maintenance of aids and
appliances.
•
Ensure access to all health care institutions and other buildings, transport, water supply,
sanitation etc., by incorporating necessary provisions in the statutes, rules, etc.
•
Implement the provisions of the existing legislation, including Persons with Disabilities Act,
1995 with respect to protection of the rights of persons with disabilities.
-5-
•
Ensure equal opportunities in employment and training for persons with disabilities, by
enforcing current legislation; enhance the provision for training and employment.
•
Health department to monitor the effectiveness of corrective surgery, aids and appliances.
•
Support the family and community financially and to set up family based and self-employed
petty businesses near their homes.
•
Provide emotional and social support to care givers who serve persons with severe and
multiple-impairments.
-6-
10.2 HEALTH OF THE TRIBAL PEOPLE
The tribals constitute 8% of India's total population and form 4.26% of the population in
Karnataka (1991). The tribal community here has been marginalized for years and their identity
has changed from self-reliant tribals to rural poor. The tribals are exposed to the fierce
competition that characterises the world around them. Relocation from their forest habitats due
to National Parks and Wild life sanctuaries and displacement due to dams (Kabini dam) have
impoverished the tribals.
Health Infrastructure & Human Resources in tribal areas
An accurate and reliable baseline data on the health infrastructure, human resources and health
status of the tribals in Karnataka is not available. The health infrastructure in tribal areas is
extremely poor. As per the 1991 census only 54.8% of the villages in ITDP (Integrated Tribal
Development Programme) i.e., Mysore, Chikamagalur, Kodagu and Dakshina Kannada had
some medical facilities. The average distance between the village and medical facility was about
8 kms. Only 8% of the total settlement had an allopathic doctor. The visits by the health workers
were grossly inadequate. Only about 33% of the settlements received weekly visits, about 17%
received fortnightly visits and 27% received monthly visits.11.2% of all tribal settlements are
non motorable. The Scheduled Tribes account for 6% of inpatients and 4% of outpatients treated
in government referral hospitals (CESCON, 1997).
Priority should be given for construction of Primary Health Centres and Subcentres equipped
with essential diagnostic facilities, adequate funds, drugs and facilities for treatment and referral
support. The norms for PHCs and subcentres in tribal areas should be based on geographical and
population basis, and they should be flexible. Proper functioning of these centers can be assured
through appointment of local tribal staff and an inbuilt monitoring and evaluation system. Tribal
girls should be selected and given appropriate training including traditional medicine. They
should be appointed as tribal ANMs and posted in tribal subcentres. Qualification criteria for
ANMs in tribal areas must be relaxed and additional incentives should be given to her.
Appointment of staff who is not accustomed to tribal tradition and culture is one of the main
reasons for non-availability of staff in tribal areas.
Health status of the tribals
Crude Birth Rate in the ST population was 26 per 1000 population. The ANC registration
among women was 74%. 57% of the children had received all the three doses of DPT and oral
polio vaccines. The extent of immunisation against measles was only 27%. Average household
size is 4.55 with a highest of 4.92 among the Hasaluru. Tribals who still have access to forest
resources and who have retained their traditional health care system better than others.
Specific Health Problems
Diseases like genetic disorders and deficiency diseases that are specific in tribal areas have not
been enough importance. Diseases like G6PD Deficiency and Sickle Cell Anaemia (prevalence
of 20%) specific to tribals should be given special importance with adequate funds and
expertise, for their treatment, research and rehabilitation. Malaria, Tuberculosis and STDs,
which are endemic in some tribal areas needs special attention and specific intervention.
Mobile Health Units
The Mobile Health Units should be made fully functional by filling up the vacant posts of
doctors and Paramedical workers, repairing vehicles or providing new vehicle, providing
additional POL and medicines
-1-
Referral Services
Referral services in tribal areas are neglected. Secondary and tertiary care, transport facilities
for emergency services and obstetric care are essential. Community financing for emergency
transport and referrals should be promoted in tribal areas.
Traditional healing systems
Traditional healing systems must be encouraged and documented in tribal areas and there should
be integration of Allopathic medicine with the Traditional systems. Promotion of herbal gardens
in tribal areas is essential. A Three-Tier system consisting of the traditional healer, health
worker and the medical officer is ideal. Traditional Tribal Dais should be trained and they
should assist the ANMs. ISM&H could assist in promoting the traditional medicine in tribal
areas.
Nutrition
The tribals have been denied the access to Minor Forest Produce (MFP) and hence their
nutritional status is on the decline. The tribals have no landholding and the Public Distribution
System (PDS) does not supply adequate quantities of nutritious food. The distribution of
agricultural land by ownership is 18.5%, with the highest of 45.8% among the Soligas and 7.0%
among the Hasaluru.
Nutrition security through kitchen gardens and encouragement to grow nutritionally rich food
crops is the need of the hours. Proper functioning of the anganwadis in tribal areas can be
ensured through appointment of local tribal staff and using locally available foods. Ideally the
PDS should distribute cereals like ragi, bajra, and pulses instead of polished rice and sugar.
Health Promotion
Community Participation through Participatory Rural Appraisal (PRA) techniques,
miroplanning, mobilisation of community resources and empowerment of the tribals for their
own health is essential for achieving "Health for All". Village Health Committees should be
formed in every village along with PHC level and Subcentre level committees. Street theatre,
skits, songs, posters and other health education material should be culture specific, easy to
comprehend and should be in the local dialect. Health promotion should be part of integrated
development for the tribals.
Health Monitoring Information System (HMIS)
A HMIS of the health infrastructure, human resources, vital statistics and other health indicators
specially for the tribals is essential and it should be an ongoing process.
Population stabilisation
Information on the demographic profile and fertility characteristics in tribal areas is lacking.
According to the Baseline Survey of Tribal Population in Karnataka (June 1995), the General
Fertility Rate of the tribals was higher than the State as a whole. It revealed that 78% of the
respondents were in favour of practicing Family Planning methods. Awareness regarding
temporary methods was 42% only. About 52% were not using any family planning method. The
average number of living children of the sterilization acceptors was 3.0. 74% of the women
were registered for ANC but most of the pregnant mothers in tribal areas are anaemic. The
population of the Jenukurubas a Primitive Tribal Group (PTG) is said to have decreased from
29,092 in 1981 to 26,608 in 1991 according to the Ministry of Tribal Affairs, Government of
India! This needs to be verified and if it is true Fertility Clinics needs to be established to
stabilize their population.
-2-
Education
As per the 1991 census 47.95% of males and 23.57% of females belonging to the Scheduled
Tribes population were literate. 32.57% of the rural ST population and 55.08% of the urban ST
population were literate. These statistics indicate that literacy levels are abysmally low
compared with the ideal and hence education should be given a lot of importance in the tribal
areas. The curriculum should be culture specific and should be oriented towards income
generating, need based, economic development programmes. Long-term investment in raising
the literacy rate among the tribals will reflect in their health status.
Drinking Water and Sanitation
Drinking water and sanitation facilities in tribal areas are poor. A study revealed that only 51%
of the hamlets have bore well facilities, 23.4% have open wells, 17% have tanks, 6.4% have
river water and 11.3% have tap facilities. Tribal housing with adequate and acceptable drinking
water and sanitation facilities and smokeless choolas should be ensured.
Voluntary Organisations
Voluntary (Not for Profit) organizations have played a crucial role in the integrated development
of the tribals in our state. They have access to the remote areas where government health care
system is yet to deliver its goods. Voluntary Organisations have done remarkable work for the
tribals living in B.R. Hills, M.M. Hills of Chamarajnagar District, and at H.D. Kote. There
should be increased collaboration between the voluntary and governmental sector. They should
be involved in every programme that is planned to be implemented in the tribal areas
Socioeconomic factors
Alienation of the tribals from their forest resources for their livelihood, exploitation by the non
tribals as unorganised workers, laying down of new roads and highways, deforestation,
displacement due to dams and claiming of ST status by other caste groups have resulted in the
deterioration of the health status of the tribals. Uncontrolled sale of illicit liquor in the tribal
areas has lead to alcoholism and related problems.
Recommendations
•
A rapid survey of the health status of the tribals should be carried out and region specific
and tribe specific health plans should be made.
•
The norms for Primary Health Centres and Subcentres in tribal areas should be based on
geographical and population basis and they should be flexible.
•
Tribal girls should be selected and trained as tribal ANMs and they should be posted in
tribal subcentres. They should also be trained in traditional medicine and health practices.
•
Traditional healing systems must be encouraged and documented in tribal areas and there
should be integration of modern medicine with the Traditional systems. Promote herbal
gardens in tribal areas.
• Genetic diseases like Sickle Cell Anaemia, G 6 PD Deficiency, which are specific to
tribals should be given special importance with adequate funds and expertise, for
their treatment, research and rehabilitation with the support of medical colleges.
• Secondary and tertiary care, transport facilities for emergency services and obstetric
care are essential. Community financing for emergency transport and referrals
should be promoted in tribal areas.
-3-
• Health education, PRA exercises and micro planning, convergent community action,
training in communication skills, mobilisation of local health resources are essential.
• Ensure nutrition security through kitchen gardens and encouragement to grow
nutritionally rich food crops. Public Distribution System should distribute cereals
like ragi, bajra, oil and pulses instead of polished rice and sugar.
• Proper functioning of the anganwadies in tribal areas should be ensured through
appointment of local tribal staff and using locally available foods.
• A HMIS of the health infrastructure, human resources, vital statistics and other
health indicators specially for the tribals is mandatory and should be an on-going
process.
• There should be increased collaboration between the government and the NGOs in
tribal areas. The voluntary agencies must be involved in all health and development
activities undertaken by the government.
• Tribal housing with adequate and safe drinking water and sanitation facilities, and
smokeless choolas should be ensured.
• The Mobile Health Units in tribal areas should be made fully functional by filling up
the vacant posts, providing equipment and drugs.
• Ban sale of liquor in tribal areas
-4-
10.3. THE ELDERLY
Age is a thing of mind over matter
If you don't mind it don't matter.
- Mark Twain
With improvement in preventive medicine and health care in the country, the expectation of life
at birth has increased from 32 years in the forties to over 60 in the nineties. In other words,
people live longer and the health of the elderly has also improved. Consequently, the numbers of
the elderly, that is those 60 years and over, have been increasing. From 12 million in 1901, the
number of the elderly was about 20 million by 1951 and 57 million by 1991. Population
projections made by the Registrar General, India indicate that this number would be 100 million
by 2016 1. The size of the aged population would have implications for most social services,
including health.
In Karnataka, the number and proportion of the aged in the population in 1991were 3,142,708
and 6.99 % respectively. The projections indicate that by 2001 the number of the aged would be
3,783,000 or 7.18 % of the population and by 2016 it would be 6,096,000 or 9.71 %. The
increases are significant.
The composition of the aged and the differential characteristics between elderly men and women
would influence policy prescriptions and determine the elements of measures for the care of the
elderly. An analysis by broad age groups within the elderly in the State is presented below for
1991 and 2016 –
Age Group 1991
2016
among the Number of elderly and proportion of Number of elderly and
Elderly
the age group in total population
proportion of the age
group in total population
Percentage
60 – 64
1, 078, 000; 2.40%
2, 165, 000
3.6%
65 – 69
798,000; 1.77 %
1, 604, 000
2.6%
70 – 74
600,000; 1.33 %
1, 086, 000
1.7%
75 – 79
245,000; 0.54 %
644,000
1.0 %
80 +
371,000; 0.83 %
598,000
1.0 %
The increase in numbers and the increasing proportions of the elderly in the total population by
2016 are noticeable.
1
The data are from two publications of the Registrar General & Census Commissioner, India. These are (i)
Population Projections for India and the States 1996 – 2016 of 1996 and (b) Ageing Population of India – An
analysis of the 1991 Census Data of 1999.
1
The distribution of the elderly within themselves would also be of significance. In 1991, this
distribution by broad age groups was as follows:
Age Groups
Number of elderly in Proportion of those in
the age group
the age group to total
elderly population in %
60 – 69
1,929,703
61.40
70 – 79
8,042,585
26.81
80 – 89
296,551
9.44
90 – 99
64,056
2.04
100 +
9,813
3,142,708
0.91
100
The proportions could be assumed as continuing till 2016. The distribution of the elderly by
broad age groups would indicate that the scale and type of health services that would be
necessary for the elderly cannot be of a uniform type. The health services that would be
appropriate for the age groups 60 – 69 and 70 – 79 would be different from those required by the
higher age groups of 80 years and above.
Every age group has its special health needs. At every stage, the need for and the type of
facilities would vary in content and accessibility - whether health and medical facilities,
transport or social support. It is in this context that the special needs relating to the elderly
become important. However, the issues relating to the elderly would have to be viewed as
concerns of the health and social welfare systems and not of the former alone. Concerns relating
to the elderly would call for inter-sectoral coordination between the various agencies concerned.
Psychological, social and economic needs
Vital socio-economic and psychological changes occur as a person gets older – sometimes
articulated to a point where they could create familial tensions, sometimes borne without protest
and often without even realization of the changes, but nevertheless inevitable. Relationships
within the family change and modern life compounds the problem. The perceptions of cultural
and behavior patterns and of life styles between generations – the generation gap – begin to
manifest themselves. Adjustments are often difficult. In the urban areas, the stress of modern life
styles, shortage of living space, mobility due to career advancement and the like – all of which
have economic implications - have eroded the strength of the joint family system. In the rural
areas social compulsions and community sympathy may be stronger and this may, to some
extent temper the need for adjustment among generations within the family. However, the
apparent difficulties in obtaining effective medical care and hospital services are more
pronounced than in the urban areas.
The question as to how to provide for the elderly does not have a unique answer. In the
Karnataka context, it would be unrealistic to prescribe state sponsored social welfare measures
and monetary support systems implemented by official agencies. The tradition of family
responsibility for the young and the elderly, which even while being eroded, still exists needs to
be sponsored and sustained. A social security system that is based on the family – an in-built
2
family based system – is probably the best, the most cost effective and most psychologically
satisfying. However, it is because such a system is getting eroded due to various reasons that
other measures have to be devised. The alternative is action by the State and by voluntary
organizations, each supporting the other, with strengthening of the family care system.
In this context, the gender issues and the economic aspects cannot be ignored. The percentage
distribution of population aged 60 plus by marital status in the rural and urban areas is as follows
–
Males
Females
Rural:
Married
84.86 %
13.00 %
Widowed
35.11 %
63.89 %
Urban:
Married
85.69 %
11.22 %
Widowed
36.83 %
61.38 %
It would be apparent that elderly men have the support of a companion, since they tend to
remarry. The proportion among the elderly of widowed men is significantly smaller than that
among elderly women. The support system within the family for women tends to be weaker than
that for men. Economically also, elderly men would seem to have an advantage. Among the
elderly males 56.67 % continue to work as against 18.14 % among elderly women. In the rural
areas, the proportion of elderly males who work is 62.43 % while that among elderly women is
21.43 %. The corresponding urban proportions are 40.01 % and 7.71 %. This would imply that
in the formulation of health and social welfare measures for the elderly, special provisions
would have to be built in for elderly women.
Some broad issues could be identified as arising from the aging of the population. These include
1. Health and medical issues, including the need to establish special geriatric services, which
have both costs and organizational elements;
2. Social issues such as diminishing family support of the elderly;
3. Gender issues as a consequence of a larger proportion of widows;
4. Economic consequences such as:
a) enhanced pension payments over longer periods,
b) a lower savings rate, with possible erosion of savings for providing care within the
family,
c) reduction in consumer expenditure on certain types of goods and services,
d) in the long-term, a possible reduction in the availability of workers, with consequent
increase of labour costs.
5. The need to restructure social services and the insurance sector to provide basic security for
the elderly.
The Constitution of India, in Article 41 of the Directive Principles of State Policy, specifies that
the State shall, within the limits of its economic capacity, provide for assistance to the elderly.
The National Policy on Older Persons of January 1999 reflects this concern for the elderly and
indicates possible action points. It mandates State support for the elderly with regard to health
care, shelter and welfare. It also provides for building up a strong and vigorous voluntary
initiative through Non-Governmental organizations. The National Population Policy 2000 also
refers to the needs of the elderly while the Draft Health Policy of 1999 specifically includes
concepts relating to geriatric care.
The issues relating to the elderly are complex since they include social welfare and cultural
parameters. In dealing with these issues the approach should be to enable the elderly to lead
3
comfortable lives with assured minimum health care, sustenance and shelter, preferably within
the family system. In particular, any system that provides for care for the elderly has to
recognize that elderly women are more disadvantaged than men, with discrimination being
based on gender, widowhood and age as reflected by lack of utility in the household. Also, a
welfare system for the elderly should permit the active and productive involvement of the
elderly, to the extent possible, in economic and social activities. Elderly persons should be
viewed as a resource capable of being used for special purposes and not just as consumers. As
society ages, opportunities and facilities would have to be provided so as to utilize this resource.
Welfare system for the elderly
The capacity of the State to provide a fully State funded welfare system for the elderly is very
limited. It would, therefore, be necessary to devise systems of care for the elderly that cater to
essentials, with periodic enhancement of facilities and extent of care over time. The need for
active involvement of the non-government sector would be evident. It would also be evident that
such measures would have to be structured on the basis of strong family involvement in the care
of the elderly.
A welfare policy for the elderly would include (a) financial measures, (b) legal measures, (c)
health and medical care issues, (d) involvement of the NGOs and (e) measures for strengthening
the family system of care for the elderly in the family. It would be evident that such measures
fall within the purview of various administrative departments of Government. The
implementation of a policy for the elderly would, therefore, call for close inter-sector
coordination. It would be necessary for the Government to formulate a policy for the elderly,
which would include all elements, including health. Some of the important elements that such a
policy would have to include would relate to the health sector and to the social sector.
Measures within the health sector:
Issues relating to the health and medical requirements of the elderly are not distinguished in the
current system of health care. It is only in the last few years that there has been recognition that
these needs of the elderly require both special organizational arrangements and special
professional skills and training. It is also recognized that health and medical issues of the elderly
cannot be disassociated from other social welfare measures such as health insurance, subsidized
costs of shelter and economic relief. Nevertheless, even as a general policy for the elderly is
being formulated and implemented, it is possible to institute certain action plans relating to the
elderly in the health system.
The goal of health services to the elderly would have to be based on the general principle of all
health services, namely to provide affordable services of adequate and acceptable quality as near
the beneficiary as possible. While reasonable charges for services could be levied, special rates
for the elderly are recommended so as to lessen the burden on the household and to induce them
to seek medical attention for the elderly with no hesitation. It is in this context that schemes for
health insurance become important.
The primary health care system would necessarily be the main provider of such services to the
elderly, because of its reach. It would have to be strengthened and oriented for this purpose
because the health and medical problems of the elderly would often be accompanied with
disability, loss of some faculties and psychological problems. These problems are not always
manageable at home or would require special training or orientation in those who cater to the
needs of such elderly persons.
Geriatric care facilities would have to be provided at the secondary and tertiary care levels. In
addition, the private health institutions should be encouraged to provide such facilities, and a
4
per-patient payment system by Government could be considered. This would reduce the
immediate investment that would, otherwise, have to be made to provide such facilities in all
public health institutions.
The management of both public and private institutions would need to be sensitized to the
special needs of the elderly. Single point counters to avoid multiple trips to various counters in
an institution, elimination of long waits and patience in personal interaction would be some of
the measures that would seem essential.
Training for care of the elderly
It would be evident that medical and para-medical personnel would need special training and
orientation on two counts. The first would be an appreciation that the health and medical
problems of the elderly have special elements that must be recognized and, second, that the
organization of services for the elderly would need special efforts. Such training and orientation
would have to be at two levels. The first would be to train the staff in all primary, secondary and
tertiary care institutions on geriatric issues and care. The second would be the need to build into
medical courses geriatric issues and their treatment. It is recommended that (a) in-house training
in geriatric care should be instituted within the Department, (b) the associations of private
institutions be requested to conduct similar courses, and (c) the content of medical courses be
reviewed so as to train medical graduates to geriatric issues. It is also recommended that such
courses on geriatric care be introduced in training of nurses and para -medical staff.
Measures within the social and legal framework:
The elements relating to the elderly that could be considered as falling within the social and
legal framework would, among others, include the following:•
•
•
•
•
•
Financial measures such as instituting health insurance schemes for the elderly. This
could be introduced by the Karnataka Government Insurance Department;
Provision of old age pensions to those below the poverty line with suitable safeguards to
ensure that the right beneficiaries receive the amounts.
Non-government organizations could be assisted in utilizing the elderly in productive
activities as teachers / guards and the like and establishing of care centers. Such
organizations could also be encouraged to establish counseling centres to advise the
elderly and their families on problems relating to the former;
Legal provisions to ensure that the family takes the responsibility of looking after the
elderly could also be considered as has been attempted through the Himachal Pradesh
“Maintenance of Parents and Dependents Act”, 1966. However, the difficulties in
implementing social measures of this nature must be kept in mind.
Efforts through the media to restore family values and also to indicate the measures
instituted for the elderly. Creative media efforts should dispel the notion of the elderly
being either of little help in the family or as a burden, especially in the case of widows.
Traditional publicity modes could be inducted for this purpose.
Panchayat institutions could be encouraged to promote the welfare of the elderly and
induct them, on fixed honoraria basis, for specific work in the community.
The role of non-governmental organizations has been referred to earlier. It would be necessary
to provide incentives, with due controls of inspection and monitoring, to NGOs that establish or
provide facilities to the elderly such as medical treatment, in-house care, recreational facilities
and the like. Such incentives could include special quotas from the public distribution system,
exemptions from stamp duty on purchases of land, lower rates of property tax and the like.
5
These elements would have to be examined further and incorporated in the policy on the elderly
suggested earlier.
The issues relating to the elderly are not confined to the health sector. They would have to be
considered as part of other social sectors such as economic assistance, housing, transport, food
supply, etc. While each sector may administer its components relating to the elderly, the issues
cannot be viewed in compartments. The need for a mechanism for inter-sector coordination
would be evident.
It would be desirable to designate a specific department that would be concerned with the issues
of the elderly and that would be responsible for ensuring coordination. This department may also
formulate a draft policy on the elderly and disseminate it for wide public and professional
reaction, before a formal policy is adopted.
Recommendations
•
A policy for the elderly should be formulated, with particular safeguards for women, and the
administrative Department responsible for implementation of this policy should be
designated;
•
The scale of user fees for health services, if charged, should be reduced in the case of the
elderly patients, so as to lessen the burden on the household in availing of medical
assistance for the elderly
•
The health problems of the elderly are often accompanied with disability, loss of some
faculties and psychological problems. Special skills would be necessary for treating the
elderly. The skills and knowledge required in treating the elderly by the primary health care
system, because of its reach, should be strengthened through sensitization and training;
•
Geriatric care facilities should be provided at the secondary and tertiary levels. In addition,
private health institutions should be encouraged to provide such facilities, and a per-patient
payment system by Government could be considered.
•
The managements of both public and private institutions would need to be sensitized to the
special needs of the elderly. Single point counters to avoid multiple trips to various counters
in an institution, elimination of long waits and patience in personal interaction are some of
the measures that would seem essential.
•
For sensitization to the health issues of the elderly and training in providing health services
to this group, (a) in-house training in geriatric care should be instituted within the
Department, (b) the associations of private institutions could be requested to conduct similar
courses, and (c) the content of medical courses need to be reviewed so as to train medical
graduates in geriatric issues.
Such courses on geriatric care should be introduced in training of nurses and para -medical
staff also.
•
Health insurance schemes for the elderly need to be introduced. The formulation of such
schemes could be assigned to the public sector Indian insurance companies, including the
Karnataka Government Insurance Department.
A scheme for provision of old age pensions to those below the poverty line with suitable
safeguards to ensure that the right beneficiaries receive the amounts should be formulated;
•
6
•
Non-government organisations could be assisted in utilising services of the elderly in
productive activities as teachers and the like and establishing of care centers. Such
organizations could also be encouraged to establish counseling centres to advise the elderly
and their families on problems relating to the former;
•
The introduction of legal provisions to ensure that the family takes the responsibility of
looking after the elderly could also be considered as has been attempted through the
Himachal Pradesh “Maintenance of Parents and Dependents Act”, 1966.
•
Efforts through the media to restore family values and also to indicate the measures
instituted for the elderly and to dispel the notion of the elderly being either of little help in
the family or as a burden, especially in the case of widows. Traditional publicity modes
could be inducted for this purpose
•
Panchayat institutions could be encouraged to promote the welfare of the elderly and induct
them, on fixed honoraria basis, for specific work in the community.
•
The mechanisms suggested elsewhere for intersectoral coordination would have to consider
issues relating to the elderly along with related issues pertaining to other social and
development sectors.
7
11. HEALTH PROMOTION
Two roads diverged in a wood,
I took the one less traveled by,
And that has made all the difference.
- Robert Frost
-
" Health promotion is the process of enabling people to increase control over the determinants of
health and to improve their health"- Ottawa Chapter. WHO, 1986.
Health promotion aims at improving the health of individuals and communities. It is "the sum
activity of the population, the health services and other productive and social services, aiming at
improving the status of the individual and collective health" – PAHO, 1991.
Continued efforts at improving health are a must. There is resurgence of old infectious diseases
such as malaria and tuberculosis and emergence of new diseases, such as HIV infection and AIDS.
There is also resistance of insects (vectors) to insecticides and bacteria to drugs. We are in a stage of
health transition causing the double burden of communicable and non-communicable diseases. The
cost of health care has been increasing, with commercialisation of health care. The new patent laws
further worsen the situation.
Enabling people
Empowerment of people for health means that they must have health literacy and skills and capacity
to acquire health and maintain it. It also means that people are aware of their rights and will demand
health care. People will participate in the planning, implementation and monitoring of health
programmes.
Strategies
The International Conferences on Health Promotion (Ottawa, 1986; Adelaide 1988; Sunderwall,
1991; Jakarta, 1997) had spelt out the strategies for health promotion. These strategies are:
1.
Build healthy public policy
2.
Create supportive environment
3.
Strengthen Community Action
4.
Develop personal skills
5.
Reorient health services.
The Jakarta declaration gave certain priorities in the call for health promotion. We can think of
other strategies.
•
Promotion of healthy life styles
The most improvement component of health promotion is the promotion of healthy life styles.
This has been advocated by Ayurveda, which placed emphasis on dinacharyas, rtucharyas
and other health promoting practices, including exercises, yoga and meditation. Ayurveda
insisted on purity in everything; purity of water, purity of food, purity of body, purity of mind
and purity of environment. It is also necessary to avoid certain harmful behaviours, such as
use of tobacco in any form (smoking, chewing or use as snuff) or alcohol or addition forming
drugs.
-1-
•
Prevention of disease
By observing certain principles, we can avoid diseases. They can be presented by procedures
such as immunisation, safe drinking water and sanitation
•
Community development
An essential element in health promotion is community development. Health promotion
requires that we face and resolve the problems of basic standards of living as well as
economic, environmental and social inequities. We must identify the factors that encourage
inequity and take action to remove them or alleviate their adverse effects. Public participation
is important in modifying unsanitary conditions and unhealthy behaviours.
Health promotion strategies must incorporate the cultural traditions and social procedures that
are integral for the development of people and societies.
11.1 HEALTH EDUCATION
A major component of health promotion is health education. Health education is " a process which
affects change in the practices of people and in the knowledge and attitudes related to such
changes". –Health education Monographs, 21, New York, 1966. Health education aims to:
•
•
•
Ensure that health is a valued asset to the community;
Equip people with skills, knowledge and attitude to enable them to solve their health problems
by themselves or with help from others; and
Promote the development and proper use of health services.
Various media can be used effectively for promoting health. Print media are very effective in giving
health information and promoting health. The readership of newspapers and magazines is
increasing (in spite of the fears that electronic media will depress it). The Health Promotion and
Education Department of the State should be vigilant to make use of opportunity. The Government
should ensure that health denying advertisement (like that of tobacco in any form, alcohol abuse) do
not appear in the print media. The recent decision of the Central Cabinet in regard to tobacco is a
most welcome measure. The State must support it fully.
Folk media
The folk media are probably the best. Health education bureau can prepare scripts (appropriate for
the location and audience) and train people in such activities as street theatre, yakshagana, etc.
Electronic media
The electronic media can be used effectively. Both Doordarshan and All India Radio can be used.
Since electronic media are often used for entertainment, efforts must be made to make the shows
and talks entertaining and instructive.
Films, posters and other audio-visual materials can be used, as also exhibitions strategically.
Monitoring of media
While it is important to have the right messages, it is still more important to ensure that wrong
messages are neither given nor unhealthy life styles shown. There can be health committees
attached to Doordarshan and AIR to enable them to communicate effectively. A Watchdog
-2-
Committee must be appointed to watch out that the media do not give the wrong messages or put
out advertisements that can lead to hazardous and unhealthy lifestyles.
State Health Education Bureau
The Bureau is concerned with the Information, Education and Communication within the Health
Services. It has two divisions. The first division is concerned with planning, implementation and
monitoring health education activities pertaining to family welfare in the rural areas of the State. It
is headed by the Project Director, Reproductive and Child health (RCH) services. The Second
Division is headed by the Additional Director, Health Education and Training.
The State Health Education Bureau has used the standard methods: mass media, folk media (drama
and street plays), exhibitions and group discussions. There has not been enough follow-up and
hence the outcome of these efforts in changing behaviour is not known.
Block Health Educators
Many of the posts in the Bureau are vacant. This is particularly so in the case of the District Health
Education Officers and Block Health Educators. There is need to rethink the location and work of
the Block Health Educators who are attached to the Primary Health Centres. There are 782
sanctioned posts of whom 517 are working, whereas there are 1676 PHCs. It is suggested that we
relocate the Block Health Educators at the Taluka level with each BHE being in charge of 2-3 PHCs
and supervised by the officer at the Taluka level.
Out of 517 Block Health Educators at the Primary Health Centres, only 51 have the Diploma in
Health Education, whereas 466 do not have the required qualification. It is necessary that all the
health educators be trained well (Diploma in Health Education). 50-60 Block Health Educators may
be trained per years. All new entrants must have the requisite qualification.
Intersectoral collaboration
There is need for strong linkages between the Departments of Health and Education (See section on
School Health). Another important department is that of Information and Broadcasting. They have
the necessary expertise and requisite contacts with respect to the media. Poverty is the greatest
killer. It breeds death, disease and disability. Health promotion measures must address the issue of
poverty and ill health. Medical and Dental Colleges, Nursing schools and colleges, schools and
colleges of Pharmacy and many other educational institutions can help in health promotion. It is the
duty of the Health Services Department (State Health Education Bureau) to collaborate with them
and get them involved in health promotion.
Health Education Bureau II
This section has 5 State level units: audiovisual, field study and demonstration, school health,
exhibition and training. Many of the posts are vacant: the functioning of this section is "not very
satisfactory", according to the study conducted recently (2001) by the International Union for
Health Promotion and Education, South East Asian Regional Bureau, Karnataka Chapter.
Audiovisual Unit
This Unit is concerned with the training of health personnel in the design, production and
procurement of audiovisual aids and their use.
-3-
Field Study and Demonstration Unit
The Unit is expected to work out effective methods and media for health education and the
planning, organizing and implementing programmes and investigation of issues in health education
and solution of the problems.
11.2 HEALTH PROMOTION IN SCHOOLS
School health promotion includes all activities that a school can use to make the children healthy
and to spread the message of healthful living and practice to all those who attend and work in the
school and to their families and communities. Effective health promotion in schools has a number
of components:
•
Safe and healthy school environment
•
Availability of safe drinking water and good sanitary arrangements, e.g.; toilets
•
Sound nutrition practices (including supplementary food, where necessary).
•
Good health services practices (including mental and emotional support)
•
Effective health education.
Health services in schools
At present, medical examination of students of first, fourth and seventh standards are carried out by
the Medical Officers of the PHCs, assisted by the Health Assistants. It is necessary to extend the
services to all the children (all standards from 1 to 10) systematically, so that every child is
examined at least once a year. Remedial measures must be taken up so that defects can be rectified.
The study on health promotion has this to say: " Though the physical targets achieved are above
80%, the quality of service appears to be very poor".
School health education
Health education is the most important part of health promotion in schools. The state has the
following goals for its school health education programmes " To enhance and promote health
education of school children in every possible manner, to enable them to adopt measures to achieve
and remain healthy and develop in them a self reliance and social responsibility and better quality of
life not only as children of today, but also as adults of tomorrow "
School health education is through instruction in the classroom through all school subjects (syllabus
and curriculum) and in the playing fields and outside. It is then translated into action, in and around
the school and in the community.
School health promotion is an investment in the future society. School children study better and are
happier if they are fit and well. School children if ill, cannot concentrate on the lessons and may
miss school and find it difficult to catch up. Sometimes they drop out of school. Children who learn
to listen, observe, communicate and take decisions about their own health can help their family
members to become healthy. They become good parents and active and useful community
members.
A school that promotes health
• Is all for health, fostering health with every means at its disposal;
• Involves all members of the school (students, teachers and non teaching staff) and the
community around it to promote health
-4-
•
•
•
•
Strives to set an example through environment protection, good nutrition and safety
measures;
Develops life skills in children;
Promotes ways of giving children responsibility; and
Raises self esteem of the children
School Health Implementation in the State
The Medical Officer of the Primary Health Centre is responsible for medical examination of
students of 1st, 4th and 7th standard students. The District Staff supervises the activities. The
District Health Officer reports to the head of the Health Education and Training section at the State
level. According to the recent (2001) study conducted by the Karnataka Chapter of the South East
Asia Regional Bureau of the International Union for Health Promotion and Education, the
performance has not been satisfactory: "Remedial measures and follow up: done very superficially";
"nutritional services: no programme"; "health education: not carried out systematically"; "teachers
training: carried out, but not sufficient"; "maintenance of school health record: not done
systematically"; "school environment, water supply and sanitation: nothing is done. "It is necessary
to improve the situation drastically.
Integration of IEC activities
There are Information, Education, Communication (IEC) activities in many programmes and
projects in Health and Family Welfare Services – namely, Health Care, Reproductive and Child
Health, Karnataka Health Systems Development Project, India Population Projects VIII and IX,
AIDS Society and others. There are IEC sections in malaria, tuberculosis, leprosy and blindness
control. Integration of all IEC activities will have a salutary effect. This can be done by bringing
them together under the Health Education Bureau. At the same time, it is necessary to ensure that
the individual programmes and projects do not suffer. Arrangements must be made in each scheme
to have a designated officer to liaise with the Health Education Bureau. The synthesis of all IEC
activities can help health promotion and education.
Collaboration between Central and State Media Units / Departments:
The Inter-Media Publicity Coordination Committee (IMPCC) is a Central Government initiative to
ensure better coordination between different media units to raise the level of awareness and promote
public welfare. It is a confederation of the media units of the Central and State Governments, Public
Sector Undertakings and Nationalised Banks functioning in the State Capitals. IMPCC meets once a
month. It discusses strategies and initiatives of various media units.
Similar committees exist in some districts under the chairmanship of the Deputy Commissioner. It
is necessary that District Committees be established in the remaining districts also. It can help in
improving grassroots communication through coordination involving all the concerned departments
and non-governmental organisations. The State and District Committees should ensure full
involvement of the people in the policies and programmes for health promotion.
-5-
11.3 ADVOCACY FOR HEALTH PROMOTION
An important component of action to achieve health promotion is advocacy. It involves all aspects
of making persons aware of the issues and problems and motivate people to act to solve the
problems. Efforts have to be made to inform, to continue and to persuade all people and especially
the policy and decision makers and the implementers.
Advocacy can lead to action at local level or to a mass movement with far-reaching results. the
Voluntary/ People's organisations are the best groups to carry out the advocacy programmes. In
order to carry out advocacy successfully, the persons involved must have the necessary information
and reliable data as also knowledge of what are the goals and how to reach the goals. It calls for
leadership. If properly applied, advocacy is the best means of achieving health promotion
Recommendations
•
Medical examination of all students (1-10 standards) by the medical officers and the team of
PHCs must be taken up seriously and the performance monitored by the District Health
Officers. If necessary, the services of general practitioners may be taken and they be paid a
suitable honorarium.
•
The Block Health Educators (2-3) may be attached to the Taluk Health officer. They must carry
out health education in every school in the area and for the population covered by the PHCs to
which they are attached. District Health Education Officers must monitor the programme.
•
The school environment must be improved, involve the students and teachers;
Safe drinking water must be available throughout;
Toilet facilities must be provided, separate for boys and girls.
Zilla Panchayats should be persuaded to invest in these activities.
•
Intensify the training of teachers for health; they should be enabled to detect diseases or
disability at the earliest; corrective action should be taken by the PHCs doctors and the students
must be followed up.
•
The programme of health promotion is the combined responsibility of Health and Education
departments
•
All the vacant posts in the different units/divisions of the Health Education Bureau must be filled
up.
•
The Block Health Educators must be fully trained and should have the necessary qualification
(Diploma in health Education); 50-60 Block Health Educators may be deputed annually for the
training. An important part of the training must be skills development in community
organization and involvement of the local people in health promotion and education.
Strengthen community action.
•
Encourage and support Mahila Swasthya Sanghas. Have Village Health Committees; health
promotion and education will be a major responsibility of these committees.
-6-
•
Have health committees attached to Doodharshan and AIR to actively help in health promotion.
Have a watchdog committee to prevent wrong messages and 'unhealthy' advertisements.
•
The Department of Health and Family Welfare Services must collaborate fully in the functioning
of the Intermediate Publicity Coordination Committees at the State and District levels for
dissemination of information and the creation of awareness on matters affecting health.
•
At least 5% of the health budget must be allotted to health promotion and progressively
increased to 10%, as Health Promotion can yield rich dividends by way of improving health.
•
The Non Governmental organisations must be encouraged in their activities for health
promotion including innovative programmes.
•
Bring all IEC activities in the Department of Health & Family Welfare Services under Health
Promotion; at the same time, ensure that the individual programmes do not suffer. Integrate the
two sections of the Health Education Bureau into a division of Health Promotion.
•
Intersectoral co-operation of the developmental departments and especially Health, Education,
Women and child welfare, industry and Information and Publicity, and Broadcasting, is
necessary for health promotion and education.
-7-
12. HUMAN RESOURCE DEVELOPMENT FOR HEALTH
" As long as millions of people live in hunger and poverty, I hold every man a traitor who having been educated at their
expense pays not least heed to them"
- Swami Vivekananda
-
Health services require large members of well-trained qualified professionals and workers, with a
variety of skills and appropriate knowledge, and attitude to improve the health of the people, and to
reduce suffering due to ill health. It is necessary to have formal and informal educational centres to
train persons in adequate numbers and of the requisite quality.
The biggest challenge to the health-care education institution is not just technical, managerial or
financial development, but quality human resources development, which includes:
1. formation of young health professionals and supportive staff who are responsive to social,
technical, scientific and management abilities to work effectively in a comprehensive health
system;
2. development of a faculty team, consisting of not just good teachers but learners – oriented
facilitators of an educational process, who are also good role models with social vision,
commitment to ethical norms and values; and inspirers of people and community oriented
vocations through precept and example; and
3. development of a supportive team of staff who will complement the faculty in the educational
institutions, laboratories, outpatients, wards and other specialized clinics, field practice areas and
community health centers, with needed skills and motivation.
12.1 HEALTH PROFESSIONALS' EDUCATION
There is distorted and disturbing situation of Human Resources Development for health. The
emphasis is too much on production of medical doctors with mushrooming of medical and dental
colleges in the State. Such large-scale increases are seen in the number of colleges for other systems
of Medicine and in disciplines such as Nursing, Pharmacy and Physiotherapy.
The existing health science institutions have been churning out graduate physicians and other
professionals, whose number is much more than the actual need. Should we sacrifice the quality of
education just to satisfy a few aspiring groups?
Out of 172 medical colleges and 123 dental colleges in the country, 23 medical and 38 dental
colleges are in Karnataka. Approximately 30-40% shortage of teachers is observed in all the health
science institutions in Karnataka State, resulting in substandard health professional’s education.
This will have direct impact on providing quality primary health care to the community. Should we
jeopardize the health care system, by producing health professionals, who lack confidence and
competency to take care of the health of the community?
It is very essential to consolidate the existing institutions by building the capacity to the desired level
and develop a better system of health professionals' education.
There is clustering of medical and other teaching institutions in certain cities and districts, while
some of the districts do not have them.
Reforms in education and training
1. Selection of students (both undergraduate and post graduate) should not be based only on the
ranking at the entrance examination. Stress should be on the aptitude of the candidate. The
selection should be based on their commitment to the social objectives and technical challenges
of education in the State. The output from these institutions should be need based.
2. The education should be competence and value based. Nurture the human resources holistically
in terms of knowledge, skill, values, attitude and social commitment. For this process to be
effective, the focus should be on three dimensions- professional, personal and social.
3. A doctor has to face moral and ethical dilemmas all the time. He/she must be prepared to face
these problems, just as he /she faces clinical or health problems. Then only can the doctor take
appropriate decisions. Rajiv Gandhi University of Health Sciences has taken the right step in
recommending teaching and medical of medical ethics throughout the course including
internship.
4. The education should be scientific and evidence based. The approach should be humanitarian
and holistic, rather than disease oriented. Day by day the doctor-patient relationship gap is
widening. Commercialisation has eroded the doctor’s concern for the patient. The education
which at present is knowledge oriented, should focus on development of required skills, and
attitude so that he/she will have the confidence and competency to face the challenges in caring
for the individual, family and community. The teaching and learning programmes should be
oriented taking into consideration the abilities identified by Medical Council of India and other
professional councils, which are required for a graduate to practise independently. The thrust
should be on student centered learning rather than to satisfy the teacher’s capability. They must
be encouraged to get involved in electives or small projects. The teacher’s role should shift from
a mere instructor to that of a facilitator and create a situation for the student to learn by
participating in the learning process. There should be stimulus to the student to apply his/her
mind and provide an opportunity for self-learning.
5. Medical and health professional colleges and other health care institutions must adapt to the
important health reforms in the society. The students must accept a certain degree of
accountability towards society’s health if they wish to continue to be forces for social progress
and consequently to merit taxpayers support. It is their obligation to direct education, research
and service activities towards addressing the priority health concerns of the community, region
and state; they have a mandate to serve.
6. At the time of admission, the student should be exposed to educational objectives, skills of
learning and communications, National Health Policy, values, group dynamics, team work
concept, dignity of labour, use of library and computer application. Foundation courses should be
organised towards development of personality and leadership qualities. During the course, equal
importance must be given towards involvement of students in cultural and sports activities. To
counter the enormous stress during the course, continuous counseling of students should not be
lost sight off.
7. Apart from concentrating only on the merit, non-scholastic capacities like: thinking skills, speed
of thinking, aptitude, group behaviour and communication skills of the candidate must be given
weightage. His /her knowledge in the field of behavioural sciences also need to be tested.
The students should be actively involved in social actions and disaster management. A brief
exposure to National Service Scheme (NSS) would enable them to understand the fabric of the
society.
Faculty development
1. Selection of teachers should be not only based on academic merit and professional experience,
but also on social / community perspective and aptitude. Commitment to the profession should
be emphasized. He / she should be a good motivator and facilitator to the student learning.
Qualities such as ability to motivate and leadership must be part of the criteria for selection.
Methods to assess these qualities have to be identified.
2. Soon after the appointment of a teacher, he / she should be oriented to the vision and mission of
the institution. Orientation or induction courses should be organized in the field of educational
science and technology (including problem based learning and examination, and assessment
methods). He/she must provide quality training to the students, which is socially relevant to the
community. He/she must actively participate in research, which is relevant and beneficial to the
society.
3. He/she must attend continuing education programmes and conferences for individual professional
enrichment. Must be encouraged to take up social/ community oriented activities.
4. He /she should not forget the obligation towards collective development of the department and
the institution.
5. A system of assessment of teachers by students, peer group and the head of the department,
should be developed. Needless to say one must be prepared for self-evaluation also. Such
assessments should be considered for promotion etc. The services of teachers who show initiative
and innovation must be recognized.
6. Private practice should not come in the way of their professional obligation to the student,
department, institution and the patient.
Vacancies of teaching staff
There are a large number of vacancies in the teaching staff in the educational institutions. These
must be filled by qualified teachers. The norms stipulated by the councils and other bodies regulating
professional education must be met.
Curriculum development
• The students should be socially oriented with emphasis on Primary Health Care approach.
• The public health concept, which has lot of relevance on the health of the community, has to
be revived.
• The students should have an exposure to the management aspects of health care delivery
system.
• Students should have an opportunity to learn through alternate parallel tracks.
•
Curriculum should be reviewed periodically depending on the changing needs.
Public health
There has been neglect of Public Health. There is need to have training in Public Health for health
professionals at various levels. These would include short orientation courses, certificate and
diploma courses. All Health Officers must have the postgraduate degree or diploma in Public Health
or Community Health.
Educational settings:
• This should be relevant to the health (felt) needs of the community. There should be adequate
clinical material for the students to acquire required skills and hands on experience.
• The training should have a definite slant towards community based learning. Programmes
should provide opportunity for the students to understand the social structure, its functions,
norms and values and social factors which precipitate disease condition in the community.
• Due emphasis must be placed on nursing care.
• Students from one system of medicine should be oriented to other systems of medicine, to be
aware of strengths and weaknesses and to encourage respect for each other.
Library
With the explosion in information, the library should be equipped to retrieve information through
modern technology. The institutions must move forward in setting up digital libraries with online
facilities. The institutions should develop networking with other institutions for mutual benefit.
Creating a library set-up at the University and linking the University library to the libraries in the
affiliated institutions will be very useful. This should be developed as an information and learning
centre at the University with audiovisual equipments.
Create more facilities for students to take up self-learning, so as to have life long learning.
Institutions
The question of granting professional autonomy to selected institutions should be seriously thought
of. If the institutions have developed well, in terms of infrastructure and faculty, providing autonomy
may have a positive effect on their obligation to the society; thereby the institution can render better
medical and health care to the community. Even the departments should be encouraged to raise
resources of its own. Reasonable amount of funds should be made available for up-gradation of
existing facilities to enable the institutions to provide better education to the students. Institutions
should be accredited based on their social accountability (relevance, equity, quality and costeffectiveness).
Commercialisation and corruption in medical education
Commercialization and corruption are two very important issues, which need to be addressed
urgently. Privatization has come to stay. This fact needs to be accepted. Many private institutions
have developed good infrastructure and are providing medical education of high standard.
Corruption in medical education has raised its ugly head at various levels. A mechanism must be
evolved to root out this cancerous process. Otherwise it may erode the credibility of the system.
Corruption is seen at every stage, including examinations, both undergraduate and postgraduate.
Examiners, against whom there are charges of corruption, must be removed from examinership and
disciplinary action taken.
In this direction Rajiv Gandhi University of Health Sciences has established a commission to curb
professional misconduct. The hands of the University should be strengthened to put an end to
corruption.
The need for health human power
At present the turnover of health human manpower is based more on political expediency than on the
felt needs of the society. Even the distribution of the health professionals is not according to the
community need. Creation of more number of educational institutions over and above the actual
need in some faculties and branches has resulted in falling standards in training, which in turn has
affected provision of quality health care to the community.
There should be effective periodical interaction between the departments of medical education and
health care providers, both in government as well as private sector. There is a need to work out the
optimal requirement of various health professionals.
The real need of the hour is to impart health professionals education in such manner to the students so
as to achieve Health For All through the concept of Primary Health Care approach. All the health
sciences professionals are equally responsible for providing HFA.
Number of institutions
The number of institutions affiliated to the Rajiv Gandhi University of Health Sciences together with
the number of sanctioned seats (undergraduate and postgraduate) is given in Appendix 1.
While there is clamour for more professional colleges and increase in the number of seats, many
courses and many institutions do not attract enough eligible students, leaving many seats vacant.
This leads to inefficiency. A few examples are given in Appendix 2, which shows the sanctioned
intake, actual admissions and percentage of admissions to the sanctioned number of seats in Nursing,
Pharmacy and Physiotherapy during 96-97, 97-98, 98-99 and 99-2000.
Majority of the Colleges have large numbers of vacancies. These colleges do not have enough
number of qualified staff. They also lack infrastructural facilities like building, lecture halls,
laboratories, equipment and library. Clinical facilities are also insufficient.
The policy of permitting more and more institutions and increase in number of seats must be stopped.
What is needed is consolidation and improvement of quality.
Family medicine
At present family medicine does not find a place in the undergraduate training. After completion of
their internship, many young doctors prefer to set up general practice. But due to lack of exposure,
they do not have adequate confidence or competency to face the realities of practising family
medicine. Curriculum needs to be developed to train the undergraduate students in this field.
Selected family medicine physicians may be inducted into the training process and the students
exposed to this field during their internship training.
RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE
This University is committed to impart quality education and to develop high quality health human
power resources. Efforts are on to develop linkages and networking with other universities and
research institutions in the State, country and abroad. Linkages are being developed with both
government and non-government organisations, dealing with development of trained manpower
resources.
Goals of education and training in RGUHS:
1. The curriculum should be oriented towards educating students of health sciences to take up the
responsibilities of physicians of first contact. The graduate should be capable of functioning
independently in both urban and rural environment.
2. Post graduate students must:
a) Practise the chosen specialty efficiently, backed by scientific knowledge and skill base.
b) Exercise empathy and a caring attitude and maintain high ethical standards.
c) Continue to evince keen interest in continuing education irrespective of whether he / she is in
a teaching institution or is practising.
d) Be a motivated “teacher” – defined as one keen to share knowledge and skills with a
colleague or a junior or any learner.
Professional registration
Professional councils should monitor and curb unethical practices. Machinery and mechanism should
be developed to take up periodical medical and prescription auditing.
Periodical renewal of registration should be introduced. This should be based on credits acquired by
attending approved Continuing Education / Continuing Professional Development programmes.
The professional councils must be strengthened to ensure ethical and competent practice.
Exposure of students to special problems
Students must be aware of the unequal distribution of health human power across the state and the
country. They must study the patient in the total environment i.e. physical, social and occupational.
Must make an in-depth study into the National and State health policies. They should have a short
exposure on community based rehabilitation of persons with disabilities.
Currently gender is recognized as a term that reflects the complex social relations between men and
women. The process of socialization has lead to generally inferior position of women within the
family and in all other institutional groupings that exist in the society.
With current global and national trend towards globalization, liberalization and commercialisation
which includes commodification of women and of medical care, it is all the more important to
emphasize and reiterate in health professionals education certain basic values in health. These
include equity, social justice; ethics, gender sensitivity, sustainability and self-reliance.
There is tremendous need for further work on gender and power issues in health professionals
education. Besides research and analyses, the coming together of different streams, with networking
and sharing of experience between groups is required. Most importantly, there is need for
engagement with bodies concerned with medical education such as apex professional councils, health
and other universities and, professional associations and NGOs.
Research
At present this is the most neglected area in health professionals education. This should develop as
an in-built culture. The University and the teaching institutions should spell out policy statement to
encourage and support research activities at the University and institutional levels. Research
activities should be prerequisite for promotional opportunities of the faculty.
Research is essential in various areas (Please see separate chapter on Research). Research is
particularly important to solve problems of public health importance and Karnataka specific health
problems, such as Kyasanur Forest Disease and Handigodu Syndrome.
Basic principles of HRD plan:
•
•
•
•
•
•
It should support institutional policy and guidelines.
Create the right environment where values are caught.
Proactive planning is required especially in today’s environment when market values of
individualism, competition, commercialization, profit motive etc. are constantly distorting
health professionals institutions and environment.
Develop faculty and role models.
The initiative should be consistent, accessible to all and evolving through feedback.
HRD initiative should be constantly monitored and the best stimulus for evolution is regular
feedback from students, faculty and trainees.
Essentiality certificates
In the interim recommendations on Health Human Resources Development, after reviewing the
existing number of institutions, the annual intake and output and the needs of the state, it had been
recommended that “the issuing of essentiality certificate by the Government and affiliation by the
University for new Medical, Dental, Nursing, Pharmacy and Physiotherapy colleges should be
stopped for the next three years, the exception being Nursing colleges in undeserved areas of
Karnataka”. The Task Force notes with regret that Essentially Certificates have been issued to more
new medical colleges. The Task Force wishes to reiterate its recommendation; “no more
essentiality certificates may be issued for the next three years”.
The Task Force had also recommended extension of the moratorium on new Ayurvedic, Homeopathy
and Unani Colleges by another 2 years.
The needs of the State for qualified health personnel for various categories of professionals may be
studied by an expert committee appointed for the purpose and criteria fixed for approving new
institutions, like absence of such institutions in the district.
12.2 TRAINING
Adequate training of allied health professionals and paramedicals in numbers and quality is extremely
important in ensuring good health care services. There are a large number of institutions and courses
both in the Governmental and non-governmental sectors. These have grown mostly in a haphazard
manner without taking into consideration the need of the State.
The names of the courses, the number of institutions, intake capacity and duration of the course are
given in Appendix 3.
Training institutions
The Directorate of Health and Family Welfare Services has a network of training institutions.
1. State Institute of Health and Family Welfare (SIHFW)
The State Institute must be developed to be the apex, nodal center for all training programmes in
health in the State. It has to be upgraded to become an Institution of Excellence. A number of
training programmes for medical officers and others are being conducted here but higher standards
are needed.
One of the objectives of the State Institute has been the development of training programmes in
Public Health. This has become an urgent need with the proposal to have medical officers at all
levels trained in Public Health. This would include orientation courses of short duration, certificate
courses and postgraduate diploma and degree courses in Public Health.
The Institute has to develop its capability for conducting other courses, including health promotion
and management. In order that the Institute may function effectively, it should be an autonomous
body, with experts and administrators in the Governing Body. The funds for its activities and
maintenance should be allocated directly from the State Health and Family Welfare Department.
The Institute should have a Director. It will be selection post. The tenure will be 5 years. There has
to be close co-ordination between the Institute Director and the Commissioner / Director General of
Health Services. Close linkages must be worked out between the Directorate of Health and Family
Welfare Services and the Institute. The Director will report directly to the Principal Secretary, Health
and Family Welfare. He / She will be medically qualified and should have had training and
experience in medical education and training of trainers. It would be preferable to have a person who
had worked a few years in the Department of Health and Family Welfare Services.
There will be a Deputy Director. Suitable persons will have to be identified by a selection process.
The qualification and experience will be similar to that of the Director.
The Institute will have the full complement of training, administrative, research and supportive staff
with appropriate qualifications. It is expected that some of the staff will have to be appointed by
different approaches (lateral entry). This will be especially so with respect to social sciences,
communication and management. These may be filled up by either full-time / part-time staff or by
engaging the services of experts as and when required during the training sessions.
The Institute will have all the necessary training equipment and facilities, including teaching space
and identified field practice areas. It will have an up-to-date library and documentation center, using
modern information technology.
2. Regional Health and Family Welfare Training Centres (RHFWTC)
There are 4 Regional Health and Family Welfare Training Centres at Bangalore, Mysore, Hubli and
Gulbarga. There is wide variation in the infrastructure and programmes of training conducted at
these centres. Some of the key posts are unfilled or are filled with wrong personnel. There is need for
optimum utilization of the resources.
RHFWTCs will be administratively under the State Institute. The budget for RHFWTC will be
released by the State Institute. The centres will cater to training needs of the regions; the training
programmes will be planned together with and coordinated by the State Institute. Qualified
competent staff will be appointed to the regional centres. All necessary facilities and equipment will
be provided to these centres to ensure efficient and effective functioning.
3. District Training Centres (DTC)
Some districts have their own training centre. This will be extended to all districts. The District
Training Centres will be under the overall supervision and co-ordination by the State Institute. The
District Centres would be administratively under the State Institute, which would release the
necessary budget. The District Centres will oversee the functioning of the ANC training centres also.
District Centres will have the necessary staff, equipment and facilities.
Training needs
A systematic comprehensive training needs assessment should be undertaken. At present, there is
either duplication of training or absence of training in some important areas.
The heads of training institutions and the faculty should undergo pre-posting training in educational
technology. The training manuals must be updated periodically.
Induction training
All categories of health personnel require induction training. Lack of induction training resulted in
lack of self-confidence and competence.
The Medical Officers of PHCs should be given training, which will help them to manage the
administration of PHCs. The duration should preferably be 3 months: one-month theory at the
training centre and 2 months at the PHC/Subcentre level. The training pattern should be one-third
fieldwork, one-third group discussion and problem solving and one-third lecture demonstrations.
▪ The paramedics should also be given induction training. The nursing staff (staff nurses and
ANMs) may be given induction training of 2-3 weeks. There is need for skill training for
laboratory technicians.
▪ The topics should include administration and office procedures, interpersonal relations,
motivation, medico legal aspects and development of leadership qualities.
In-service training/continuing education
In-service training helps to update skills, knowledge and attitude. The contents, method and duration
will vary depending on the needs. The training should generally be participatory and skill based.
group techniques and problem solving methods should be used.
Promotional training
It is necessary to give additional training when a person is being promoted to a higher post, especially
when it involves more administrative and supervisory responsibilities e.g. when an ANM is being
promoted to an LHV or when a Medical Officer is promoted as a DHO or Medical Superintendent.
12.3 CONTINUING EDUCATION
All health professionals and functionaries must update their skills, knowledge and attitude through
continuing education / continuing professional development programmes. This should be mandatory.
A credit system must be introduced where the health professionals will participate actively in
approved programmes. The Councils, regulating the professions, must introduce a system of renewal
of registration every 5 years for which the health professionals must earn sufficient credits. Credits
may also be made a pre-requisite for promotion to higher cadre.
The continuing education / continuing development programmes may be conducted by recognised
professional associations, or medical and other academic professional institutions. Each programme
must be assessed carefully and credits assigned to such programmes. The State Institute of Health
and Family Welfare may also take up the continuing education of health professionals.
Recommendations
•
•
The issuing of Essentiality Certificates by the Government and affiliation by the University for
new Medical, Dental, Nursing, Pharmacy and Physiotherapy Colleges should be stopped for the
next two years, the exception being Colleges in underserved districts of Karnataka. This is to
ensure quality of education, with adequate teaching staff and other facilities.
Extend the moratorium on new Ayurvedic, Unani and Homeopathy Colleges for two more years.
•
Take up urgently the repairs of the building of the colleges, hospitals, hostels, equipments and
vehicles of the Government teaching institutions. All equipments must be maintained in good
working condition.
•
Fill up all vacancies of teaching staff by suitably qualified persons.
•
Improve the emergency and casualty services.
diagnostic (x-ray and laboratory) services.
•
Essential drugs must be available at all times. The list must be relevant to the level of care.
•
The medical, dental and other institutions (pharmacy, nursing) must take up the teaching of the
concepts of Rational Use of Drugs and Essential Drugs.
There should be available round the clock
•
Medical Colleges should take up 3 PHCs for training and service. Dental and Nursing Colleges
should take up 1-3 PHCs for the same purpose.
•
Corruption at the University examinations should be eliminated. Extra vigilance is necessary.
Corrupt examiners should be debarred from examinerships.
•
Monitoring and evaluation (performance appraisal) of teaching and other staff in the health
professional colleges and affiliated institutions should be carried out once a year; the
performance should be taken into consideration for promotion and other benefits.
•
Appropriate training and re-training of Heads of Departments, Resident Medical Officers,
Medical Superintendents, Principals and Directors in management, (personnel, financial,
materials and time) should be taken up on priority basis.
•
Every professional college should have an education unit to improve the teaching capability of
teachers. RGUHS should organize teacher-training programmes. Make use of the facilities at
the National Teacher Training Institute at JIPMER, Pondicherry.
•
The possibility of bringing the non-teaching staff in Medical College Hospitals under the control
of Department of Medical Education may be studied and action taken to implement the decision.
The Officers in the Department of Medical Education should have sufficient powers to take
suitable disciplinary action even on staff who are on deputation from the health department. An
administrative manual setting out the powers and duties may be brought out.
•
Promote research in the professional institutions. Provide financial support.
•
Have a detailed survey of the need for training of paramedics and take appropriate action.
Review the job oriented paramedical courses.
•
Auxiliary nurse midwives training to be taken seriously. Whether there is need for extension of
period of training to 24 months (from 18 months) must be examined.
•
Use developments in Information technology for continuing education of all health and allied
professionals and paramedical personnel.
•
The State Institute of Health and Family Welfare should be upgraded to become the apex
training institute, making it an institute of excellence.
-
The State Institute will be an autonomous body, with adequate funds for its activities and
maintenance allocated from the State Health and Family Welfare Department Budget
directly.
-
The post of Director will be selection post. The tenure will be 5 years. There has to be close
co-ordination between the Institute Director and the Commissioner / Director General of
Health Services.
The Director will be medically qualified and will have training and
experience in education technology and training of trainers. It would be preferable to have
persons with some experience of having worked in the Department of Health and Family
Welfare Service.
•
•
•
-
The Institute will have full complement of training, research, administrative and supportive
staff with appropriate qualifications.
-
Considering the importance of social sciences and communication skills, the Institute will
have either full-time / part-time staff for these departments or engage the services of experts
as and when required for the training sessions.
-
The Institute will have all the necessary equipment and facilities including teaching / learning
space and identified field practice areas.
-
The Institute will have an up-to-date digital library and documentation centre.
-
The State Institute will conduct induction and orientation programmes for medical officers
and other staff and arrange for continuing education for all the staff of the Department of
Health and Family Welfare Services and the Department of Indian Systems of Medicine and
Homeopathy.
The Regional Health and Family Welfare Training Centre will be administratively under the
State Institute.
- The budget for the regional centre will be released by the State Institute.
-
The regional centers will plan and execute the training programmes based on the needs of the
region; these will be supervised and coordinated by the State Institute.
-
The Regional Centres should have adequate staff with requisite qualifications, competence
and suitability, as also all necessary equipment and facilities.
All Districts will have their own District Training Centres to meet the training needs of the
district.
-
The District Centres would be under the State Institute administratively
-
The budget for the District Centre will be released by the State Institute, which will plan
(along with the District Centre), supervise and co-ordinate the training programmes.
-
The District Centres will oversee the functioning of the ANM training centers.
-
Adequate staff with necessary qualifications and competence and all necessary equipment and
facilities will be provided to the District Centres.
-
The District Centres will have reasonable libraries, whose facilities will be available for the
training programmes and also all the doctors and other staff working in the district. The
possibility of making available these facilities to non-governmental health professionals (on
payment of a small deposit) may be considered in order to improve quality of care.
The State Institute will, along with the Strategic Planning Cell or the Planning and Monitoring
division of the Directorate of Health and Family Welfare Services, identify the training needs and
draw up a master plan for the training of staff at all levels.
•
The training should be in the State mostly. Fellowships / scholarships offered by WHO, Common
health and other similar organizations must be availed of. The State Institute and the Planning
and Monitoring Division should work together to get the relevant information and have the staff
deputed according to the needs of the State and the suitability of the staff member.
•
Encourage the staff at all levels to participate in distance learning programmes of reputed
Universities and institutions.
•
The State Institute must plan and conduct courses in Public Health:
-
•
short term orientation courses (2 weeks?) for all medical officers and selected other staff;
longer certificate courses (6 months?) for all medical staff in the public health cadres. This
will be for the period of transition till we are able to get sufficient number of persons with
DPH or higher qualification.
post graduate courses such as DPH, Masters or Doctorate in Public Health, in collaboration
with the Rajiv Gandhi University of Health Sciences, to be started in 3 years.
Encourage the Medical Colleges in the State which are conducting courses in Community Health
/ Community Medicine to have the courses strengthened to serve the needs of the State.
General Recommendations
•
The nurse:patient ratio may be studied and action taken to have sufficient number of nurses.
•
Financial support to carry out research activities and publish papers may be provided.
•
Teachers who present papers at National and International Conferences may be deputed for the
same, meeting the expenses for registration, travel and stay at the conference.
•
A scheme of providing sabbatical leave may be worked out to upgrade skills and knowledge of
teaching staff, taking into consideration the needs of the department, institutions and the State.
Appendix 1
Number of colleges affiliated/ and number of students in RGUHS, 1999-2000
Sl.No.
1.
Medical
Faculty
No. of Colleges
UG
PG
20
22
No. of Students
UG
PG
2301
1249
2.
Ayurveda
44
10
1770
73
3.
Homeopathy
11
2
570
24
4.
Unani
2
-
75
-
5.
Naturopathy & Yoga
3
-
90
-
6.
Dental
38
12
2177
305
7.
Pharmacy
48
10
2480
234
8.
Nursing
36
5
1410
62
9.
Physiotherapy
37
2
1240
-
10.
B.Sc. MLT
7
-
157
-
11.
B.Sc. Radiography
4
-
67
-
12.
Hospital Management
-
2
-
30
13.
M.Sc. Speech & Hearing
-
1
-
14
14.
Paramedical Technical
Courses
5
-
28
-
Appendix 2
Details of Year Wise Admissions in Nursing, Pharmacy and Physiotherapy Colleges under the
Rajiv Gandhi University of Health Sciences, Karnataka.
Sl.
No.
Faculty
01
Nursing
02
Pharmacy
03
Physiotherapy
Academic
No. of
Colleges
Sanctioned
intake
96-97
97-98
98-99
99-00
96-97
97-98
98-99
99-00
96-97
97-98
98-99
99-00
20
22
32
36
45
46
47
48
24
32
33
37
835
1030
1250
1410
2340
2380
2400
2480
905
1140
1165
1240
No. of
Admissions
Made
709
726
886
992
1856
1354
1189
1241
839
807
796
683
% of
admissions
made
84.91
70.49
70.88
70.35
79.32
56.89
49.54
50.04
92.71
70.79
68.33
55.08
Appendix 3
Paramedical training facilities in Karnataka (1997-98)
A. Government
Health and Family Welfare Training Centres: 5
Name of the Course
MPW training course (Male)
No. of
Institutions
4
Intake
Capacity
240
Duration
(Months)
12
ANM training – MPW (female)
19
570
18
Laboratory technicians – junior
X-ray technicians
Dental mechanic/ hygienist
Staff nurses – general
4
6
1
9
80
36
20
370
12
12
12
42
Refractionist/ Ophthalmic Asst.
Food inspector
Sanitary inspector
Ophthalmic technician
4
1
3
1
60
40
60
20
24
3
Medical records technician
3
60
B. Non – governmental
There are 71 non-governmental institutions recognized by the Government offering diploma course
in paramedical subjects.
Subjects
Intake
Medical laboratory technicians
723
X-ray technicians
Physiotherapy
530
640
Operation theatre technicians
30
Dialysis technicians
E.C.G. technicians
5
25
Inhalation technicians
5
Sanitary inspectors
Medical records technicians
Ophthalmic technicians/ Refractionist
Dental mechanic
170
58
140
54
Dental hygienist
Anaesthesia technicians
34
15
Appendix 4
The following in-service training programmes are conducted by the Department of Health and
Family Welfare Services:
Name of the Course
Block Health Educators
Paramedical-leprosy staff
No. of
Intake
Institutions Capacity
5
30
2
60
Health inspectors
LHV training for Senior HA (female)
Laboratory technician, Senior
Continuing Education for Med. Officers
7
4
1
2
Health Asst.- Senior
5
Health Asst. – Junior
5
525
120
12
30 per
batch
30 per
batch
30 per
batch
Duration
(Months)
2 weeks
4
12
6
12
2 weeks
2 weeks
2weeks
13. RESEARCH IN HEALTH
"People look at things and ask why,
I look at things as they never were and ask why not?"
- George Bernard Shaw
Introduction
Research in health and health care is a neglected area in the State. If we are to make progress in
health and, through it the quality of life of our people, it is necessary that we address the relevant
problems and find solutions to them. The problems must be selected, establishing the priorities,
based on morbidity and mortality.
It is important that research projects are designed carefully, including the formulation of the
objectives, hypotheses and the statistical design. The study may be based on observational or
experimental research. Observational research would include studies on the incidence and
prevalence of the disease, its distribution (geographical), trends (changes over time) and others.
Experimental research would include planned interaction, involving laboratory, animals or human
settings (e.g., clinical trials).
All studies in health and health care, whether individual patient based or population based, would
involve ethical principles. All studies would require clearances by scientific and ethics committees.
Besides, the design of the studies should include data processing, analysis, evaluation and
interpretation of the results, conclusions and publication.
Experimental methods and complex statistical analyses have contributed immensely to the
generation of effective treatment interventions. While biomedical researchers can model their
research problems to highly specific questions, health care scientists have to deal with much broader
concepts. For effective understanding of health, disease and suffering, health care physicians need
to integrate specific causes of disease with a variety of other variables that goes with the territory.
Extent of the problem
Health care investigators can contribute much to our knowledge on the origins and natural history of
disease. Studies of physician’s activities, problem distributions, training schemes, prescribing
patterns, appointment policies, office staffing, specimen collection, and management plan are
helpful. These are health services research. What this type of research does not do is to throw light
on the interacting factors that predispose to, precipitate, and perpetuate ill health and disease. In
other words, these studies rarely expand our knowledge of prevention, treatment, and amelioration
of disease.
Another development has accompanied the evolution and dominance of medicine. That is the myth
of the single “cause” of each disease. Modern medicine, in general, has failed to distinguish
between necessary and sufficient factors in the genesis of ill health. This distorts both its theoretical
base and clinical practice. The public harbors the notion that most physical ills are due principally to
genes or germs. Both are important but rarely sufficient to cause disease. Undue focus on them
1
tends to suppress further thought about the multitude factors that impose on each individual’s
disease.
Years ago one visiting doctor accompanied a local doctor making rounds in a village. A troubled
mother brought him her feverish, coughing infant. The visiting doctor asked, “what seems to be
the trouble?” for which the local physician replied: “the child seems to have bronchitis but the
mother is depressed because her husband is chronically drunk. The husband is drinking because
the cow, the family’s main source of wealth, is dying. The cow is dying because it is the rainy
season and the roof is leaking. The roof can’t be repaired because there is no money.” So, what is
the problem, one may ask. “The rain pouring, roof leaking, cow dying, husband drinking, wife’s
depression or the child’s bronchitis!” What is the point of clinical examination of the child when
so many unspoken pitiful messages are being sent back and forth from rain to roof to cow to
husband to wife to child? Would the child have developed bronchitis if a kindly neighbor had
repaired the roof?
The delivery of public health services is a priority area and we have not been able to identify the
best practices that could be replicated in our state to reach out to the needy. Although infrastructure
for providing primary curative care has been enlarged, it is not matched by qualitative improvement
in the delivery of health care. Focused research in this area can identify the worrisome issues and
plug the loopholes. Women are considered as primary health care providers and their perception of
the services and knowledge regarding health is also crucial.
•
Intersectorality of Health Care
The definition of health would not only mean health services as provided by the Department of
Health and Family Welfare, but has a larger association which includes the area of water supply,
sanitation, issues related to women and child welfare, family welfare and nutrition. We must
evolve strategies such as support, community organisations and partnership.
•
Other Pressing Problems
Added to all that has been mentioned earlier is the appearance of morbidity that is associated
with an increasingly ageing population base. We have to tackle this along with the unfinished
agenda of controlling communicable diseases, under-nutrition, and others. Research into the
social, educational and public health strategies must be put in place employing the models
already tested in developed countries. One could start this with estimating the burden of
common diseases in all districts of the state and compare the burden among the districts. Next,
provide estimates (district-wise) for communicable diseases, non-communicable diseases and
injuries and accidents. In addition, estimates of illnesses related to gender and age group also
need to be developed.
2
Areas of Research-Karnataka Related Projects
A young primary care physician was frustrated with the job he was doing. One particularly distressful
night he was called 12 times by a troubled woman who had 8 children. It was just one thing after
another; there were colds, fevers, vomiting and pain. Just no end to the problems. One could have asked
this young doctor whether it ever occurred to him that there was something else going on in the family
that was upsetting everyone. Actually a careful enquiry revealed that the father had lost his job and was
drinking heavily; there was no money and the mother did not know what to do. The children were
receiving the desperate nonverbal messages from the parents; their immune systems were impaired
allowing “germs/microbes” to wreak them harm by manifesting assorted physical illnesses.
These are good hypotheses, however, they are not research. If such stories are to have any impact on
medical practice, they require support with CREDIBLE RESEARCH.
Research can contribute to our understanding of causality and this knowledge could serve as
essential components of medical theory and practice that could be applied in many settings.
Priorities and aspirations for health care need to be looked at carefully. The critical question is how
should we start? Of course, the first criterion for selecting any research problem is that it should be
an important one. There is little justification for wasting time on unimportant matters. But how does
one define important? Some of the research problems are listed in the table.
EXTENT OF THE PROBLEM
Problems involving large numbers of people
Many days in pain and/or suffering
Many days lost from work or school
DISEASE BURDEN
Tuberculosis, Malaria, HIV/AIDS, Leprosy,
Cancers
Diabetes, Hypertension, Psychiatric disorders
(schizophrenia, depression)
Occupational disorders, Allergy, and others
RESEARCH PROJECTS REQUIRING EXTENSIVE HUMAN AND MATERIAL RESOUCES AND
MONEY
1.
2.
3.
4.
5.
6.
7.
Socio-cultural
Health Economics
Public Health
Sanitation
Pollution
Nutrition
Special Groups (children, women, elderly, disabled (disabilities)
Less common problems are also important in their origins which when better understood result in
more effective prevention or resolution.
Potential Role of Epigenetic Phenomena
The potential role of epigenetic phenomena in modifying the substrate of many diseases provides
additional support for the need to broaden our notions of causation. There is a need to incorporate
vital information describing the circumstances surrounding the onset of each individual’s disease.
3
There is no denying the fact about the outstanding success and effective interventions of modern
medical practice. But if a broader model can accommodate a wider array of clinical and historical
evidence and generate more enlightened understanding of illness, disease, and health, is it not
preferable?
As with any hypothesis, however, acceptance is unlikely in the absence of credible research.
Research is needed that will persuade the skeptics in the medical establishment that changes in the
emphasis and content of medical education and scientific thinking, are fully warranted, if not long
overdue.
Some of the research questions that need to be investigated at the primary care level are listed in the
table.
TOPICS
PARAMETERS
ONSET CIRCUMSTANCES
Situation surrounding initial signs/symptoms of patient’s discomfort
or illness
2. Location
3. Who was the patient with?
4. What was patient doing or thinking?
5. What was new or different? what did patient think and feel
about it
6. What were other persons in the house, in the family, in the
neighborhood doing or saying ?
7. What was the unspoken messages patient was receiving?
Were there more or fewer messages than usual? Were they
more or less intense and emotional?
Number of interacting or enforcing circumstances or encounters surrounding
the onset of patient’s discomfort or illness? Eg. job stress, weather, infection,
etc.
1. Genetic, family-related, cultural background
2. Belief system
3. Why me? What’s patient’s theory about the problem?
Events, comments, thoughts, or behavior triggering patient’s decision to seek
doctor’s assistance at this precise time. What if anything changed? Why now?
Why here?
Patient’s feelings, perception, imagination, about behavior of doctor/nurse,
technology procedures, medication, ambience of treatment setting?
Characteristics, hallmarks, and reputation of the health care personnel,
institution, system, or clinic?
CONCOMITANT FACTORS
PREDISPOSING FACTORS
PRECIPITATION OF HELPSEEKING
THERAPEUTIC
ENVIRONMENT
1.
Alternative medicine
There is no systematic research effort in understanding the various indigenous health care systems
like ayurveda, unani, siddha and others, and their contribution to the health care services. We don’t
know much about public perception and public faith in these systems. Do people have accessibility
to health practitioners including ayurveda? Siddha, etc.? We should consider the usefulness and
possibility of integrating the alternative systems of medicine in a decentralized system of health
services.
4
Need for a Think Tank
Collaboration of physicians and biomedical scientists with immunologists, neuroscientists,
psychiatrists, psychologists, epidemiologists, sociologists, clinical specialists, and other scientific
colleagues is essential. Research designs will require development of generic protocols,
including survey instruments, that enable the reporting physicians to record categories of
responses derived from conversations with each patient and probably one or more family
members or friends.
Need for resources
In addition to a wide range of quantitative methods, a substantial armamentarium of qualitative
research methods is available for use in primary care.
Generation of adequate numbers – large numbers – for studies of each clinical entity and its
explanatory patterns at the primary care level needs substantial networks of primary care
practitioners/investigators who report to a central coordinating office.
The ultimate objective is to sensitize the health planners and policy makers about the need for
preparation of research projects to analyze health problems thereby reduce the burden of disease on
society. While we do all this, it is critical to assess the quality and robustness of the data with
reference to different data sources.
To undertake such a complex endeavor the Government will need to allocate adequate budget and
involve personnel from universities, health department, population center, state institute of training,
medical colleges, professional associations, independent researchers and pharmaceutical industries.
Who will do the Research?
Karnataka has a large number of professionals and scientists and institutions that can carry out
quality research of varying types and magnitude. The Rajiv Gandhi University of Health Sciences,
with its more than 200 affiliated institutions, including academic centres (colleges in different
disciplines), hospitals and field practice areas can certainly contribute a great deal to the research
activities. The teaching (and non-teaching) staff can carry out quality research. The postgraduate
students have to submit their thesis / dissertations. Their quality can be improved, with proper
selection of the problem and guidance. The undergraduate students must also be encouraged to
carry out project studies; they should be trained in research methodologies.
Considerable research can be done into the drugs used in the Indian Systems of Medicine and
particularly Ayurveda.
Other Universities can also contribute to research on problems allied to health.
In the Health Department itself we have the Population Centre, which has been doing good
research. The State Institute, the Vaccine Institute Bellary and other institutions can be developed
to carry out pertinent research.
5
There are large specialised institutions like the National Institute of Mental Health and
Neurosciences which are already doing considerable amount of research into problems of
importance to the State, Kidwai Institute of Oncology is another important centre. Other
institutions such as the Sanjay Gandhi Hospital and Accident Centre can be encouraged to carry out
quality research.
Centres such as the Southern Centre for Occupational Health and the Malaria Research Centre,
Bangalore, can carryout relevant research.
The State has a premier institution in the Indian Institute of Science. This can be of immense
importance in carrying out fundamental and applied nature. Other institutions like the Institute for
Social and Economic Change and the Indian Institute of Management can help in solving problems
in the social, economic and management aspects of health and health services.
The Professional Associations can help in promoting relevant research.
Industries, including Information Technology and Pharmaceuticals and others, can help in research
useful for improving the health of the people. Advances in Information Technology can be applied
for improving health and health care.
Publication
It is important that the results of research be published. Controlled trials are the foundation of safe
and effective health care. Research findings go unreported for a number of reasons:
• The researchers may think that the results are ‘not interesting’
• Resources may not be available for report writing.
• Investigators may change their jobs and research may remain unfinished.
• Someone else might have published their results in the meanwhile on the same topic.
• Editors might have returned the reports for clarification or further work.
It is important that whatever be the reason, the research work should be published or at least
presented to a suitable audience.
Summary:
Studies that incorporate responses of patients to various issues surrounding their illness are usually
best done at the primary care level. This goes a long way toward understanding the issues related to
causality. These research problems cry for deeper understanding. In order to ensure validity and
acceptance by the policy makers the initial findings require replication with large numbers in
diverse settings. Only then are the results likely to be incorporated widely in medical education and
practice. Each problem deserves critical thought, careful refinement, and several pilot studies.
Health care can rise up to the expectation by internalising the clinical wisdom and undertake the
serious investigation of important clinical problems. Research should be done in ways of promoting
health involving a process of enabling people to increase control over them and to improve their
health. The projects should reach and involve people through the context of their everyday lives
where they live, work, learn and play. An organised effort in this direction will tell us how health
promotion could be developed in the State scenario. In summary, there is a dire need to
6
comprehensively examine and to evolve methodologies that may be adopted for health promotion in
Karnataka.
Recommendations
•
Develop Vision, Mission and Strategy Statement on research at the primary health care level as
also at the secondary and tertiary levels.
•
Study the status of research projects (completed and ongoing) managed by the Department of
Health and Family Welfare.
•
Classify research programs into various categories such as:
•
•
•
•
•
Clinical Research – Drug Regimens
Public Health related problems (tuberculosis, leprosy, cancer, etc)
Karnataka-specific health problems, eg. Kyasnoor Forest Diseases; Handigodu Syndrome.
Sociology and Health
Life style and life style diseases: tobacco, alcohol, and others
•
Evolve programs in Health Economics
•
Research and integration of Alternative Systems of Medicine into Public Health Programs
•
Projects addressing delivery of health care, disparities due to gender, regional and
socioeconomic issues
•
Epidemiological research- population demographics
•
Issues related to nutrition and its role in health and disease
•
Research on pollution-related health problems, management of health indices (IMR.MMR etc.,),
health promotion, etc.
•
Set up a research board and a think tank to identify the problems. Invite experts to brainstorm,
allocate funds and resources from Government (state and central), Universities, Indian Council
of Research, Department of Science and Technology ICMR, DST and Pharmaceutical
Industries.
•
Create infrastructure for digital library, information and documentation center. Set up access to
the Internet and databases. Make available leading research journals and publications.
7
14. HEALTH SYSTEMS MANAGEMENT
" God grant me the serenity
To accept the things I cannot change;
The courage to change the things I can;
And the wisdom to know the difference;"
- Reinhold Niebuhr.
14.1. Administration
Introduction:
The structure and management practices of the health system have to be such that they serve the
purposes and meet the objectives of the system. The latter include providing comprehensive
health care, including basic health services, of acceptable quality, optimum efficiency, easy
accessibility and at reasonable cost. Such services have to be available at the primary and
secondary levels, with particular emphasis on rural areas and the urban disadvantaged, the
economically vulnerable, women and children and elders, supported by adequacy of tertiary
care. A strong surveillance system and an efficient referral network would be essential elements.
In particular, since the health services cannot be viewed in isolation, there should be a
mechanism for inter-sectoral co-ordination. The management system should be responsive to
community needs and permit interaction with the latter.
The efficiency of the health services is dependent on two factors. The first would be the
management of the services as an administrative structure, while the second would be the quality
and adequacy of external but related aspects. The latter include quality of medical education,
adequacy of funding and the recognition within government of the relative priority of health
services, as indeed of the social services, in investment decisions.
This Chapter restricts itself to the administration and management of the health services as
such. In view of their importance, the planning and the information components of the system
are discussed separately. Certain aspects such as the management of drugs, training, regulation
of the private sector in health services, and the like have, for more comprehensive treatment,
been dealt with separately. Similarly, education of health professionals and health workers has
been dealt with separately though it obviously has close links with the public health issues
discussed here.
The health structure has been reviewed in a study 1. The restructuring of the Department
recommended here is indicated in Section I. Section II deals with some important general issues
of administration.
Section I – Structure of Health Services
The current structure of health services has evolved over the years, with differing emphasis on
the preventive and curative aspects at various points of time. There is a need for the reinstitution
of a strong public health element in health services. This element, which was the foundation on
which these services were instituted, has virtually disappeared due to changing approaches
towards the content of these services, mainly from a preventive approach to a curative approach.
It is evident that even in current times the absence of the public health element has resulted in
1
Review of Organisation Structure and Design of Job Responsibilities, Vols. I and II, A.L.Ferguson & Co. March
2001
1
skewed services, de-emphasizing fundamental issues such as sanitation and prevention. What
would seem essential is to reconstitute the system to have a fair balance between both preventive
and curative approaches.
The proposed structure of health services is indicated in Annexure I. The current posts have been
redistributed / redesignated. For example, the Maintenance / Engineering Division now included
in the Directorate is the transfer, in effect, of the one that is now part of the Karnataka Health
Systems Development Project. Also, the posts at all levels have been redistributed. It most
unlikely that many new posts would have to be created.
The posts indicated herein do not include supporting staff. It would also be necessary to take
into consideration the current levels and numbers in the professional cadres while putting in
place the proposed structure with the revised positions and designations. Therefore, the
following course of action would be necessary.
1.
2.
3.
Listing out all the professional posts in the present structure and match them with the new
structure proposed to ensure that there have been no omissions. This would also provide a
clear indication of the excess or deficit in some levels and indicate how the current posts
could be redistributed. It would also assist in budgeting for the new structure more
realistically;
Similar listing would have to be made for all supporting staff such as clerical, accounts,
etc, and allocations to the extent necessary would have to be made;
Based on this exercise, orders would have to be issued adopting the new structure, with the
revised placements and designations.
The following principles have been kept in view while considering the changes necessary to be
made in the structure of health services:
1. The emphasis on Public Health should be revived and its essentiality recognized;
2. The Department would be designated as the Directorate of Health Services;
3. Separate cadres would be constituted for Public Health and Medical (clinical)
responsibilities of the Department;
4. Common functions such as IEC and publicity, supplies and maintenance would be
integrated to avoid duplication and lack of internal coordination;
5. The Divisions would be reorganized on the basis of integrated responsibilities and
current needs;
6. The cadres should be reorganized so that all health personnel up to the district level form
District Cadres, selection being the mode for filling up higher posts. The latter would
constitute State Cadres.
7. The State Cadres would constitute the Karnataka Health Service.
8. The availability of services at PHC and taluk levels should be ensured through
administrative means, including institution of special pay, a team at taluk level, etc;
2
9. All national programmes which now function in vertical fashion would be integrated into
the system so that local supervision and management of these programmes is at District
level;
10. The structures for implementing Externally Aided Projects (EAP) would be built into the
structure of the Directorate of Health Services, with a Director, EAP;
11. Discipline and control measures would be strengthened while, at the same time building
up both expertise and morale through nurturing enhancement of skills and a transparent
transfer policy;
12. There would be an Additional Director, under the Commissioner, in charge of the
districts of Northern Karnataka.
13. An Additional District Health Officer would be appointed in the districts of Gulbarga
and Belgaum in view of the size of the districts. Necessary numbers of Additional
Programme Officer would also be appointed. These posts would continue till such time
as the level of services is considered on par with the other districts.
14. A Commission on Health would be constituted as a mechanism for interaction with
professionals and to assist in policy formulation.
The Directorate of Health Services is proposed to be made up of two wings. One would relate to
Public Health and the other to Medical (clinical). The main elements would be:
1. The common direct recruitment point would be at the level of the PHC doctor. While the
basic qualification would be MBBS, those with Post Graduate qualifications would also be
eligible to be selected.
2. All newly recruited doctors would serve a minimum period in the PHC.
3. After this minimum period of service in the PHC –
a) Those with Medical (Clinical) Post Graduate qualifications would be assigned to the
Medical Cadre;
b) Those with Public Health qualifications would be assigned to the Public Health Cadre;
c) Those with no Post Graduate qualifications may opt for either cadre, subject to
acquiring the Post Graduate qualification necessary for that cadre within a stipulated
period. The State would meet the costs for acquiring this qualification only for the first
attempt and only for one subject.
d) Those who do not have Post Graduate qualifications and who do not wish to acquire
these, would continue as PHC doctors permanently. Appropriate time scales would be
worked out.
4. Vacancies in the post of MO (PHC) could be filled up by temorary contract appointments,
till such time a direct recruitment is made.
5. Vacancies in the posts/cadres above the level of the MO ( PHC) which cannot be filled by
promotion due to nonavailability of suitable officers with postgraduate qualifications, it
could be filled by appointment of persons on a temporary contract basis. Such persons would
have to satisfy the stipulated conditions with regard to qualifications. Such appointments
would be till such time as suitable internal candidates become available.
3
6. It is recognised that at a given point of time, there may not be sufficient number of officers
with the necessary post graduate qualifications for promotion. In this event, it is
recommended that the quota for inservice candidates for acquisition of postgraduate
qualifications be enhanced to the extent necessary.
The choice of post-graduate course would be guided by the needs of the Directorate and not be
based on the personal preferences of the officers.
7.
Thereafter, promotions would be within these Cadres and no interchange would be
permitted;
8.
The Public Health and Medical Wings would consist of Divisions based on current needs.
Each of these wings would be headed by a Director;
9.
The overall management and coordination of the Directorate would be by the
Commissioner or Director General of Health Services. This post would be filled by a
senior officer of the IAS Cadre of the State or through contract appointment of an eminent
health professional.
10.
There would be independent Divisions directly under the Commissioner / Director General
of Health Services for specialized functions. These would be (a) Director, Externally
Aided Projects, (b) Director, Procurement and Maintenance, (c) Director, NGO Partnership
Cell, (d) Additional Director, Planning, (d) Financial Adviser, (e) Joint Director for Special
Groups and others as described in Annex I.
11.
A Procurement and Maintenance Division would be established within the Directorate.
12.
The posts of Divisional Joint Directors would be abolished.
The cadres, both Public Health and Medical, up to the District level would be District Cadres
coming under the management of the Zilla Panchayat. The posts of District Health Officer,
District Surgeon / District Medical Officer and equivalent posts would be excluded. The latter
would form the first levels of the State Level Cadres.
Promotion to the first level State Cadre posts would be by selection-cum-merit. The posts of
DHOs / DMOs would, in future be filled only by promotion by selection from among the Taluka
level Health Officers. Selection procedures would have to be evolved by Government.
Karnataka Health Service
All posts that constitute the State level cadre could be constituted into a service called the
“Karnataka Health Service”. This would contribute to morale building and create a sense of
common identity. The major advantage of constituting such a Service would be that young
professionals would, through a process of selection, rise to occupy middle level management
positions fairly early. This would ensure that officers with a reasonably long tenure would, in
due course, hold senior positions so that stability in management is ensured at higher levels.
Often, officers are promoted to senior positions when they have very short periods (a few
months) of tenure remaining before they are due to retire. The possibility of ensuring that
persons who are promoted to senior positions have at least two years of service remaining
should be considered. If the remaining period of service is less, they may be continued in a
parallel post as in the department of Engineering.
4
The main features of this Service would be as follows:
1. The Service would consist of all posts above the District Cadres and would include both the
Public Health and Medical Cadres;
2. Posts in the Service would be filled through two methods:a. Promotion from the District Cadres, as indicated earlier, on the basis of merit cum
seniority; and
b. Through a process of direct induction from the District Cadres.
3. Appropriate proportions of the posts of the State Cadre, in both Public Health and Medical
Cadres, would be reserved for promotion and for induction from the District Cadres. It is
recommended that this proportion be 50 per cent each;
4. The procedure for induction could consist of (a) a preliminary written examination to gauge
professional knowledge, followed by (b) interview. The selection process could be assigned
to an appropriate authority, depending on the general principles of recruitment for this level
of posts. Transparency would have to be ensured in the selection process;
5. All officers in the District Cadres who have the necessary qualifications and satisfy such
other criteria as may be specified, including minimum period of experience, would be
entitled to apply and compete for the posts reserved in the Health Service for recruitment
through this method.
6. All officers appointed to the Karnataka Health Service will, on appointment, be trained in
administration and management.
7. All further promotions within the Service would be on the basis of merit cum seniority;
8. In public interest, if officers who satisfy the stipulations of the Cadre and Recruitment Rules
are not available for appointment to posts at any level in the Service, and for such time as
they are not available, such posts may be filled by induction of suitable persons, with the
stipulated qualifications, laterally, on contract basis.
District Cadre
The cadres, both Public Health and Medical, up to the District level would be District Cadres
coming under the management of the Zilla Panchayat.
With the institution of Constitutional local governments at the village, taluka and district levels,
it would be necessary to consider how, in the long run, social services, including health services,
appropriate mechanisms could be established to ensure community participation and
management of social services, including health services at the district level. It would be recalled
that some decades ago there were District Development Boards which were in charge of local
development under delegated authority. This historical experience would provide some guidance
in formulation of a possible participatory structure at the district level.
All health services at all area levels are now departmentally organized and managed. The revised
structure envisages all health services within a district being managed by the Zilla Panchayat.
The health services assigned to the ZP would be those currently offered by PHCs (and Sub
Centres), CHCs and Taluka Hospitals. All specialized institutions would continue to be under
the Department.
5
Zilla Panchayat
In effect, the ZP, and at the lower area levels, the other panchayat organizations would be
responsible for management of the health services in their local areas. The ZP would be the
nodal agency and would oversee the working of these services in the talukas and at village level.
Such an arrangement is already partly in existence, but what is envisaged in the revised structure
is assigning full responsibility to the ZP and including all health services and programmes
within the ambit of its responsibilities. It need hardly be mentioned that financial allocations
commensurate with these responsibilities would have to be allocated, to that extent reducing the
allocation to the Departmental budget.
The revised structure would imply that all posts of health and medical officers from the village
level up to and including the district level, excluding all district level posts such as the DHO /
DMO and equivalent, would be part of the establishment of the ZP. The recruitment, control,
postings within the district and related matters would be entirely within the competence of the
ZP. It must be emphasized that this would not at all mean the absence of Government control,
supervision and monitoring. The ZPs would function within guidelines and other stipulations
specified by Government with regard to all matters relating to health services. The DHO / DMO,
as at present, would continue to represent Government. In effect, a distinct cadre of health
personnel would have to be constituted for each district, with common features.
The elements of the health cadre in a district could be as follows:
1. The cadre would include all posts in the district from PHC level to District level, excluding
the DHO / DMO and equivalent posts;
2. The recruitment to all posts of the district health cadre would be made according to rules
stipulated by Government. Pay scales and C & R Rules would also be uniform. Recruitment
would, as far as possible, be limited to persons from the district. This would eliminate the
difficulty of filling rural posts.
3. The recruitment to the posts in the district cadre could be made either by:a)
A District Recruitment Committee consisting of the Deputy Commissioner as
Chairman, the members being the CEO of the ZP, Additional Director designated by
the Director, the DHO and a prominent well known personality not from the same
district to which recruitment is being made;
b)
Or, through a Local Services Recruitment Board which would have to be established
for this purpose through specific orders or legislation. It is recognized that this would
be a general issue relevant to all other Departments that may constitute district cadres
on the lines suggested here.
c)
The level of posts coming under the purview of these recruiting organizations would
need to be specified, keeping in view general orders of Government.
4. Appeals against findings in disciplinary cases or against punishment imposed by the CEO
ZP, as Cadre Controlling Authority, would lie to the Directors concerned. Such appeals
would not be permitted in cases of minor punishments such as censure and fine;
5. The CEO ZP would be responsible for ensuring that all persons in the district health cadre
are trained. The State Institute of Health and Family Welfare would provide all training
facilities.
6
6.
Transfers from one district cadre to that of another would not normally be permitted.
Transfers under special circumstances would be permitted under rules that would be framed
for this purpose, and would be subject to the approval of the Director. In particular, such
transfers should not confer any advantage with regard to relative seniorities among those
eligible for promotion to the next level;
It is recognized that the structure suggested here is a radical departure from the current one.
However, it has the merit of ensuring that local persons find employment within their districts,
which would reduce the difficulty of filling rural posts. It would also mean that the community,
through their elected bodies, takes full responsibility for the adequacy, accessibility and quality
of the health services in their district. The Department would then be responsible for overseeing
and monitoring of the health services and not have direct administrative responsibility for these
services. Its energies would then be better spent in ensuring the efficiency and effectiveness of
these services and setting standards through more intensive inspections and reviews.
It is evident that the adoption of this cadre structure would need basic changes in the C & R
Rules, the mechanisms of financial allocations, monitoring systems and associated aspects.
Transitory Provisions
One of the major issues would be the treatment of personnel now in position. The following
alternatives could be considered –
1. Present personnel at the appropriate levels could be given the choice to opt for induction into
a particular district cadre, with no option to return to the departmental cadre later. Posts
would, in this case, be reassigned to the districts with personnel. Those that do not so opt
would continue on the departmental cadres as at present and the current system of postings
continued.
2. As and when there are vacancies in posts up to the District level, these could be transferred
to the ZP, with the financial allocation, as a first step in constituting the new cadre over time
3. All new vacancies could be assigned to the district cadre concerned and recruitment could be
made as suggested earlier. Over time, the present departmental cadres at the district level
would be phased out.
Commission on Health
The health services must be responsive to the expectations of the public and must meet current
needs. The working of the Department should be transparent and the structure should be able to
induct outside expertise as and when necessary for special studies or consultancies. It would be
desirable to create a mechanism for general overseeing of the health system which would assist
the Government and for providing policy inputs. The facility of lateral advice being tendered at
the highest level would assist in ensuring both transparency and public confidence. For this
purpose, it is recommended that a Commission on Health be established by Government
consisting of both senior officers and non-official professionals.
7
Commission on Health
Chairperson
Principal Secretary of Health and FW
Members
1. Secretary (Medical Education)
2. Director of Health Services
3. Director of Medical Services
4. Director of Medical Education
5. Director, State Institute of Health and Family Welfare
6. Director, Indian
Homeopathy
Systems
of
Medicine
and
7. Drugs Controller
8. Vice Chancellor, RGUHS
9. 8 to 10 eminent persons from professionals, NGOs and
prominent persons
Member Secretary
Commissioner of H & FW
The Commission may co-opt experts or knowledgeable persons as and when necessary for
specific purposes. Senior officers of the Department would also be invited to the meetings of the
Commission to assist it. It is expected that decisions would be by consensus and that
Government would normally accept the views and recommendations of the Commission. The
duration of the Commission could be for a limited period to start with of about three to five
years. If experience indicates that it has provided the support that the Department needs, its
continuance could be considered.
The functions of the Commission would include:
1. Preparation of the Perspective Plan for health services;
2. Monitoring inter-sector issues and recommending corrective appropriate measures;
3. Monitoring implementation of Plan programmes, funded projects and Central Schemes and
general management of health services;
4. Ensuring that public health is an important component of the health services;
5. Suggesting such studies or consultancies that are found to be necessary from time to time;
6. Reviewing all such aspects of health services as it may consider necessary for ensuring
improvement of such services.
The Commission would not be concerned with the administration of the Department, or with
disciplinary cases as such.
The Planning and Monitoring Division could serve as the secretariat of the Commission.
8
Section II – General Administrative Issues
Review and Amendment of Cadre and Recruitment Rules
The structure suggested would need considerable amendments to the existing Cadre and
Recruitment Rules.
Recommendations have been made with regard to introducing mandatory tenures of service in
rural areas and selection criteria being introduced for certain posts. Also, elsewhere in this
Report, there are recommendations that have implications for the C & R Rules. It would,
therefore, be necessary to review these rules to take into consideration the recommendations
made herein and to bring them up to date. In particular, the rules should identify posts which for
which selection criteria should apply such as Joint Directors and above, introduce stipulations
regarding tenure in rural postings for entitlement to confirmation / promotion. It is
recommended that a Committee for Review of the C & R Rules be set up, with the
Commissioner as Chairman, and the Director of Health Services, Joint Secretary, Health
Department and a representative of the Law Department as members.
It is recommended that the new structure should be in place within the next one year, with
recruitment and cadre choice to new recruits being as suggested above.
Annual Performance Reports
The present system of annual appraisal of performance would bear review. The formats used and
the procedure both of recording and appeal would need to be evaluated so that they fully serve
the purpose they are meant for such as selections to higher level posts, post graduate courses,
special assignments and the like. The formats could include parameters regarding public
satisfaction and other performance indicators. Non-performance should be particularly noted and
recorded. The Committee suggested above could also do this.
In this context, the possibility of establishing a system of medical audit for the institutions
should be considered.
Private Practice
Consideration of the issue of whether private practice by the medical personnel of the health
system should be permitted or not has had a chequered history. At various points of time private
practice has been permitted with periods of prohibition in between. Currently, it is banned.
However, it is common knowledge that some of the medical personnel carry on private practice,
often to the detriment of their official responsibilities. The question of whether private practice
should be permitted or not is closely associated with the general issue of discipline in the health
services. Conducting private practice when it prohibited is both an act of indiscipline and
corruption. However, the question of whether private practice should be permitted or not and, if
so, at what levels, would need consideration from two points of view. The first is the need to
ensure availability of medical services at all hours and the second is to ensure such services at
local level, particularly in the rural areas. In other words, this issue is also part of the issue as to
how to maximize medical services in the rural areas.
In principle therefore, it would be reasonable to prohibit private practice. However, the
imposition of such a ban must be accompanied by a reasonable enhancement of scale of pay
which would at least partially reflect the opportunity cost of the private sector. It is, therefore,
9
recommended that private practice should be banned, with reasonable enhancement of pay
scales.
If, for any reason this is not possible, it is recommended that private practice be permitted
subject to certain conditions as indicated below.
It is also recognized that in some posts private practice should be prohibited in order to ensure
full availability of the services of the incumbents of these posts at all times. Keeping in view the
circumstances that currently prevail, the following policy with regard to this issue is
recommended:
•
Hours of duty will be stipulated in all health / medical institutions of the Directorate and
prominently displayed for public knowledge. The hours of work would take regional,
seasonal and other factors into consideration. All personnel will be expected to adhere to
these hours and the responsibility to ensure this would be that of the superior officer;
•
Private practice would be allowed outside these stipulated duty hours and only when not on
call, and when not needed to attend to emergencies, subject to the remission every month to
Government of one-third the basic pay of the staff member who so practices;
•
The Directorate would identify and notify those posts where private practice is banned,
based on criteria to be evolved. The incumbents of these posts would be paid a monthly
“non-practicing allowance” of one-third the basic pay of the post;
•
All doctors in the Directorate, at all levels, would provide an affidavit at such periodic
intervals as may be specified affirming whether they are or are not carrying on private
practice. This would form part of the service record;
•
Those found contravening the affidavit would be subject to punishments as may be
prescribed in the relevant rules.
Corruption and enforcement of discipline
The prevalence of corruption in the health services is a serious issue. Corruption in any official
agency is deplorable and must be eliminated. However, its presence in an essential social sector
such as health is particularly obnoxious because it increases the costs of the services the public
is entitled to and quite often determines both availability and quality of the services provided. It
is pernicious and pervasive and operates at different levels in different manner. It could range
from (a) demanding payment for services which are free or even paid for and for carrying out
the legitimate duties of the personnel involved, (b) direct diversion of supplies meant for patients
or from hospital supplies, (c) carrying on private practice when this is prohibited, (d)
deliberately treating patients outside stipulated hours and charging personal fees for such
services, and (e) diverting patients to private clinics with which one is associated and charging
fees or obtaining commissions. In particular, corruption in government hospitals has a serious
effect on the availability of medical services to the poor.
How to eliminate corruption?
That corruption exists, the various methods adopted in its practice and points at which it is
practiced are well known. The issue is the mechanisms for its detection and elimination. The
detection of corruption is dependent on the cooperation of the public and the internal
mechanisms for this purpose. In this context, it is admittedly difficult for the public to complain
10
of corruption in a situation where medical services are required because, unlike other official
contacts, the need for these services cannot be postponed. However, the system should
encourage complaints being received even after the event. Secondly, the consideration of
complaints and completion of enquiry proceedings must be quick and thorough. The latter is
particularly important to avoid enquiries being deemed as improperly conducted on procedural
issues, as is quite often the case.
The current mechanisms inhibit quick enquiry. In particular, the procedures where major
punishments are proposed to be imposed are complicated and invariably tend to delay enquiries
beyond reasonable periods of time. It would, therefore, be vital for these procedures to be
reviewed so that, without taking away constitutional rights to justice, enquiries could be
completed within two to three months. It is recommended that the Commissioner of H & FW
evaluate the current procedures to determine how they could be modified to ensure quick
completion of enquiries.
In the majority of cases, under the current procedures, officers of a senior level are appointed as
enquiry officers in individual cases. Such assignments are invariably viewed as an additional
burden and given very low priority. There is rarely a sense of urgency and quite often enquiries
have dragged on indefinitely. This results in a feeling of complacency in the corrupt that the
system is incapable of dealing with them while, at the same time, reducing the morale of the
honest and hardworking. The mechanisms for enquiry being within the Department would also
seem to inhibit quick enquiry and strong action.
The enquiry into corruption cases, depending on the nature and content of the complaint, are
either dealt with by the Vigilance Commissioner or within the Department by the appointment
of an enquiry officer. There is, however, no institutional mechanism for detection of corruption.
It is recommended that such a mechanism be set up on the lines similar to the Food Cell or
Forest Cell. In the latter, a senior police officer on deputation is independently assigned the
responsibility of follow up of complaints on corruption, carrying out test checks and the like.
This cell should be preferably under the Principal Secretary or under the Commissioner for
Health and not an adjunct of the DHS. The specific role and duties of the Cell could be defined.
It should be empowered to investigate and take action against corruption and absenteeism. An
appeal procedure would have to be provided but time limits must be fixed for disposal of such
appeals. The details of the structure of the cell, its procedures etc would have to be considered
by Government.
Depending on the gravity and nature of the offence, the enquiry could be entrusted to an
appropriate enquiry officer. In this context the recommendations of the Karnataka
Administrative Reforms Commission 2 are supported.
The public should be aware of the services they are entitled to in the Sub Centres, the PHCs, at
the Taluka and District levels and in Government Hospitals. Prominent boards should be put up
indicating what services are free and the fees for services for which charges are levied. The
officer who should be contacted if money is demanded should be indicated and an assurance
held out that corruption charges would be investigated. The hospital Visitor system should be
strengthened and one of the functions should be to enquire about harassment and demands of
money, particularly from the poorer patients. Wide and constant publicity should also be made
of measures taken promptly. All complaints of corruption should be acknowledged against
corruption.
2
Page 102, Karnataka Administrative Reforms Commission, Interim Report, January 2001
11
Centrally Funded Projects and integration of vertical programmes
A number of Centrally Sponsored Schemes have been implemented, at various points of time, as
part of the successive Plans. These include programmes relating to control of blindness, malaria,
AIDS, tuberculosis, leprosy and goitre, and enhancement of nutrition. The general principle of
funding has been that for the Plan period these are funded either fully or partially by the Central
Government, with the financing being taken over by the State at the end of the Plan period.
There have, of course, been some exceptions to the latter.
The main issue is not so much the funding or the content of these schemes, since they all deal
with important aspects of health services. It is the structural aspects that need consideration since
separate hierarchies, with Programme Officers, were established under each such scheme for a
specific purpose. This has created vertical hierarchies of a specialized nature within the
Department. Also, it has complicated the reporting system by requiring different streams of
reporting within the Department and to the Government of India. Such a structure does not lend
itself to cost effective use of personnel or coordinated management of services. The difficulty of
control and management of such separate vertical hierarchies for some activities is particularly
noticeable at the district level. It is at this level that management and coordination need to be
clear and effective. The relative seniorities between the DHO and the Programme Officers have
added to the problems of coordination.
The vertical programmes must be reviewed to determine the mechanisms of eliminating the
concept of independent vertical hierarchies, better utilization of the professionals in the
Department, and establishing only one focal point of administration of personnel, management
of services and reporting at the district level. It must be emphasized that this can be done
without in anyway diminishing attention to these important programmes. As in most activities of
the Department, designated officers would be responsible for specific activities. What is
desirable is to eliminate vertical hierarchies that are under-utilized and give rise to loose
administrative practices. Such integration is possible at all levels, including the senior posts at
headquarters. It may, at this point be mentioned that a revised structure for the Department has
been suggested later. The review of the vertical programmes would be part of this new structure.
Externally Aided Projects
There are a number of externally aided projects in operation in the State. In the health sector, the
Karnataka Health Systems Development Project and the India Population Project are the major
externally funded projects. These projects deal with specific health issues and are not
experimental in nature. They operate independent of the DHS though they are very much
concerned with health issues in terms of objectives, structure and content. The management
structure of these projects is independent of the DHS and so devised as to ensure efficient
performance. Special officers are placed in charge of such projects, with officers of various
specializations on deputation, and the induction of outside expertise is often assured through a
system of appointment of consultants. Decision-making in these projects is expeditious because
the high power Project Governing Board and the Standing Committee are delegated with full
powers. The conventional system of seeking sanctions, administrative and financial, with many
layers of official scrutiny and many departments to be consulted, is absent. There are no
financial constraints and performance is intensively monitored by both external and internal
agencies. In view of the structure and management independence, these projects are successful
and appear as islands of excellence in governance of health services. The only constraint, which
is unfortunately willingly accepted, is the mandatory conditionalities attached by the funding
12
agency, specially in relation to operational and service concepts. Quite often, these do not
coincide with the current department thinking or with ground realities either 3.
These projects are successful because they have well defined objectives, with leadership not
generally available in other activities of government, selected competent staff and with
operational independence. They provide lessons in management of the health services and
innovative structures of delegation of authority and of monitoring and internal control and
review systems. However, experience would indicate that once the project is over and the
maintenance phase commences, the same performance levels rapidly disappear and the work
gets “routinised”. While the projects definitely add to both assets and experience, there are
fundamental issues that need to be considered if full and, more importantly, permanent
advantages have to accrue to the health system from the implementation of such projects. These
are (a) how one transplants the work culture of these projects into the larger, parent organization,
namely the Health Department, (b) how the tempo and efficiency of the project implementation
period could be sustained, (c) how the assets created are maintained for effective use, (d) how
the human resources created could continue to be used effectively and productively and (e) how
is adequate funding to be ensured for these purposes. In short, the issue is one of sustainability
over time of both the organizational and professional advantages of these projects and building
them into the culture of the department itself.
In considering these issues, it would be necessary to recall that the larger proportion of the funds
for these projects is from the resources of the State. It is also important to remember that
government departments can reasonably be expected to perform only at an optimum and
acceptable level of efficiency, given the procedures, even if simplified, and large hierarchies and
that “islands of excellence” are difficult to maintain over the long term.
Sustainability
The issue is essentially one of sustainability of the projects objectives and systems. It would be
difficult to integrate the project structure in toto into the departmental structure at the end of the
project period, nor would this be necessary. However, the main difficulty would be that the
project leadership would no longer be available and the Director of Health Services would have
been only generally associated with the project 4. If integration of project activities in the
maintenance phase has to be effective, it would be necessary to ensure that the project is built
into and implemented within the departmental structure from the start. While a separate wing or
division could be considered desirable because of the special needs of the project and the need to
complete it within a fixed period, this wing / division should be a part of the Department; an
exclusive project division within the Department should implement such a project. This would
ensure that the Director is not merely involved in the project but is also responsible for its
efficient implementation. It is recognized that this could limit the choice of officers for being
appointed as project administrators but the Project Governing Board and the Steering Committee
of the project should be able to enhance their supervision / monitoring to ensure effective
implementation. Also, the Commission on Health, suggested as part of the restructuring of the
Department, could also be empowered to monitor / review the implementation of the project.
3
For example, it is an article of faith that institutional deliveries should be the norm in the IPP
with a bias against home deliveries – against all realism in the rural areas and smaller towns.
4
The Director is on the Board and is well within his rights to insist on being kept informed about project activities.
If this right were exercised, integration at the end of the project period would be easier. However, the involvement
of the Director in project activities / monitoring has generally been minimal. This is a classic case of where the
structural provisions are rendered non-operative by traditions of relationships between different official and power
structures.
13
The present practice of establishing a separate but temporary project administration structure
outside the Department should be given up and the special unit created for implementation of
such projects should be placed within the department, even while maintaining its separate
identity, with the appropriate structure and operational freedom, for expeditious and efficient
completion of the project. The Director should be responsible for not merely fostering the work
culture of the project but also for the spread of such a work culture in the other divisions of the
Department.
Transparency / morale building
The Department of Health Services is one of the larger administrative organizations of the State.
Its importance both in terms of size and responsibilities dictate that the morale of the officers
and staff should always be high. It should be managed in such a manner that administration is
not accused either of favouritism or lack of direction. Morale building would depend on the
personnel having a conviction of fair dealing in matters such as postings, selection for
postgraduate courses, promotions and quick redressal of grievances. At present, unfortunately,
there would appear to be no internal guidelines or traditions for many of these aspects.
Transfer Policy
Transfers are admittedly necessary in the department for manning vacant posts, on promotion or
for other reasons. However, the system of routine transfers that are made every year has virtually
deteriorated into a scramble for “good” postings or for postings in Bangalore, with pressures and
pulls of all sorts having free play. In particular, it is most unfortunate that political pressures
predominate. This works to the disadvantage of those who adhere to the rules or who have no
political backing, and encourages indiscipline and inefficiency. It would be necessary to
formulate and adopt a transfer policy under which the transfers would be transparent and
unassailable. Towards this end, the following recommendations are made:
1. A transfer policy has to be evolved on the basis of well-defined criteria. The general
principle should be that no transfers are necessary in what is essentially a service sector. In
fact, unless there are compelling reasons, transfers in the current routine manner at periodic
points seem unnecessary.
2. If transfers have to be made for compelling reasons the criteria could include – (a) a three to
five year tenure in one post or place as a requirement for being considered for transfer, (b) a
compulsory posting in a rural post / area, ensuring that positions in less favoured areas such
as Northern Karnataka are particularly manned, (c) seniority and increased personal
responsibilities guiding postings to urban areas, particularly Bangalore, subject to selection
stipulations in the Cadre and Recruitment Rules for any particular post.
3. In making transfers care would have to be taken that there is no mis-match between
qualifications / experience of the individual concerned and the requirements of the post;
4. A format of the personal and service particulars of the personnel should be developed which
would contain all necessary particulars for application of the above criteria. These should be
computerized and maintained both at the Secretariat and Department levels. The transfers
could then be made on a transparent basis.
5. A committee chaired by the Commissioner for Health with the Additional / Joint Secretary
in the Health Department and the DHS as members may recommend transfers, on the basis
of the criteria indicated above.
6. Any pressure for choice of postings (except for authentic compassionate reasons) should be
treated as an act of indiscipline and action taken.
The adoption of the procedures suggested above would go a long way towards ensuring both
equity in postings and discipline in the hierarchy.
14
There are some cadres in which the vacancies to which direct recruitment have to be made are
large. It would be advisable, in such cases, to stagger the direct recruitment over two or three
years to avoid problems relating to career management or bunched retirements in future. care
should be exercised to ensure that there is no delay in filling up the vacancies.
The postings of personnel on OOD basis are often used as device to favour a particular person
rather than to meet essential needs of the Department. This practice needs to be regulated.
Therefore, the practice of postings of officers and staff on OOD should be kept to the minimum
and restricted to essential requirements. This would ensure that postings based on individual
preferences or to avoid transfers are minimized.
Selection for higher studies
The selection of in-service doctors for Post Graduate courses should be transparent and not
made in a manner that favours individual members of the staff. It should be based on the needs
of the Department for specific specializations and not on the preferences of the officers. It is
recommended that the need for specializations be identified and selection be made on the basis
of experience, seniority and capacity.
Regularisation of contract appointments
The Department has appointed a large number of doctors on a contract basis as MOs for the
PHCs. They have continued on a fixed pay basis for some years now. It would be inequitable if
they are replaced through direct recruitment and the Department also loses experienced
personnel if this is done. It is recommended that the contract doctors be regularized, with due
weightage being given to their years of service and inter-se seniority. This process of
regularization may include a criterion of selection that takes into account the performance of the
doctor. Such amendments to the C & R Rules as may be necessary may be processed quickly so
as to expedite the process.
Induction and reorientation training
Morale building includes training. A foundation training course on appointment that equips the
recruit with the structure of the department and administrative and financial procedures would
ensure better performance. Also, a public health orientation could be imparted at this early stage
and a sense of pride of belonging to an essential service developed. Similarly, morale and
honing of skills among middle level and senior officers should be built up through periodic inservice training, orientation courses and internal seminars / workshops. The State Institute for
Health and Family Welfare could assume this role.
Delegation of duties and powers
Morale and functional efficiency are also dependent on the ability to exercise powers
appropriate to each level in the hierarchy. Currently, there are orders delegating both
administrative and financial powers various levels. In particular, the powers of the senior
officers are well defined to permit them to function with adequate independence. However, in
practice, these powers do not seem to be exercised fully because traditions have been built up
that favour centralization of decision-making or excessive caution operates in exercising them.
This is reflected in complaints of inability to carry out adequate touring, delays in processing of
even simple requisitions, etc. The adequacy of the delegations and, more importantly, the
processes through which they are exercised would need review.
15
It is recommended that the Commissioner carry out a review of the administrative and financial
powers delegations in the Department to –
1. Evaluate their adequacy and determine if any further delegations are necessary;
2. Examine the procedures of exercising of the delegated powers to determine if there are any
procedural factors that reduce their effective use.
Building up and sustaining morale would also depend on working conditions. The need for
ensuring adequate facilities has been repeatedly stressed. In this context, the providing of
transport and other facilities to the PHC doctors and other personnel at the field level would
need consideration. The measures that could be considered would include (a) providing soft
loans for purchase of two wheelers or other transport and (b) house rent allowances where
quarters are not provided.
General Issues
There is unfortunately no complete information on the various institutions within the
Department from the Sub-Centres, PHCs, CHC, and upwards. There is no consistency in the
figures reported on posts, vacancies, equipment available and condition of the equipment and the
like. It is particularly distressing to note that even figures on the number of such institutions vary
with the source. It is necessary to carry out a full survey, based on a well-structured
questionnaire, to collect full information on these institutions. Such information would, when
compared with specified norms of personnel and services, provide guidance in reorganizing the
distribution of existing institutions or establishing new ones.
It is necessary to emphasize that in a “service” department such as health, vacancies and cuts in
budget allocations operate against public interest. Such vacancies and cuts result in insufficient
maintenance of assets created or deterioration in services that have been built up over time. It is
strongly recommended that all vacancies in the Department be filled expeditiously and that no
budget cuts be made in allocations.
Ensuring Overall Responsibility on Health Matters in Urban Areas
The administration of health services in urban areas is largely the responsibility of the local
administrations such as the municipalities and Municipal Corporations. The staff in the larger
cities are appointed and managed by the Corporations. While the administration of the services
in these areas and the management of the staff would be the responsibility of the municipal
body, it would be necessary to ensure that the Commissioner, the Director of Public Health and
Director of Medical Services have overall responsibility for the technical aspects of these
services so as to ensure quality and availability. The Directors should have the right of
inspection and monitoring. Such general authority would be specially important in periods of
outbreak of diseases and emergency situations. In particular, the public health aspects of urban
areas, including water quality and the like, should be reviewed by the Director of Public Health.
A clear enunciation of the overall jurisdiction of the Directors over such services would be part
of a Public Health Act, when enacted. Meanwhile, it could be stipulated by issue of
administrative directions under the relevant municipal laws and / or suitable amendments to
these laws. Information on the services in these urban areas should be built into the
comprehensive information system that has been recommended in this report.
16
Inter-sectoral Coordination
It has been repeatedly emphasized in this report that health should not be viewed in isolation.
While, for pragmatic administrative purposes, the DHS is in charge of health services, the
success of the latter depends on the successful implementation of many other programmes. The
latter include programmes relating to nutrition, sanitation and water supply, meeting minimum
housing needs, literacy, transportation, communication, and the like. It is also dependent, in a
larger sense, on social policies, as for example, raising the age of marriage of girls. More
specifically, the health services are closely associated with the ICDS and school health
programmes.
It is evident that health services would need to be coordinated with activities of the programmes
referred to. Such coordination would be necessary both with regard to the relevant elements of
these programmes and with the implementing agencies. The establishment of an effective
coordination mechanism would also ensure more optimum use of the funds invested in the
health services and these programmes. The establishment of a high level mechanism for
coordination would develop synergy among these activities. It is recommended that a High
Power Coordination Committee be set up with the Development Commissioner as Chairperson,
and members being the Commissioner of Health and FW, Director of Health Services, Principal
Secretary and Director of Primary / Secondary Education, Principal Secretary, Woman and
Child Welfare Department and Director ICDS, Principal Secretary Rural Development and
Panchayati Raj, and officers in charge of rural water supply and sanitation programmes. Other
officers could be co-opted if necessary. Representatives of prominent NGOs could also be
inducted as members.
Similar coordination mechanisms must be established at the district and taluka levels.
Coordination with other institutions
There are autonomous specialty institutions, which include the Kidwai Memorial Institute of
Oncology, Sri Jayadeva Institute of Cardiology, Sanjay Gandhi Accident Hospital and Research
Institute, and others. Government is represented on the management of these institutions and,
therefore, mechanisms are present for ensuring coordination. The links permit review of
performance, monitoring of activities and also provide for an active role of intervention if
necessary.
The representatives of Government are on the managements of the Central institutions such as
NIMHANS and National Institute of Communicable Diseases. To this extent, interaction is
provided for as part of the system.
Contracting out non-clinical services
The KHSDP has identified 28 non-clinical services, which could be performed by private sector
agencies on contract. The advantages are obvious. Large number of staff need not be on the
permanent payroll of government. Services are likely to be performed better because penalty
clauses could be enforced, which would not be easy in the case of government employees. It
would allow more time and effort to be invested in health and medical issues. It is recommended
that this system of contracting out non-clinical services could be extended to as many hospitals
as possible.
In the context, the view that general services cannot be contracted out under the laws relating to
abolition of contract labour would seem to be of doubtful validity. In the arrangement
contemplated, the contract would be with service firms and not individuals.
17
Improving Registration of Births and Deaths
The importance of improving the system of registration of births and deaths cannot be
overemphasized. The data provided by the system, if complete in coverage and valid in recorded
information, would provide information at regional, sub-regional and micro level on health
parameters.
The placement of the system of reporting would seem to need consideration. Currently, it is
monitored by the Director of the Bureau of Economic and Statistics, with a network of notifiers
and registrars at the field level. The latter are revenue officials. The system merits a review for
its reorganization and vitalization. It is recommended that this be examined in consultation of
the Departments involved. The Government of India would also have to be consulted at the final
stages.
Recommendations
SECTION I – Structure of Health Services
•
The emphasis on public health should be revived and its essentiality recognized;
For this purpose, and to generally enhance functional efficiency, two separate cadres may
be constituted relating to Public Health and Medical (clinical). The Department would be
designated as the Directorate of Health Services;
•
The Directorate would be in charge of a Commissioner / Director General of Health
Services. This post would be filled by a senior IAS Officer of the State Cadre or through
contract appointment of an eminent health professional;
•
The Divisions would need to be reorganized on the basis of integrated and common
functions, to avoid duplication and lack of coordination;
The restructuring may be made as indicated above and described in Annex I;
•
All State level posts may be constituted into the “Karnataka Health Service”. The Service
would include both the Public Health and Medical Cadres. The posts in the Service would be
filled fifty per cent through a process of selection on the basis of merit-cum-seniority from
the senior officers of the district cadres, and the other fifty per cent would be filled through a
process of selection consisting of both tests and interviews from among all the officers of the
District Cadre, subject to criteria of qualifications and other parameters. A small portion
may be through open selection. The principles on which it would be constituted and the
procedures for selection from District Cadres could be as indicated herein.
•
All further promotions within the Service would be on the basis of merit cum seniority;
•
In public interest, if officers who satisfy the stipulations of the Cadre and Recruitment Rules
are not available for appointment to posts at any level in the Service, and for such time as
they are not available, such posts may be filled by induction of suitable persons laterally, on
contract basis.
•
The levels of health personnel up to the district level should constitute district cadres,
selection to State cadres being made from these cadres on the basis of merit cum seniority;
18
•
Appropriate transitory mechanisms for exercise of options by the present staff to the
reconstituted cadres would have to be adopted, on the lines suggested above;
•
A suitable recruitment mechanism should be established for appointment of doctors at the
basic level. This could be either a District Recruitment Committee or a State level Local
Services Recruitment Board, depending on the level / grades of staff to be recruited;
•
Recruitment would be at the level of the PHC, assignment to the Public Health or Medical
Cadres being made after a certain period and subject to qualifications as specified;
•
A Taluka Health Team under the Taluka Health Officer may be constituted which includes
the Block Health Educators, Senior Health Inspector, the Refractionist and the Senior Lady
Health Visitor;
•
The DHO and the DMO would be designated as the district health chiefs and be made
responsible for all concerned activities in the district;
•
A Commission on Health may be constituted as a mechanism for interaction with
professionals and to assist in policy formulation;
SECTION II – General Administrative Issues
•
The restructuring of the health services would call for amendment of the Cadre and
Recruitment Rules and for consideration of the transitory arrangements. A Committee with
the Commissioner as Chairman should be set up for this purpose, with a mandate to
complete the process in a specified time so that the new structure is in position in a year’s
time;
•
The present system of annual appraisal reports needs to be reviewed and made performance
specific. Also, a system of medical audit should be instituted for assessing performance of
hospitals;
•
It is recommended that private practice be banned, with reasonable enhancement of
scales of pay. However, if this is not feasible, it is recommended that private practice by
health personnel be allowed subject to the following conditions:
a) Hours of duty will be stipulated in all health / medical institutions of the
Directorate and prominently displayed for public knowledge. The hours of work
would take regional, seasonal and other factors into consideration. All personnel
will be expected to adhere to these hours and the responsibility to ensure this
would be that of the superior officer;
b) Private practice would be allowed outside these stipulated duty hours and only
when not on cal or when not required for emergencies, subject to the remission
every month to Government of one-third the basic pay of the staff member who so
practices;
c) The Directorate would identify and notify those posts where private practice is
banned, based on criteria to be evolved. The incumbents of these posts would be
paid a monthly “non-practicing allowance” of one-third the basic pay of the
post;
19
d) All doctors in the Directorate, at all levels, would provide an affidavit at such
periodic intervals as may be specified affirming whether they are or are not
carrying on private practice. This would form part of the service record;
Those found contravening the affidavit would be subject to punishments as may
be prescribed in the relevant rules.
•
Internal institutional mechanisms for detection of and enquiry in cases of corruption should
be set up for expeditious detection and punishment;
•
All externally aided projects would be within the structure of the Department, even if
implemented by a distinct Division within the Department, as suggested in the restructuring
of the Department;
Morale needs to be built up by adoption of transparent procedures with regard to transfers,
selection for training or courses, regularization of contract doctors, providing soft loans for
transport to PHC doctors and field personnel and the like. The orders relating to delegation
of powers, both financial and administrative, need review. The Commissioner may carry out
such a review;
•
•
All vacancies should be filled expeditiously. Vacancies in a “service” Department results in
serious reduction of quality and availability of health facilities;
•
Budget cuts for health services should not be made since these not only reduce the scale of
the services but also result in deterioration of existing ones due to low maintenance and
enhancement. Such cuts are counter productive;
•
It is necessary to extend the technical authority of the Director, Public Health / Director,
Medical over health matters in urban areas that are under he control of the municipal
authorities. This could be done through the issue of orders under the existing Municipal
Acts.
•
It is recommended that a Public Health Act based on the Model Public Health Act, GOI,
with suitable modifications, be considered for the above and other purposes;
•
Inter-sectoral coordination should be ensured. For this purpose a Committee should be
constituted as suggested;
•
The existing mechanisms should be used effectively to monitor and interact with the specialty
institutions, including the Central ones;
•
The possibility of contracting out non-clinical services in increasing degree should be
explored;
•
The Population Centre may be redesignated as the Centre for Population and Health
Research, and its role expanded. It may be placed under the Principal Secretary;
•
The system of registration of births and deaths needs to be reviewed to enhance its accuracy,
coverage and utility.
20
21
ANNEXURE
PROPOSED ORGANISATIONAL STRUCTURE OF THE DEPARTMENT OF HEALTH
AND FAMILY WELFARE, KARNATAKA
I. Organization Structure at the District
Sub-Centre
The sub-centres will continue to have the existing structure with the Female Health Worker and
the Male Health Worker carrying out the functions of registering the cases of pregnant women,
administering immunisation dosage and attending to minor ailments and first aids and refer to
PHC, the cases beyond their competence. These personnel will report to the Medical Officer at the
respective PHC.
•
•
•
•
Junior Health Worker – Female (ANM) for 3,000 to 5,000 population
Tribal ANMs for Sub-Centres in Tribal Areas.
ANMs will be assisted by Dais, Anganwadi Workers and Village Health Workers.
Junior Health Worker – Male: for every two subcentres or for every Gram Panchayat.
Primary Health Centre
The PHC will have at least two Medical officers - one lady medical officer and male medical
officer. The senior amongst them will be the administrative head. These medical officers will have
a team of one Staff nurse, Pharmacist, Junior and Senior Health Assistants – Male and Female, a
Lab Technician and related support staff. All these staff report to the Administrative Medical
Officer.
Community Health Centre
A composite primary health care concept will now consist of one CHC with 3-4 PHC’s. The
specialists of the CHC will assist the PHC Staff in the execution of public health activities under
the guidance and monitoring of the Taluk Health Officer. The routine clinical work of the
specialists at the CHC will be monitored by the AMO of the CHC.
Taluka Level
•
The distinction between Public Health and Medical is initiated at the Taluk level. Each of the
two streams will have their own infrastructure and will draw upon the other’s resources in
terms of consultation and expertise. Thus, the medical specialists will primarily be responsible
for providing clinical care to the patients of the hospital and the public health specialists will
be involved in implementation of the various health programs initiated by the DHS. The
common seniority list of PHC entry level will have to be reworked with 2 independent
seniority lists of Medical and Public health.
•
In the medical wing, the specialists will look after curative work. A CHC / Taluka hospital will
be headed by the Administrative Medical Officer (AMO). The post of the AMO will be a
promotional post from the Specialists post. Among the seniors of the AMO’s of the Taluk,
there will be a Taluk Medical Officer (promotional post) who will supervise, monitor and
evaluate all the CHC’s and Taluk Hospital.
-1-
•
The Taluk Health Officer (THO) will head the public health wing of the Taluka and will have
Public Health officers and program officers, assisting him to carry out various national and
state health programmes. These are monitored by district programme officers who in turn
report to Zilla Parishat (administratively) and DHOs & concerned JDs (functionally). THO
must have a public health PG qualification (atleast DPH). He will be assisted by Taluk Health
assistants (promoted Senior HAs from the PHC level), Block Health Educators, Assistant
Statistical Officers for HMIS, Refractionist and clerical staff.
District Level
• The District hospital will conduct the functions of clinical service. The district hospital is
headed by RMO / District Surgeon / Superintendent depending upon the number of beds in the
hospital and its affiliation to a Medical College and supported by specialists and other staff.
The district office will also have a post of the District Medical Officer (DMO) who will look
after all medical hospitals (CHC’s and TLH/DH) in the district. The DMO is a promotional
post and he will be the senior-most specialist with managerial/ administrative qualifications
and experiences. This cadre is equivalent to the District Surgeon. The senior most programme
Officer becomes the DHO.PG qualifications in public health is must for this post. He must
have additional managerial/ administrative qualifications & experience.
•
A detailed work motion study may be carried out for the DHO and in depth analysis to be
carried out about his time utilisation. Based on this report a necessary GO in Consultation
with the ZP authorities to be framed permitting the DHO to attend only the most important
meetings. Programme Officers at District level to be given more autonomy (financial and
administrative) with technical directions from the DHO. These officers should be accountable
financially also for their respective programmes to the ZP. Presently only DHO operates all the
financial matters. A joint account of Programme Officer with another ZP official to use the
programme funds effectively could be considered.
•
The DHO, which is a promotional selection post, will be assisted by an ADHO who will be the
senior most programme Officer. ADHO will supervise and monitor the health programmes,
prepare district health plans and monitor HMIS.
•
The Gulbarga and Belgaum Districts will have 2 DHO’s each in view of the large size of the
District and number of PHC’s. The Additional DHO will be assisted by 5 to 6 programme
officers each.
•
The following Programme Officers will report to the ADHO for smooth functioning at the
District level: a) District Leprosy Officer with STD/HIV b) Health Promotion with 2 Officers
(one for nutrition – new post and other for health education – District Health Education
Officer) c) Reproductive and Child Health d) Family Welfare Officer e) Vector Borne
Diseases f) TB Officer g) Blindness Control Officer, Programme Officers for urban health and
STD/HIV can be added later as and when these programmes are launched.
•
The District Surveillance Officer with his staff will be responsible for the disease surveillance
in the district Both the DHO and DMO will be responsible for an efficient surveillance system
of communicable diseases and referral systems respectively in their areas of operations. The
DHO and DMO will be trained in applying epidemiological skills for micro level planning to
the dynamic and changing health scenario both at the public health & hospital level.
-2-
•
The district laboratory, District Medical Store, district maintenance unit and district health
management information units will be jointly shared by DHO and DMO. The unit constituing
these services would, for administrative purposes, be placed under the DHO.
•
Though the District Health Officer and District Medical Officer / District Surgeon belong to
state cadre, they have to work closely as officers of the Zilla Parishat.
•
The DMO will be a promotional selection post. His office will be located within the District
Hospital. The Medical Suptd. (earlier DS) of the District hospital, all the Administrative
Medical Officers of the CHC / Taluk and other hospitals in the district will report to the DMO.
The DMO will monitor the quality of care in all the hospitals in the district. The Program
Officers for Ophthalmology and NCD will also report to the DMO. Presently there will be a
separate program officer for Ophthalmology to supervise the cataract surgeries and a combined
Program Officer for CVS / Diabetes/ Mental Health / Oncology of the rank of senior specialist
till these programs are launched as independent programs with funds allocation. The physician
at the District hospital will monitor the TB Centre in the District hospital in coordination with
the DTO. Training in public health and program management will be given to all Program
Officers. The DMO will also have a maintenance unit of civil, equipment and vehicles under
him. (The reorganisation charts of the proposed district level structure are enclosed at the end
of the Annexure)
II. Organisation at the State
The Directorate of Health Services will be headed by the Commissioner / Directorate General of
Health Services (DGHS), who will report to the Principal Secretary. (The reorganisation charts of
the proposed structure at the state level is enclosed at the end of the Annexure)
Commissioner / Director General of Health Services
The main function of the Commissioner of Health Services / Directorate of Health and Family
Welfare Services would be to bring about better internal and inter-sector co-ordination and to
achieve a greater degree of accountability in health services both in financial and administrative
terms. The key activities of this post are:
•
Monitoring, supervising and implementing all National and State health and family
welfare programmes in the State
•
Ensuring co-ordination among the various directorates and divisions within the Health
system and also with related departments
The post would be filled through direct recruitment, through a process of selection from the
open market. Officers of the Karnataka Health Services would also be eligible to be
considered. The post would be held on contract basis for a specified period.
In the event that direct recruitment of a suitable health professional is not possible, the post
may be filled temporarily by a senior IAS Officer of the State cadre.
-3-
Reporting Structure to Commissioner/DGHS:
The Commissioner/DGHS will have the following functional heads reporting to him / her:
•
Director – Medical
•
Director – Public Health
•
Director – External Aided Projects
•
Director – Procurement and Maintenance
•
NGO Partnership Cell
•
AD – Planning
•
AD – North Karnataka
•
CAOs (Administration I & II, Finance and Surveillance)
This division of work among the key functions of Commissioner / DGHS keeps in view the
dynamic nature of the work and effective monitoring of the activities. The structure and functions
of each Director’s office are indicated below:
Public Health Vs Medical
Continuing the proposal for two main cadres namely Public Health and Medical at the District
level, it is proposed to have a similar structure at the Directorate. Thus, he key preventive,
promotive and curative functions of the Directorate of Health are divided split among two
directors, i.e. Director – Medical (for curative and clinical services) and Director – Public Health
(Preventive and promotive services). This will ensure equal commitment from the Directorate to
the District for both Public Health as well as Medical. Further, it will provide focused supervision
in each of the areas. It will also address the promotional opportunity to each cadre to their
respective Directors
Director – Medical
This functionary heads the clinical and curative services of the Directorate of Health. The Director
– Medical is reported to by two ADs, namely, AD – Medical and AD – NCD.
AD-Medical: The AD- Medical currently exists in the KHSDP and due to need for integration
between externally aided projects and the DHFWS, it has been brought under Director – Medical.
The AD – Medical will look after the Hospital and Hospital management aspects in the
Directorate. He will ensure that a proper referral mechanism is in place in the state to ensure
speedy treatment at various levels of hospital care. This post will be assisted by the following
JDs:
•
JD – Medical
•
JD – Hospital
•
JD – Pharma
The JD – Hospital is a new post created for focused supervision of hospitals under the DHFWS.
The JD (GMS) has been re-named to JD (Pharma) with emphasis on distribution of drugs and
pharmaceuticals. The detailed reporting relationships and duties and responsibilities of the above
are provided in Volume II of this report.
-4-
AD-NCD: To bring about greater emphasis and co-ordination in identification and treatment of
Non- communicable diseases, it is proposed to have an AD post who would look after noncommunicable diseases likes Cancer, Ophthalmology, Diabetes, etc. In addition, it is proposed to
have the following JD posts reporting to the AD-NCD:
•
Joint Director – Ophthalmology
•
Joint Director – NCD (Cardiovascular and Diabetology)
•
Joint Director – Emergency Medicine / Traumatology
•
Joint Director – Mental Health
•
Joint Director – Oncology
•
Joint Director – Dental Health
Recent studies Murray & Lopez: WHO and other reports – NIMHANS, AIIMS, NCAER etc) have
shown the rising incidence of NCD cases. This will necessitate that the Dept of Health have
senior officers of the rank of JD’s in each of these specialities to monitor the identification,
curative, preventive and promotive aspects of the NCD’s.
Taking into consideration the future requirements of Health care delivery, it is proposed to have
focussed attention in these areas. The various JDs will primarily be responsible for the curative
and research aspects of these specialisations. The detailed reporting relationships and duties and
responsibilities of the above are provided in Volume II of this report.
Director – Public Health:
The Director –Public Health will be overall in-charge of the Public Health development in the
State of Karnataka. He will utilize his resources for effective implementation of the various
National and State level public health programmes. He will be assisted by the following ADs:
•
AD - RCH / Primary Health
•
AD – Health Promotion
•
AD – CMD
•
AD – AIDS
AD -RCH is an existing post and will continue to perform the current key functions. He will be
assisted by the JD – RCH. He will also look after Primary Health Care which is essentially a part
of RCH and assisted by JD – PHC.
AD – Health Promotion: The current AD (HET) is renamed as AD – Health Promotion and will
handle the functions of Information, Education and Communication (IEC) along with other health
promotional activities. He will be assisted by the following JD:
•
JD – IEC
•
JD – Nutrition (new post)
JD (IEC) currently is under AD (RCH). As the main function of the JD (IEC) relate to
communication of health related programs to the public it is proposed to re-locate this post to be
under AD – Health Promotion. Thus, bringing all health communication activities under a single
head will facilitate higher level of integration and maximum utilization of resources.
-5-
AD – CMD is re-located from the KHSDP and will supervise the activities of various national and
state programs relating to vector borne diseases, TB, Leprosy as well as the Vaccine Institute and
the Laboratory. Each of the above functions are managed by the Joint Directors. He will be nodal
officer for the State Surveillance Unit; the detailed job description is in Vol. II of the report. The
JDs reporting to AD- CMD are:
•
JD -Vector Borne
•
JD – TB
•
JD – Leprosy
•
JD – Vaccine Institute
•
JD - Labs
The JD (Vector Borne) post is renamed from JD – Malaria & Filaria with the scope to incorporate
additional vector borne diseases.
AD – North Karnataka
In view of the existing backwardness in the districts specified in terms of the medical & public
health standards, there is a need for focused attention on the development of this region. It is
proposed to have a post namely AD – North Karnataka, held by a senior person with exposure to
both public health (programme management) as well clinical, reporting directly to the
Commissioner/DGHS.
The key role of this post will be to monitor the activities at Bijapur, Raichur, Gulbarga, Belgaum,
Bidar, Bagalkot, Bellary, Koppal, and Gadag districts. His office acts as a nodal office for all the
activities of DHS. He acts as a coordinator between different functionaries in the department and
also liaison with the Directorate on behalf of the districts mentioned.
AD - Planning
The need for integration of planning at the Directorate Level necessitates a post of AD - Planning
(reporting directly to Commissioner / DGHS). This post replaces the existing Strategic planning
Cell and will take up the activities of long-term, short-term and perspective planning for the
department, with the inputs from different national and international agencies as well as the
Management Information Systems (MIS) functionary of the department. He will monitor the
changing epidemiological profile, the burden of disease, recommend cost effective measures to
achieve best use of limited resources. Also carry out studies on a continuous basis and interpret,
analyse trends initiate policy initiatives for reform and change. Will also review the annual plans,
five-year plans and MMR. Will edit the annual report of the department. He will be assisted by
the following personnel:
•
JD -MIS
•
JD -Planning
The JD –MIS will be the nodal point for all information relating to the DHFWS. He will collate
information from all medical, hospital and public health functionaries in the department and
interprets for any inferences or corrective actions. The bureau of health intelligence, demography
cell and all statistical units in some divisions will function under the JD (MIS).
The JD (Planning) will be the nodal Officer for preparation of annual plans, five-year plans and
annual report of the department. Detailed JD’s are in volume II of the report.
-6-
DD (Law & Ethics and Forensic Medicine) will be the nodal point for all aspects of Law, Ethics
and Forensic Medicine.
Director – External Aided Projects:
The various operations of the Externally Aided Projects is proposed to be conducted in the main
stream of the DHS. However, a need was felt to introduce a functionary reporting to the
Commissioner/DGHS to oversee the management of these projects and to handle any coordination with external agencies, if any. The Director – EAP will have the following key
functions:
•
Monitor all the existing External Aided Projects, if needed by having different
reporting authority for each. He stands the overall responsibility for the financial
accountability of the Projects
•
Identify new areas of collaboration with other agencies and bring them to reality.
•
Work in close association with mainline department in carrying forward the objectives
of all External Aided Projects with a programme mode of approach rather than a
project mode.
Director – Procurement and Maintenance
In the current structure, the procurement and maintenance of various equipment and civil works
are distributed across the various departments. It is proposed to centralize these activities by
creating a separate cell reporting to the Commissioner/DGHS. It is proposed to place an IAS
person in charge of this Division. He will be assisted by the following people:
•
JD – Procurement
•
JD – Equipment & Maintenance (Bio-Medical)
•
Chief Engineer – Civil
JD – Procurement’s key functions include receiving the indent for any equipment from all
respective functionaries in the department about their requirement, placing tenders for acquiring
those equipment and finally acquiring them from the most feasible bidder. The person to hold this
position can be one with engineering/logistics background since it involves appraising of tender
documents, acquiring equipment and supplying to the destined location. He should be well versed
in all the procurement procedures of World Bank and other funding agencies.
JD – Equipment and Maintenance (Bio-Medical) takes care of all the machinery and equipment
including the vehicles of Directorate of Health Services. He will be assisted by
•
DD – Equipment
•
DD – Equipment (training)
•
DD – Transport
These posts are already existing under KHSDP and same to be transferred to the Directorate
of Health and Family Welfare.
Chief Engineer – Civil has functional reporting to the Secretary – PWD and administrative
relationship to the Commissioner through Director – Procurement. He is in charge of all the civil
related construction and maintenance work of the Directorate of Health services. He appraises the
tenders for construction and allots the work to the eligible persons. He is assisted by
-7-
•
Superintendent Engineer – Civil
•
Dy. Chief Architect
NGO Partnership Cell:
NGO participation in Health Care has become very essential at levels of Public Health Care and
first referral. These need to be supported and encouraged with special focus esp. in the backward
and remote region of the State. A number of NGO are registered with the Health Department
under various schemes and various programmes. It is important that all NGO’s have a single
source of interaction, coordination with the Health Department.
It will also enable the
Government to monitor and evaluate the activities of the various NGOs participating with the
Health Department. Hence it is suggested to have a NGO Partnership Cell as a single window in
the department headed by preferably by a Advisor/ Consultant to coordinate the activities of this
cell with the Commissioner/ DGHS to simplify procedures for grant in Aids avoiding delays.
Joint Director (Special Groups)
A new post needs to be created to cater to the problems of women (gender sensitivity ,Tribals,
Elderly and the Disabled). He will report directly to the Commissioner / DGHS and coordinate
with other departments and sectors.
Director of ISM&H
For the purpose of better co-ordination between the Director of ISM&H and Directorate of Health
Services, it has to be brought under the Commissioner. The Medical Education component of the
Department of ISM&H will be supervised by the Secretary, Medical Education.
Drugs Control Department
Drugs Control Department will be reporting the Principal Secretary directly.
Centre for Population and Health Research (Population Centre)
The Population Centre, which currently carries out studies on the State’s demography and also
conducts evaluation studies, is under the Principal Secretary, Health. It is expected to meet current
needs of projections and evaluations and generally provide professional inputs that are
independent of the Directorate. It is an organisation with professional expertise and serves a very
useful purpose. Its reports provide valuable inputs for mid-course corrections, for evaluation and
policy formulation. Its continuance and strengthening would be desirable.
The Centre could, with advantage, be located as a wing under the Commissioner. This would also
enable its expertise being available to the Commission on Health that has been suggested as an
advisory body. To reflect its true functions, it could be designated as the Centre for Population and
Health Research and its role reassessed / expanded
Director – State Institute of Health and Family Welfare (SIHFW)
Currently, he is a functionary reporting to Project Director – IPP – IX. It is proposed that
henceforth he will head the training function of the department and SIHFW, which will be a
autonomous and report functionally to the Principal Secretary of Health. The hierarchy of the
proposed structure of the office of Director SIHFW includes:
-8-
•
JD
•
DD
•
District Training Officers
Other training personnel involved in training in Health & Family Welfare throughout the state
Medical Education:
The Secretary, Medical Education will consult the Principal Secretary, Health regarding policy
matters. The Director, Medical Education will coordinate with Commissioner. The staff on
deputation from the health department to the Medical Education Department will be under the
Administrative control of Medical Education Department.
Benefits of proposed structure
The key benefits of the proposed structure are outlined below:
•
The structure is Programme based thereby leading to more accountability for
programme officers from Taluka level itself
•
The split of DHFW functions into Public health and medical for better monitoring and
execution of duties and responsibilities, thus increasing the scope for accountability at
each stage
•
Equal promotional avenues for all medical professionals in the department
•
Scope to have seniority cum merit during promotions
•
Removal of divisional structure, leading to concentrating the activities at district level
•
Direct monitoring of all national and state programs from the directorate itself, thus
paving way for better coordination among districts and with the directorate
-9-
Autonom Hospital
PRINCIPAL
SECRETARY
Drug Controller
SIHFW
COMMISSIONER
/ DGHS
Pop & Hel Research
CAO Finance
CAO Vigilance
AD Plan & Mon
JD Sp Gr
JD Plan
Dir Public Health
AD AIDS
JD HMIS
JDAIDS
PD RCH & PHC
JDRCH
AD Hel Promo
JDPHC
JDIEC
CAO
Promo
JDNut
AD -CMD
JDVBD
JDTB
AD-BMP
JD Lep
JD Vac
District Health
Officer
JD Lab
Dist Hos Laboratory
Micro+Path+Bioch
Pro. Co-ord
Dt. Sur Off
Dt. Maint Unit
Civil+Veh+Equip
RCH -PO
F W-PO
Vect Borne
Lep+STD+
TB-PO
Blind - PO
HP-PO
Entam
Statis
HIV
Dt. Medical Store
Nutrition
IEC
Dt. HMIS Unit
Taluk Health Officer
Sr. HA – M&F
BHEs
Refraction
ASO
Lady MO
Med Off
AWW
Staff Nurse
Pharmacist
Lab Tech
Sr. HA (F)
Sr. HA (M)
VHW
(F)
TBA
JHA (F)
JHA (M)
JHA (F)
JHA (F)
JHA (M)
JHA (F)
Secretary (ME)
Autonomous Teaching Hosp/Inst
Dir ISM&H
Director (ME)
Dir Ext Aid Proj
Dir Medical
NGO Cell
Dir Proc & Maint
SE
AD Medical
JDMed
JD GMS
JD Hosp. N
CAO
JD Hosp S
JD-Emerg
AD NCD
JD Opthal
JD CVS
JD Dent
District Medical
Officer
District Hospital
RMO/BS/Suptd
Mental Health PO
JHA (F)
Opthalmic PO
Oncology PO
AMOs
Driver
FDC
FDC
Off Manag
CVS & Diab PO
AWW
* Driver
Ayah
VHW
JHA (M)
JHA (F)
TBA
* Driver only for PHCs with vehicles
AD North Kar
JD Ment
JD-Onco
Proc
Eqip
S
T
A
T
E
L
E
V
E
L
D
I
S
T
R
I
C
T
T
A
L
U
K
P
H
C
L
E
V
E
L
ORGANISATIONAL FLOW CHART OF DEPARTMENT OF HEALTH & FAMILY WELFARE
PROPOSED
CHART NO. 1
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
DISTRICT LEVEL
Public Health
Stream
Clinical
Stream
Ob&G
Paed Gen Surg
Fam Phy
Need based
temporary contract
appointments
AMO
GDMO
THO
Taluk
Need based on numbers
Inservice
Inservice
PG
PG
Medical (clinical)
MO (PHC)
MBBS
Public Health
PHC (MO)
MBBS
MBBS + PG
Need based
temporary
contract
appointments
CHART NO.2
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
DISTRICT LEVEL
Public Health
Medical
DMO (DS)
PG in Clinical + Hos Adm
Dist. Med Store
Dist. Maint Unit
Dist. Laboratory
Dist. HMIS Unit
Taluk
Taluk Health Officer
(THO)
Community
Health Centre
Medical Officer
PHC
MBBS min.qualification
PGs can also enter
State cadre (KHS)
PG qual. compulsory
Merit cum seniority
District Cadre (ZP Cadre)
Programme Officer
Deputy DMO/RMO
AMO
Taluka Hospital
DHO
PG in Public Health
CHART NO. 3
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
DISTRICT LEVEL
STRUCTURE OF PRIMARY HEALTH CENTRE
Lady Medical Officer
Staff
Nurse
JHA
(F)
Pharmacist
JHA (M)
Lab Tech
JHA
(F)
JHA
(F)
Sr. HA
(Female)
JHA (M)
Medical Officer
Sr. HA
(Male)
JHA
(F)
FDC
Manager
JHA
(F)
Driver*
JHA(M)
Aya
JHA
(F)
TBA
VHW
AWW
* Driver for PHCs which have vehicles.
CHART NO. 4
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED
DISTRICT LEVEL
TALUK HEALTH OFFICE - PROPOSED
Taluk Health Officer
DPH Qualification
Senior Health Assistant
(Male & Female)
BHE's
(Shift from PHC
to Taluk Level)
Refractionists
(Shift from PHC
to Taluk Level)
ASO
(Statistics person must
for HMIS)
FDC
Driver
CHART NO. 5
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED
DISTRICT LEVEL
STRUCTURE AT DISTRICT HEALTH OFFICE
Health Officer
Corporation/Municip
DISTRICT
HEALTH OFFICER
Entomologist
Urban Primary
Health Centres
RCH
programme
officer
Programme
Co-ordinator
Family Welfare
Programme
Officer
Vector Borne Dis
Programme
Officer
District Surveillance
Officer
Tuberculosis
programme
officer
Statistical
Officer
Lep/HIV/STD
programme
officer
Blindnessprogramme
officer
Dt. Nutrition
Officer
Health Promotion
programme officer
IEC
(DHEO)
CHART NO. 6
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
DISTRICT LEVEL
STRUCTURE AT DISTRICT MEDICAL OFFICE
District Medical Officer
(DMO)
District Hospital
RMO/DS/Superintendent
Mental Health
Programme officer
(NIMHANS)
CVS / Diabetes
Programme Officer
Ophthalmic
Programme Officer
(MINTO)
Oncology
Programme Officer
(KIDWAI)
Administration
Medical Officers
CHC/Taluk Hosp.
CHART NO. 7
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
DISTRICT LEVEL
STRUCTURE AT DISTRICT HEALTH OFFICES – DHO & DMO
DHO
DMO
District Hospital
District Laboratory
Prog Co-ordinator
RCH-PO
Microbiologist
Pathologist
Biochemist
DSO
Entm
Mental-PO
CVS-PO
Statis
Dt. Maint Unit
Vector -PO
Civil works
Vehicle maintenance
Opth-PO
Equipment maint
TB - PO
Dt. Medical Store
Onco-PO
FW - PO
Dt. HMIS Unit
LEP+STD/HIV
Blindness PO
Nutri
HP- PO
IEC
AMOs
CHART NO. 8
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
STATE LEVEL
Autonom Hosp.
PRINCIPAL
SECRETARY
Commission on
Health
Secretary (ME)
Drug Controller
SIHFW
Commissioner / DGHS
Autonomous Teaching
Hospital / Institute
Dir. ISM&H
Director (ME)
Pop & Health Research
CAO
Finance
CAO
Vigilance
Director
Public Health
Director
Medical
Additional Director
Planning
Joint Director
Special Groups
Director
EAP
Director
Procurement /
Maintenance
Additional Director
N. Karnataka
NGO Cell
CHART NO. 9
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
STATE LEVEL
DIRECTOR
PUBLIC HEALTH
Add. Director
AIDS
(KSAPS)
JD
AIDS
Project Director
RCH & PHC
JD
RCH
JD
PHC
Add. Director
Health Promotion
JD
IEC
AD (CMD)
State Surve Off
JD-Vect
Borne Dis
JD
Nut
DD
KFD
JD
TB
DD
Dis Surv
Chief Acc.
Officer
JD
Leprosy
AD-BMP
Urban PHCs
JD
Vaccine
JD
Lab
CHART NO. 10
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED
STATE LEVEL
DIRECTOR
MEDICAL
Addl Director
Medical
JD
Medical
JD
GMS
JD-Hosp
North
Addl Director
NCD
JD-Hosp
South
JD-TrauEme Med
JD
Ophthal
(MINTO)
JD-CVS
& Diabet
JD-Dent
Health
CAO
JD-MH
JD-Onco
(NIMHANS)
(KIDWAI)
CHART NO. 11
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED
STATE LEVEL
DIRECTOR
Ext. Aided Projects
DIRECTOR
Procurement & Maint
Secretary PWD
AD (SPC)
Planning & Monitor
Joint Director
Planning
Joint Director
HMIS
DD-Law & Ethics
(Forensic Medicine)
Joint Director
Procurement
JD-Bio-Medical
Equip Maintenance
Superintendent Eng
Civil
Civil Engineering.
Staff
as in KHSDP
CHART NO. 12
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE: PROPOSED
DIRECTORATE OF ISM&H
DIRECTOR
ISM&H
Directorate level
JD
Med Edu
JD
ISM&H
Admin
Officer
Accounts
Officer
Ast Drug
Controll
DD
Ayurveda
DD
Unani
DD
Homoeo
DD
Nat & Yog
3 DrugInspectors
Physician Gr I
District Hospital
Dt. ISM&H Officer
Phy Gr II
Hosp & Disp
Principals
Col & Hos
Aided
Col & Hos
DD
Pharmacy
Div DDs
?
CHART NO. 13
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED
STATE INSTITUTE OF HEALTH AND FAMILY WELFARE (AUTONOMOUS)
PRINCIPAL
SECRETARY
Director
Selection Post
SIHFW
(Autonomous)
Governing Board
Commissioner /
DGHS
Directorate
Joint Director
Training
Joint Director
Research
(Social Scientist)
Deputy Director
Course Content
Deputy Director
Training
Specialists
Communication
Health Mgt
RCH/NCD
Principals RHFWTC/DTC
ANM Training Centres
CHART NO. 14
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE
DRUG CONTROL DEPARTMENT
DRUGS CONTROLLER
ADDITIONAL DRUGS
CONTROLLER
Enforcement Division
Head
Quarters
Drugs Price
Control
Cell
Bl bank
& Intellig
Dy. Drugs Controller - 8
Asst. Drugs Controller -19
Drugs Inspector
-56
Drugs Testing Laboratory
Circle &
Dt. Off
Superintendent (Admn) -1
Superintendent (Lab) -1
Other Technical
-7
Officers
Junior Chemists
-30
Pharmacy Education
Govt.
College of
Pharmacy
Board of
Examining
Authority
Principal & Chairman
-1
Member Secretary
-1
Professor
-6
Asst. Professor
-8
Lectures (Pharmacy Lect) -17
(Non Pharmacy)
-5
CHART NO. 15
DEPARTMENT OF HEALTH AND FAMILY WELFARE – ORGANISATIONAL STRUCTURE : PROPOSED
DEPARTMENT OF MEDICAL EDUCATION
SECRETARY
MEDICAL EDUCATION
Autonomous Teaching
Hospitals/Institutions
Director
Medical Education
DEAN
BMC
*Dir
RIO
DEAN
MMC
Vice Prl
Vice Prl
BMC
MMC
AD
Med Edu
Supr
Hos 1
Supr
Hos 2
Supr
Hos 3
Supr
Hos 4
DEAN
GDC
Supr
Hos 5
Supr
Hos 6
PROFESSORS and HOD BMC / MMC
ASSOCIATE PROFESSORS
ASSISTANT PROFESSORS
LECTURERS
REGISTRARS / TUTORS / DEMONSTRATORS / RESIDENTS
* Regional Institute of Ophthalmology (RIO) could be made into an Autonomous Institution
Supr
Hos 7
JD
ME
Vice Prl
DD (ME)
DD (DE)
GDC
14.2 PLANNING AND MONITORING
"I owe all my success in life to the fact that I
have always and in everything been a
quarter of an hour ahead of time"
- Nelson
Health services must meet current needs and the management must have the capacity to adapt
them to such needs. It would, therefore, be necessary to review the system periodically in terms
of both content and adequacy. The character and content would be influenced by the population
projections and also by the need to cater to under-serviced areas in the State. Any modifications
or expansion of services have implications in terms of staff, training, and financial outlay. It is
therefore necessary to have an in-built ability for carrying out such reviews and in the
preparation of perspective plans.
It has been separately recommended that the Department should also have a strong, unified
system of reporting as part of the Health Management Information System. This would
necessarily have to form part of the planning and monitoring structure of the Department. These
activities would call for the establishment of a Planning and Monitoring Division.
Present structure
There is, at present, a Joint Director in the office of the DHS in charge of planning. The post is
currently designated as Joint Director (Health and Planning). The JD (H & P) is assisted by a
Deputy Director (Planning) with supporting staff.
The functions of this post include preparation of the annual plans, five -year plans, and
preparation of the monthly monitoring reports (MMR) which deals with financial and physical
progress and the Karnataka Development Plan which deals with staff and organizational issues,
that are submitted to Government.
An important function is the preparation of the Annual Report of the Department. The
Preparation of these reports involves obtaining information from all units in the Directorate,
including the Programme Officers on a monthly basis. Coordination and constant interaction
with the other Divisions and sections in the office of the DHS are essential elements of the post.
However, the JD (H & P) has no direct responsibility for preparation of the reports of the
projects such as KHSDP and IPP. It obtains the information for incorporation in the reports that
are produced.
The JD (H & P) is concerned with the preparation of only schemes relating to the Plan. NonPlan elements are prepared by the Chief Accounts Officer cum Financial Adviser. This is
because the latter are more concerned with staff and maintenance issues. However, information
on the latter is incorporated in the reports mentioned above.
The JD (H & P) is also in charge of the Bureau of Health Intelligence.
Role of the Planning and Monitoring Division
The planning process in the office of the DHS is restricted in scope and serves the immediate
administrative needs of routine reporting. The process of preparation of Plan schemes is also
fairly well established, as well as statistical reporting in specified formats. These are essential
activities in themselves but the constant internal monitoring of performance, particularly the
sensitive appraisal of available information, is near absent. The Planning Unit, which should be
designated as the Planning and Monitoring Division in view of its importance, should play a
more central role in the management of information systems within the Directorate. It should be
responsible for all information flows, appraisal of such information and feed back of such
appraisal to the functional divisions concerned. Currently, the appraisal of performance is within
the functional divisions concerned, which would render it routine. Also, a total appreciation of
the functioning of the Directorate would not be available to the Director.
The improvement in the Health Management Information System (HMIS) has been considered
elsewhere in this Report. The reporting system is envisaged as common to the Department and
not in sectional components, more related to individual programmes, as at present. With this
change in the structure and focus of the HMIS, it would be logical to place its management
under the Planning and Monitoring Division.
Functions of the Planning and Monitoring Division
1. Coordination of all reporting activity as part of the unified system of the HMIS and
providing the information that other Divisions would require on the basis of the unified
HMIS;
2. Coordination of all statistical activity in the Department, at various levels, including
ensuring of quality of data, and processing and analysis of such data in the prescribed
manner as may be required for various purposes;
3. Production of the Annual Report, periodic reports such as the Monthly Monitoring Reports,
Karnataka Development Plan, and such other prescribed reports. The reports of the projects
such as IPP and KHSDP should be incorporated so that there is one report for the entire
health department;
4. Monitoring progress in implementation of Plan programmes and schemes each month to
enable mid-course corrections to be made;
5. Preparation of Annual Plans and Five year Plans of the Department, coordinating with the
other wings such as Medical Education, State Institute of Health and Family Welfare and the
like;
6. Preparation of a perspective plan for the Health Sector and its updating at appropriate
intervals.
7. Organization and management of the Geographical Information System that is recommended
for establishment;
8. Organization and management of the Computer System that is recommended for
establishment;
The Current Statistical System in the Health Department
The statistical system within the Department has developed in a rather ad-hoc manner. The
statistical and reporting system at headquarters could be said to consist of three distinct wings as
follows:
a) The Bureau of Health Intelligence (BHI)
b) The Demography and Evaluation Cell (D & E Cell)
c) The statistical units / personnel attached to some Divisions on an independent basis.
The BHI is the unit that generates the Annual Administration Report and all statistical reports,
excluding those relating to the RCH programme. It is also responsible for collection and
collation of information on health indicators, including the macro indicators from the RCH
programme. One important responsibility of the BHI is collection and processing of data relating
to morbidity and mortality.
Its responsibilities include the following –
a) Compiling periodical reports on rural health services and national programmes for the
Government of India, in addition to reports for the State Government;
b) Preparation of the Annual Report, Annual Administration Report and the Status Reports of
the Directorate;
c) Maintenance of statistics on Health and Medical Institutions and their bed strength;
d) Annual morbidity and mortality statistics;
e) Quarterly Progress Report on the Rural Health System;
f) Monthly Health Condition Report;
g) Report on indoor and outdoor patients treated and deaths among inpatients;
h) Collection / compilation of information on snake bites and thresher accidents;
i) Half yearly report on doctors working in rural and urban areas;
j) Furnishing information for the Statistical Abstract of Karnataka, Karnataka at a Glance, and
similar publications to the Directorate of Economics and Statistics.
The Demography and Evaluation Cell is located in the State Family Welfare Bureau. It is
responsible for monitoring and evaluating the family welfare and RCH programmes and for
rendering operational the Community Needs Assessment Approach of the RCH programme. It
has ten field evaluation workers, all based at Bangalore, for carrying out field verification and
surveys relating to prevalence of family welfare methods. However, they are evidently used for
other work too.
In addition to the BHI and D & E Cell, statistical personnel are located in the Transport Section,
Planning Section, Health Education Division and with the Programme Officers in charge of
leprosy, malaria and filaria, TB, control of blindness, AIDS, goitre and communicable diseases.
The BHI is under the JD (Health and Planning) while the D & E Cell is under the Additional
Director, RCH who also controls the unit in the Transport Section. The independent units come
under the respective officers concerned. These statistical units are independent of each other and
there is little coordination between the three wings.
Table 14.1 The statistical posts and their distribution in the Health Department is as
follows:
Name of Wing/ Programme Staff Sanctioned
Joint
Director
Deputy
Director
Assistant
Director
Assistant
Statistical
Officer
Statistical
Investigator
Field
Evaluation
Workers
Demography & Evaluation
Cell (Family Welfare), under
Additional Director RCH
1
2
-
2
-
10
Bureau of Health Intelligence,
under Joint Director Planning
-
-
1
2
-
-
Transport Section, under
Additional Director, RCH
-
-
1
1
-
-
Malaria and Filaria
-
-
-
1
-
-
-
-
-
1
-
-
Leprosy
-
-
-
1
-
-
CMD
-
-
1
-
-
-
TB
-
-
-
-
1
-
AIDS
-
-
-
1
1
-
TB
-
-
-
-
1
-
Goitre
-
-
-
1
-
-
Control of Blindness
-
-
-
1
-
-
Planning Section
-
-
-
2
-
-
Total posts in office of DHS
1
2
3
13
3
10
Health
Training
Education
and
All statistical posts are filled by deputation from the Directorate of Economics and Statistics,
except for the ten field workers who are employees of the Health Department.
There are no statistical posts at the Division level. At District level there are four posts of
Assistant Statistical Officers, with one officer separately for (a) family planning, (b)
immunization, (c) TB control and (d) leprosy. The ASO for family planning and ASO for
immunization come under the DHO while the other two are under their respective Programme
Officers. These sets of four ASOs are currently only in the old twenty districts. The posts have
not been created in the seven new districts.
There is no statistical staff in hospitals, except in teaching hospitals where there would be a
Lecturer in Statistics.
It would be relevant to note that certain statistical / reporting activities relating to RCH and the
PHCs are carried out by independent agencies with minimal coordination with the DHS. The
Programme Research Centre located in the Institute for Social and Economic Change computes
RCH indicators on the basis of surveys of 1000 households. Reports are not regularly received
by the DHS and there would appear to be little feedback into the health management system of
the conclusions of such surveys. The Centre for Operations Research and Training (CORT)
carries out a facility survey for assessing availability of drugs and equipment in the PHCs. These
reports are also sporadically received by the DHS. It would be desirable to ensure greater
involvement of the DHS in these activities so that the results of the surveys augment
management information for improvement of the services.
Need to establish a Geographical Information System
The establishment of a GIS is recommended. The system would be most useful for assessing the
adequacy of health services and planning future needs. It would be a most useful management
and planning tool. Incidentally, the computer system that would have to be established for this
purpose could, at appropriate levels, also be used for the Health Management Information
System.
Structural Changes
It would be evident that if the planning process in the health sector has to be unified, as indeed it
should, it would be necessary to recognize the need for basic structural changes. Such changes
would include (a) unifying the statistical functions at all levels and of the various units, (b) the
inclusion of the reports of distinct projects such as the IPP and KHSDP within the unified
reporting system, and (c) coordination within the Department with the Chief Accounts Officer /
Financial Advisers of the Department itself and of the special projects.
The distribution of the posts in the various statistical / reporting units, as would be seen from the
table above, is very uneven. The D & E Cell is headed by an officer, designated as
Demographer, of the rank of Joint Director of the Bureau of Economics and Statistics while the
BHI is headed by an Assistant Director of Statistics. There is no uniformity in the work load and
the levels of posts seem to have been determined more by what was acceptable to the
sanctioning authorities than any rational considerations of work load, position in the hierarchy,
etc.
The efficiency of the HMIS and GIS, the ensuring of quality of data, the management of the
computerized system of maintenance and analysis of data and production of monitoring reports
for better management would depend on the structure of the reporting and statistical system. If
the system has to perform at peak efficiency and be able to serve its purpose, it would be
necessary to consider certain structural changes.
In principle, it would be desirable to have a unified statistical and reporting system so that the
planning and monitoring requirements are adequately met. The Planning unit in the office of the
DHS may be designated as the Planning and Monitoring Division, as suggested earlier, and
assigned a central role of information management and appraisal, with the functions indicated.
Structural changes at Headquarters
The Planning and Monitoring Division should be constituted with the following sections:
•
The Reporting and Monitoring Section for production of reports based on the analytical
statements generated by the Computer Section, and for preparation of all monitoring
reports required by Government or needed for internal management;
•
The Computer Section for information processing
•
The GIS Section for assisting in monitoring and planning
•
A Perspective Planning Section which would formulate the Five Year Plans and the
annual plans, monitor plan implementation, prepare and continuously update the
perspective plan of the Department and monitor implementation of the Health and
Population Policy of the State.
This Division should be responsible for the following:
•
Strategic Planning of activities of the entire health system, including long term planning;
•
Coordination with the Zilla Panchayats to ensure that the health plans of the districts are
formulated, including taluka and Gram Panchayat plans, and integrate them into the State
Health Plan;
•
Assess budget resources for current and future needs, taking into consideration
population, level of services, norms for services and other relevant parameters;
•
Assess human resources and all material resources on a continuing basis.
All statistical and reporting functions in the headquarters should be unified. The various wings
and units referred to earlier would form part of the Planning and Monitoring Division. These
would include the BHI and the D & E Cell. There is a senior officer of the rank of Joint Director
on deputation from the Directorate of Economics and Statistics, who heads the D & E Cell. This
officer could be the Joint Director in charge of HIMS, the GIS and all statistical reporting within
the Directorate. This Joint Director could be designated as Joint Director, Health Information
System. This officer would be the Chief Statistical Officer and Head of the HIMS / Monitoring
Section.
The Perspective Planning Section would be under a separate Joint Director. The post could be
designated as Joint Director, Planning;
A GIS system should be established in the Planning and Monitoring Division, as part of the
HMIS, with the necessary computer capacity and operators. A system of requisite capacity
should be installed, with the appropriate software, which would permit display and analysis of
multiple parameters.
A well-equipped computer section would have to be established in the Planning and Monitoring
Division to store all relevant information, produce reports in standard formats, carry out
analytical studies and generally serve the purposes of the HMIS. A Systems Engineering /
Manager would be necessary, who could be appointed on contract or through deputation, since
this would be a single post. This officer would also be responsible for the technical supervision
and maintenance of the GIS system;
The information and analysis activities, those relating to GIS and the maintenance of the website
of the Department should be unified. The present unit in the office of the Project Administrator,
KHSDP, could be expanded and assigned these functions.
A website would have to be developed and maintained which would provide information on all
aspects of the health services, including names of officers and locations of facilities, budget
details and progress reports. This would provide transparency of the management of the system
and also permit interventions by the public for whom the system is meant. The present website
developed in the KHSDP could be the basis for this expanded and common departmental
website.
Structural changes at District level
Strong statistical units would have to be established in the offices of the DHO / DMO and all
reporting and statistical functions in the district should be placed under them so far as their
jurisdictions are concerned. A computer cell in their offices would also have to be set up. These
cells would generate reports in standardized formats, which would be sent to Headquarters for
consolidation and analysis. However, analysis at the district level would also be carried out so
that monitoring by the DHO / DMO is possible at the district level. The Programme Officers of
the district would get the reports in the formats they need from this cell
Two Assistant Statistical Officers, with two clerical assistants and one Computer Operator
would have to be appointed for each district. The reporting format would be a unified document
and at defined periodicity. This would imply that processing the report for consistency and
quality of data would be that much easier and not require too much clerical attention.
Posts of two Assistant Statistical Officers should be provided in each of the seven new districts.
There are at present 80 posts of Assistant Statistical Officers (on the basis of 4 per district in the
old 20 districts). On the basis suggested above, there would be a surplus of 40 Assistant
Statistical Officers of whom 14 would have to be allocated to the seven new districts. The
resultant surplus of 26 posts could be used to finance partially the posts of computer operators
and clerical assistants in the districts. It would be useful to carry out a review after two years of
the workload of these officers to assess whether two officers are required in the smaller districts
or whether more than two are necessary in the larger ones.
The computer unit in the office of the DHO would also provide the facility of the GIS for local
monitoring and planning;
The central role of the Planning and Monitoring Division
The role of the Planning and Monitoring Division, as envisaged herein, is much wider than what
it is at present and its responsibilities are much heavier. It is the Division that plans for and
monitors the performance of the Department. In view of this expanded role, the Planning and
Monitoring Division may be headed by an Additional Director.
The Additional Director, Planning would, as indicated elsewhere, be responsible for functions
relating to liaison with voluntary and community organizations, and human resources
development including training. In effect the Additional Director, Planning and Monitoring
would oversee four Joint Directors, namely (i) Joint Director, Health Information System (ii)
Joint Director, Planning (iii) Joint Director, Voluntary Organizations and (iv) Joint Director,
Human Resources Development. In addition, the Additional Director would oversee the Systems
Engineer / Manager.
It has been suggested that a Commission on Health should be established. This body would
require information and assistance. It is recommended that the Planning and Monitoring
Division be the secretariat of the Commission.
Recommendations
•
The Planning and Monitoring Division should be organized on the lines suggested above
and vested with the authority to call for information from all other Divisions;
•
In particular, this Division should be responsible for • Strategic planning of activities of the entire health system, including long term planning,
• Coordination with the Zilla Panchayats to ensure that the health plans of the districts
are formulated, including taluka and Gram Panchayat plans, and integrating them into
the State Health Plan,
• Assessing budget resources for current and future needs, taking into consideration
population, level of services, norms for services and other relevant parameters, and
assessing human resources and all material resources on a continuing basis.
•
The Division would have to include a Reporting and Monitoring Section, a Geographical
Information System, a Computer Division and a Perspective Planning Section. The structure
and responsibilities of these units have been indicated above;
•
All reporting activities with regard to the HMIS should be vested in this Division. The
analysis of information and generation of monitoring reports for various levels would be the
responsibility of this Division, to enable assessing performance and initiating corrective
action;
•
A website would have to be developed and maintained with all information relating to health
services, including financial and performance details;
•
The statistical (HMIS) offices in the districts may be established on the lines indicated, with
adequate computer facilities. District level monitoring reports must be produced for
enhancing management capacity at the district level;
•
This Division would function as the secretariat for the Commission on Health that has been
recommended to be established.
14.3 HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)
"The information you have is not what you want;
The information you want is not what you need;
The information you need is not what you can get;
The information you can get costs more than what you want to pay"
- Finagle's Law
An information system is a set of people, material and procedures, whose primary aim is to collect,
transform and disseminate information in an organization.
An information system which supports the managerial function is called Management Information
System or MIS. In the present era of information technology it is an integrated Man-Machine
monitoring tool for the performance that provides information to support planning, decision making
and executive control for managers of an organization.
Health Management Information System (HMIS) will need an integrated MIS as well as a
Disease Surveillance System to ensure an efficient & effective functioning of the Health services
A Disease surveillance system is required to continually scrutinize, monitor, evaluate and plan for
control & / or eradication of diseases, especially diseases of Public Health importance. A very
important part of this is prevention and early management of disease outbreaks. The earliest signal
of an outbreak is a second case of a disease with an epidemiological link to the first. Disease
surveillance by prompt case reporting (not by summary reports), when monitored by an HMIS
linked with a Geographical Information System (GIS), will detect clustering in time and space
and therefore early recognition of outbreaks.
A good HMIS can be characterized by 5 C's- that the management information be correlated,
consistent, correct, complete and concise. Therefore minimum, essential, needs- based data, which
is as basic as practical is collected and registered at the point of collection. Aggregation of the data
and relevant information generated permits monitoring and planning at the micro level as well as
strategic planning at higher levels.
Present HMIS
HMIS in the state originated in 1975 from the family planning program with a reporting system
called "Family Planning Health Information System (FPHIS). The Population Centre, Bangalore
developed a Management Information & Evaluation System (MIES) between 1975-1980. Finally
the Health Management Information System (HMIS) (version 2), was introduced in all the states in
1994-95 which specified:
• The minimum records and registers that would have to be maintained at the sub-centre level.
• The minimum information content of the single report emanating from sub-centre and PHC to
District and State
• Training modules for paramedical personnel and their trainers
HMIS version 2.0 however, soon fell into disuse due to lack of consensus among the staff in the
department about its use, non-availability of printed forms for collection of data and so on.
1
At present information collected on conventional, manual reporting formats by the female & male
health workers from the Sub Centre levels is collated at the PHC level, and sent as monthly reports
to district, state and National levels.
However,
• The data collection is not standardized as different vertical health programs e.g. RCH, TB,
malaria, leprosy etc each have separate and differing reporting formats and monitoring systems.
• Printed forms even for the existing system are not available and therefore the reporting is
irregular and inaccurate. Validity of the data is therefore difficult to establish, and tracing of
data requires detailed inquiry.
• Often many common factors, demographic data for example, are entered many times in each of
the different forms. This lack of integration and uniformity results in duplication and waste of
internal resources.
• Aggregation of data is done only at the Directorate level, and very little analysis is carried out.
Therefore the existing HMIS is not used for meaningful monitoring, planning and action at the
micro level or for strategic planning and management of the Health system.
• The Department of Health & Family Welfare, Karnataka has 1676 Primary Health centres with
about 6 Sub Centres each, about 250 Secondary care hospitals at taluka and district levels, and
several Teaching and Tertiary care Hospitals. There are about sixty thousand staff working for
the department. The information on Human Resources including details of available personnel,
vacancies, training etc. is not up to date. The details of other infrastructure including buildings,
equipment, drugs etc remain scanty. A laudable effort has been made by Karnataka Health
Systems Development Project to develop an HMIS for secondary care hospitals. But this is not
integrated with (personnel) data available with the Directorate.
• Epidemic reporting and analysis does not utilize the latest technology such as GIS and is not
available for prevention and control of outbreaks. In fact, frequently, the department gets to
know about disease outbreaks only after the first reports appear in the press.
• Reasonable input and output indicators are being generated even now. But good process &
outcome indicators are not identified. This should include equity sensitive indicators for gender,
regional disparities, SC/ST and other marginalized and vulnerable groups; indicators of quality
of service; certain developmental indicators that impact on health; follow up & outcome of
training programmes; cost-effectiveness and so on. It is recommended that skilled investigators
from the Planning and Monitoring Division of the Directorate evolve process and outcome
indicators so as to continually look at ways to improve the programmes. They would therefore
also have to specify data to be generated; the action required as well as the
managerial/administrative levels at which the action should be taken and so on.
• Based on the above, it would also be possible to identify specific and needs-based areas for
research.
• Census data and data from other relevant quantitative & qualitative research of government or
private origin should also be used as a source of information and to identify indicators.
Following the recommendations in the interim report of the Karnataka Task Force on Health,
certain actions have been initiated.
A committee constituted in the year 2000 is working on integration of formats and databases to
develop a comprehensive system that will be computerized and integrated with a geographical
information system (GIS). Efforts will be made to increase the efficiency and validity of reporting
2
mechanisms and to evolve methods to use information generated for decision making at PHCs,
CHCs, taluks and district level.
An MOU has also been signed with a soft ware company to assist in the development of limited
modules relating to personnel, infrastructure, disease surveillance, etc. CNA reporting will largely
follow the HMIS version 2 module but will be integrated into the whole system.
Computerization will be at District and State level initially. Connectivity to the State HQs and
national level will be worked out.
The proper installation and development of such a system, including training of personnel, testing
of the soft ware, will take a long time and it is expected that several initiatives will continue to be
required throughout the project period to make the HMIS function well.
In addition, to the regular disease surveillance system data, a model using the postcard system
which has been piloted in some centres in Tamil Nadu and now being implemented in Kerala, will
be pilot tested in two districts (Dharwad & Chickmagalur). This may be useful in generating data
from private hospitals and nursing homes, which is not available now.
Recommendations
A comprehensive Health Management Information System (HMIS) should be put in place by end of
the year 200I to enable the Health and Family Welfare Department to improve its service delivery.
This should include the following elements:
•
To adequately fulfill manpower requirements and avoid mis-matches especially in the posting of
Medical officers, details regarding all personnel, at all levels, (viz. Number of sanctioned posts
& number filled; recruitment, transfers, leave etc) should be computerised and monitored.
•
Details regarding infrastructural facilities – buildings, equipment; etc. should be monitored
continually to ensure adequate availability, timely repairs, civil works and so on.
•
The HMIS should be an effective monitoring tool to assess the performance of the system and
which provides for informed planning and decision by the DHS. At the same time it should also
support micro-planning and management at all levels where action is essential. The
performance indicators and protocols required for objective monitoring of all health activities
up to the subcentre level should be worked out.
•
To increase the efficiency and validity of reporting mechanisms, minimum data that has to be
collected should be identified; integrated reporting formats should be developed and adequate
supply of registers/forms especially at the SC level should be ensured.
•
A comprehensive Disease surveillance system should be evolved. This should continually
scrutinize, monitor, evaluate and plan for control & / or eradication of diseases, especially
diseases of Public Health importance and should be useful at grass roots levels for prevention
and management of disease outbreaks.(Please see subchapter on disease surveillance)
•
The HMIS, Disease surveillance system and a geographical information system (GIS) should be
integrated into one computerized system
3
•
Computerization which is envisaged at the District and State level initially, should be extended
to the Taluka and PHC levels at the earliest.
•
The staff at decision- making levels should be trained to use the HMIS & GIS effectively for
micro-level action and planning.
•
Training in basic computer literacy and data entry and analysis of all categories of staff
involved should be effected.
•
Connectivity and communication systems between the different health institutions, offices and
levels should be established.
•
The present system concentrates on information on communicable diseases. It should also get
geared up for management of non-communicable diseases, especially with the changing
patterns of diseases due to urbanization, industrialization, pollution and changing life styles.
•
The web page of the department should be constantly up-dated. It should be maximally utilized
not only for awareness and information but also as a means for promotion of transparency.
•
An expert panel should monitor and upgrade the system to keep up with the constant and rapid
evolution in IT.
•
In the long run mechanisms to utilize the computer networking for “Distance-Learning”
programmes, “Tele Medicine” etc. for the health personnel, and for Health Education and
Health Promotion activities for the community could be identified and implemented.
4
15. HEALTH FINANCING
15.1 ALLOCATIONS AND EXPENDITURE
In assessing the financing of the health sector, the issues that would need consideration would
include the following –
•
•
•
Adequacy of funding in relation to the present and future needs and to the functions and
responsibilities of the Department;
The adequacy of financial delegations;
Operational issues relating to reduction of accounting workload at field levels and
simplification of procedures,
It must be stated at the outset that the focus here is on the financing of health services by the
State. Municipal Corporations and other municipalities also finance health services. These have
not been included here. However, it is necessary to conduct a comprehensive study of such
services and their financing.
Though the public health services in India play a vital role, their contribution to total health
services in the country is low. The proportions of public and private expenditure to total
expenditure on health and related parameters, are presented in the following table 1 1:
Table 15.1: Public and private expenditure on health in some selected countries
Country
India
Bangladesh
Pakistan
Sri Lanka
Malaysia
Indonesia
Singapore
Philippines
China
Cuba
Japan
France
Canada
United
Kingdom
USA
1
Public
Expenditure as
% of total
expenditure on
health
Private expenditure
as % of total
expenditure on
health
Public
expenditure on
health as % of
total public
expenditure
Per Capita Public
expenditure on
health in
international
dollars
13
46
22.9
45.4
57.6
36.8
35.8
48.5
24.9
87.5
80.2
76.9
72
96.9
87
54
77.1
54.7
42.4
63.2
64.2
51.5
75.1
12.5
19.9
23.1
28
3.1
3.9
9
2.9
5.2
5.1
3
5.5
7.2
5.5
10
16.2
13.8
15.3
14.3
11
32
16
35
116
21
26.8
48
18
96
1410
1634
1322
1156
44.1
55.9
18.5
1643
From Table 8, World Health Report 2000 – Health Systems – Improving Performance, WHO
-1-
Public expenditure as a percentage of total expenditure on health is very low in India, compared
with some of the neighbouring countries and generally in Asia. Bangladesh and Sri Lanka have
a higher proportion on health out of total public expenditure. The comparatively higher outlay in
the public sector, combined with the efficiency of the health services, is reflected in the per
capita expenditure in international dollars in the countries. The figures do not reflect the sections
of society that are deprived of better health services. In India, clearly, the low scales of outlays
result in the rural areas and the economically weaker sections being so deprived. There is a case
for higher public expenditure on health services in the country.
Outlays on health in Karnataka
The revenue expenditure under medical and public health which was Rs. 379.87 crores in the VI
Plan (1980 –85) increased to Rs. 739.98 crores in the VII Plan (1985 –90). The capital outlays
during these plans were Rs. 13.85 crores and 13.64 crores respectively. The investment in
capital assets has not apparently kept pace with revenue expenditure.
The expenditure on health and family welfare has been about 6.1 % of the State’s revenue
expenditure, except in 1996-97 when it fell to 5.1 % 2. As a proportion of the State Domestic
Product, it was 1.2 % in 1990-91 but is 1 % in 1997-98.
The expenditure on health and family welfare under plan and non plan at current and constant
prices, with1993-94 as the base year, as shown below indicates that there has been an erosion
of outlay 3:
Table 15.2: Plan and non-plan expenditure on health in Karnataka
Year
at Current
Prices
PLAN
at Constant Prices
PLAN
Base year 1993-94
at Current Prices
NON PLAN
at Constant Prices
NON PLAN
Base year 1993-94
1993 – 94
1994 – 95
1995 – 96
1996 – 97
1997 – 98
1998 – 99
122.02
163.84
206.35
218.89
263.81
232.32
122.02
153.15
179.75
177.34
203.53
167.79
269.22
293.91
290.11
306.20
360.55
476.08
269.22
274.73
252.71
248.08
278.16
343.84
The figures at constant prices indicate that there has been no steady pattern over the years of
increasing investment, both revenue and capital together, in health services.
The per capita expenditure on health and family welfare services at current prices and at
constant prices are given in Table 15.3. 4:
Table 9, “The Health Budget in Karnataka” by Indira and Vyasulu
Tables 3 and 4, Indira and Vyasulu
4
Computed from Tables 4 and 9, Indira and Vyasalu
2
3
-2-
Table 15.3: Per capita expenditure on health and family welfare
Year
1993 – 94
1994 – 95
1995 – 96
1996 – 97
1997 – 98
1998 – 99
1999 – 2000
Per Capita expenditure Per Capita Expenditure
at Current Prices
at Constant Prices
127.9
132.3
134.5
126.6
143.1
174.1
185.1
127.9
123.7
117.2
102.6
110.4
125.74
The per capita expenditure on health has not tended to increase in real terms over the years. The
comparatively larger figures in some of the years are attributable to injection of funds through
externally aided projects. At best what could be said is that the outlay on health and family
welfare has kept pace with population but that there has not been any additionality that would
have contributed to an enhancement of services in quantum terms.
The per capita expenditure on health, which includes public health, medical and family welfare,
in Karnataka and the neighbouring States 5 in 1999-00 was Rs.185.10 in Karnataka, Rs. 128.11
in Andhra Pradesh, Rs. 186.65 in Kerala and Rs. 166.20 in Tamil Nadu.
The per capita expenditure in the State compares favourably with those in the neighbouring
States. However, in the absence of a norm of optimum expenditure, which again would have to
be based on defined scale of services, it would be difficult to assess the adequacy or otherwise of
outlays. The more important point in such comparisons would be the efficiency of use of the
financial outlays rather than the quanta. It must also be noted that inter-state comparisons can at
best be used as pointers since the components within the health budgets may vary.
The expenditure on the primary sector has had a growth rate of 6.4 per cent, which is only
marginally higher than that of the Secondary Sector of 6.3 per cent and of the Tertiary Sector of
6.0 per cent 6. The investments in primary, secondary and tertiary care and between rural and
urban areas should be based on the norms that would have to be developed regarding scale of
services in these sectors and areas. Resource flows would have to so managed as to increase
health facilities in the rural areas.
Both the total and per capita allocations to the districts do not follow a pattern that would be
consistent with parameters such as population size, area and general development of health
services in the districts.
The per capita outlay also indicates the lack of adoption of parameters for allocations to the
districts, as the following Table 15.4.indicates 7 for two years 1991 and 1995:
Data for the neighbouring States has been compiled from the “Public Finance: Economic Intelligence Service,
CMIE, May 1998 and Feb 1999”. Mid year (as on 1 st October) estimates of population in million has been used
from the Socio-economic Statistics, India 1998 for the calculation of per capita income. The data for Karnataka is
from Table 2.2, Page 22 of the Draft Project Proposal “Karnataka Integrated Health, Nutrition and Family Welfare
Services Development Project, Government of Karnataka.
6
Expenditure Pattern of the Health Sector in Karnataka, Subramanya and P.H. Reddy, Southern Economist, 1997
7
Pages 23 to 29, and Table 22 Indira and Vyasulu.
5
-3-
Table 15.4: Per capita outlays in the districts
Districts
Per Capita 1991
Bangalore (Urban)
Bangalore (Rural)
Chitradurga
Kolar
Shimoga
Tumkur
Mysore
Chikamagalur
Dakshina Kannada
Hassan
Kodagu
Mandya
Belgaum
Bijapur
Dharwad
Uttara Kannada
Gulbarga
Bellary
Bidar
Raichur
0.94
8.62
7.57
6.15
5.22
7.24
6.05
10.68
5.61
9.06
10.27
7.88
7.47
8.58
5.50
11.12
7.50
8.35
8.45
3.55
Per Capita 1995
1.67
12.82
9.97
7.62
7.87
6.65
6.67
13.08
6.60
12.79
19.14
9.71
6.62
9.09
6.97
11.35
10.49
9.10
10.85
5.35
The allocations generally would be based on the staff component in each district, need to
upgrade services in them and similar administrative considerations. However, this is an aspect
that would further study and analysis so as to determine some logical and reasonable norm for
budget allocations that also provides some degree of flexibility. The allocations would also have
to take into account the District Health Plans.
The Tables attached (Annexures A and B) presents the budget figures for the two major revenue
heads 2210 – Medical and Public Health and 2211 – Family Welfare. For budgetary purposes,
the revenue Head Medical and Public Health includes Allopathy services (rural and urban),
Other Systems of Medicine (rural and urban), Medical Education, Training and Research, Public
Health and a residuary category General which includes the budget allocations to the local
bodies. It also presents the figures on capital outlays.
The revenue head 2210 and the corresponding capital head 4210 include the allocations relating
to the Directorate of Health Services, Department of Medical Education, Directorate of Indian
Systems of Medicine and Homoeopathy, the Office of the Drugs Controller, the Karnataka
Health Systems Project, and the autonomous institutions.
The revenue head 2211 and the corresponding capital head 4211 include the allocations to
Family Welfare (RCH), IPP VIII and IPP IX.
In the case of Medical and Public Health, the allocations under Non Plan have increased over the
years. This is largely due to the salary element. However, it must be recognized that the human
resources would necessarily constitute the single largest component in the health services. The
growth in the staffing cannot by itself be considered a negative element. The more important
issue would be the efficiency of this human resource.
-4-
The budget allocations have rarely been fully utilized. In some cases, there have been variations,
both in savings and excess expenditure over the allocations that suggest lack of continuous
review and mid-course corrections. For example, for the year1998-99, the budgeted and actual
expenditure under 2210 – Medical and Public Health are as in Table 15.5.
Table 15.5: Expenditure on 'Medical and Public Health', 1998-99
Head of Account
Budgeted
Actuals
lakhs
lakhs
Savings (-)/
excess (+)
lakhs
01 – Urban Health Services Allopathy
Plan
7397
Non Plan
20921
02 – Urban Health Services – Other
Systems of Medicine
5905
18878
- 1492
- 2043
Plan
Non Plan
24
313
14
318
- 10
+5
219
287
144
387
- 75
+ 100
9
115
- 16
-8
03 – Rural
Allopathy
Plan
Non Plan
Health
Services
–
04 – Rural Health Services – Other
Systems of Medicine
Plan
25
Non Plan
123
05 – Medical Education, Training and
Research
Plan
Non Plan
06 – Public Health
2026
6594
Plan
Non Plan
3876
2815
3832
4422
1736
2292
+ 1806
- 2172
- 2140
- 523
80 – General
Plan
3059
3107
+ 48
Non Plan
20626
20425
- 201
Except under Medical Education, Training and Research – Plan and small amounts under certain
other heads, the trend has been towards savings. The savings under 06 -Public Health is
particularly unfortunate since this includes outlays on prevention and control of diseases, drug
control, manufacture of sera and vaccines, public health laboratories and health education and
publicity. The head 01 – Urban Health Services – Allopathy, where also there are massive
savings includes medical stores, hospitals and dispensaries, among others.
From the table attached it would be seen that under 2211 – Family Planning on revenue account,
there have been savings. In the year 1998-99 the savings have been particularly high.
-5-
The budget support over the next few years could be computed on an approximate basis,
including both outlays on revenue and capital together, assuming the maximum norm of 213 per
capita, as in Table 15.6.
Table 15.6: Budget support needed for 2000-2005
Year
Population
in Total minimum Outlay in
millions
Crores
2000
2001
2002
2003
2004
2005
52.09
52.72
53.33
53.99
54.69
55.42
1109.51
1122.93
1135.92
1149.98
1164.89
1180.44
These are at current values and would have to be adjusted for inflation over the years. Given the
current trend in increase in annual allocations, it is likely that these outlays would be provided in
the budgets of these years. However, these outlays would be just sufficient to maintain the
current level of services, with no enhancement in the scale or quality. In other words, this scale
of financing would only maintain the status quo.
It would, therefore, seem that there is no apparent inadequacy of funds only if the current level
and efficiency of the services is considered as adequate. There would, however, be a need for an
internal review of specific allocations. For example, the adequacy of funds for repairs of
vehicles and equipment, especially in the laboratories, repairs to buildings, outlays for touring
costs for ensuring adequate supervision, funds for administrative expenses of the PHCs, would
bear a critical review. This would have to be undertaken by the Planning and Monitoring
Division on an urgent basis.
The question of sustainability of the desired enhanced level of funding needs attention. In times
of financial constraints, it has been the practice to impose budgetary cuts on the social sectors,
with education and health being the worst hit. This is most unfortunate because the
establishment of the health services and their being built up to reasonable levels of efficiency
takes effort and time. Unlike sectors in which the creation of fixed assets is predominant, in the
health sector the placement of doctors, their training and local acceptance are processes over
time. Abrupt cuts in allocations destroy continuity and waste expertise and experience, with long
term effects on the services. It is, therefore, recommended that budgetary cuts should not be
made in the health sector.
In this context, it would be relevant to keep in mind the need to provide funds for maintenance
of the assets. A separate Division for this purpose has been recommended while considering the
management structure. In particular, it would be essential to review the condition of the vehicles
in the Department so as to render all of them usable for enhancing supervision. There are 1492
vehicles in the H & FW Department alone, of which 1150 are under he control of the Zilla
Panchayats 8. Of the 1492, about 105 are assessed for condemnation and about 100 are under
repairs. The rest are being used but many are in bad condition. There are many vehicles lying
around as junk. It is necessary that a review is carried out of the condition of the vehicles to
identify those that need condemnation and those that need repairs. Action to dispose off
unserviceable vehicles is necessary so that realistic need for funds for repairs and maintenance
could be estimated. This would be necessary with regard to all assets.
Page 60, Booklet of answers to the Legislative Assembly Estimates Committee Questionnaire, 2000 – 2001,
Directorate of Health and Family Welfare.
8
-6-
It is also necessary to provide sufficient funds for the maintenance of assets and continuation of
the activities created under externally aided projects. The latter constitute an injection of large
funds over a short period which are not allocations made from the normal revenues of the State.
However, at the end of the project period, it would be essential to provide by way of
enhancement of the budget funds for sustaining the gains of these projects. The additional funds
for this purpose would have to be found and the budget allocations enhanced to the extent
necessary. In this context, a review of the condition of the vehicles must be made to condemn,
repair and replace them as may be necessary to enhance supervision capability;
Equally important is the need for both adequate and timely releases of allocations. Such releases,
in combination with sufficient financial delegations, would go a long way towards maintaining
and improving the health services.
-7-
15.2 EXTERNAL ASSISTANCE FOR HEALTH
Considerable external assistance is availed of by the State for projects. In 2000-01 there were 22
externally agencies, including the World Bank. The expenditure incurred on these projects since
inception and up to 31 March 2000 was Rs. 1501.43 crores 9. Of the 22 projects 3 relate to
health. The details are as in Table 15.7.
Table 15.7: Project costs and expenditure
Sector
Project Cost
in crores
Year of
Expenditure as
Commencement on 31 March
2000, in crores
Various years, 28.90
five projects
Various years, 343.50
two projects
Various years, 12.80
one Project
Various years, 467.72
three projects
Various years, 4.58
two projects
Various years, 322.12
five projects
2000 – 01
nil
1179.62
Outlay in
2000 –01, in
crores
7.05
1996-97
289.62
112.24
29.25
1991-92
28.62
7.07
Development
of 45.00
Secondary
Level
Hospitals
Sub Total for Health 620.06
1996-97
3.57
1.79
321.81
121.10
Agriculture
and 260.73
Allied Activities
Forest
703.77
Irrigation
27.10
Rural Development
586.71
Commerce
and 20.03
Industries
Urban Development 2854.87
Public Works
300
Sub Total
4753.24
Health and Family
Welfare
KHSDP
545.81
OPEC –
Development
of
Raichur Hospital
98.48
8.00
119
6.14
367.50
42.68
648.85
Grand Total
5373.33
1501.43
769.95
The assistance received for the India Population Projects and RCH must be added to the total
indicated for health above. The funding for IPP – IX is Rs. 114.75 crores and that for IPP – VIII
is Rs. 39.21crores. The outlay on RCH is 190 crores. If these are also included, the total external
aid for health projects would be of the order of Rs. 964.02 crores. Nearly 18 per cent of the total
external assistance is for the health sector.
Even discounting for the grant element, if any, the long-term loan burden is noticeable.
However, there is the advantage of immediate funding for projects, with repayment being over a
long period and on soft terms. Quite apart from the financial implications, there is the equally
Economic Survey 2000 – 2001, Planning, Statistics and Science and Technology Department, Government of
Karnataka, March 2001, Page 169
9
-8-
important issue of maintenance of the assets created through such aided projects and the
integration of the improved systems developed in their implementation into the main stream of
health administration. These issues have been discussed elsewhere.
15.3 MANAGEMENT STRUCTURE
At present there is one separate Chief Accounts Officer cum Financial Adviser in each of the
offices of the Director of Health Services, Director of Medical Education, Project Director IPP
VIII, Project Director IPP IX and Project Director KHSDP. In the offices of the Additional
Director, Family Welfare and RCH, Drugs Controller and Director, Indian Systems of Medicine
and Homeopathy there is an Accounts Officer. Supporting staff is available in all these units.
Currently, they work independently. The coordination of the budgets and other financial matters
occurs at the level of the Internal Financial Adviser in the office of the Principal Secretary. The
latter would be concerned more with the mechanisms of formulating the budget proposals,
sanctions and control over expenditure and the like. The needs of the health services and the
priorities would not be a concern. In order to ensure that the needs of the Department are
provided for and that priorities both among programmes and among regions are maintained, it
would be necessary that there is focal point for budgeting. This would, logically have to be the
Commissioner (or Director General of Health in the reorganization that is suggested). The
Commissioner would have to be vested with the authority to call for information from associated
Departments / Directorates.
The reorganization of the health services into two distinct wings for public health and medical
has been recommended. It would, therefore, be necessary to reorganize the financial control
mechanisms. Accounts offices, with supporting staff are recommended as follows:
1. Chief Accounts Officers cum Financial Advisers in the Offices of the Director of Medical
Services, Director of Public Health, Director of Medical Education;
2. One Chief Accounts Officer cum Financial Adviser in the Office of the Director, Externally
Aided Projects;
3. Accounts Officer in the other Directorates.
It would also be necessary to continue the accounts sections for the IPP Project Officers and for
the other Externally Aided Projects, since accounts for these activities have to be maintained
separately.
It would be essential to ensure coordination among these units, particularly from the point of
view of preparation and execution of perspective plans. The Additional Director, Planning and
Monitoring Division, who reports directly to the Commissioner, would have to be responsible
for such coordination. It would be necessary to endow this officer with the necessary authority
to call for information, make suggestions and generally coordinate the plans of the various
Directorates / Divisions. It would be necessary to provide an officer with budgeting and
financial experience in the Planning and Monitoring Division to assist the Additional Director.
A senior position of Financial Adviser may be established in this Division. This could be filled
by a health economist or by selection, based on experience, from the State Accounts and
Planning cadres of Government.
Delegation of financial powers
The financial delegations within all the Directorates would bear review. Many of the delegations
would have to be enhanced in real terms to adjust for inflation. Further delegations would also
be desirable. The adequacy of delegations and the amendment of the existing orders may be
-9-
reviewed by the Commissioner who has been designated as the coordinator for all Directorates
in the structure proposed.
While further delegations would be desirable, it would, at the same time, be necessary to
reiterate that unless officers are prepared to assume the responsibility that such delegated powers
impose, the whole purpose of delegations would be frustrated. Currently, the stipulations of
checks and balances within the system are taken advantage of to avoid assuming such
responsibility. It would be desirable to include the manner of exercise of such authority with
responsibility in the annual review of performance.
Management of Budget allocations
The management of the budget would seem to bear review. For example, in the Inspection
Report of November 1999 on the accounts of the Family Welfare Programme, it is pointed out
that nearly Rs. 380 lakhs was unutilized from the Plan funds of 1997-98 and that these continued
to be unutilized even in the next year though the Government of India had permitted such use.
The same report mentions sanctions accorded on the last day of the financial year for equipment,
resulting in drawing and crediting of the amount to a Personal Deposit Account, which is an
irregularity and, more importantly, non-procurement of the equipment in time. Internal
procedures for monitoring expenditure, particularly that relating to purchase of equipment,
would need to be reviewed to ensure expeditious utilization of allocations in the best manner
possible. An important issue that would need to be monitored is the timeliness and adequacy of
releases within the sanctioned budget. Experience indicates that delays in releases and sanctions
have very often resulted in nonperformance. In other words, an integrated system of financial
review needs to be developed. This could be one important component of the HMIS that has
been recommended.
The reports relating to accounts and financial matters now prescribed at the field level would
need to be reviewed. Currently, numerous forms have been prescribed, mainly based on the
minor heads of accounts. While this facilitates aggregation of accounts at higher levels, it casts a
repetitive workload on the ANMs. A comprehensive review of he reporting system has been
recommended. As part of this review, it is recommended that the component of reporting on
accounts be also reviewed to consider consolidation of reports and integration with the
recommended HMIS.
15.4 BUDGET PLANNING AND CONTROL
There would be three elements in planning the budget for health services – (a) preparation of the
annual budgets, (b) planning for long term needs and (c) monitoring utilization and outcomes.
The procedure for preparation of the annual budgets is well established. They are based on
annual requirements as assessed by the Departments and include both plan and non-plan
elements. The general practice is to provide an ad hoc increase, unless obvious large outlays are
known such as salary revisions. This process would bear refinement so that the estimates reflect
real needs on specific activities more realistically. This would require an examination of the
more important elements to assess the outlay that would be necessary to ensure efficient use of
the resources. Such elements would include travel, maintenance costs of equipment, buildings
and vehicles, costs of installation of new equipment with associated training costs, and the like.
Such a review would have to be carried out within the financial year 2001-02 so that future
annual budgets reflect the important elements adequately.
The long-term financial requirements of health services would need to be assessed on the basis
of certain parameters. The latter would include norms for health services and their estimation in
annual estimated prices. It would also have to be based on the reorganization of the services that
- 10 -
has been recommended. The long-term budget requirements would also have to be based on the
perspective plan for health services that would have to be prepared and take into account the
important aspects relating to sustainability of assets and activities created through externally
assisted projects.
As a measure of sustaining health promotion, a proportion of the State taxes on tobacco and
alcohol should be made available for programmes to counter the adverse health aspects of the
abuse of these substances. If feasible, a specific surcharge on the taxes payable on these
substances could be levied and reserved for the health promotional measures.
While it is necessary to provide adequate budgetary support for health services, it is equally
important to institute efficient mechanisms for monitoring of expenditure and determining
whether the expected outcomes of the expenditure have been achieved. The existing system of
monitoring expenditure concentrates on the former, but even this would need improvement.
Monitoring of expenditure should particularly include a review of maintenance, acquisition of
equipments, constructions, training and similar items.
Outcomes are rarely monitored. Norms for such monitoring need to be developed, which would
include both quantitative and qualitative elements. This would have to be done through a
professional review of the major services in terms of expected outcomes. The monitoring of this
aspect would, in course of time, have to be built into the proposed composite HMIS.
Auditing of PHCs
There is no audit of the PHCs at present. These are too many in number and annual audit would,
therefore, be difficult. However, it would be useful to institute a system of test audit at this level,
the purpose being not so much from the accounting point of view but rather as an attempt to
determine efficient use of resources. The test audit would, while covering the financial aspects,
more importantly concentrate on performance in relation to outlays on specific activities. Such
test audits, while instilling a sense of financial discipline, would also help in evaluating the
performance of health services at the community level and help in making improvements. It is
recommended that such a system of test audit be tried out on a pilot basis to determine both
feasibility and utility. The State Accounts Department would find it difficult to carry out such
activities. The pilot audit could be instituted in consultation with the Institute of Chartered
Accountants.
In due course, this system of both financial and performance audit could be extended to the
taluka level.
The appropriate agency that could be assigned the responsibility for the purposes mentioned
would be the Planning and Monitoring Division. The Division could develop the formats, norms
and mechanisms through consultants.
15.5 INFORMATION FOR HEALTH FINANCING
There are at present no norms, based on adequacy and quality, of health services at various
levels. The absence of such norms renders financial planning difficult and, as currently, makes
the exercise largely ad hoc. It would be desirable to develop indicative norms for health services
in its various elements at the primary, secondary and tertiary levels. Such norms would be
dependent on what are determined as the minimum services that should be available at a given
point of time. Such norms would provide guidance in developing a budget that reflects needs
more realistically. Subject to availability of resources, budgetary allocations could then be made
over a reasonable time span to be able to achieve the standards.
- 11 -
The performance budget that is now being prepared would also become more outcome oriented
than what it is at present if such norms and the outcomes in relation to such norms are built in.
The norms would obviously need to be reviewed periodically.
Health services are provided by Municipal Corporations and other local bodies. The structure of
these services, the scale of services and their financing would need study. Certain Departments,
as for example the Police Department, have internal medical facilities. In addition, there is wide
network of private health services. To assess the needs at State and district level, it would be
desirable to carry out a composite study of the total availability and financing of health services
in the State. The fact that in many cases the municipal bodies do not have the funds to maintain
even basic health services which they are required to do must be noted. In such cases, the State
Government would have to provide the minimum additional funds that may be necessary to
these bodies to maintain the essential health services.
The availability of health services within the broad regions of the State would also need
examination. This would permit the allocations among the districts on a rational basis. As
mentioned earlier, some flexibility would be necessary to provide for special needs of a district
or a sub-region.
The family expenditure on health and medical services
The costs incurred a family for health and medical services need to be assessed. There are
studies that have investigated these costs in terms of private and public health services. The
results of these studies, supplemented with further investigations would provide information on
the contribution of public health services in comparison with that provided by the private sector.
This would help in planning the public services for the benefit of a larger proportion of the
economically and socially weaker population.
It would also be necessary to review the staffing pattern at periodic intervals to determine the
numbers and the need at various levels, their location and training. This could be done by a Staff
Inspection Unit, trained in organization and management principles, at specified periods so that
the staffing needs and expertise of the health services keep pace with requirements and
technology.
A database would need to be built up of the essential information needed for financial planning.
This database would, logically, have to be part of the database recommended to be instituted as
part of the HMIS.
15.6 COMMUNITY FINANCING AND INSURANCE:
Enhancing Community Financing for Health
It is the responsibility of the State to provide health services of acceptable quality and, for this
purpose, provide sufficient budgetary support. However, it would be desirable to evoke the
participation of the community in partially meeting the costs of health care. This could be done
in two ways. Firstly, charges could be levied for certain services and secondly, schemes relating
to community insurance could be adopted.
- 12 -
User fees
The charging of user fees has already been introduced in the State, with the services that would
be charged for and the scale of fees being specified. A District Development Fund has been
established, managed by a District Level Health System Committee. The fees collected are
meant to be used for specific purposes such as urgent repairs to buildings and equipment and the
like. The collection of fees in the State is of the order of Rs. 3.5 crores and augments the
resources available for use improvement / maintenance of the hospitals within the district.
The Fund and the Committees originated as part of the KHSDP. The original intention was that
the hospital collecting the fees would be entitled to the full amount collected for the purposes
mentioned. However, the orders creating the District Development Fund are slightly ambiguous
and seem to permit the amount collected in a district being used for any hospital in the district
and in some districts the collections in a hospital have not been exclusively used for that
hospital. This needs to be corrected. People are likely to willingly pay these charges if they are
sure that the amounts would be used in the hospital they use and even enhancements would be
tolerated. It is recommended that the user fees system be continued even after the KHSDP
ceases as a project. The orders may also state clearly that the use of the fees would be specific to
the hospital collecting the amounts.
The designation of the Committee would need review since this is a “hospital development fund
and not a general “development fund”. Periodic review of the fee structure would also be
necessary.
It would also be desirable to formulate schemes for community insurance. The latter could be
based on the principle of Self Help Groups that collect annual contributions from the member
households and provide financial help for non- hospitalization cases, or with the participation of
the insurance companies, preferably the national companies, for hospitalization cases.
Insurance for doctors
There is likely to be an increasing trend in personal liability suits against government doctors. It
would be necessary to provide insurance to the doctors to cover the costs of damages that may
be awarded. In cases of negligence attributed to a doctor there would necessarily have to be an
internal enquiry within the Department, irrespective of the outcome of any civil / criminal /
consumer litigation. This would be more to correct faults in the procedures and systems as also
to impose such punishment by the disciplinary authority as may be warranted. There is also
likely to be the possibility of damages being awarded against the doctor by the competent courts.
In the latter event, insurance cover should be available to the doctor.
It is recommended that a scheme for such insurance cover to doctors in the health services be
formulated in consultation with the public sector insurance companies, including the Karnataka
Government Insurance Department. The possibility of developing a Group insurance scheme
could also be explored since this would reduce the premium costs.
It is recommended that the doctors should pay half the insurance premium from their personal
funds. This would ensure that due regard is given to all safety and medical procedures and that
complacency consequent on no personal cost does not result in neglect of such safety standards
or prescribed procedures.
- 13 -
Financial Implications of the Restructuring of Health Services
The recommendations made in this Report could be broadly classified as follows:
a) Those that relate to the changes in the basic structure of the health services and involve
formulation of new Cadre and Recruitment Rules and associated elements;
b) Those that relate to “governance” issues such as training, moral building, transparent transfer
polices, relationship with the Panchayat institutions and other elements of management;
c) Those that relate to enhancement of both quality and coverage and building in emphasis on
new elements in the health services provided. These include the elements such as expansion
and addition of services, better surveillance, better access and reach of services and the like
The possible financial implications of the recommendations are rather difficult to work out with
a reliable degree of specificity because the outlays would depend on the priority in which the
recommendations are sought to be implemented.
The first category of recommendations would involve almost no new posts. As suggested
elsewhere, the restructuring would largely consist of identifying current posts and fitting them
into the new structure. While new designations and Divisions have no doubt been suggested,
these would be filled by existing incumbents or by shifting wings from the current projects to
the Directorate itself.
The second and third category of recommendations also have cost implications. Good
governance is essentially a matter of devoted and sincere management. However, admittedly,
there are elements that would need additional funding because what has been recommended is
not only enhancement in most services but also new ones. Additional financing would be
necessary for elements such as expansion of training facilities so as to cover all districts,
upgrading the State Institute of Health and Family Welfare into a full fledged independent
training institution of excellence, increasing frequency and content of the training programmes.
Recommendations have also been made for the posts of Lady Doctors in the PHCs, setting up
blood banks and trauma centres, and other staff needs in certain critical areas. An important
element that would need extra financing is the construction of quarters and PHC buildings or
repairs to existing ones. Similarly, the improvement of internal transport facilities, providing soft
loans for field staff for acquiring two wheelers, providing transport for emergency services and
generally enhancing mobility for medical care, would need enhanced financing.
The scale of financing would depend on the phasing of the implementation of these
recommendations and, therefore, no attempt has been made to estimate the likely necessary
outlays. Mechanisms have been suggested towards the end of this Report for implementation of
the recommendations. Part of the process of consideration and implementation would be the
estimation of financial outlays that would be necessary and providing for them.
- 14 -
Recommendations
•
A study of the availability and financing of health services provided by the State, by local
authorities and by the private sector should be carried out;
•
Parameters should be evolved for rational allocation of funds to districts and sub-regions to
ensure a degree of equity in availability of services, with flexibility being built in for special
circumstances, taking into account the health plans of the Zilla Panchayats;
•
An internal review of specific allocations is necessary to reflect the needs of certain essential
activities in a realistic manner. This would be particularly necessary in the case of
supporting and infrastructure services. Some of the critical areas, which would need
enhanced allocations, would include repairs of vehicles, equipment and buildings, touring
for better supervision and administrative charges of the PHC. In this context, a review of the
condition of the vehicles must be made to condemn, repair and replace them as may be
necessary to enhance supervision capability;
•
Budgetary cuts should not be made in allocations for health services. Such cuts destroy
continuity and levels of services built up over time and only prove counterproductive in the
long run;
•
It should be ensured that release of funds and sanction orders are issued well in time and
that the quantum of funds released should be adequate since such releases, in combination
with sufficient financial delegations, would ensure maintaining and improving health
services;
•
It is necessary to ensure coordination in the budgeting of the various Departments and
Divisions of the health and medical services. This responsibility may be assigned to the
Commissioner as a coordinating officer, with authority to call for information from
associated Departments / Directorates.
•
The Planning and Monitoring Division recommended to be established directly under the
Commissioner may be assigned this role. To assist this Division, it is recommended that a
post of Financial Adviser be created in this Division. This post could be filled by a health
economist or by selection, based on experience, from the State Accounts Department or
Planning cadres of Government;
•
The adequacy and implementation of financial delegations within the health services would
need review. This may be done by a Committee under the Chairmanship of the
Commissioner.
•
Nonperformance and non-utilization of delegated authority should be important parameters
for assessing annual performance;
•
Internal procedures for monitoring expenditure, particularly in the case of acquisition of
equipment and infrastructure, would need to be reviewed to ensure expeditious utilization of
allocations in the best manner possible;
•
The reporting system and formats prescribed for the field level officials, particularly the
ANMs, would need to be reviewed to rationalize them and reduce workload.
- 15 -
•
A comprehensive review of the financial reporting system is necessary so that it becomes
part of the HMIS that has been recommended;
•
The system of user fee is a good feature and should be periodically reviewed to enhance
both the base and the scale of fees, if called for. It would be necessary to reiterate that the
collection of user fee by a hospital would be exclusively meant for its improvement;
•
Schemes for community insurance based on Self Help Groups for non-hospitalization cases
or with involvement of national insurance companies for hospitalization cases should be
formulated and tried out on a pilot basis to develop a replicable model;
•
A scheme for liability insurance for doctors in the Department, including group insurance
schemes, needs to be formulated in consultation with public sector insurance companies,
including the Karnataka Government Insurance Department. The scheme may stipulate that
doctors meet half the costs of the premium;
•
Norms for health services based on adequacy of services and quality should be developed as
guidelines for formulation of budget requirements. These norms would also provide
guidance for assessment of the financial elements of the perspective plan for health services;
•
Norms in terms of both quality and adequacy, with regard to expected outcomes of
expenditure need to be evolved for monitoring of efficiency of use of funds. Such norms must
be developed for various functional levels, including the Zilla Panchayats;
•
The long-term requirements of health services would need to be assessed on the basis of the
norms suggested above and on the basis of the perspective plan for health services. In
assessing these requirements, the requirements to sustain the assets and services created at
considerable cost through externally aided projects must be built in.
•
Test audit through chartered accountants may be tried on a pilot basis for evaluating the
performance of health services at PHC and taluka levels and also to induce a sense of
financial discipline. A pilot audit could be instituted in consultation with the Institute of
Chartered Accountants. The Planning and Monitoring Division could be the nodal office for
this pilot study;
•
A study is necessary of the scale of health services and the financial outlays on such services
in Municipal Corporations and other municipal bodies to assess the total health expenditure
on health in the public domain. Such a study would help in assessing the needs in urban
areas.
•
It would be necessary to augment the health budget, to the extent necessary, of the weaker
local authorities to enable them to provide essential health care services in their areas.
•
A study of costs on health services to families may be conducted, after an evaluation of the
results of studies already available, for guidance regarding enhancement of services for the
economically weaker sections of society at affordable costs;
•
The staffing pattern would need to be reviewed at intervals to determine both adequacy and
excess, and critical shortages. A Staff Inspection Unit trained in Organization and
Management principles could be assigned this task;
- 16 -
•
A financial database may be built up as part of the composite HMIS that has been
recommended for the health services. The system of computerization of financial information
and of the accounts should be built up as soon as possible.
- 17 -
Annexure - A
BUDGET ALLOCATIONS AND ACCOUNTS
Revenue – in Crores
Year
2210
Medical and Public Health
Budget
Accounts*
2211
Family Welfare
Budget
Accounts*
1991-92
Plan
Non Plan
Total
52.74
212.56
265.3
39.39
202.12
241.51
50.77
2.95
53.72
50.38
3.48
53.86
1992-93
Plan
Non Plan
Total
64.19
244.47
308.66
52.92
248.56
301.48
56.31
3.81
60.12
54.98
3.74
58.72
1993-94
Plan
Non Plan
Total
97.10
280.33
377.43
62.60
265.60
328.20
50.67
4.50
55.17
59.42
3.63
63.05
1994-95
Plan
Non Plan
Total
105.45
309.19
414.64
87.29
289.27
376.56
88.64
4.45
93.09
76.55
4.64
81.19
1995-96
Plan
Non Plan
Total
119.95
337.11
457.06
119.54
285.44
404.98
106.64
5.14
111.78
86.81
4.67
91.48
1996-97
Plan
Non Plan
Total
191.28
373.46
564.74
144.26
300.62
444.88
106.48
5.97
112.45
74.63
5.58
80.21
1997-98
Plan
Non Plan
Total
204.27
452.72
656.99
157.72
354.2
511.92
115.20
6.57
121.77
106.09
6.34
112.43
1998-99
Plan
Non Plan
Total
166.27
516.81
683.08
147.46
468.4
615.86
145.41
7.39
152.80
84.85
7.68
92.53
1999-2000
Plan
Non Plan
Total
162.05
599.48
761.53
167.92
11.37
179.29
2000-01
Plan
Non Plan
Total
177.69
639.73
817.42
195.21
10.18
205.39
* Actual expenditure
- 18 -
Annexure - B
BUDGET ALLOCATIONS AND ACCOUNTS
Capital Outlay – in Crores
4210
4211
Medical and Public Health
Family Welfare
Years
Budget
Accounts *
Budget
Accounts *
1991-92
2.60
2.93
0.65
2.34
1992-93
17.64
6.75
0.50
0.37
1993-94
36.46
9.99
0.50
0.26
1994-95
25.24
10.91
0.50
0.20
1995-96
21.06
13.82
10.50
3.10
1996-97
19.98
7.93
8.80
2.46
1997-98
17.28
68.16
8.80
15.53
1998-99
56.29
87.88
10.50
22.52
1999-00
79.78
39.32
2000-01
55.38
33.45
Total
331.71
208.37
* Actual expenditure
- 19 -
113.52
46.78
16. RATIONAL DRUG MANAGEMENT
“ A physician who, though unacquainted with drugs and their effects or is ignorant of the nature of disease, yet takes
money from the sick (for giving treatment) shall be punished like a thief’
- Sacred Books of the East. Vol.15
16.1 INTRODUCTION
The Rational use of drugs requires that patients receive medications appropriate to their needs, in
doses that meet their own individual requirement, for an adequate period of time & at the lowest
cost to them & their community.
Rational use of drugs in a biomedical context includes the following criteria:
• Correct drug
• Appropriate indication-that is, the reason to prescribe is based on sound medical consideration
• Appropriate drug, considering efficacy, safety, suitability for the patient and the cost
• Appropriate dosage, administration and duration of treatment
• Appropriate patient-that is, no contraindications exist, and the likelihood of adverse reactions is
minimal
• Correct dispensing, including appropriate information for patients about the prescribed
medicines
• Patient adherence to treatment.
16.1.1 Definitions:
1. Essential drugs are those drugs that satisfy the health care needs of the majority of the
population. They should, therefore be available at all times in adequate amounts and in the
appropriate dosage forms.
2. "Quality assurance" is a wide-ranging concept covering all matters that individually or
collectively influence the quality of a product. It is the totality of the arrangements made
with the object of ensuring that pharmaceutical products are of the quality required for their
intended use.
3. Good manufacturing practice (GMP) is that part of quality assurance which ensures that
products are consistently produced and controlled to the quality standards appropriate to
their intended use and as required by the marketing authorization. GMP rules are directed
primarily to diminishing the risks, inherent in any pharmaceutical production, which cannot
be prevented completely through the testing of final products.
4. Quality control is the part of GMP concerned with sampling, specifications, and testing and
with the organization, documentation, and release procedures which ensure that the
necessary and relevant tests are actually carried out and that materials are not released for
use, nor products released for sale or supply, until their quality has been judged to be
satisfactory. Quality control is not confined to laboratory operations but must be involved in
all decisions concerning the quality of the product.
-1-
5. Banned drugs: When the Government of India is satisfied that the use of certain drugs is
likely to involve risk to human beings or the said drugs do not have the therapeutic value
claimed or purported to be claimed for them or contain ingredients in such quantity for
which there is no therapeutic justification and it is necessary and expedient in the public
interest so to do, the Government prohibits the manufacture and sale of the said drugs; the
drugs are banned.
6. Bannable drugs: When the use of certain drugs is likely to involve risk to human beings or
the said drugs do not have the therapeutic value claimed for them or certain ingredients are
in such quantity for which there is no therapeutic justification but the Government has not
announced its decision prohibiting them, those drugs may be considered as "bannable
drugs".
7. Hazardous Drugs are those where the risk outweighs the benefits.
8. Spurious Drug means a drug:
a)
imported / manufactured under a name which belongs to another drug; or
b)
which is an imitation of or is a substitute for another drug or resembles another drug in
a manner to deceive or bear upon its label or container the name of another drug unless
plainly or conspicuously marked so as to reveal its true character and its lack of
identity with such other drugs; or
c)
the label or container bears the name of an individual or company purporting to be the
manufacturer of drug, which individual or company is fictitious or does not exist; or
d)
which has been substituted wholly or in part by another drug or another substance; or
e)
which purports to be the product of a manufacturer of whom it is not truly a product.
16.2 ESSENTIAL DRUGS
The essential drugs lists contain those drugs selected by the state based on the health needs of its
people and relevant to the level of health care (Primary Health Centres, C.H.Cs and Taluka
Hospitals, District Hospitals and others). The 'Criteria for selection of essential drugs' suggested by
WHO is widely accepted. These criteria preclude the registration of any new drug, which is not
more effective, safer or cheaper than one that is already in use.
16.2.1 Priority Drug List: is drawn from within the essential drug list to give priority to drug
production, distribution and availability for use in diseases having
• Greater mortality
• Greater morbidity
• Severe sequelae
• Communicability
and for use in national programmes such as Tuberculosis, Malaria, Blindness control,
Goitre control, immunisation, etc.
-2-
16.2.2 WHO criteria for selection of essential drugs:
1. Essential drugs are those that satisfy the health care needs of the majority of the
population; they should therefore be available at all times in adequate amounts and in the
appropriate dosage forms.
2. The choice of such drugs depends on the pattern of prevalent disease; the treatment
facilities; the training and experience of the available personnel; the financial resources;
and genetic, demographic, and environmental factors.
ESSENTIAL DRUGS
The International Conference on Primary Health Care, in Alma-Ata on 12th September 1978
defined Primary Health Care as essential health care based on practical, scientifically sound and
socially acceptable methods and technology made universally accessible to individuals and families
in the community through their full participation and at a cost that the community and country can
afford to maintain at every stage of their development in the spirit of self-reliance and self
determination. Provision of essential drugs and appropriate treatment of common diseases are
components of primary health care.
The WHO Expert Committee on Essential Drugs attempted to provide guidelines to member
countries to help them draw up a list of essential drugs:
"It is clear that for the optimal use of limited financial resources, the available drugs must be
restricted to those proven to be therapeutically effective, to have acceptable safety and to satisfy
the health needs of the population. The selected drugs are here called 'essential' drugs, indicating
that they are of the utmost importance, and are basic, indispensable and necessary for the health
needs of the population".
The key elements in the concept of essential drugs are that, they be:
• Rational
• Scientifically proven
• Therapeutically effective
• Economical
• Socially acceptable
According to Health Action International (HAI) an international pressure group working towards
rational drug policies and rational drug use, all drugs must:
1.
2.
3.
4.
Meet real medical need: their use is likely to improve the quality or extent of medical care.
Have significant therapeutic value: they must be efficacious, and patients will benefit from
them.
Be acceptably safe: their benefits must far outweigh their risks.
Offer satisfactory value for money
This favours the introduction and use of drugs that are as efficient and efficacious as
alternatives, but cost less.
-3-
3.
4.
5.
6.
7.
Only drugs, for which sound and adequate data on efficacy and safety are available
from clinical studies, and for which evidence of performance in general use in a
variety of medical settings has been obtained, should be selected.
Each selected drug must be available in a form in which adequate quality,
including bioavailability, can be ensured; its stability under the anticipated
conditions of storage and use must be established.
When two or more drugs appear to be similar in the above respects, the choice
between them should be made on the basis of a careful evaluation of their relative
efficacy, safety, quality, price, and availability.
In cost comparisons between drugs, the cost of the total treatment, not only the unit
cost of the drug, must be considered. The cost-benefit ratio is a major consideration
in the choice of some drugs for the list. In some cases, the choice may also be
influenced by other factors, such as pharmacokinetic properties, or by local
considerations, such as the availability of facilities for manufacture or storage.
Most essential drugs should be formulated as single compounds. Fixed-ratio
combination products are acceptable only when the dosage of each ingredient
meets the requirements of a defined population group and when the combination
has a proven advantage over single compounds administered separately in terms of
therapeutic effect, safety, or patient adherence to treatment.
16.2.3 Advantages of the concept of essential drugs:
Preparing a rational list of essential/restricted drugs has several advantages: medical,
economic, social and administrative.
Medical Advantages:
•
It remains medically and therapeutically sound.
•
It limits the potential irrational and hazardous use of drugs and decreases the risks
of iatrogenesis.
•
It simplifies the process of identifying adverse drug reactions in patients.
Economic Advantages:
•
It is economically beneficial to the nation because it maximises the utilisation of
limited resources.
•
The economy of scale achieved in the larger production of priority drugs reduces
cost.
•
It curtails the aggressive marketing of non-essential formulations.
Social Advantages:
•
It responds to the real health needs of the people
•
It facilitates the dissemination of correct information about the drugs to health
personnel, medical practitioners and consumers in general.
•
It makes it imperative to draw up priorities to meet the most urgent needs of the
people for essential health care.
-4-
Administrative Advantages:
•
It makes quality control easier because of the limited number of drugs to be
monitored.
•
It facilitates the streamlining of production, storage and distribution of drugs,
because of the limited number of drugs involved.
•
It facilitates the fixing of prices as well as the revision/withdrawal of excise duties,
sales tax etc.
Advantages to the patient:
•
All the medical, economic, social and administrative advantages directly or
indirectly benefit the patient.
•
Reduces confusion and increases patient compliance.
•
Focuses education efforts and facilitates patient participation in his/her own health
care.
16.3 LEGISLATION AFFECTING USE OF DRUGS
16.3.1 DRUGS & COSMETICS ACT, 1940
Objective: The act was passed in 1940 to regulate import, manufacture, distribution and sale
of drugs and cosmetics. It is implied that no adulterated, spurious &misbranded drug shall
be manufactured in India or imported into India. Similarly no misbranded and spurious
cosmetic shall be manufactured in India or imported into the country. The Act also provides
for the sale and distribution of drugs only by qualified persons. It also provides for control
over manufacture, sale and distribution of Ayurvedic, Siddha, Unani & Homoeopathic
Drugs. Control over manufacture is exercised by drug inspectors. Analysis of samples is
carried out at drugs control laboratory. The licensing authority exercises control over issue
of license for manufacture, sale & distribution of drugs.
Drugs & Cosmetics Act provides for establishment of Drugs Technical Advisory Board
(DTAB) to advise central and state governments on technical matters arising out of
administration of the act. Drugs Consultative Committee (DCC) aids in securing uniformity
in administration of the act through out India. DTAB consists of 18 members with
representatives like Director General, Health Services, President, Pharmacy Council of
India, Medical Council of India, Indian Pharmaceutical Association, Indian Medical
Association, Directors of institutes like Central Drug Research Institute, and nominated &
elected members. Drugs Consultative Committee has one representative from each state.
16.3.2 THE DRUGS AND MAGIC REMEDIES (OBJECTIONABLE ADVERTISEMENTS) ACT
1954
Objective: To control the advertisements of drugs in certain cases, to prohibit the
advertisement for certain purpose of remedies alleged to possess magic qualities.
The objectionable advertisements tend to cause the ignorant and unwary to resort to selfmedication or to resort to quacks who indulge in such advertisements for treatments, which
cause great harm. It was therefore found necessary in the public interest to put a stop to
such undesirable advertisements.
-5-
16.3.3 PHARMACY ACT 1948
Objective: To regulate the profession and practice of pharmacy and for that purpose to
constitute Pharmacy Councils.
16.3.4 DRUGS (PRICE CONTROL) ORDER-1995
Objective: To regulate the selling price of bulk drugs and formulations. The number of
drugs under the Price Control has been reduced progressively and this has resulted in
substantial increases in the price of drugs.
16.3.5 Good manufacturing practices
The Rational use of drugs starts with the manufacture of pharmaceuticals. The concept of Quality
Management is an essential criterion.
The concepts of quality assurance, GMP, and quality control are interrelated aspects of
quality management.
The basic elements of quality management are:
•
an appropriate infrastructure of "quality system", encompassing the organisational structure,
procedures, processes, and resources; and
•
systematic actions necessary to ensure adequate confidence that a product (or service) will
satisfy given requirements for quality. The totality of these actions is termed "quality assurance".
16.4 RATIONAL PRESCRIBING, POLYPHARMACY, COMPLIANCE
Programs to ensure rational use of drugs should be an integral part of health and medical care
services. The responsibility for promoting rational use of drugs belongs to decision-makers,
administrators, and clinicians. It is also the responsibility of health care professionals, consumers,
educators and pharmaceutical companies.
Strategies to improve rational prescribing:
16.4.1 Educational strategies include
• training of prescribers (formal and continuing education, supervisory visits, group
lectures, seminars, workshops);
• printed materials (clinical literature and newsletters, treatment guidelines, drug
formularies, flyers, leaflets):
• approaches based on face-to-face contact (educational outreach, patient education,
influencing opinion leaders).
• prescribing and dispensing approaches (structured drug order forms, standard diagnostic
and treatment guidelines, course-of-therapy packaging);
• financing (price setting, capitation-based budgeting).
16.4.2 Regulatory strategies include
• drug registration;
• limited drug lists;
• prescribing restrictions;
• dispensing restrictions.
-6-
16.4.3 The ultimate goals of studying and intervening in drug use practices include
• improvement of quality of health care through effective and safe use of pharmaceuticals;
• improvement of cost effectiveness of health care through economic and efficient use of
pharmaceuticals.
16.4.4 Polypharmacy defeats the purpose of rational use of drugs. At this juncture, it is important
to note the importance of drug-drug interactions when a few drugs are prescribed together.
To avoid these problems, Drug use indicators can be used for self audit and feedback.
16.4.5 Adherence (Compliance) to treatment is the degree to which patients adhere to medical
advice and take medicines as directed. Compliance depends not only on acceptance of
information about the health threat itself but also on the practitioner’s ability to persuade the
patient that the treatment is worthwhile and on the patient’s perception of the practitioner’s
credibility, empathy, interest and concern.
The consequences of non-compliance are:
• Treatment failure as in tuberculosis or sexually transmitted diseases.
• Recurrence or relapse of infection /disease.
• Development of microbial resistance e.g.. Nonadherence with antibiotic therapy.
• Increased risk of transmission of communicable diseases from incompletely cured
patients.
• Increased health care costs due to readmissions or reconsultations, lost work timings,
travel costs etc.
It is important to understand why drug defaulting occurs. The next step is to develop the
communication skills needed to interact with patients so those problems may be identified
and resolved. It is equally important to remove barriers to good communication. Finally, it is
important to assist the patient to a position of autonomy supported by problem solving and
self-management skills.
16.4.6 Misuse of drugs, strategies of drug use, prescription audit
Improving drug use by prescribers, dispensers and the general public helps to reduce
morbidity and mortality, and to contain drug expenditure. The challenge is how best to
ensure therapeutically sound and cost effective use of drugs, at all levels of the health
system, in both the public and private sectors, by both health professionals and consumers.
The three major components are:
- Rational drug use strategy & monitoring: Policies & regulations related to RUD
- Rational drug use by health professionals: Develop standard treatment guidelines,
Essential drugs list, formulary, educational programs, and other effective mechanisms to
promote rational drug use by all health professionals.
- Rational drug use by consumers: establish effective systems to provide independent &
unbiased drug information to the general public and to improve drug use by consumers.
-7-
Drug utilization review and feedback:
Drug utilization review (DUR) is a tool to identify problems in the medication use process: drug
prescribing, dispensing, administration and monitoring. As problems are identified, strategies are
developed and implemented to improve the use of drugs. If actions are successful, the result
will be improved patient care and more efficient use of resources.
Drug and therapeutic committees play an important role in improving prescribing practices. Their
role has expanded in some settings from selecting drugs for formularies to
• reviewing drug requisitions and revising them to fit budget allocations;
• determine which drugs should be made available to each type of health facility (if this is not
determined at the national level.);
• developing standard treatment norms for the common illnesses treated in the area or institution;
• establishing prescribing limitations aimed at controlling irrational drug use (for example,
limiting certain antibiotics to use only under the recommendation of a consultant)
• limiting the amount dispensed at one time to curb abuse of particular drugs and reduce waste;
• reviewing antibiotic resistance patterns and revising guidelines for antibiotic use;
• stimulating drug education activities among hospital staff;
• supervising and monitoring prescribing practices.
16.4.7 Principles of antimicrobial use
In hospitals, the choice of which drugs are used may be influenced by such local factors as trends in
susceptibility of current isolates, cost of the drugs and in some instances traditional preference or
familiarity. When an antimicrobial is indicated, the choice of agent should be based on factors
such as spectrum of activity in relation to the known or suspected causative organism, safety,
previous clinical experience, cost, and the potential for selection of resistant organisms and
associated risk of superinfection.
Educational responsibilities: Educational functions of hospital drug committees should include the
provision of information on antimicrobial use, supplemented by local decisions and data on new
antimicrobials as these become available. Drug committees should encourage the provision of
information to clinicians on current antimicrobial susceptibility patterns of organisms from their
patients.
Overcoming antimicrobial resistance is a global problem. Unregulated use of antimicrobials has
been associated with frightening increases in resistance of major human pathogens. Adherence to
the principles of antimicrobial use is increasingly important. Restraint in the use of new and often
powerful antimicrobials is the best way to ensure their continuing efficacy because NEWER DOES
NOT NECESSARILY MEAN BETTER.
-8-
Containing Antimicrobial Resistance
Antimicrobial resistance among disease causing bacteria represents a serious and growing
problem. The problem of resistance can be contained.
• Antibacterial drugs should only be used in situations where a bacterial infection is
either proven or strongly suspected.
• The type of bacteria involved in an illness and its antimicrobial susceptibility pattern
should generally be identified before and antibacterial is chosen.
• The antibacterial chosen should be targeted for the specific organism to be eradicated
rather than opting for a more broad spectrum drug
• Antimicrobial therapy should be modified once microbiological results (both pathogen
involved and susceptibility patterns) are available.
• Patients should be counseled about the proper use of antibacterials and the importance
of taking them only as directed.
- Source: Karnataka Medical Journal, 2001:71, 16-18
16.4.8 Pharmacovigilance:
An adverse drug reaction (ADR) has been defined by the World Health Organisation as "a response
to a drug which is noxious and unintended and which occurs at doses normally used in man for the
prophylaxis, diagnosis or therapy of disease or for the modification of a physiological function".
Medicinal products are safe, that is, the benefits are much greater than the risks. Not all the risks
from drugs, better called medicinal products, are known when such a product is first marketed.
Since there is no programme of testing prior to the marketing of a medicinal product that will find
all the risks of its use in everyday clinical situations, we must learn by experience.
Aims:
Pharmacovigilance is concerned with the detection, assessment and prevention of adverse reactions
to drugs. Major aims of pharmacovigilance are:
• Early detection of hitherto unknown adverse reactions and interactions
• Detection of increases in frequency of (known) adverse reactions
• Identification of risk factors and possible mechanisms underlying adverse reactions
• Estimation of quantitative aspects of benefit/risk analysis and dissemination of information
needed to improve drug prescribing and regulation.
The ultimate goals of pharmacovigilance are:
• the rational and safe use of medical drugs
• the assessment and communication of the risks and benefits of drugs on the market
• educating and informing of patients.
Continuity: Continuity in accessibility and service is a basic feature of a successful
pharmacovigilance centre. The centre therefore needs a permanent secretariat, for phone calls, mail,
maintenance of the database, literature documentation, co-ordination of activities, etc. Secretarial
-9-
continuity may be achieved through collaboration with related departments, provided there is
sufficient capacity.
16.4.9 Formulary
A formulary manual contains summary drug information. It is a handy reference that contains
selected information that is relevant to the prescriber, dispenser, nurse, or other health worker. A
formulary is drug centered, as it is based on monographs for individual drugs or therapeutic groups.
Formularies may or may not contain evaluative statements or comparisons of drugs. Some
formularies also include comparative price information, which can help guide prescribing decisions.
Intended to be a ready reference for doctors the formulary contains information which includes the
category of the drug, its indications, cautions to be observed when using the drug,
contraindications, side effects, drug interactions and dosage forms available. Additional notes
on use of the drugs will be provided wherever necessary to use the drugs more rationally and
avoid complications in therapy. Thus the prescribing doctor will have a publication providing
him objective unbiased information about the drugs that will be prescribed.
A state formulary manual is based on the national/state list of essential drugs. The production of a
formulary is one step in an ongoing process. The development process of these publications is a
continual effort, not limited to the one time production. The process involves gaining acceptance of
the concept, preparing the text based on the wide consultation and consensus building,
implementing an introductory campaign and training activities, and undertaking regular reviews and
updates. To maintain the credibility of the information, a system for regular updates and for
incorporation of accepted amendments into the next edition is essential.
Hospital formulary: In many countries, especially those with highly developed health systems,
hospitals develop their own formulary manuals. The advantage is that the formulary can be tailored
to fit the particular requirements of the hospital & to reflect departmental consensus on first choice
treatments from the national list of essential drugs. Additional information presented in hospital
formularies may include details of recommended hospital procedures, hospital antibiotic policy,
guidelines for laboratory investigations and patient management.
16.4.10 Drugs and therapeutic information services
Access to clinically relevant, up-to date, user- specific, independent, objective and unbiased drug
information is essential for appropriate drug use. Prescribers, dispensers, and users of medicines all
need objective information. Although access to good drug information does not guarantee
appropriate drug use, it is certainly a basic requirement for rational drug use decisions.
The factors influencing drug use are many and interrelated. No single approach is likely to work.
Rather, a variety and combination of strategies tailored to the needs of the different groups in
society and the different working environments of health workers will be needed.
Objective drug information
A medicinal product must be accompanied by appropriate information. The quality of information
accompanying the drug is as important as the quality of the active substance. Information about
drugs and drug promotion can greatly influence the way in which drugs are used. Monitoring and
control of both these activities are essential parts of any national drug policy.
- 10 -
Drugs and Therapeutics Committee
Objectives: Each of the larger hospitals should have its own Drugs and Therapeutics Committee. It
should define its specific objectives. In general, the objectives may be:
• Formulate and implement policies for selection and use of drugs.
• Develop a hospital essential drug list (based on the Essential Drug List of the State).
• Develop and implement standard treatment regimes for the main diseases in the hospital,
based on the guidelines of the State / National Health Programmes
• Carry out drug utilization review in the hospital.
• Provide objective drug information to prescribers and users.
• Carry out educational programmes to improve the prescribing, dispensing and
administration of drugs.
• Monitor, report and have action taken on adverse drug reactions and errors in medication.
Criteria that should apply to the development of objective information are that it should be: based
on agreed standards; available, accessible and understandable to users; flexible and provided in a
variety of forms; relevant to user needs, recognising the multicultural nature of societies;
independent, unbiased and with no advertising; developed with user input; and pilot tested for
usefulness and acceptability.
The primary role of a DRUG INFORMATION CENTRE is to keep up – to- date with
pharmacological and therapeutic literature and disseminate relevant information when it becomes
available. A secondary role of the center is to give clear and definitive information on essential
drugs and promote their rational use.
16.4.11 Self medication
Self-medication is the selection and use of medicines by individuals to treat self recognized
illnesses or symptoms. The increase in self care is due to a number of factors. These factors include:
Socioeconomic factors; lifestyle; ready access to drugs; the increased potential to manage certain
illness through self care; public health and environmental factors; greater availability of medicinal
products; and demographic and epidemiological factors.
Responsible self-medication is the practice whereby individuals treat their ailments and conditions
with medicines that are approved and available without prescription (OTC-Over The Counter
products), and which are safe and effective when used as directed.
Responsible self-medication requires that:
-
Medicines used are of proven safety, quality and efficacy.
-
Medicines used are those indicated for conditions that are self-recognizable and for some
chronic or recurrent conditions (following initial medical diagnosis).
In all these cases, these medicines should be specifically designed for this purpose, and will require
appropriate dose and dosage forms.
- 11 -
Such products should be supported by information, which describes:
•
•
•
•
•
•
•
how to take or use the medicines;
effects and possible side-effects;
how the effects of the medicine should be monitored;
possible interactions;
precautions and warnings;
duration of use; and,
when to seek professional advice.
16.4.12. Public education for rational use of drugs
On one side, Medicinal drugs represent an indispensable contribution to humankind and to the
reduction of morbidity and mortality, but on the other side, it is important to realize that proper use
of drugs remains a challenge. Public health problems resulting from drug misuse are serious, and
could worsen if they are not addressed now.
The Alma Ata declaration clearly stares that "People have the right and duty to participate
individually and collectively in the planning and implementation of their health care". But,
public education is seldom allocated the necessary human and financial resources and is frequently
treated as a marginal activity or one which should only be tackled when the other elements of drug
policy have been dealt with. There is a need to increase the priority given to public education.
The overall aim of public education in drug use is to provide individuals and communities with
information, and to foster skills and confidence, which will enable them to use medicines in an
appropriate, safe, and judicious way.
Educational campaigns are unlikely to be effective if conducted primarily from a top-down and
biomedical perspective without an understanding of the socio-cultural framework within which
decisions are taken.
16.4.13 Ethical criteria for medicinal drug promotion
The main objective of ethical criteria for medicinal drug promotion is to support and encourage the
improvement of health care through the rational use of medicinal drugs. Ethical criteria for drug
promotion should lay the foundation for proper behavior concerning the promotion of medicinal
drugs, consistent with the search for truthfulness and righteousness. The criteria should thus assist
in judging if promotional practices related to medicinal drugs are in keeping with acceptable ethical
standards.
- 12 -
16.5
PROCUREMENT OF DRUGS IN KARNATAKA
The Government Medical Stores at Bangalore is currently responsible for procurement and
distribution of drugs to all the health care institutions, out of the 40% of the budget allotted for
purchase of drugs. The rest (60% of the budget) is given to the respective Zilla Panchayats as part of
the decentralised governance. They are responsible for purchasing and distributing drugs to the
government health care establishments in their districts.
In the current system, the Government Medical Stores prepares the list of drugs and formulations
for purchase on the basis of recommendations of the Therapeutic Cum Expert Committee. After
approval of the government, the Director of Health and Family Welfare Services issues tender
notification in the newspapers and the official gazette to workout a Rate Contract for all essential
drugs. The quantities of drugs needed are not mentioned in the Rate contract; this is a major
drawback.
Once the Rate Contract is issued, the concerned institutions place their indents before the Joint
Director, GMS for the budgetary allotment of 40%. The main drawback is that the indenting
institutions do not send the details of their needs in time. The Primary Health Units and Subentries
are not required to send their indents. The Government Medical Stores meet the requirement of
these institutions on the basis of the drugs identified by the Committee and the GMS meets their
entire requirements.
Transport facility for the delivery of drugs is not available at the GMS. Currently it is the
responsibility of the indenting institutions to make arrangements for the same. The inventory
system and Quantity control of the drugs is inefficient.
16.5.1 Deficiencies in the present system in procurement and distribution of drugs.
1
Infrastructure:
• Inadequate storage facilities / space at the Government Medical Stores warehouse in
Bangalore.
• No storage facilities at the district level.
• Manual inventory system has delayed both procurement and distribution of essential
drugs.
• No transportation facilities.
• Excess staff in Group C and Group D cadre at the GMS.
• No sanctioned posts of Pharmacists at the district level.
2
Procurement:
• Finalisation of the drug list, tender process and the Rate Contract not done in time.
• Desired quantity of drugs is not mentioned in the Rate Contract list.
• All the essential drugs are not covered in the Rate Contract list.
• Delay in the release of budget allotted for the purchase of essential drugs.
• Procurement of drugs at the Zilla Panchayats done mostly towards the end of the
financial year.
• Some drugs are purchased in excess due to lack of coordination between the GMS
and the Zilla Panchayats.
• Delay in indenting process at all levels.
- 13 -
3
Distribution:
• Due to non availability of certain drugs the indenting institutions are required to
collect the drugs 2 – 3 times / year.
• No transportation facilities
• Drugs purchased by some hospitals in containers against the Government of
Karnataka policy of blister/ strip packing.
4. Monitoring and Evaluation:
• Currently the monitoring and evaluation system in procurement and distribution of
drugs is inefficient.
• The Director of Health and Family Welfare who is in charge of procurement of drugs
is unable to devote enough time, since he has too many job responsibilities.
• Non-uniformity due to lack of coordination between the district committees
responsible for the purchase of drugs.
• Storage and distribution at the district level is carried out by clerical staff who lack
adequate pharmaceutical knowledge.
Quality Control:
• Drug Collectorate staff and laboratory facilities are inadequate.
• Sample testing takes a minimum of 4 – 5 months.
Makapur Committee Report
The Makapur Committee constituted by the Government of Karnataka to look into the drug
procurement and distribution system in the State has recommended for pooled procurement by the
General Medical Stores. The drugs are to be selected from the essential druglist. It has
recommended computerization and re-organisation of the General Medical Stores and District
Medical Stores to bring in better monitoring and evaluation and greater efficiency in the
procurement and distribution of essential drugs. The Task Force recommends that Makapur
Committee Report be adopted with necessary modifications.
16.6 DRUGS CONTROL DEPARTMENT
The main objectives of Drug control is to ensure that all the drugs that are made available to people
who use them for prevention, mitigation, treatment and cure of diseases and disorders, are of
standard quality, purity and strength.
The philosophy of drug control is that unless quality control discipline embracing ancillary
requirements are imposed by law at all stages of import, manufacture, storage, sale or distribution,
people cannot be assured of the quality and safety of medicines used by them. Besides, these
medicines are required to be sold at reasonable prices fixed by the Government and also to ensure
that unwary public are not misled by objectionable advertisements in respect of drugs for certain
ailments, diseases and disorders.
- 14 -
Presently, in the State of Karnataka the number of licensees is as follows:
1.
2.
3.
4.
5.
6.
7.
Drug Manufacturing licenses
Drug Loan licenses
Cosmetics manufacturing licenses
Cosmetics Loan licenses
Blood Banks
Approved Laboratories
Sales Establishments
-
229
274
74
7
109
7
13,377
16.6.1. Drug Inspectors
The Task Force appointed by The Government of India to suggest measures for enforcement
recommended that for every one hundred sales establishments there should be one Drugs
Inspector and for every 25 manufacturing licenses there should be one Drug Inspector.
Drugs Inspectors are required to carry out the following duties:
1. To draw samples of Drugs and Cosmetics from manufacturers, distributors, wholesalers,
retailers, Government Hospitals, District Health Officers, private hospital and nursing
homes.
2. To inspect each licensed premises at least twice in a year as a mandatory requirement as
per the law to ascertain the compliance of various drug rules
3. To monitor the movement of spurious drugs and not of standard quality drugs which are
already in the market and to see that the drugs which are opined as spurious, adulterated,
misbranded, not of standard quality are not stocked or sold.
4. To check the prices of drugs and to see whether the prices marked by the manufacturers
are as per the notifications issued by the Government from time to time.
5. To investigate any complaint received
6. To launch the prosecution against the offenders and to follow up cases
7. To scrutinize the advertisements for any possible violation under Drugs and Magic
Remedies (objectionable advertisements) Act and to take suitable action against the
offenders.
To fulfill the above duties and responsibilities covering more than 13,000 licensees, the department
needs at least 130 Inspectors. Presently, the staff strength sanctioned is 46 inspectors and thus there
is a short fall of 84 inspectors. Out of 46 sanctioned posts, 8 posts are vacant.
16.6.2 Drug Testing Laboratory
The provisions of Drugs and Cosmetics Act are very critical in the field of medical care as
success of any treatment depends on the quality of drugs consumed by the patients. The
primary responsibility of ensuring that quality drugs are manufactured and distributed rests
with industry. However, with the advent of newer synthetic drugs, Biotechnological
products, it is very essential that proper quality control measures are to be taken by
Government agencies to see that situation is not exploited by unscrupulous elements by
pushing spurious drugs. Hence, role of Drugs Testing Laboratory assumes more importance
than ever.
- 15 -
Drug Testing Laboratory was established in Bangalore in 1964 and facilities in this
laboratory needs to be upgraded both in terms of technical personnel and other infrastructure
facilities including equipments, library facility etc. There is a need to establish an exclusive
"Reference Standard" and "Working Standard" section that is essential for carrying out test
and analysis for various drugs. Unless the laboratory has reference standards, the sample
received cannot be analysed to certify the quality of drug.
Presently the laboratory is analyzing about 2,500-3,000 samples per annum. By analyzing
2,500-3,000 samples per year, it is not possible to assure the quality of all drugs moving in
Karnataka. The number of samples analysed should at least be increased to 15,000 per year.
At present, on an average 150 samples are analysed by each junior chemist per annum. The
strength of Junior Chemists required to meet the task ahead is at least 100. Presently, there
are only 30 Junior Chemists posts sanctioned out of which 8 posts are vacant. In the
analysis of drugs, Junior Chemists have to be supported with laboratory technicians and
laboratory attendants.
Karnataka Antibiotics and Pharmaceutical limited (KAPL):
KAPL is a Government of Karnataka Company, manufacturing medicines of quality. During 19992000, the company produced medicines of the value of Rs.7510 lakhs with an export turnover of
Rs.709 lakhs. KAPL won the Prime Minister's MOU Award for Excellence for the achievement of
the targets for 1989-99. The State has to make full use of the services of this State-owned, profit
making company to make available quality drugs for the people of the State.
Recommendations
•
Procedures should be established for quantifying the essential drugs required for the State, to
optimize the pooled procurement through the Rate Contract.
•
The Zilla Panchayats may make use of the rate contract for 90% of its requirements, reserving
10% for discretionary purchase.
•
Procedures should be established for developing, disseminating, utilizing & revising Standard
Treatment Guidelines.
•
Procedures should be established for developing & revising Essential Drug Lists and a State
Formulary based on treatment of choice for the on level of expertise- primary, secondary,
tertiary, speciality and teaching.
•
Every hospital should have a Pharmacy & Therapeutics Committee with defined responsibilities
for monitoring & promoting quality use of medicines. Specific guidelines for Rational Use of
Antimicrobials and Analgesic are a must.
•
Use Generic names of drugs for procurement, supply and prescribing.
- 16 -
•
Implement problem based training in pharmacotherapy in undergraduate medical &
paramedical education based on Standard Treatment Guidelines to promote Rational use of
Drugs.
•
Encourage targeted, problem-oriented in-service educational programs by professional
societies, universities and the ministry of health, and require regular continuing education for
licensure of health professionals. Involve the Karnataka State Pharmacy Council.
•
Stimulate an interactive group process among health providers or consumers to review & apply
information about appropriate use of medicines. The Karnataka State Pharmacy Council may
be involved in this training programme.
•
Train pharmacists to be more active members of the health care system & to offer better advice
to consumers about health & drugs.
•
The concept of Drug Information should be popularized among the health care professionals &
the public. Drug Information Centre must be accessed for unbiased, object information. The
Services of the Karnataka Pharmacy Council may be utilized.
•
Monitor adverse drug reactions so that appropriate and early measures can be taken to ensure
safe use of drugs.
•
Encourage active involvement by consumer organizations in public education about drugs and
allocate government resources to support these efforts.
•
Procedures should be established to ensure proper labeling of drugs. The packages and the
inserts should be adequately labeled to enable people to use drugs properly. It should also
mention most common side effects and danger signals to enable patients to contact the doctor
immediately. Special precautions in case of children, pregnant and lactating mothers, and old
people should be mentioned clearly. The labeling should be printed in adequately bold size.
The labeling in case of O.T.C. drugs should be more detailed, giving all indications,
contraindications, common side effects and danger signals. The labeling should be made in
English, Hindi and the regional language.
•
The Government Medical Stores and the District Stores to be re-organised to ensure proper and
on-time distribution of all essential drugs. Monitoring of drugs to be received from the centre,
their actual receipts and supply to be monitored vigorously.
•
The Drug Control Department to be re-organised with sufficient number of Drug inspectors and
Drug testing laboratory.
•
Establish a “ Reference Standard” and “ Working Standard” section for carrying out testing
and analysis of drugs.
•
Have a functional library for the drugs Control Department.
•
Regulation of Drug Company's Promotional Activities is important. Promotional literature for
pharmaceuticals, guidelines for sponsorship of Symposia and Other Scientific Meetings,
- 17 -
Advertisements, Free samples of prescription drugs for promotional purposes, Post-marketing
scientific studies, surveillance and dissemination of information should conform to guidelines.
•
A strategic approach is to be developed to improve prescribing in the private sector through
appropriate regulation & long-term association & collaborations with professional
associations.
•
Systems to be established to routinely monitor key pharmaceutical indicators in order to track
the impact of health sector reform & regulatory changes.
•
In view of the trends in increased use of medicines, it is essential to facilitate the establishment
of regulation and registration of traditional medicines.
•
The services of the Karnataka Antibiotics and Pharmaceuticals Limited to be made full use of,
for the production of quality drugs needed by the State.
- 18 -
- 19 -
17. LAW AND ETHICS
" Among the most important freedoms that we can have
is the freedom from available ill health and escapable mortality"
- Prof. Amartya Sen.
17.1 General
Legislation is designed for the regulation of the health profession and practice, and health care
providers (persons and institutions). Ethics is wider. It is self-regulation by the health profession.
Law tells us what we can (and more often, cannot) do; ethics tells us what we ought to do.
Constitutional Protection to Health Care
Many articles of the Constitution of India provide for health and health care of the people.
Article 47: “ The State shall regard the raising of the level of nutrition and the standard of living of
its peoples and the improvement of public health as among its primary duties….”
Law
Legislation in health helps in implementing the health policy of the government and in protecting
the society. There are a large number of Acts, Rules and Regulations, Central and State, affecting
health care and health care providers. There are laws that have direct effect on health care, but there
are many more which indirectly affect the health of the people. Among them are:
• The Medical Council of India Act, 1956
• Indian Medicine Central Council Act, 1970
• Homeopathy Central Council Act, 1973
• Dentists Act, 1948
• Nursing Council Act, 1947
• Pharmacy Council Act, 1948
• Mental Health Ac, 1987
There are laws affecting primarily industry, agriculture, food processing, pollution of air, water and
others. There are other laws such as the Law of Torts (based on the common law principle),
Criminal Liability (Indian Penal Code) and the Consumer Protection Act, under which action can be
taken for negligence or malpractice.
These Acts, the Rules framed under them and the amendments regulate the Health Professions. The
Councils have their State branches. All these are expected to play important roles in ensuring
quality of care and health professions education.
Registration of health professionals
While registration under the appropriate council (Medical, Dental, Nursing, Pharmacy) is
mandatory for the practice of the profession, the law does not require renewal of registration in
many cases (e.g., Medical Council). This leads to a situation where:
•
•
the exact number of persons practicing the particular health profession is not known;
and
the health professional may not be updating his/her knowledge, skills and attitude,
which can lead to incompetence.
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There is need for periodical renewal of registration (say, once in 5 years), with evidence of having
effectively participated in continuing education in the appropriate discipline.
Health Care Establishments Regulation:
Karnataka had the Karnataka Private Nursing Homes (Regulation) ordinance, 1976 and the Rules
there under. But, this was never implemented. A new bill has been introduced: The Karnataka
Private Medical Establishments (Regulation) Bill, 1998. This bill also needs considerable change to
make it effective. There is need for an Act, which will be regulatory and facilitatory, with Quality
Assurance and appropriately defined standards, relevant to the size, type and location of the health
care institutions (hospitals, nursing and maternity homes, physiotherapy establishments, blood
banks, pathology laboratories and others).
Accreditation
The voluntary process of accreditation of health care institutions can assure quality of service.
Standards have to be worked out by a recognised body. The institution is then inspected on behalf
of the accrediting body. Based on the results of the inspection, the health care institution may be
given accreditation. It is a process of self-regulation and is in vogue in many countries.
Consumer Protection Act, 1986:
An important piece of legislation, affecting doctors and health care institutions, is the Consumer
Protection Act, 1986. The recent judgment of the Supreme Court has brought out the applicability
of the Act. It comes into effect when there is deficiency in service by way of negligence or
incompetence. The medical profession has a duty of care. When there is breach of that duty of
care, the Act and the Rules there under come into play. Service rendered on payment of charges
comes under its purview. It is applicable even where service is rendered on payment by some and
free to others, the recipient of such service (paid or free) will be a consumer under the Act.
There have been arguments for and against the inclusion of doctors and health care institution under
the purview of the Act. There is a suggestion that in view of the possibility of frivolous complaints
which can affect the reputation of the doctor or health care institution even if the complaint is found
to be wrong, the complaint may be screened by a committee with a senior medical professional or
the redressal forum must have a senior doctor (chosen from a panel) when hearing complaints
against the doctor or health care institution.
Drugs and Cosmetics Act, 1940:
This Act and the Rules there under (1945) and the amendments control the different aspects of the
manufacture, classification, storing and use of drugs.
Right to information:
A new bill has been introduced as an Ordinance: the Karnataka Right to Information Bill, 2000.
This will lead to greater transparency in health care services.
Problems in implementation
There are many problems and loopholes in implementation of the law. One such problem is female
foeticide. To prevent female foeticide, the Prenatal Diagnostic Techniques (Regulation and
Prevention of Misuse) Act, 1994 was enacted. But it has failed to achieve the objective. Medical
termination of pregnancy is permissible (Medical Termination of Pregnancy Act, 1971 and Rules,
1975); hence, foeticide, including female foeticide, is legal. What is illegal is prenatal sex
determination and sex selective abortion. The person who conducts the sex determination (usually
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the ultrasonologist) communicates only orally; there is no written evidence. One doctor identifies
the sex of the foetus; another doctor terminates. What is lacking is ethics.
Human Organs Transplant Act, 1994:
The purpose of the Act is to stop or at least reduce the unethical practice of the sale of organs
(usually kidneys) by unrelated live donors and to promote cadaver transplants. Though the Act and
Rules laid down penalties for offences related to organ trafficking, paid organ transplantation of
unrelated donors continues. There are middlemen and touts to induce sale of kidneys by poor live
donors. The Authorization committee has not been able to reduce the unrelated transplants; so also,
there has been failure to motivate cadaveric transplants.
17.2 Quackery
Unqualified and untrained persons often practice medicine. Such unlawful practice may take
different forms:
•
•
totally unqualified person practicing medicine;
a person qualified in one system of medicine, practicing another system, in which he or she
is not qualified (cross practice).
Wrong medication can lead to adverse reactions. Inappropriate use of drugs can cause drug
resistance. Delay in proper diagnosis and treatment can be hazardous, preventing cure or causing
complications. The Karnataka State Branch of Indian Medical Association has brought forward a
draft Karnataka Quackery Prohibition Bill, which is now under consideration of the Government.
The Supreme Court in the Civil Appeal 2016 of 1996, dated 25 April 2000 (D.K. Joshi vs. State of
U.P. and Ors) gave the following directions:
“The Secretary, Health and Family Welfare Department, State of U.P., shall take such steps as may
be necessary to stop carrying on medical profession in the State of U.P. by persons who are
unqualified/ unregistered and in addition shall take the following steps.
(a)
All District Magistrates and the Chief Medical Officers of the State shall be directed to
identify, within a time to be fixed by the Secretary, all unqualified/ unregistered medical
practitioners and to initiate legal actions against these persons immediately;
(b)
Direct all District Magistrates and the Chief Medical Officers to monitor all legal
proceedings initiated against such persons;
(c)
The Secretary, Health and Family Welfare Department shall give due publicity of the
names of such unqualified / unregistered medical practitioners so that people do not
approach such persons for medical treatment;
(d)
The Secretary, Health and Family Welfare Dept. shall monitor the action by all District
Magistrates and all Chief Medical Officers of the State and issue necessary directions
from time to time to these officers so that such unauthorized persons cannot pursue their
medical profession in the State.”
Karnataka can follow these directions of the Supreme Court.
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Citizen's Charter and rights of patients
Legislation is needed to protect the right to health and patient's rights. The courts are aware of this
situation. The health care institutions, governmental and private, can voluntarily display the
Citizen’s Charter, including the rights of patients. In Karnataka, a beginning has been made in
some Government and private hospitals and in the institutions under the IPP VIII programme.
Public Health Act
There is need for a comprehensive Public Health Act that will replace the Mysore Public Health
Act. The Central Bureau of Health Intelligence, New Delhi, had brought out the "Model Public
Health Act" in 1987. The new Act in the state may be based on the Model Act, taking into
consideration later developments and especially the decentralization through the Panchayat Raj and
Municipalities enactments (73rd and 74th amendments to the constitutions).
Tobacco
The Karnataka Prohibition of Smoking in Show Houses and Public Halls Act, which will replace
the Mysore Public Health Act. 1963 prohibits smoking in show houses and public halls in the State.
This Act was a consolidation of two earlier Acts in Mysore and Coorg. It is necessary to update this
Act, knowing the hazards of using tobacco in any form and of smoking (active and passive).
17.3 Ethics
Ethics deals with the right conduct, with adherence to values. The branch of ethic that deals with
problems in health is biomedical ethics. It assures the profession and the public a standard of
professional relationships and behaviors. It is necessary that all health professionals are aware of
the code of conduct and practice accordingly.
Cardinal principles:
There are four main principles in medical ethics.
1.
Beneficence: Doing good. Medical intervention must be for the good of the patient. There
is a hierarchy of values in Medicine.
• Preservation of life. There is sanctity of life and right to life.
• Relief of suffering and care of the person.
• Cure of the disease.
• Prevention of disease.
• Promotion of health.
There are many cases of inadequate care and unnecessary investigations and useless,
avoidable treatment
2.
Non-malfeasance: Primum non nocere: first of all do no harm. Harm can happen through
negligence or incompetence or lack of concern for the patient, e.g.; irrational use of drugs
can cause harm.
3.
Autonomy: Every person (patient) has the right to determine what shall be done to his / her
body. It is part of individual liberty and choice. We were accustomed to paternalism and
subscribe to thinking “doctor knows best”. But the situation today is different. Medical
intervention should be carried out only with the voluntary, informed consent of the patient
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and the community, when it affects the community. The duty of the doctor is to inform the
individual (and the community) of the pros and cons, benefits and risks of the proposed
intervention, listen to the person (and the community) and take suitable action. A major
cause of action is that the doctor did not get informed consent.
4.
Justice: Doctors are responsible to the society. Justice includes social and distributive
justice and non-discrimination. Included in this concept are honesty, integrity and equity.
Medicine in an unjust society is likely to be unjust. Can our health programmes help to
reduce the injustice? Will our programmes be in favour of the needy and the disadvantaged?
Code of conduct
To guide the medical practitioner on the professional path, there are a large number of codes of
conduct, ancient and modern. Among them are:
• Atreya anushasana.
• Charaka Samhita
• Sushruta Samhita
• Oath of Hippocrates
• Declaration of Helsinki on Human Experimentation.
• Geneva declaration.
• Tokyo declaration on torture.
• International Code of Medical Ethics.
• Code of Ethics of Medical Council of India.
• ICMR guidelines on Research.
The best known among them is the Hippocratic Oath (Hippocrates of Cos, Greece). Most of the
graduates in Medicine take a modified oath at the time of graduation or registration. The Code of
Ethics of the Medical Council of India, 1970, is binding on the profession in India. It is elaborate
and consists of general principles and duties of the doctor to the patient, to the profession, to each
other and the public.
Teaching and learning of medical ethics
The Rajiv Gandhi University of Health Sciences has included the teaching and learning of Medical
Ethics in the curriculum. It is necessary that it be implemented seriously so that all graduates are
aware of the problems and are enabled to tackle them ethically.
The ethical problems facing the health professions concern mainly three areas :
•
Professional conduct of the health professional in relation to the patient, other health
professionals and the public.
•
Ethical problems at the beginning and end of life.
•
Problems of social justice and equity in health.
Problems relating to professional conduct
• Malpractice, negligence, incompetence, unethical advertisements.
• Autonomy of patient, beneficence, non-malficence
• Informed consent
• Confidentiality; privacy
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•
•
•
•
Irrational use of drugs / technology
Organ transplantation
Human experimentalism
Conduct towards colleagues, peers and public.
Problems connected with the beginning and end of life
• Right to life; quality of life
• Genetics
• Fertility, contraception, abortion
• Sex pre-selection, female foeticide, infanticide
• Assisted reproductive technology
• Care of terminally ill
• Euthanasia
Problems involving social justice and equity in health
• Right to health
• Health policy; allocation of resources; costs to patient, family and society.
• Distributive justice in health care
• Commercialization of health care.
Professional Misconduct
The Medical Councils constituted under the enactments in India are vested with powers to
investigate and take disciplinary action against the doctor for professional misconduct, which is also
referred to as “infamous conduct”. The State Medical Council has the power to remove the name of
the doctor indulging in professional misconduct from the register, thus disentitling them from
practicing as doctors. But the powers are seldom exercised.
HIV infection and AIDS
Important legal and ethical issues have arisen concerning HIV infection and AIDS :
• Public health notification; individual good vs. public good.
• Confidentiality; consent for testing vs. mandatory testing.
• Right to health care and medical attention.
• Employment of HIV positive persons and pre-employment testing.
A major ethical problem is the stigmatization by the society of persons with HIV infection.
COUNCILS
Karnataka Medical Council
The Karnataka Medical Council was established by an Act of the legislature (Act no. 34 of 1961).
The Council provides registration to doctors qualified in Modern Medicine. The Council is
empowered to enforce the code of medical ethics. It can conduct enquiries regarding professional
conduct, negligence, moral turpitude, false certification and infamous act. It can award punishment
to the erring doctor, byway of warning, suspension or removal of the name from the register.
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The Karnataka Medical Council has suggested some amendments to the Act.. Among them are
•
empowering the council to remove quackery by suitable legislation;
•
the Consumer Protection Courts to consult the Council while deciding on cases where doctors
are involved;
•
the President of the Indian Medical Association, State Branch, may be an ex-officio member
of the Council; and
•
Continuing Medical Education to be made compulsory for all medical practitioners.
Forensic Medicine
There is need for better training of medical officers at various levels in dealing with medico legal
cases, conduct of postmortems and appearance in the Courts of Law. This training can form part of
the induction training and be reinforced periodically.
Recommendations
▪
Implement effectively the existing laws affecting health and health care, and especially the laws
such as the Human Organs Transplant Act, 1994 and the Prenatal Diagnostic Techniques Act,
1994.
▪
Renew the registration of health professionals in the State once in 5 years, with evidence of
sufficient credits of having participated in approved continuing education programmes.
▪
The respective councils should ensure that the members of the profession practice ethically,
following their codes of conduct. This may be done through an amendment of the respective
Acts.
▪
Enact a comprehensive law to ensure registration and quality assurance of all health care
institutions in the state, on the lines suggested by the Task Force and forwarded to the
Government. Promote accreditation.
▪
Enact a comprehensive Public Health Act, based on the Model Public Health Act (1987) with
suitable modifications.
▪
Examine in depth the problem of quackery and take effective steps to stop it.
▪
Arrange for monitoring of the activities under the Human Organs Transplant Act, by an
independent agency, to stop the sale of organs.
▪
The Appropriate authority for Organ Transplantation may be reconstituted with inclusion of
representatives of voluntary organisations.
▪
Every health care institution to have a charter of citizens rights and rights of patients. The
Charter should be displayed prominently.
▪
Update the "Prohibition of Smoking Act". Increase the tax on tobacco products. Ensure the
welfare of tobacco growers when cultivation is restricted and of beedi workers when
manufacture and use is reduced.
▪
Make the teaching/learning of ethics as part of health professions education.
▪
Make the health personnel aware of the codes of conduct. Have training programmes in
medical ethics for all health care personnel and particularly the doctors and nurses.
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Appendix
Laws and Health Care: Some of the Acts
1. Karnataka Private Nursing Homes (Regulation) Ordinance 1976 and Rules 1976. Karnataka
Private Medical Establishments (Regulation) Bill, 1998.
2. Medical Termination of Pregnancy Act, 1971 and Rules 1975.
3. Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuse) Act, 1994 and Rules
1996.
4. The Transplantation of Human Organs Act, 1994 and Rules, 1995.
5. Drugs and Cosmetics Act 1940 and Rules, 1945; The Drugs (Control) Act, 1950; The Drugs
(Prices Control) order, 1995.
6. Drugs and Magic Remedies (Objectionable Advertisements) Act, 1954.
7. The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full Participation)
Act, 1995 and Rules, 1996.
8. The Mental Health Act, 1987.
9. Epidemic Diseases Act, 1897.
10. Consumer Protection Act, 1986 and Rules, 1987.
11. Maternity Benefit Act, 1961.
12. Dangerous Drugs Act, 1930.
13. Narcotic Drugs and Psychotropic Substances Act, 1985.
14. Poison Act, 1919.
15. The Industrial Disputes Act.
16. The Water (Prevention and Control of Pollution) Act, 1974.
17. The Air (Prevention and Control of Pollution) Act, 1981.
18. The Environment (Protection) Act, 1986
19. Hazardous Wastes (Management and Handling) Rules, 1992.
20. Insecticides Act, 1968.
21. Infant Milk Substitutes Act, 1992.
22. Prevention of Food Adulteration Act, 1954 and Rules 1955.
23. Fatal Accidents Act, 1855.
24. Personal Injuries (Emergency Provisions) Act, 1962.
25. Personal Injuries (Compensation, Insurance) Act, 1963.
26. Medical Degrees Act, 1916.
27. Indian Medical Council Act, 1956 and Rules, 1957; Medical Council of India
(Regulations on Graduate Medical Education) 1997.
28. Indian Medical Council (Amendment) Act, 1993.
29. Indian Medicine Central Council Act, 1970.
30. Homeopathy Central Council Act, 1973.
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31. Dentists Act, 1948.
32. Nursing Council Act, 1947.
33. Pharmacy Act, 1948.
34. Cigarettes (Regulation of Production, Supply and Distribution) Act, 1975.
35. The Mysore, Ayurvedic & Unani Practitioners Registration and Medical
Practitioners Miscellaneous Provisions Act, 1961 and Rules 1964.
36. The Minimum Wages Act, 1948.
37. The Biomedical Waste (Management and Handling) Rules, 1998.
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1
18. INDIAN SYSTEMS OF MEDICINE AND HOMOEOPATHY (ISM&H)
"By doing well the duty which is nearest to us,
the duty which is in our hands now, the make ourselves stranger;
and improving our strengths in this manner step by step,
we may even reach a state in which it shall be our privilege
to do the meet coveted and honoured duties in life and society."
- Swami Vivekananda
Introduction
A large part of our population utilizes Indian Systems of Medicine, Homoeopathy and other systems
of healing, to meet health needs. A variety of community based local health cultures also exist.
But, the budget allocation and support to these systems and traditions is very meagre.
Many life threatening infectious diseases have been effectively controlled, leading to increased life
expectancy. This has created situations of challenging chronic diseases. The role of Indian Systems
of Medicine, Homoeopathy, and other traditions effectively combating these chronic diseases that
are refractory, non-life threatening and often disabling, is important. ISM & H have been providing
health care at grass root levels for several years. Its importance has been recognised and the
Department of ISM&H was bifurcated from the Department of Health & Family Welfare in 1972.
Despite the popularity of these systems, it is observed that they have problems in the Government as
well as in the private sector. Problems exist at several levels in medical education, health services,
research, manufacturing and practice. There is an urgent need to review these problems,
undertake remedial measures, revive and revitalize these systems in order to offer a range of
safe, cost effective, curative, and preventive therapies-which could be very useful in realising
the goal of ‘health for all’.
18.1 Department of Indian Systems of Medicine and Homoeopathy (ISM&H)
The Department renders Medical relief to the Public in Ayurveda, Unani, Homoeopathy,
Naturopathy, Yoga and Siddha systems of medicine. It regulates Medical Education, Drug
Manufacturing, publication of books and practice of medicine in these systems.
Table 18.1: ISM&H Budget: 2000-2001
Budget: 2000 - 2001
State Sector
C.S.S
District Sector (Z.P)
Total
Grand Total:
Plan
320.00
7.90
319.28
647.18
35.01 Crores
Non-Plan
1539.36
1314.00
2853.36
(Rs. in lakhs)
Total
1859.36
7.90
1633.28
3500.54
2
Health Services
There are 93 Hospitals and 609 Dispensaries functioning in the State as on 1-4-2000. The Systems
wise break up is given hereunder.
Table 18.2: ISM&H Hospitals and Dispensaries
Name of the System
Ayurveda
Unani
Homoeopathy
Nature Cure
Yoga
Siddha
Total
No. of Hospitals
68
11
07
03
03
01
93
Bed Strength
1077
202
100
26
15
10
1430
Dispensaries
521
48
35
05
----609
Ayurveda
16 Ayurvedic Hospitals are at District Level of which the following three serve as teaching
hospitals.
1.
2.
3.
Institute
Sri Jayachamarajendra Institute of Indian Medicine, Bangalore
Government Ayurvedic College and Hospital, Mysore
Government Taranatha Ayurvedic Hospital, Bellary.
Bed Strength
225
140
85
There are 38 Taluk Level Hospitals; 14 Ayurvedic Hospitals are in rural areas, each with bed
strength ranging from 5 to 10. There are 521 Ayurvedic Dispensaries in the State.
Unani
There are 11 Unani Hospitals and 48 Unani Dispensaries in the State. The Unani wing (100 beds)
attached to Sri. Jayachamarajendra Institute of Indian Medicine, Bangalore serves as a teaching
hospital for Government Unani Medical College, Bangalore.
Homoeopathy
There are 35 Homoeopathic Dispensaries in the State. The Government Homoeopathic Hospital
functioning at Bangalore with 40 beds serves as a teaching hospital to Government Homoeopathic
Medical College, Bangalore. Four more 10-bedded Homoeopathic Hospitals are functioning at
Somavarpet, Hassan, Mysore and Shimoga. Two more 10-bedded hospitals have been sanctioned at
Bijapur and Kolar.
Naturopathy
One 6 bedded Nature Cure Hospital is functioning at Mysore and another two at Bangalore and
Bellary with 10 beds each. There are 5 Nature Cure Dispensaries in the State.
Yoga
Yoga wings with 5 beds each have been established in teaching hospitals at Bangalore, Mysore and
Bellary. Here Yoga classes are being conducted regularly for the public and for the patients of the
Hospital.
3
Siddha
A Siddha wing with 10 beds has been provided in the Sri Jayachamarajendra Institute of Indian
Medicine, Bangalore.
Utilisation of Health Services
Several hospitals, dispensaries and institutions were established decades ago; some nearly a century
old. Some of them are located in prime places of the state like Bangalore, Mysore, Bellary,
Shimoga, Bijapur, Tumkur, Hassan etc., During the last couple of decades, the utilization of these
health services has nose dived due to two factors: lack of infrastructure and personnel.
Infrastructure
There is no ISM&H hospital in the State that can offer all the necessary diagnostic facilities,
hygeinic wards, toilets and bath room, linen, basic communication equipment like intercoms,
telephones, ambulance, herbal gardens, mattresses, water, sewage and waste disposal systems,
electricity, fans, special pay wards, well equipped pharmacy and stores, labour room, panchakarma
theatre, kitchen etc. Information and registration centres to assist and help the patients who are
desirous of admission are not available.
Personnel
Most dispensaries and hospitals lack the necessary strength of medical, para-medical and other staff.
Norms have to be worked out. The existing staff lack drive, dynamism and courtesy for patient
care. There are many instances of ignorance related mishaps, uncaring attitudes of nursing staff and
pharmacists; while housekeeping staff are not duty bound.
18.2
MEDICAL EDUCATION
There are 61 colleges under the Indian Systems of Medicine and Homoeopathy. System wise
details are given in the table.
Table 18.4: ISM&H Colleges as on 01-04-2000
Colleges
System
Private
Government
Aided
Unaided
Total
Ayurveda
3
5
35
40
Unani
1
-1
1
Homoeopathy
1
-13
13
Naturopathy
And Yoga
--2
2
Total
5
5
51
56
Grand
Total
43
2
14
2
61
The total intake capacity in these colleges is 2570 students (Ayurveda - 1760, Unani - 80,
Homoeopathy - 665 , Naturopathy and Yoga - 65)
4
A Post-Graduate Degree Course in Ayurveda (M.D) is being conducted in the colleges mentioned
below.
Government Ayurvedic Medical College, Bangalore:
a) Dravyaguna
b) Shalya tantra
c) Shalakya Tantra : each 7 seats (intake)
Government Ayurvedic Medical College, Mysore:
Kayachikitsa - 10 seats (intake)
Government Taranatha Ayurvedic Medical College, Bellary:
Rasashastra and Bhyshajya Kalpana - 7 seats (intake)
Unani
The Government Unani Medical College at Bangalore is functioning with an intake of 50 students.
One Private Unani Medical College is functioning at Gulbarga with an intake of 30 students. Two
more colleges were sanctioned, one at Tumkur and another at Bijapur, but they are not started so
far.
National Institute of Unani Medicine
It is being established in Bangalore by the Government of India, The Government of Karnataka has
agreed to pay Rs.5 crores lumpsum payment in 4 years instead of releasing 1/3 share of total
Recurring and Non-Recurring expenditure every year.
Homoeopathy
One Government Homoeopathy Medical College is functioning in Bangalore with an intake of 40
students. 13 Private Homoeopathic Medical Colleges are functioning at different places of
Karnataka. A Private Homoeopathic Medical College at Humnabad (40 seats) was sanctioned but
not started so far.
Naturopathy
A Diploma course conducted at the Government Nature Cure and Yoga College, Mysore has been
upgraded to a Degree course which will be started during this year. One private Nature Cure and
Yoga College is functioning at Ujire with an intake of 40 students. Another Private Nature Cure and
Yoga College was sanctioned at Moodbidre (25 seats) during 1999-2000 but not started so for.
Research
There is a Research wing attached to Sri.Jayachamarajendra Institute of Indian Medicine,
Bangalore. Clinical Research is being conducted for Tamaka Swasa disease.
A Clinical Research Unit in Unani system of Medicine has been established at Sri
Jayachamarajendra Institute of Indian Medicine, Bangalore by the Government of India. Here
research on skin diseases, Psoriasis, Eczema and Rheumatoid Arthritis are in progress.
5
18.3
DRUG CONTROL
The Department regulates manufacture of Ayurveda, Unani and Homoeopathic Medicines and sale
of Homoeopathic medicines from December 1976 onwards. The number of licences issued so far,
for manufacture of Ayurveda, Unani and Homoeopathic medicines and sale of Homoeopathic
medicines are as follows.
Table 18.5: Manufacturers and Licence Holders as on 1-4-2000
Systems
No. of Manufacture No. of loan Licence No. of Sales
Licence Holders
Holders
Holders
Ayurveda
225
32
-Unani
12
--Homeopathy
11
-Whole Sale
Retail
Total
248
32
Licence
59
114
173
Government Central Pharmacy, Bangalore
Ayurveda and Unani medicines are being manufactured at the Government Central Pharmacy,
Bangalore and supplied to all the Government Ayurvedic and Unani Hospitals and Dispensaries in
the State.
Drug Testing Laboratory
This unit has been established to ensure the quality of raw drugs and medicines at the Government
Central Pharmacy, Bangalore.
Herbal Gardens
Herbal Gardens are being maintained at Bangalore, Mysore and Bellary which are attached to
respective Ayurvedic Colleges. Further the "Dhanwantri Vana" has been developed on 30 acres of
land near Bangalore University campus. About 500 medicinal plants are raised so far.
Publication Cell
There is a publication cell in the Directorate. So far, 58 books relating to Indian Systems of
Medicine and Homoeopathy are published by this Cell.
Practice of medicine
There are 2 Statutory Boards to regulate the practice of Medicine.
i)
Karnataka Ayurvedic and Unani Practitioners Board, Bangalore:
This Board regulates the practice of medicine in Ayurveda, Unani, Siddha, Naturopathy and
Yoga. The total number of practitioners registered as on 01-04-2000 are as follows.
Table 18.6: ISM&H Practitioners registered (1-4-2000)
Ayurveda
13,834
Unani
901
Integrated System of Medicine
2,376
Naturecure & Yoga
79
Siddha
2
Total
17,192
6
ii)
Karnataka Board of Homoeopathy System of Medicine, Bangalore.
The Board regulates the practice of medicine in Homoeopathy.
registered in Homoeopathy as on 01-04-2000 are 6,326.
The number of practitioners
Private institutions
There are 56 private colleges of ISM &H which have their own hospitals with inpatient and
outpatient facilities. Two Ayurveda colleges run by SDM educational Trust, Kuthapady at Udupi
and Hassan have full fledged facilities including surgical theatres. ALN Rao Memorial Ayurvedic
Medical College at Koppa has an exclusive Ayurveda hospital and research centre, conducting postgraduate level research and educational activity.
A.M.Shaikh Homoeopathy Medical College, Belgaum is one of the oldest college and hospitals
with the highest number of admission facility of 100 seats, followed by Fr.Muller's Homoeopathy
Medical College, at Kankanadi, Dakshina Kannada having 75 seats.
SDM College of Naturopathy and Yogic Sciences, Ujire, D.K., has admission strength of 40 seats.
7
Budget Provisions of the Department and Expenditure during the last 3 years (Rs.in Lakhs)
Table 18.7: Budget Provision:1997-98
Scheme
Budget
Expenditure
Surrender
Reasons
During the year 1997-98 there was a plan cut.
A sum of Rs./50.96 lakhs under Plan was
surrendered. Under the Non-Plan schemes due
to non-filling up of vacant posts and savings a
sum of Rs.159.28 lakhs was surrendered.
Under the CSS a sum of Rs.2.17 lakhs
expenditure was incurred as against the
provision of Rs.6.00 lakhs. The Govt. of India
is reimbursing the amount spent initially.
Estimates
Plan
150.00
99.05
50.95
Non-Plan
1196.35
1037.07
159.28
C.S.C(10
6.00
2.17
1352.35
1138.39
0%)
Total
210.23
Table 18.8: Budget Provision: 1998-99
Scheme
Budget
Expenditure
Estimates
Surrender
(Laps)
Plan
200.00
128.69
71.31
Non-Plan
1296.12
1082.69
213.43
C.S.C(100
6.00
4.23
1502.12
1215.61
-
%)
Total
Reasons
The new proposals were sanctioned during the
end of the financial year. Hence the new posts
could not be filled up. So also new hospitals and
offices could not be started and due to low
progress under capital outlay by PWD there is
savings under plan. Due to vacant posts and
control over other expenditures there is savings
under Non-Plan.
84.74
Table 18.8: Budget Provision: 1999-2000
Scheme
Budget
Expenditure
Estimates
Surrender
(Laps)
Plan
270.00
241.24
28.76
Non-Plan
1547.43
1464.94
82.49
8.00
5.76
1825.43
1711.94
C.S.C(100%)
Total
Reasons
-
111.25
Due to slow progress under capital
outlay there is savings under Plan.
Due to vacant posts and control over
other expenditures there is savings
under Non-Plan.
8
18.4 PROBLEMS
1. Vacancies
In order to share, support and assist the efficient functioning of department with the Director, a
Post of Joint Director was created by the Govt. in the year 1999. This is lying vacant till date,
and has to be filled up to improve functioning.
2. District level officers
At present there are four Deputy Directors located in four revenue divisions; they are not able to
attend the Zilla Parishad (ZP) monthly meetings because the meetings of all the ZPs fall on the
same day. Besides, the administration and services are centralized, making it difficult to reach
district and subdistrict levels. Hence there is a need for district level officers.
3. Pay Disparities
3.1. Teaching and non-teaching cadres
Most dispensaries of Indian Systems of Medicine and Homoeopathy are functioning in the
rural areas; 30% of these are located in remote areas. The physicians of ISM & H are
rendering medical service to the rural people in Ayurveda, Unani and Homoeopathy
system of Medicine. The cadres of lecturer, Assistant Professor, Professor and Principal
(teaching) exist in the collegiate branch of the department of ISM & H.
There is disparity in the pay scales among the non teaching and teaching cadres even
though the basic qualification prescribed for the initial appointment to Group-B posts of
non- teaching and teaching cadres viz., physician Grade – II and lecturer is a degree
awarded by a University. This disparity in the pay scales among physicians and teachers
prevailed in the 1977, 1982, 1987, 1994 revision of pay scales. However the Government,
in its order-dated 27.8.1997 merged the posts of physician GR-III with physicians GR-II.
The pay scales of physician GR-II and lecturer were made equal.
Now government has extended the benefit of AICTE scales of pay to the teaching staff of
the colleges of ISM & H, creating a disparity between the non-teaching and teaching
cadres in the department.
3.2 Disparity between pay scales of ISM & H doctors and allopathic doctors
The minimum qualification for admission to the course, the duration of the course, the
period of internship is one and the same for both ISM & H and Allopathic Medical
courses. The duties and responsibilities of officers of both systems are similar.
The Government of India, Government of Tamilnadu and Government of Uttar Pradesh
are understood to have granted equal pay scales to the ISM & H doctors and Allopathic
doctors.
9
4. Inadequate Infrastructure
• Most of the dispensaries and hospitals of ISM & H are in remote places and housed in substandard rented or donated buildings. These are unattended to for repairs and renovations
and do not offer a congenial atmosphere for health care.
•
There are fewer dispensaries (below 10) in Kodagu, Udupi, DK districts and only one
hospital in Davangere, Dakshina Kannada, Dharwad and Gadag Districts. Udupi does not
have a government hospital. In these districts ISM & H are popular among the public.
5. There have been efforts of mainstreaming of ISM & H at national level in order to utilise the
expertise of the practitioners of these systems for RCH & National Health programmes. The
immediate availability of these doctors in the centers of mainstream medicine is important for
consultation and referral.
6. Many ISM & H dispensaries are supplied with insufficient quantity of prepared medicines
which are constituted mainly with herbs and herbomineral ingredients.
7. ISM & H dispensaries and hospitals are established in the available accommodation and
infrastructure. Eventually it has resulted in non-uniformity in respect of plan, space,
infrastructure, staff and etc.
Given the above situation there has been no provision of residential accommodation for the
work force in these dispensaries and hospitals. This has led to medical and paramedical staff
searching for accommodation away from their place of work and often out of the village, town
or even district. The reason for irregularity in attendance and services has been attributed to
these factors.
8. Laboratory Services
The need for accurate clinical diagnosis with well-supported laboratory services is indisputable.
Many of the major ISM & H hospitals are running with primitive and out dated laboratories.
These hospitals do not even have facilities to do the routine laboratory investigations. Even
major ISM & H hospitals are not equipped with laboratory for advanced investigations, like biochemical, microbiological, ECG and ultrasound scanners.
9. Doctors of ISM & H were recruited on contract basis a couple of years ago for an urgent need to
streamline and efficiently deliver health care service. Their appointments must be regularized
following performance appraisal.
10. The Boards of visitors of all the major hospitals of the state have not been re-constituted for the
last several years.
11. None of the dispensaries and many of the hospitals are not connected through telephone
facilities. This has resulted in lack of communication and coordination between the central and
peripheral organisations.
12. Non-communicable chronic diseases are on the increase. The therapeutic approaches of
detoxification, rejuvenation and rehabilitation are well delivered through a group of Ayurvedic
procedures called Panchakarma as well as Ksharasutra especially in ano-rectal disorders like
fistulas. District hospital needs to be fully equipped for these procedures.
10
13. Referral system
In order to undertake special treatments and consultancy for the patients attending dispensaries,
there is need for an establishment of referral service system.
14. With an increased attendance for OP department of the major hospitals situated at Bangalore,
Mysore and Bellary, there is not enough space, equipments, and other infrastructure to offer
better service.
15. Procurement of Medicines
The existing budget allocation for procurement of medicines in dispensaries has been
Rs.18,000/- per annum which is very insufficient to cater to all the patients who attend these
dispensaries. It is essential to increase this budget substantially.
Medical education
16. At present the admissions to UG courses in ISM & H is based on merit in pre-university
examinations along with the quotas of reservation. A CET examination may be instituted for
admission to these courses.
17. There are complaints that the top scorers in P.U. Examination who get admitted in order of
merit at Bangalore, Mysore and Bellary Government Ayurvedic medical colleges fail or under
score in the undergraduate examinations and the average and below average PU students who
are admitted to private Ayurvedic medical colleges in the state are awarded high merit; as a
result, the graduates of the private colleges secure PG seats based on the so-called merit. A
common entrance test for admission to postgraduate examination could reduce this problem.
18. The Central Council of Indian Medicine has stipulated 14 separate departments of different
disciplines in Ayurveda at UG level with qualified people in the faculty, whereas there are only
eight departments in all the Government Ayurvedic Medical Colleges. There is a mismatch
between qualifications and the subjects taught. This has resulted in reduction of quality of
teaching, knowledge and expertise. It is also possible that the CCIM (Apex Body) may at any
time de-recognise these colleges of Ayurveda.
19. Hostel Facility
Many of the major medical colleges are not having hostels for boys pursuing UG & PG studies.
20. Disparity in stipend
The candidates of under graduate courses at the end of 4 1/2 years study will have to undergo 1
year of internship, during which a monthly stipend of Rs.2250/- is paid; internees of modern
medicine for the same period are receiving Rs.3250/- per month. Similarly the students of ISM
& H pursuing M.D. Course for three years are receiving Rs.3100/-, Rs.3300/- and Rs.3500/- per
month as compared to their counter parts in modern medicine who are given Rs.5200/-,
Rs.5400/- and Rs.5700/- per month in I, II and III Year respectively.
11
21. Training Facilities
With the expansion of health care facilities along with provision of specialty treatment, it has
been very difficult to offer these without the availability of trained paraclinical staff. Similarly
to propagate these systems to the community, there are no trained and informed health extension
workers.
Even in case of nursing staff there has been a need for training in ISM & H treatment methods,
as they have to handle the patients in a very special way. There is also a need for trained
pharmacists who have to handle these natural medicines with a scientific method of dispensing.
22. The practitioners of ISM&H who are rendering their services in remote places are deprived of
having an access to the information and updating of their knowledge and skills. There is need
for Continuing Medical Education.
In 1974, Government of Karnataka had introduced a reservation of two seats in all the four
Govt. Medical Colleges (Bangalore, Mysore, Bellary and Hubli) for the graduates of Ayurveda,
who were interested in pursuing M.B.B.S. course. A couple of years later it was withdrawn for
unknown reasons.
23. Public Awareness Programmes
23.1. The need for further popularising these systems for the lay public is necessary. There
has not been either an effort or a unit for the purpose under DISM & H
23.2. Awareness regarding these systems at primary educational levels is not existing. The
inclusion of these subjects in the syllabus and curriculum would enhance the recognition
of values of these systems.
Drug control
24. Government Central Pharmacy
At present the government Central Pharmacy is manufacturing Ayurvedic and Unani drugs to
cater to all the dispensaries and hospitals in the state. These are manufactured with outdated
technology, with least consideration for quality, stability and efficacy. The pharmacy
manufactures medicines in insufficient quantities to dispense all through the year. The
pharmacy has to comply with the recently notified GMP guidelines by Government of India. It
has to be upgraded within two years.
25. Homeopathic Drug Manufacturing
The department does not have facilities to manufacture Homoeopathic drugs to cater to all the
dispensaries and hospitals in the State. This has to be rectified.
26. With the advent of enforcement of Good Manufacturing Practices (GMP) the small-scale
industries have to comply with the test of quality when they apply for manufacturing licence.
27. Assistant Drug Controller
The number of manufacturers of ISM&H is increasing due to the demand and need for these
drugs in the market. The drug licensing authority under DISM&H has only two drug inspectors
for Ayurveda, Unani & Homeopathy. The work pressure for the authority is increasing with the
12
acceptance of loan licensing procedures in addition to main manufacturing units. There is need
for more drug inspectors.
28. Homoeopathic Drug Inspector
The manufacture of Homoeopathic medicines is different in terms of ingredients and technology
from that of other Indian systems of medicine. At present the licensing authority does not have
a qualified homoeopathic doctor as a drug inspector.
29. Collection, Preservation and Utilisation of Medicinal Plants
There are several major global and national pharmaceutical manufacturing companies operating
in Karnataka. Besides them, there are many medium and small-scale manufacturers who are
also operating internationally. They require many plant materials for their products. There are
no Nodal Agencies either at Govt. level or NGO level available to cater to the needs of these
industries or control and support the operations in collection and preservation in natural
environment as well as cultivation of these plants which are in demand.
Research
30. The research is a part of continuing process, which would help to update the knowledge, make
contemporary the application of ancient knowledge, as well as provide an evidence base for all
these systems to be accepted in the scientific world. There is only one research unit in
Bangalore which is devoid of a senior research officer to guide the research projects. The
Research Advisory Committee is not functioning.
31. With the impetus to research on these ancient systems which needs to be put to test with modern
scientific tools, there is a need for establishment of a multi-disciplinary team in the field of
ISM&H medicine.
32. Deputy Registrar of ISM&H at RGUHS
Post graduate research project protocols are submitted to RGUHS as a mandatory procedure for
the award of MD degree. These protocols must be screened by the Health University with the
help of experts who are qualified or trained in these systems.
Similarly at undergraduate levels there is confusion regarding the matters of examination,
syllabus, training etc. Hence, there is a need to appoint a qualified person from ISM&H as a
Deputy Registrar.
33. The research grants by the government to post graduate students is a very meager amount of
Rs.600/- for the course, which is insufficient. This results in dilution of interest to do research
amongst the PG students
There has been no financial support for research amongst practitioners or private institutions or
private institutions or private industry. Research and Development activities are facing an acute
financial crunch that has resulted in disinterested attitudes towards conducting any substantial
research projects that may include health promotion, prevention of disease and unique
therapeutic measures.
34. The promotional opportunities for all technical cadres in the department of ISM&H has been
delayed, which has resulted in demoralization of the work force in this department
13
Medical practitioners
35. With the increased awareness, interest and need of the ISM&H health care services, the
Government should include these qualified practitioners in the list to be considered as
authorized medical attendants or area doctors which would benefit the patients.
36. It is necessary for the Govt. to update the list of reimbursable drugs and should add the cost of
panchakarma and other rejuvenation therapies for reimbursement to its employees who
undertake these treatments. Furthermore the insurance companies should cover the cost of these
specialized therapies for the employees of public sector undertakings, banks and other
institutions.
37. Registration / regulation
The government should also come out with a list of authorized ISM&H health service centers
run by the private individual or institutions for reimbursement facility, after working out the
norms.
38. In order to recognize and reward the traditional practioners of ISM&H who are economically
backward and involved in social service the government has sanctioned Rs.250/- per month as
pension. This has to be increased as the existing amount in very meager.
39. The private practitioners depend on the raw materials for making medicinal products to be
dispensed in their dispensaries. To procure these raw materials that are mostly herbal, they
approach the forest and other natural habitats for collection of plants and their parts. This has
resulted in the depletion of many medicinal plant genetic resources.
40. It is necessary to provide about 100 acres of land for DISM&H in each district for cultivation of
medicinal plants which should be harvested and utilised by the Government Central Pharmacy.
41. There is a departmental service manual for ISM&H written several years ago. It is necessary to
revive and review this manual for immediate implementation, which would streamline the
whole organisation.
42. There is need for an in-house journal. This may be published in collaboration with the
Pharmacy Council and should be useful to doctors of ISM&H and other health workers.
43. It is necessary to ensure that doctors qualified in a particular system practise only in that system
(avoiding cross-practice). They must be happy to own that system. It has been reported that
ISM&H qualified doctors prescribe allopathic medicines. This should be discouraged.
44. Training in hospital management is necessary for doctors in charge of the hospitals.
14
Recommendations
•
The sanctioned post of Joint Director is to be filled. In the absence of C & R rules a competent
senior person may be placed in charge and duties may be assigned.
•
Existing senior doctors may be designated as district level officers of the respective districts. In
11 districts where there are already hospitals, it can be implemented immediately. These
district level officers posts are to be filled by selection based on merit-cum-seniority.
•
Parity in pay scales with those of modern medicine to be considered.
•
Dispensaries and hospitals are to be renovated and modernised after a survey by the
Department. There is an urgent need to construct special wards with all amenities atleast in the
major hospitals attached to teaching institutions at Bangalore, Mysore and Bellary.
•
Establish or relocate units of ISM&H with necessary infrastructure at CHCs, Taluka and
District hospitals.
•
Establish herbal gardens in ISM&H units, PHCs and CHCs for utilisation and demonstrations
for the public with the help of forest department (social forestry).
•
There is a need for developing uniform norms for dispensaries and hospitals, with regard to
plan, space, infrastructure and staff.
•
There is an urgent need for providing residential accommodation near the place of work for
physicians of ISM&H. If Government accommodation is not available, houses may be taken on
rent.
•
There is an urgent need to make available the facilities for investigative procedures with
qualified and technical staff in all the hospitals. This can be done in collaboration with the
hospitals of modern medicine at various levels.
•
The services of contract doctors need to be regularized, based on performance appraisal.
•
The Boards of Visitors are to be re-constituted immediately in order to improve the functioning
of the hospitals.
•
Provide all dispensaries and hospitals with a working telephone.
•
Establish the specialty units of panchakarma and ksharasutra in all district hospitals first and
then taluk hospitals.
•
Fill up the vacant post of Siddha Physician in the 10-bedded Siddha ward at Sri.
Jayachamarajendra Institute of Indian Medicine, Bangalore.
•
The major hospitals are to be upgraded and enlarged to meet the requirements and demands
with adequate human force, equipments and other accessories, after a need assessment.
15
•
Construct new well-planned OP blocks in all the major hospitals of Bangalore, Mysore and
Bellary.
•
There is a need to enhance the budget provision for procurement of medicines in dispensary
atleast to a sum of Rs.36,000/- p.a.
•
As per the norms of admission to modern medical colleges the application of CET and
counseling should be applied to ISM&H courses (under graduate and post graduate) with
immediate effect.
•
There is need for appointment of a person qualified in ISM&H as Deputy Registrar in RGUHS,
to look after the needs of the colleges and students in ISM&H.
•
Steps have to be taken to provide hostel facilities in all the major medical colleges
•
The disparity in stipend between internees of ISM&H and modern medicine may be studied and
action taken to remove the inferiority feeling or low esteem prevailing amongst students of
ISM&H
•
Study the need for developing appropriate training courses with special modules for paraclinical staff such as Masseurs, Nurses, Health extension workers and pharmacists and take
necessary action
•
The facilities of the State Institute of Health & Family Welfare should be made use of for the
training of ISM&H personnel. The training should include hospital management for those in
charge of hospitals.
•
CME courses must be periodically conducted to update knowledge and skills of the practitioners
of ISM&H. Sufficient credit hours must be earned for the renewal of registration by the
Karnataka Ayurveda and Unani Practitioners’ Board and Karnataka Council for
Homoeopathic Medicine. Professional and Technical support may be obtained from the
teaching institutions (Both Private and Government).
•
Ten seats may be reserved in the MBBS course in the Government Medical Colleges for eligible
ISM&H graduates, 7 for Ayurveda, 2 for Homoeopathy and 1 for Unani, to bring about
integration.
•
All the teaching institutes of ISM&H must take up defined geographic areas in order to
effectively execute public awareness programmes and for primary health care (through the
dispensaries and mobile units). The need for trained ISM&H health workers for extension work
may be studied and action taken so that they can take up health promotion work in the
periphery.
•
Introductory lessons on ISM&H systems viz., Ayurveda, Unani, Naturopathy, Yoga, Siddha and
Homoeopathy should be included in the curriculum of schools and colleges, which would create
awareness among the children. The institute of ISM&H should take up school health
programmes in the neighbouring schools.
16
•
An expert committee may be appointed to consider the upgradation of the Government
Pharmacy after studying TAMPCOL of Tamil Nadu or AUSHADHI of Kerala.
•
A Homoeopathic Drugs Manufacturing Unit may be started to make medicines in sufficient
quantities to meet the demands of the entire state.
•
To meet the increasing needs of ISM&H, a post of Assistant Drug Controller may be created
and filled up by a suitably qualified candidate
•
Qualified homoeopathic doctor may be appointed as drug inspector to inspect the
Homoeopathic manufacturing units.
•
The department of ISM&H must prepare essential drug lists for each system. A medicinal plant
board may be established which would ensure quality, consistency and price.
•
Drug testing laboratory to be established for ISM&H, with all the needed facilities. The
services of this laboratory may be made available to private manufacturers also, to improve the
quality of the medicinal products.
•
Encourage research. Appoint a Senior Research Officer in ISM&H. Reconstitute the research
advisory committee. Rajiv Gandhi University of Health Sciences may be requested to establish
an interdisciplinary research board, comprising of experts of ISM&H, modern medicine and
scientists of basic sciences.
•
RGUHS may be requested to frame standard guidelines for protocols for thesis / dissertations
for postgraduate courses in ISM&H and to create a post of Deputy Registrar for ISM&H
•
The financial support to PG researches may be enhanced to Rs.2,500/- p.a. The monthly
pension for ISM&H physicians to be enhanced to Rs 2000/- per month.
•
Encourage research in ISM&H through financial support to interested and dedicated
practitioners and private academic institutions.
•
Externally Aided Project benefit should be extended to ISM&H to achieve wider coverage,
enhance the knowledge base and application in the field of health promotion and prevention of
diseases.
•
Government should provide about 50-100 acres of land for ISM&H in each district for
cultivation of medicinal plants, which should be harvested and utilised by the Government
Central Pharmacy.
•
The government should effect immediately the promotions that are due and implement time
bound promotions
•
Appoint a qualified person competent in editing / publishing to effectively bring out publications
including health promotion materials
•
Ensure effective utilisation of budget allotted and augment the allocation where necessary.
17
•
Doctors qualified in a particular system of medicine should practice only that system; cross
practice must stop in the interest of the public and to develop the particular system of medicine.
•
Have a comprehensive HMIS for all the institutions and services under ISM&H.
18.5 COMMUNITY BASED LOCAL HEALTH CULTURES
Introduction
Folk health culture is diverse and varied. It is ecosystem and ethnic community specific. The health
knowledge in the folk stream has been generated over centuries by sensitive and intelligent people –
tribals, farmers, artisans, shepherds, barbers, housewives, wandering monks – there are also some
elements in it that have been drawn from the classical codified stream. The folk stream has
knowledge of home remedies, food and nutrition, obstetrics, bone setting, treatment of poison,
chronic and common ailments, acupressure, pulse diagnosis, use of plants, animals and minerals.
The carriers of the folk health culture are primarily millions of ordinary households. The culture
also has specialized carriers who have no legal status but enjoy a definite social legitimacy in their
own localities. These specialized carriers are birth attendants, bonesetters, herbal healers, healers
who treat ‘visha’ i.e. poisonous snake, scorpion bites and rabies, vets etc. These carriers are seen in
all rural areas in the country.
Transmission of knowledge takes place through family and community tradition, in a people to
people process guided by local cultural codes. There are a few groups researching, preserving and
promoting these valuable local health traditions. However, there is no state support and in fact there
is alienation in the culture and practices of the state health systems and local health culture. Folk
health traditions on the whole are being eroded, resulting in a loss of resources and allies to the
movement of health for all.
Recommendations
•
Revitalization of household health traditions and folk medicine by increasing the understanding
of the preventive, promotive and curative practices of local health cultures among health
personnel (through educational institutions) and through the educational system in schools and
colleges.
•
Recognising and utilizing folk practitioners such as dais (traditional birth attendants), herbal
practitioners/ healers etc. as part of the primary health care systems.
•
Systems for transmission of knowledge need to be strengthened and supported possibly through
the State Institute for Health and Family Welfare and the district training centres.
•
Conservation, cultivation and propagation of medicinal plants and other natural resources in
collaboration with the Dept. of Forestry and NGOs.
•
Research into local folk health traditions and culture to be supported through the proposed
research body.
18
18.6
OTHER HEALING PRACTICES
Various other systems and forms of healing outlined below are being increasingly used by people.
Most are non-drug based and non-invasive. They give people greater control over their own health
and healing.
a. Tibetan System of Medicine
The Tibetan System of Medicine (Amchi system) is an ancient one in vogue in India, including
Karnataka. The system traces its origin to Lord Buddha and uses many components of Ayurveda.
Treatment is by use of herbs, minerals, animal organs, spring and mineral water.
Tibetan system is being practiced wherever there are Tibetan settlements. There are many
dispensaries in India, of which 5 are present in Karnataka. The system is popular among nonTibetans also. Tibetan system has a Medical Institute at Dharmashala, Himachal Pradesh, a Tibetan
Medical College with hospital, a museum of drugs and instruments. The Central Council for
Research in Ayurveda, under the Ministry of Health and Family Welfare has a Research Wing to
carry out clinical research into the drugs used in Tibetan Medicine.
b. Reiki
• Discovered and propounded by Dr Mikao Usui in 1800, it is the ancient Japanese art of healing
by the ‘laying on of hands’. Reiki meaning universal energy in Japanese.
• A powerful and spiritual experimental technique that opens up the vision, heart, palm chakras,
third eye and other psychic abilities.
• Providing holistic, positive energy without any side effects, it can be undergone independently
or with other medical treatments.
• It enhances the body’s natural ability to heal itself and maintains equilibrium of both body and
mind to promote complete relaxation, thereby raising the life-force energy.
• The therapist first makes a body scan of the seven chakras to determine individual needs.
Actual therapy follows when the universal energy flows through the therapist into the client.
The various stages in the entire process:
The First degree stage
This is the primary stage where the patient gets attuned as the universal energy activates the patient
through transmission, for approximately four hours, over some days. When the attunement is
established, information is given on four levels of energy – physical, mental, emotional and
spiritual.
The Second degree stage
Slightly more advanced, great changes in the energy levels are achieved here and symbols are
introduced to unlock the chakras that will improve health.
The Third degree stage
In this most advanced and powerful stage, the patient is taught the intricate process of passing on
the reiki energy and ways of enhancing personal growth, transformation and increased
enlightenment.
19
c. Acupressure
Based on the principle of manipulation of crucial pressure points in the body, acupressure cures
difficult and chronic aches and pains – backaches, spondylitis, abdominal cramps, neurological
disorders, arthritis etc. These pressure points, over a 1000 of them, are often embedded in or near a
muscle or tendon. Safe and effective, it involves no pin-pricks, no heat foementation, nor any
chemical or electric stimulations. However, it is a very exact art and should be carried out by a
trained practitioner, absolutely sure about the pressure points to be tapped and the correct pressure
to be applied.
d. Acupuncture
• The modern name is derived from the Latin words Acus (needle) and Punctura (penetration). It
is, however, an ancient Chinese art of healing the sticks needles into a patient’s skin or even
muscles to correct imbalances in the ‘yin’ & ‘yang’ of the body.
• Yellow Emperor’s Classic of Internal Medicine, one of the oldest medical texts in the world,
comprises a special section called ‘Magic Gate’, which is devoted to this therapeutic style.
• Although modern acupuncture charts more than 2000 points in the body, located along invisible
energy called ‘meridians’, traditionally there were only 365.
• The western explanation for this is that a needle inserted at specific acupuncture point of the
body releases certain chemical substances, that activate neuro-transmitters, which then pass on
nerve impulses to the brain to obtain the desired effects. Must be performed by trained
practitioners only.
e. Magnet Therapy
A system of medicine that is gaining popularity and recognition all over. It is based on the principle
that the earth is one big magnet and that all our bodies are surrounded by magnetic waves
emanating from the earth and other spatial bodies, including the sun and the moon. This natural
magnetism influences and supports all forms of life. Disease is caused by the imbalance between
the various electro-magnetic forces present within our bodies. Thus strategic placement of magnets
on specific parts of the body can cure chronic ailments that standard medicine might find difficult to
control.
Some of the basic principles of this therapy are
Use of mutually opposite properties of the North and South poles. The use of two methods –
Unipolar and Bipolar. The use of only one pole on a diseased organ gives desired results but only if
diagnosis and selection of poles is correctly made. During the course of treatment the patient is
made to sit or lie down on an insulating wooden chair or bed, for best results. While shape or size of
the magnet does not matter, for sensitive organs as eyes, brain and heart, weak magnets need to be
employed. Never given on a full stomach, pregnant women should opt out of it and all metallic
objects that absorb magnetic waves should be taken off before treatment. In the treatment of skin
diseases, a cloth should be used between the magnet and the skin.
Recommendations
Currently no specific recommendations are being made to integrate these forms of healing into the
system. However, it is advisable that all physicians are aware about these systems, as many
patients use more than one system simultaneously.
20
VISION STATEMENT
There is increasing, widespread interest and recognition of the Indian Systems of Medicine and
Homoeopathy and other systems and traditions of healing, based on evidence of efficacy in many
preventive therapeutic and prophylactic situations. Collaborative studies in several research
institutions, on developing effective adaptogenic and anti-stress regiemes, show the possibility of
development of world class health interventions through integrated research, so that they not only
serve the country and the state, but also entire humanity.
The example of Japan Medical Association’s vision for its healthcare system reform, in the form of
systematization of health promotion programs at all stages of life, stands as a model for all countries
to emulate. The positive concept of “health”, that incorporates promotion of healthy living as well
as the prevention of disease, forms the core strength of these ISM&H systems. This can be
harnessed for a better healthy society of the future.
The health care coverage, which has suffered a set back, all these years for a variety of reasons
already well recognized even by the WHO lends credence to the responsibility, role and importance
of these ISM&H systems in the years to come. There is need for all round support, with plans to
efficiently utilize the services of these systems.
The next two decades will see dramatic changes in the health needs of the populations. In our
regions, non-communicable diseases such as heart disease, autoimmune diseases, depression and
others are adding on to the traditional enemies, infectious diseases and malnutrition, as the leading
causes of disability and premature death. This poses serious challenges to the health care systems
and force difficult decisions about the allocation of resources. The help of ISM&H systems, is
necessary.
These systems were not considered at par with the mainstream health services and have not been
given due recognition, which has brought about an inferiority feeling amongst the practitioners.
This has resulted in the dismal participation of these systems, although the people believe and
utilize the services of these systems at personal levels. There is a great need for support and
recognition from mainstream medicine and for the research programs for developing an evidence
base for their therapeutic utility.
With the recognition of the importance of fostering and developing positive health, there is need for
executing research projects in areas such as – lifestyles and “lifestyle diseases”, patient behaviour
studies and the behavioural medicine field, health investment and its effects and effectiveness,
assessment of health risks and integration of health information at all stages of life. This will help to
bring about total health coverage for the people and improve the quality of life.
19. PANCHAYATI RAJ AND EMPOWERMENT OF THE PEOPLE
"All the wealth of the world
cannot help one little Indian Village
if the people are not taught to help themselves".
- Swami Vivekananda
Health Management by Panchayat Institutions:
After decades of providing basic health care and building up an impressive and massive
infrastructure for this purpose, through a network of Sub Centres and PHCs, it is recognized that
these services, in the rural areas, are neither universal in reach nor adequate in quality. Health
services cannot be said to be reaching those who need it most, when they want it or in adequate
measure. This is evident from the high levels of infant and maternal mortality and prevalence of
high morbidity in the rural population. There are many reasons for this lack of access to health
services in the rural areas including skewed distribution of facilities, inadequacy of
administrative supervision, lack of training in public health or management at the micro-level,
insufficiency of supporting infrastructure such as communication and commutation facilities and
the like. However, one of the main deficiencies in the system has been the lack of mechanisms
that permitted those entitled to these services to demand them, monitor their availability and
supervise their management.
Universal health care, by definition, must be what the people perceive as their need at a point
of time and must be available where the people are. It would have to be community based and
the mechanisms for intervention by the community must be built in. The latter is appropriately
through the panchayat institutions that have been established in the State. The panchayat system
provides for the involvement and active participation of the people in health programmes
and services through local community organizations.
The advantages of involvement of the community through panchayat institutions in
implementation and management of health services are that the focus on vulnerable and special
groups would be enhanced, preventive measures would get emphasized and services would,
instead of being on a uniform pattern be modified to meet specific local needs. Inter-sectoral
coordination with programmes closely related to health such as sanitation and water supply
would also be facilitated. It is necessary to involve the panchayat institutions in the
administration of basic health services at all the three levels – village, taluka and district. In
essence, the panchayat system entitles rural communities to assert their right to health services
in terms of adequacy, quality and accessibility. However, it also casts a responsibility on the
community to assist in ensuring that their entitlements are met. The system, thus, provides for
not just entitlements but also assigns responsibility. In this process, the larger goal of
empowerment of the community is, over time, achieved.
The involvement of the panchayat in providing health services has many objectives. The
community evolves from being just recipients of information and services to being able to
vocalise their needs and expectations and assume a more “interventionist” role. The rural
population would be able to identify health needs relevant to them and project these as
requirements. Community participation would also improve the perceptions of the people
regarding better health practices and regarding associated areas such as nutrition, sanitation,
water supply and the like.
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Karnataka Panchayat Raj Act, 1993
The mechanisms for the involvement of the rural community in development programmes,
especially in the social sector including health, have been established by the enactment of the
Karnataka Panchayat Raj Act, 1993. The Act specifies the responsibilities of these bodies
regarding health services. It also prescribes the mechanisms, through Committees, for
performance of these duties and for the involvement of the community.
However, it must be recognized that for participation of the community in the total sense, as
envisaged in the Act and as recognized as essential, to be successful, certain pre-conditions
would have to be satisfied. These include the:
(i) availability of information to the community
(ii) the development of the consciousness that health is a community concern
(iii) a forum that provides for and permits intervention by the community and
(iv) the acculturation and sensitization of the official agencies that provide health services.
These are inter-linked. It also includes a clear definition of the roles of each of the
partners in health – the community represented by the panchayat body and the official,
professional agency. The perception of mutual roles of the panchayat body and the health
officials must be clear.
The Act provides for community intervention and management of health services in the local
area at the levels of the village through the Grama Panchayat, the taluka through the Taluka
Panchayat and the district through the Zilla Panchayat. It casts responsibility on these
institutions for planning and management of the health services through committees. In the
Grama Panchayat, the Amenities Committee established under Sec 61 (1) (iii) is stipulated as
responsible for education, health, public works and other functions. The inclusion of “public
works” with the social sectors of education and health would clearly reduce the emphasis in the
committee on the latter. The importance of the social sectors must be emphasized if they are to
receive the attention they deserve. It would be desirable to amend Sec 61 of the Act to establish
a committee uniquely for the social sectors of health, sanitation and education. It would also be
desirable to specify that the membership of this committee would have to include a sufficient
number of women members of the Grama Panchayat. It may be noted that there is an Education
and Health Committee at the Zilla Panchayat level.
Orientation training of panchayat members
The development of the consciousness that health is a community concern is a process that is
dependent on the responsibility that is assigned to the panchayat institutions to manage health
services within their area. Devolution of management responsibility forces the pace of social
change. However, if this process of change has to be smooth and rapid, it would be essential to
orient the members of the panchayat at all levels with regard to their responsibilities,
entitlements and duties to the community. Training programmes for this purpose, which include
management procedures, must be organised on a continuing basis. Premier institutions such as
the Institute for Social and Economic Change, the Community Health Centre and the like could
be inducted for this purpose.
The health concerns of women and children are of special importance. Associated with these
concerns are health concerns such as social issues as raising the age at marriage of girls,
environmental sanitation, personal hygiene, and improving literacy among girls. Since a large
proportion of the panchayat members are women it would be desirable to orient them in these
-2-
matters and involve them in the relevant programme and motivational activities. Training
courses for empowering women members to play their role in programmes relating to RCH,
ICDS, school health and similar programmes should be organised. They should be motivated to
take up the role of community leaders in health and health-related issues.
Auxiliary Nurse Midwife
The ANM is a key functionary at the village level. Her ability to provide vital assistance during
deliveries would be considerably enhanced if she is provided some minimum assistance. During
deliveries, the ANM is often constrained to pay attention to the mother if there have been
complications. The newborn infant, during this period, is without the essential attention needed,
which could result in unfortunate results. Also, if multiple deliveries were to take place almost
simultaneously, the ANM or the Dai would not be able to render the necessary assistance to the
mothers. It would, therefore, be desirable to have a “second person” to assist the ANM or the
Dai but more importantly to provide the necessary attention to the infant. The Grama Panchayat
should appoint a woman of the village for this purpose as a health functionary. Such a
functionary should be appointed for each of the villages falling within the jurisdiction of the
Grama Panchayat. Such a person should be appointed specially where the Anganwadi worker is
unable to assist the ANM. This person would also provide the Grama Panchayat assistance in
management of field activities relating to health within each village.
The panchayat system, particularly at the Grama Panchayat level, needs fostering. The system
would need assistance in preparation of plans and management of funds, training of its
members, and special training for empowering the women members. Such assistance could be
provided by the premier institutions referred to earlier through development of model plans,
manuals and training programmes. In particular, model development plans for health could be
formulated which would assist in preparation of the District Development Plan under Sections
309 and 310 of the Act.
Relationship with Health Hierarchies
One key issue is the relationship between the official health hierarchy and the panchayat bodies.
This is more important at the taluka and district levels where the interaction between the
hierarchy and the elected body is closer than at the Grama Panchayat level and quite often
determines the degree of implementation and supervision of programmes.
The Act, in Sec.196, requires that Government appoint or post officers to the Zilla Panchayat.
Apart from such postings, Government have stipulated that district officers of departments,
except some, shall be officers of the Zilla Panchayat on what could be considered as “deemed
deputation”. In the Health Department the staff upto the level of DHO is thus an officer of the
Zilla Panchayat.
Views have been expressed that this arrangement reduces the capacity of the DHO to perform
supervision and management duties efficiently; particularly a large part of one’s time is devoted
to attending meetings of the Zilla Panchayat. To delink the DHO from the Panchayat system
would be against the spirit of the system and militate against the principle of decentralization. It
is noted that Government have recently instructed that meetings must be specific in subjects and
limited to four a month. Also, as provided in Sec. 155 (3) of the Act, the administrative powers
of transfer of the staff of the Department, who are not officials appointed by the Zilla Panchayat,
is within the power of the DHO.
Continuing responsibility of the Department of Health and Family Welfare Services
The impression of the health hierarchy that it has been divested of its responsibility with the
establishment of these bodies is most misplaced. The Panchayat institutions operate under the
authority delegated to them under the Act and perform their functions under the supervision and
-3-
guidance of Government. These latter functions are performed through the Health Department
so far as health services are concerned. The Department has, therefore, both a responsibility and
duty to associate itself with the functioning of these bodies. The Director of Health Services has
the right to exercise technical supervision and of inspections under Sec.233 of the Act. The
initiative to guide these Panchayat bodies should come from the Head of Department. The
functions and responsibilities of the Zilla Panchayat continue to be concurrently that of the
Government through the Head of the Department. To ensure that health programmes are
implemented effectively and that health services are efficient, the Commissioner could call for
and review periodic reports on financial and operational issues and interact with the Zilla
Panchayats.
The officers are part of these bodies but continue to exercise their administrative powers over
their staff under their delegated authority. The delivery of health services by the staff would be
dependent on the professional and administrative control that the controlling officer at the taluka
or district level is able to exercise without interference. This recognition of the mutual roles of
the officers and the panchayat members is important. Traditions, assisted with necessary
orientation of both officials and elected members and instructions whenever necessary, must be
built up for this purpose. The Government, in both the Health Department and the Rural and
Panchayati Raj Department, would have to monitor this process.
It would be desirable to conduct orientation courses / workshops for the health hierarchy so that
there is a better understanding of both their role and responsibility in the Panchayati Raj system.
So far such orientations appear to have concentrated on the members of these bodies. Since the
hierarchies of the Health Department, as is the case with almost all development and service
Departments, have to work with and as part of the Panchayat institutions, such orientation
courses would be useful. The Rural Development and Panchayati Raj Department could
organize such courses.
People’s Empowerment for Health
The management and monitoring of the basic health services that a community is entitled to by
the community itself would go a long way to ensuring availability, accessibility and quality. It
should be a tenet of policy to empower the people to do so or, in other words, to ensure that in
people’s health is in people’s hands. The community should be capable of determining their
basic health needs, evaluating the local health situation and the services that exist and improving
upon them. Mechanisms to create such awareness and to enable the local community to prepare
Village Health Action Plans would need to be developed. These would include health
campaigns, imaginative adoption of participatory techniques such as PRA, PLA and microplanning exercises. The involvement of youth and women’s association, in conjunction with the
panchayat institutions would be essential.
Village communities should be encouraged to form Village Health Committees. The Village
Health Committee could include the Gram Panchayat Member, the ANM, Anganwadi Worker,
School Teacher, leaders in the community, and representatives of self-help groups, the Mahila
Swasthya Sanghas, village education committee, youth clubs and similar bodies. At least half of
the membership should be from the Scheduled Castes and Scheduled Tribes, with a strong
proportion of women. Similar Committees could be formed at the levels of the Sub-Centres and
Primary Health Centres. The Gram Panchayat is empowered to constitute such committees
under Sec. 61 – A of the Act.
The Village Health Committees would have to be trained in conduct of meetings, prioritising
issues and procedures so that they function effectively. This should be done through local
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orientation sessions that could be organized in phases by an institution such as the Institute for
Social and Economic Change which has experience in the training of panchayat members.
These Committees would be responsible for assessing health conditions in their area, reviewing
the health needs and determining requirements, and for preparing work plans on a periodic basis
such as monthly or quarterly. The Committees would provide support to the Health Workers in
carrying out their functions so that health services are available and accessible to the people.
Such constructive interventions would render the service providers accountable to the people.
These Committees would also serve as change agents, if oriented and sensitized to social issues
such as schooling of all children, especially of girls, raising the age at marriage of girls, need to
maintain minimum standards of both public and private hygiene, and similar matters. In this
context, the role of women’s groups would be most important. A conscious movement would
have to be initiated for this purpose.
The formulation of a pilot project for the formation of such Committees, developing necessary
training material and sensitization could be assigned to the Institute for Social and Economic
Change, Bangalore. The State Institute for Health and Family Welfare should also be involved
in the process of sensitization of the official hierarchies.
Recommendations
•
The involvement of the Panchayat institutions and of the community in providing health
services should be encouraged for improvement and enhancement of these services based on
real needs;
•
For enhancing such involvement, information should be available to the community and a
forum must be developed. It would also be necessary to sensitize the officials in this regard;
•
Sec. 61 of the Karnataka Panchayat Raj Act may be amended to establish a separate
Committee for health, sanitation and education in the Gram Panchayat;
•
Continuous training programmes for health need to be organized to orient members of the
Panchayat bodies regarding their responsibilities, powers and duties and to impart
management skills. Such training programmes could be organised by the premier Institutes
in the State.
•
Training courses in health for empowering women members of the Panchayats and women
community leaders need to be organized. Such empowerment would improve the
effectiveness of programmes such as RCH, children’s and women’s health in the community;
•
A woman of the village should be appointed by the Gram Panchayat as a health functionary
to assist the ANM.
•
Model health plans need to be formulated for adoption by the Panchayat institutions. Such
model plans would assist in developing the health component of the District Development
Plan;
•
The health hierarchy needs to be oriented regarding its role in the Panchayat system and its
relationship with these bodies. In particular, there is a need to emphasize that monitoring of
implementation of State funded activity, supervision and inspection continue to be a direct
responsibility of the hierarchy;
-5-
•
A system of monitoring the health activities of the ZPs by the Commissioner needs to be
established;
•
The Rural Development and Panchayat Raj Department and the Health Department may
develop a system of feedback from the health hierarchies in order to render the mutual interactive role between the Health Department and the Panchayat bodies more productive;
•
It would be necessary to conduct orientation courses / workshops for the health hierarchy so
that there is a better understanding of both their role and responsibility in the Panchayati
Raj system. The Rural Development and Panchayati Raj Department could organize such
courses.
•
The meetings of the ZPs may be regulated according to the circulars of the Department of
Rural Development and Panchayti Raj regarding frequency, so as to permit district health
personnel, particularly the DHO, to carry out inspections and supervision more intensively;
•
Village communities should be encouraged to form Village Health Committees with wide
membership, including representatives of women’s groups, the youth, the ANMs, the
Anganwadi Workers, and others. The Gram Panchayat is empowered to constitute such
committees under Sec. 61 – A of the Act.
These Village Health Committees would have to be trained in the conduct of meetings,
prioritizing local health issues, preparation of health plans, etc. Institutions such as the
Institute for Social and Economic Change could be assigned this function;
•
The formulation of a pilot project for the formation of such Committees, developing
necessary training material and sensitization could be assigned to the Institute for Social
and Economic Change, Bangalore. The State Institute for Health and Family Welfare should
also be involved in the process of sensitization of the official hierarchies.
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20. STRENGTHENING PARTNERSHIPS
20.1 PRIVATE / CORPORATE SECTOR AND VOLUNTARY ORGANISATIONS
The non-governmental organisations, which participate in health care, may be divided into two
broad groups:
•
Voluntary Organisations: These are not-for-profit organisations, committed to human
development. The institutions like hospitals, health centers and dispensaries are established
and managed by voluntary organisations, charitable and religious, and philanthropic persons.
They are motivated by Gandhian, Sarvodaya or religious philosophies and thinking. Often,
there are financial deficits, which are made good by donations from individuals or other
organisations, national or international. If there is any surplus (rare), the surplus is ploughed
back into the organisations or institutions, to improve the services.
•
Private-for-profit health care institutions: These include nursing homes, corporate
hospitals and clinics. They are established, owned and managed by single individuals or
groups of persons. Recently the number of corporate hospitals has shown a large increase.
20.1.1 Situation Analysis
1.
Relative Size of Private Sector
• Bed-availability: The private sector is large in most states including Karnataka, except
West Bengal. At primary health care level, the private sector is heavily used inspite of
the vast network of Primary Health Centres (PHC's) run by the government. Even at the
secondary and tertiary levels, private sector participation is increasingly felt. In
Karnataka, the total bed strength of registered private and voluntary organisations was
40,900 in 1709 institutions in 1992, as compared to 31,840 beds in government hospitals.
West Bengal is an example of a state where only 10% of total bed strength is in the
private sector, of a total of only 6,912 beds. (Survey by Institute of Health Systems in
1992). The distribution of private and voluntary hospitals by the type of ownership and
bed strength is shown in Table I. It suggests more than 80% of the hospitals are owned
by individuals / family and 3/4th have less than 30 beds. Very few hospitals have 100
beds. These are usually attached to private medical colleges and some voluntary
organisations.
TABLE 20.1: Distribution of Private and Voluntary Hospitals by type of Ownership in
Karnataka.
Ownership
Charitable Trust
Religious Mission
Registered Society
Limited Company
Partnership
Individual
Total
<10
10-29
8
3
6
1
17
575
610
20
10
10
5
67
717
829
Bed Strength
30-49
50-99
100
and Total
above
18
13
9
68
2
4
8
27
6
1
19
42
3
5
5
19
34
7
3
128
90
31
12
1425
153
61
56
1709
1
• Health Care Provider: The percentage of patients seeking outpatient treatment from
various sectors in both urban and rural areas is indicated in Table II (42nd round of NSS
No.364). Majority of outpatients (43.19%) get their treatment from private doctors, 22%
of them from private hospitals in the urban areas with a similar trend seen in rural areas.
There is almost equal distribution of in-patient treatment in public and private sectors in
urban areas whereas in rural Karnataka 60% receive their in-patient treatment in public
hospitals (Table III). The dividing line between public and private providers is thin, as
public providers do private practice, officially and unofficially.
TABLE 20.2: Percentage Distribution of Out-patient treatment over Sources of Treatment
Type of Hospital
Public Hospital
Primary Health Centre
Public Dispensary
Private hospital
Nursing Home
Charitable Hospital
(ESI) Doctor
Private Doctor
Others
Urban%
27
1.71
1.23
22.07
1.01
0.24
1.36
43.19
2.19
Rural%
25.72
8.47
1.27
18.48
1.16
0.17
0.94
41.51
2.28
Total
100.00
100.00
TABLE 20.3: Percentage Distribution of In-patient treatment over Sources of Treatment
Type of Hospitals
Public Hospital
Primary Health Centre
Private Hospital
Charitable Hospital run by
Public Trust
Nursing Homes
Others
Urban%
48.51
0.39
40.49
1.26
Rural%
55.31
2.71
32.94
2.59
9.06
0.29
5.62
0.91
Total
100.00
100.00
• Health Spending: The total health spending in India accounted for about 6% of Gross
Domestic Product in 1991, which is about Rs.320/- per capita at 1991 price levels. The
private health spending, which mainly includes out of pocket household spending,
accounts for 78% of total health spending. The share of the central, state and local
government is about 22% only. Private spending accounts for 82% of primary care,
70% of secondary and tertiary care. Hardly 27% is spent on the preventive and
promotive health activities. (Table II Derived from India: policy and finance strategies
for strengthening Primary Health Care Services. World Bank report No.13042-IN, May
1995). The above expenditure data on health clearly indicates the dominance of nongovernmental spending in spite of government role in the health sector. However it is
important to note that out of pocket spending on health is often made from borrowings.
In the case of chronic and serious diseases this results in indebtedness and
impoverishment. Medical expenditure is the second highest cause of rural indebtedness.
2
Willingness to pay must thus be distinguished from ability to pay and from consequences
of paying.
2.
Registration:
Inspite of the dominance of the private sector the government has not clearly defined the
role of this sector in the context of its overall health strategy. We do not have a system of
registration of private medical establishments, including private clinics, and hence we have
an incomplete picture of the private sector as a whole. In recent years, there is an ever
increasing number of nursing homes and corporate hospitals especially in urban areas. In
the absence of registration, monitoring and regulation of quality of care is not possible.
3.
Accessibility:
In both the private and public sector, access to health services is inadequate due to
physical, economic and social issues. There are many areas especially in North Karnataka,
where the infrastructure in terms of roads, transport and communication is poor and
patients have to travel long distances to reach a government or a private doctor. However,
some of these areas are served by private doctors – including under qualified persons and
quacks also practice in these areas. Non-availability of staff, especially doctors is the one
of the important reasons for seeking private medical aid. Further the health centres in
these areas are not adequately supplied with drugs and basic equipments. Hence there is a
special need to strengthen the government health care networks, and to encourage the
development of non-governmental sectors to provide out-reach services which the
government sector is unable to provide.
Various surveys, point out the health services are underutilised by the depressed classes,
women in general and tribals due to misplaced beliefs, hesitancy and economic reasons. In
Karnataka, the sex ratio amongst hospitalised patient is 786 female patients for 1,000
males, whereas the ratio in population is 964 females to 1,000 males. (Census, 2001)
There is a need for special efforts to change the "health seeking" behaviour of special
groups even in the private sector.
Even the economically, weaker sections seek medical aid from the private sector inspite of
financial limitations in view of the "faith" in the private sector. The expenditure incurred
is on doctor's fees, drugs, investigations and transport. Naturally, the poor postpone
treatment until the problem becomes acute and serious. The charges are subsidised in
hospital run by charitable and religious institutions and some hospitals run by private
medical colleges. In order to address this high level of out of pocket spending, the
government encouraged pre-paid risk pooling mechanisms in the long run, such as
insurance schemes like the ESI and CGHS schemes. But these schemes do not cover nongovernmental population. Private voluntary insurance, covers barely 3.3% of the
population. Community financing schemes and social insurance schemes may be
encouraged.
4.
National Programmes and IEC Activities:
The private sector is mainly confined to individual curative aspects and they play an
insignificant role in preventive and promotive health care. They are not involved in
information, education and communication activities (IEC). The national vertical
programmes like, malaria, filaria and tuberculosis control programmes have become only
governmental programmes. A small survey conducted suggested, none of the government
3
functionaries approached the private sector for involvement in IEC programmes or
regarding training programmes (survey commissioned by Task Force). Hence there is a
need to involve the private sector in all preventive, promotive health care programmes
either individually or through professional bodies like IMA & various specialist
organisations.
5.
Contracting-Out:
The private contracting of health services, involves employment of some specialists and
clinical and non-clinical support services. There are number of specialists in the private
sector especially in district and taluka levels, whereas the governmental hospitals may be
deficient in them. Further the clinical support services like diagnostic laboratories, X-ray
and scanners may be available either in private or public sectors. There is a need for
utilisation of these services either in private or public sectors. There is a need for
utilisation of these services either by government hospitals or by private institutions on
agreed conditions for the benefit of the community as a whole. The terms of agreement
needs to be carefully spelt out.
The private contractual services especially in non-clinical services are reportedly more
efficient and cost effective than direct labour. The contracting out of non-clinical services
like cleaning, catering, pharmacy, laundry, maintenance and security is justified in terms of
lower costs, easier implementation greater flexibility and efficiency (Anne Mills:
contractual relationship between government commercial private sector in developing
countries are they a good idea in Health 1995). The government should also take into
account the quality of services as well as the administrative capacity to supervise such
contract. However payment of minimum wages and social security benefits like leave and
medical benefits should be ensured. The experience of KHSDP concerning contracting out
should be studied.
6.
Tertiary Care Hospitals in Private Sectors:
There are increasing numbers of tertiary care hospitals being established especially in
cities, with some being attached to private medical colleges. It is prudent, to utilise these
hospitals as referral centres and for training purposes.
7.
•
•
•
Quality of services, monitoring and cost of treatment:
Although, private health services are easily accessible, the quality of medical services is
variable. The quality of service provided depends on the staffing, equipment and availability
of drugs.
A study commissioned by Task Force reviewed the level of care and quality in private sector
through "exit patient perception " of quality. The quality of care is perceived to be high
when the expectations of patient with respect to outcome of service are met. Almost all the
patients felt that their expectations fully or partially met (Table I).
Data on the total number of "medical practitioners" is not available in India. Government
figures indicate the national average of one private practicing physician for every 3,500
people. The official figures provide information only on the registered medical practitioners
and there are any numbers of unqualified "doctors". Hence there is a need to strengthen the
registration of all doctors or medical practitioners by different medical councils (Allopathy
or alternative medicine).
4
TABLE 20.4: Patient Expectation Response
Expectation
Fully met
To some extent met
Not met
•
•
•
•
•
In-Patients
54%
46%
0%
Out-Patients
48%
48%
3%
At present there is no registration of private clinics, nursing homes or any other private
medical establishments. There is a need for minimum standards to be observed by practicing
doctors and in physical structure, equipment and personnel of medical establishments. The
minimum standards may depend on the location of the establishment (cities, semi-urban or
rural areas) and the type of institution. Hence there is a need for detailed consultation with
the various professional bodies, regarding minimum standards.
The Consumer Protection Act (CPA) 1986 is one of the most revolutionary legislations, to
protect the consumer and monitor the quality of service. In November 1995, the Supreme
Court passed a landmark judgment making it finally clear that the service rendered by a
doctor will come under the definition of service in C.P. Act. This has raised concerns in the
medical community with regard to sanctity of doctor-patient relationship the spread of
defensive medicine increasing the cost of health care and the appropriateness of determining
right or wrong" of medical decisions by consumer courts. The above issues highlight the fact
that there is no standardised medical audit system, which can provide the patients and legal
community with information regarding "acceptable procedures" for diagnosis and treatment.
One other aspect that concerns the patient is the cost of treatment in the private sector. It is
difficult to prescribe a particular fee for a procedure and consultation etc., due to several
variables like, the experience of doctor, type of hospital and the situation of the hospital etc.
However, it is necessary to have transparency in charging by providing a brochure
containing charges and explaining to the patient the cost of management of a particular
disease or condition.
The Government of Karnataka has placed before the Legislative Council " The Karnataka
Private Medical Establishments (regulation) Bill 1998 for regulation and control of private
medical establishments. However there is a need for several changes and modifications of
the Bill and consultation with the appropriate associations and professional bodies is
desirable.
In addition, there is a need for Quality Assurance (QA) that focuses on continuous
improvement in service delivery and on consumer satisfaction. Self-assessment programme
and self-regulatory mechanisms may be established by the IMA, Nursing Home Association
or any other appropriate body. The Q.A. programme will offer a standard in medical
management against which medical auditing and reviewing can be carried out.
Financing of Health care
The income group profile of patients seeking various types of hospitals is shown in the table.
(Study Commissioned by Task Force). It suggests that the high income and upper middle
income groups are served by Corporate hospitals, lower and middle income groups by teaching,
trust and to a certain extent missionary hospitals. The nursing homes cater to middle and upper
middle-income groups. The household "out of pocket" spending is significant and this forms a
considerable burden on middle and low-income group. Hence there is a need for Health
insurance especially for middle and low-income groups.
5
TABLE 20.5: Income Group Profile of patients across Hospitals
Income Groups
High Income Group
(>Rs.10000p.m.)
Upper
Middle
Income Group (500010000p.m.)
Middle
Income
Group
(30005000p.m.)
Lower
Middle
Income
Group
(Rs.600-3000p.m.)
Low Income Group
(<600p.m.)
Total
Corporate
A
B
Urban Urban
40
25
Percentage of Total Patients Visited
Teaching
Missionary
B
A
B
A
B
Urban Urban Rural Urban Rural
20
-5
N.A
10
Trust
A
Urban
10
N.H.
Avg.
12.5
Govt.
A
B
Urban Rural
5
5
50
35
20
30
--
5
N.A
15
50
10
10
10
25
50
30
20
5
N.A
15
25
30
15
--
10
20
10
70
80
N.A
30
7.5
25
20
--
5
--
10
10
5
N.A
30
5
30
50
100
100
100
100
100
100
N.A
100
100
100
100
India has two main mandated contributory health income schemes – Employees State Insurance
Scheme (ESIS) and Central Government Health Scheme (CGHS). Other insurance policies are
from the Government owned General Insurance Company (GIC) and its subsidiaries.
A sample survey was conducted to determine the extent of premium payable by the crosssection of the society (study commissioned by Task Force). The premium affordable ranged
from Rs.300 per annum (Lower income group) to Rs.500 (middle income group). A low
premium scheme, JANA AROGYA BIMA was introduced by GIC in 1996 that requires a
premium of Rs.70-140 p.a. for the maximum benefit of Rs. 5000/-. A modified scheme with
higher premium may be considered.
20.1.2 Collaboration may be achieved by the following measures to be introduced in
various levels:
Primary Care level:
1.
The government must encourage private practitioners to establish clinic and hospitals by
providing infrastructure and soft loan facilities as are done in case of small-scale
industries. These facilities may be extended to doctors from alternative medicine as well.
2.
The majority of patients still consult the private practitioners, including economically
weaker sections. The basic drugs and vaccines may be provided to the registered, willing
practitioners for dispensing to the poorer section of society, the weaker section may be
recognised on the basis of green/yellow cards. Proper record keeping is to be insisted
upon. The drugs used in the national programmes may also be given to these practitioners
so that they also actively participate in the national programmes as per the norms of the
programme.
3.
There may be PHC's where the doctors are not available and a willing private practitioner
may be recruited on "ad hoc" basis. The private practitioner may be given access to the
facilities of PHC's including admission and laboratory facilities with the concurrence of
PHC medical officer. Such patients may be charged according to government tariff. Even
the industrial houses may be invited to adopt local PHC's.
6
4.
The private practitioner should be encouraged to participate in preventive and promotive
health programmes. The government should actively seek the co-operation of the private
practitioner in disseminating public health messages, by involving them in information,
education and communication activities (IEC).
Secondary level:
5.
At secondary level hospitals, there may be a deficiency of specialists, but who may be
available in the private. The services of these specialists may be obtained to serve the
government hospitals on an agreed honorarium. The specialists may be selected by the
board of visitors attached to the hospital.
The x-ray, blood bank and laboratory facilities of government hospitals should be allowed
to be used by private practitioners on payment, especially where such services are not
available out side. There could be a misuse of these facilities by the private practitioners
as well as government doctors that could be minimised by proper supervision by the chief
medical officer. In spite of the possible misuse, the benefits of the arrangement are much
more for the suffering patient. The government will also be benefited financially. The
money may be utilised for the improvement of the hospital.
6.
At secondary level the services of IMA may be obtained for active involvement in national
programmes and IEC activities. "Pulse Polio", Leprosy and oral rehydration programmes
are some of the successful examples of private-public co-operation. The services of
experienced private doctors may be utilised for training of junior doctors and other paramedical staff.
Tertiary Care:
Tertiary care and super-speciality hospitals may be left to be developed largely by the private
sector.
7.
Private tertiary care hospitals may be asked to offer concessional services, as a matter of
social responsibility. A separate fund may be created in the government with public and
government contribution, to be utilised for deserving patients treatment on the
recommendation of respective hospitals. Independent machinery may be created for the
disbursement of the money.
• The private hospitals are encouraged to conduct teaching and training programmes for
doctors and para-medical staff, drawn from both governmental and private sectors.
• The private medical colleges are asked to manage the PHC's of the block. This is useful
for their teaching programme also. There should be greater involvement of the staff and
students of medical colleges in preventive, promotive and health educational activities.
Contracting out
The State Government, wherever economically attractive, may contract out support services
such as sanitation, dietary, security and laundry etc.
Monitoring
1.
Registration of all doctors is essential whichever system of medicine they practice. By
doing so quackery may be minimised.
7
2.
All private medical establishments including private clinics have to be registered:
• A committee may be formed and empowered to lay down minimum criteria/standards
for registration.
• The committee may consist of representative of IMA, KMC and representative of
Nursing Home and private practitioners associations, apart from government
representatives.
There must be substantial number of non-governmental
representatives.
• This committee is empowered to register and monitor private medical establishments.
Due consideration has to be given while registering regarding the location of medical
establishments (urban or rural).
• There should be transparency in charges for various medical treatment.
• The Karnataka Private Medical Establishment Bill 1998 which is placed before the
Legislative Council, has to be discussed with concerned parties and modified to have
the desired effect. Appropriate recommendations are made by the Task Force in the
Karnataka Private Health Care Establishments Bill.
3.
The government may ask professional bodies to prepare a standardised medical audit
system that should indicate the acceptable procedures for diagnosis and treatment.
Quality Assurance is a continuous process and professional bodies may be encouraged to
have a self-assessment / self-regulatory mechanisms.
Financing the Health Care:
Government must encourage family insurance scheme from LIC or private insurance agency. "
Jana Arogya Yojana" is one such scheme put forward by Oriental Insurance Scheme. A
modified scheme with higher premiums and benefits must be considered.
TABLE 20.6 : National Health Spending: An Estimated "Source and Uses" Matrix
(In percent of total expenditure)
Uses
Primary Care
Curative
Preventive and promotive
Health
Secondary/Tertiary
Inpatient Care
Non-service Provision
4.3
0.4
4.0
State &
Local
Govt.
5.6
3.0
3.7
0.9
8.4
2.5
27.0
38.8
0.9
1.6
N/A
N/A
2.5
Central
Govt.
Corporate/
3rd Party
Households
Total
0.8
0.8
48.0
45.6
2.4
58.7
49.7
9.0
Total
6.1
15.6
3.3
75
100
Derived from: India: Policy and Finance strategies for Strengthening Primary Health Care
Services. World Bank Report No.13042-IN: May 1995
8
20.2 GENERAL PRACTITIONERS
Situation
General Practitioner (Family Physician) is a primary care doctor in the community. Most of
these General Practitioners are in the private sector; some of them may be employed in certain
non-governmental health organizations. The General Duty Medical Officers in government
service are the counterpart of the General Practitioners in the private sector. In Karnataka 60%
of the primary medical care is provided by the private medical practitioners; hence we have a
large number of medical men & women catering to the medical needs of our people. Most of the
work done by the General Practitioners is curative. The General Practitioners is usually
approachable, knows the family and leaves in the community.
We need to focus our attention as to how the services of the General Practitioners can be utilized
to the health care needs of our population particularly in rural areas. Today the basic doctor
(MBBS) who are churned out of the portals of the medical colleges are under-trained for the job
they are expected to do. Today's graduates do not get good training in Family Physician work.
Therefore it boils down to the fundamental aspect of training our graduates in family medicine
soon after they acquires basic MBBS degree. The general practitioner (family physician) must
have career prospects. This could be by starting a Postgraduate diploma and degree in Family
Medicine in our State Health University and also recognizing senior well trained Family
Physicians in private to train the young doctors such that they can take up the National Board of
Examination in Family Medicine. Family Medicine must be treated as yet another evolving
speciality by itself.
The services of the private medical practitioners in every locality must be enlisted by the Taluk
Medical Officers and PHC, MOs in all the National Health Programmes. Such of those General
Practitioners who participate in the preventive and promotional work must be given some
encouragement by training them and deputing them for training programmes in National Health
Programmes just like government General Duty Medical Officers.
The services of General Practitioners can be availed of when the posts of medical officers
remain vacant for a length of time, due to any cause. The incentives must be further extended
for those General Practitioners who settle down in rural areas by offering a very low rate of bank
interest to establish their clinics in the areas underserved by the Medical facilities. Wherever
acceptable NGO's are functioning with reputed General Practitioners, PHC's can be handed over
to the NGO on trial basis to maintain the function of the centre, providing comprehensive
primary health care.
There has to be a good rapport between private sector General Practitioners and Governmental
agencies to provide the best care of health for all by the services of the qualified medical
personnel.
9
20.3 VOLUNTARY HEALTH SERVICES
Introduction
Voluntarism in health care has been an old tradition in Karnataka, with many institutions in the
voluntary sector being over a century old. Many of these institutions have become major
hospitals, especially in the mission sector.
The role of the voluntary organisations may be classified as follows:1. Directly providing health care services.
• Rural health care providing primary health care services to rural/tribal and other
remote areas where governmental agencies may not exist.
• Hospitals, mainly situated in the urban areas represented by charitable and
religious organisations.
• Basic curative and health education services to the urban poor.
• Urban based hospitals with rural outreach services, providing curative /
preventive services.
• Voluntary organisation providing exclusively family welfare services through
urban health and family welfare centres.
2. Resources Groups: Providing training and information to personnel of voluntary
organisations.
3. Networking and facilitating voluntary organisations providing expert advice and
consultancy services.
4. The voluntary organisations innovate new strategies in health care e.g. integration of
traditional system in primary health care.
5. Research and issue raising groups.
The voluntary organisations work at different levels:•
•
•
•
working at grass root levels, concentrating on education, health, environment and
women's issues etc,
involved in training at various levels, networking and supporting other organisations,
focusing on advocacy, lobbying, communication and policy research,or
only concentrating on special issues like AIDS, leprosy and tuberculosis.
Situation analysis
The voluntary organisations focus on a range of issues like tribal health, health of the
disadvantaged sections of the society (women, persons with disability). They are able to reach
the poor, and the needy because of their motivation and empathy. They have more freedom to
act and implement and less hierarchy so that the implementation of programme is quicker.
We do not have the exact number of voluntary agencies in the state or their scope of activities.
There are some associations which joined hands to establish co-ordination of activities and help
in the interaction with the government. These are the Voluntary Health Association of Karnataka
(VHAK). Catholic Health Association of India – Karnataka region (CHAI – Ka), Christian
Medical Association of India (CMAI), and Federation of Voluntary Organisation for Rural
Development in Karnataka (FEVORD-K).
10
The percentage of voluntary organisations is situated in cities and rural areas is reportedly 70 to
30 respectively. There are fewer agencies working in the Northern Karnataka and drought prone
areas.
Strengths of Voluntary Organisations in Health Care
Voluntary organisations and institutions are usually small and autonomous. There is flexibility
in approach and activities. They are in favour of the weaker sections and respond to their needs
and priorities.
Weaknesses
There is often lack of funds. There is also the likelihood of lack of professionalisation. Not
enough attention is paid to financial management and accounts. This can affect sustainability.
Government and Non-Government Organisations:
Why does Government want NGOs? Non-governmental organisations can augment resources
(human, material and financial) for health care. NGOs (and especially not for profit
organisations) have close rapport and relationships with the people. NGOs are flexible, less
formal and more effective in providing health care services. They can usually execute programs
at less cost (greater efficiency).
Relationship between Government and NGOs:
This can take many forms
•
Dependency: This may be of resources or of ideas. The NGOs accept the role of
Government in defining health services, and implement programmes prepared and
financed (largely) by Government. NGOs are accepted, recognised and legitimised.
•
Subcontracting: NGOs become implementers of Government programmes. They fulfill
targets prescribed by government.
•
Collaboration: There is mutual respect, autonomy and independence. It creates
partnerships, valuing the different opinions. There can be a 'sweet and sour' relationship.
•
Adversary position: The NGOs may challenge government policies and styles of
functioning. They may support social (including health) movements, which may be
contrary to Government's strategies.
Promoting Healthy Relationships
It is necessary to have a healthy, collaborative relationship. This can be achieved by
•
Policy support, through appropriate legislation and procedures, which affect NGOs
•
Creating a climate conducive for collaboration through dialogue and mutual support.
•
Providing access to information.
•
Formulation of plans after discussion
•
Having partnership in action
•
Eliminating areas of conflict
•
Sharing expertise and know how
•
Convergence of services with people as focus
11
How to choose voluntary organisations?
Government sometimes faces problems in having to choose NGOs for collaborative efforts or
when NGOs apply for support in carrying out health and development programmes. NGOs must
help in identifying the NGOs who can be accepted by the Government. It may be worthwhile to
have a small committee or a forum of a few known NGOs in the State who can help the
Government in this matter.
The committee of the forum must develop the criteria for selection of NGOs:
•
Does the NGO have credibility? Does it maintain records? Does it have transparency? Is
it accountable to the people?
•
Does the NGO have an empowerment approach? Does it help people to help themselves?
•
Does the NGO have appropriate persons?
- Professional and technical
- Management
- Supportive staff
•
How efficient and effective has it been in
- Solving problems
- Making use of opportunities?
Collaboration between the Government and non-governmental organizations can have a salutary
effect in improving efficiency and effectiveness of health care services. Government has to
continue as a main functionary, but the voluntary organisations can give a qualitative boost to
the efforts of the Governments and the people.
There are some inherent weaknesses in voluntary organisations. They are individualistic and
there is a lack of second line leadership. The organisations that depend on external agencies for
funding might have to limit their activities depending on the funds.
Financial administration and accounting is poor in voluntary agencies and hence there is some
hesitancy for financing by external agencies.
There is a considerable amount of duplication of programmes between the agencies and between
the Government and voluntary agencies. The duplication may be avoided by maintaining a
proper registry of voluntary agencies and their field of interest and activities.
Voluntary organisations and the government
There is a growing realisation for the need to develop a healthy partnership between the
government and voluntary organisations. There is a need for better understanding, identification
of roles, complementary action, mutual learning and cooperation. There is a Standing
Committee Of Voluntary Agencies (SCOVA) to collaborate and formalise the relationship.
The government is the main functionary and all voluntary agencies play a supportive role in all
aspects of social welfare rural development besides health care.
12
Recommendations
The over all strategy of the government should be to recognise and appreciate the importance of
the voluntary and private sector, to create an atmosphere of trust, and to foster public-private
partnership in delivering comprehensive health care. There is need to develop a policy for the
entire health sector inclusive of public, private, voluntary groups and people traditions. It may
be initiated in the following ways:
•
Enhance the scope/importance of collaboration with the private and voluntary sectors in
primary, secondary and tertiary level of health care.
•
Involve the private and voluntary sector in preventive and promotive care in addition to
curative care.
•
Promote partnership between public, private and voluntary organisation.
•
Evaluate and monitor quality of services in the private and voluntary sectors.Set standards
and accreditation sectors.
•
All the voluntary agencies working for the health sector should have a central cell at the
state level. The cell should register all organisations and bring out an annual report of the
activities of voluntary organisations.The grant-in-aid procedures must be simplified and the
bottlenecks removed, to help better collaboration and remove the feeling of frustration.
•
The logistics of partnership between the government and voluntary organisations have to be
worked out by the central cell and the government. Voluntary agencies should be invited to
participate in the planning and monitoring of health policies and strategies by the
Government.
•
The agencies, have to be used more and more for the effective implementation of national
programmes, spread of health education and to act as a watch-dog over the provision of
health services within the public/private sectors.
13
14
21. MULTISECTORALITY AND INTER SECTORAL
CO-ORDINATION
ALL FOR HEALTH
1.
Health Sector cannot achieve health for all on its own. Most of the determinants of health are
outside the narrowly defined "health" sector. It is well known that education can play a
significant role in the development of better health. The higher the level of education the
better the health status. This is especially so with respect to female education. We can have
health promoting schools. In all the developmental activities, health sector can (and should)
provide technical expertise. Health sector can provide "added value". We should have
partnership approach between the health sector and other sectors. Integrated approaches are
needed. In the health sector itself, there is need for better partnership between the public,
voluntary and private sectors, so as to provide better care, especially for the disadvantaged and
public health.
"Health profession has a key role to help ensure that the policies and strategies of various
sectors and organisations contribute positively to health protection and promotion".
- Intersectoral Action for Health, WHO, Geneva, 1997
Intersectoral Action for Health calls for positive mutually supporting relationship between
health sector and other sectors to achieve health outcomes, which are more efficient, effective,
equitable and sustainable than could be achieved by the health sector alone. Whether within
the Government or outside it, decisions affecting health should be taken collaboratively.
•
The action taken should involve consideration of links between health and various factors in
the physical, social and economic environment.
•
The action must modify activities among the determinants of health so as to achieve better
health.
•
The action should carry out the activities through widespread community participation.
2.
Determinants of Health
The determinants of health are varied. They may be
•
Biological; genetic;
•
Environmental;
•
Social and cultural
•
Demographic
•
Economic
•
Food and nutrition
•
Health Care Services
•
Violence and conflicts
-1-
3.
Communication:
Each sector in the development field has its own kind of functions, its own culture, its own
priorities. But parts of these functions are allied to health. The web that holds intersectoral
actions together is intersectoral communication. There is a need for exchange of information.
4.
Current health challenges:
• Environment related health problems
- Poor housing and living conditions; slums.
- New and re-emerging infectious diseases.
- Microbiological contaminants; chemical contaminants
5.
•
Social health issues.
- Accidents
- Violence
•
Public health hazards
- Unsafe drinking water
- Unsafe food
- Poor sanitation
- Unhealthy lifestyle
A few of the more important areas for intersectoral action for health can be considered.
5.1. Agriculture and health:
Food: India blessed with good monsoons in the past many years, has adequate
production of food. Yet there are many people without adequate food intake. Food and
nutrition security targeted to the poor and free nutritious midday school meals are
often necessary.
Horticulture: Improvement in the nutrition of the people can result from better
management of the food that is grown. Health centers and schools can have kitchen
gardens, as demonstration plots, which can then be replicated in the houses and
dwelling places, particularly in the rural areas.
Food Safety: It is important to assure food safety. Monitoring must be done at every
stage of food production, processing and use. Food is being marketed on the streets,
often open to dust, flies and other insects, which can lead to infection.
Nutrition: Security is a must for good health. Karnataka has a large number of
malnourished persons throughout the age cycles (See chapter on nutrition).
Land reforms can affect food production. Kerala has done well as regards almost all
health services. One of the major reasons leading to better health is the land reform,
which has enabled large number of tenants to become landowners. They cultivate their
own land with improved production of cereals, fruits and vegetables for their
consumption. It also gives them more " living " space.
-2-
Irrigation schemes while essential for improved productivity of food, can affect the
health of the people adversely in many ways. It can spread parasitic and diarrhoeal
diseases. It can also spread vector borne diseases, such as malaria. Sometimes sewage
water is used for irrigating vegetables. It is essential to have health professionals
involved in the design and use of water, as also disposal of wastewater.
Substitution of crops and diversification can help to improve nutrition and purchasing
power. We are short of pulses, which are needed for balanced nutrition.
5.2.
Education and health
The partnership role between education and health is well known. Education plays a
key role in improving all health indices, whether it is in reducing infant mortality rate,
maternal mortality rate or improving healthy life expectancy.
Greater education often translates into improved health status. Investment in the
education of girl can yield high pay offs in terms of health and development. It often
delays child bearing; it can lead to better pregnancy outcomes. The children are also
healthier.
School health programmes include health promotion, periodical health check ups and
health services. The school environment can be improved. Better use of toilets can
improve sanitation and health. This becomes a lesson for the children and through
them, their parents and siblings. Education can be the vehicle for prevention of
diseases.
5.3.
Industry and health
The Environment (Protection) Act, 1986, lays down the standards of quality of
environment and of pollutants from various sources. It also restricts areas in which any
class of industries, operations or processes shall not be carried out or shall be carried
out subject to certain safeguards, laying down procedures for handling of hazardous
substances. Unfortunately, not enough action is taken to prevent pollution. The recent
decision of the Supreme Court asking that the large number of polluting industries be
removed from Delhi is an exception. This example should be followed by the state, to
ensure a livable environment. At the same time, it is necessary to ensure that the
workers who lose the jobs get alternate work.
Workplace: Stressful living and working conditions characterize many industries
leading to increased morbidity and mortality.
Safety (occupational) ; Dangerous and dirty work take toll of the health of the
workers. Measures must be in place to ensure the safety of workers. Procedures that
are toxic or unsafe must be banned.
5.4.
Housing and Health
Good shelter is necessary for good health. It provides for health promotion and
protection. Unsafe and over crowded housing, near waste dumps or in flood zones
must be avoided. But the poor have little choice; the alternative is often absence of
shelter. The Housing Boards and Urban development authorities can play a key role.
-3-
5.5.
Animal Husbandry and Health
Animal Husbandry can play a major role in determining good health. While it can
give nutritious food, safety must be ensured. The Department of Animal Husbandry
can help in ensuring safe nutrition.
5.6.
Environment and Health
The World Commission on Environment and Development (1987), headed by the
present Director – General of WHO, Mrs. Gro Harlem Brundtland, produced the report
" Our Common Future", linking economy and environment. The United Nations
Conference on Environment and Development held in Rio de Janeiro in 1992 (Earth
Summit) had " Agenda 21" which had key health related objectives.
•
•
•
•
Meeting primary health care needs,
Controlling communicable diseases
Protecting vulnerable groups
Reducing environmental health hazards.
Health sector seems to have abdicated much of its responsibility with regards the
environment affecting health.
5.7.
Water Supply and Health:
Water in adequate quantity and quality, is essential for good health
Safe Drinking Water: Often the water is contaminated. It is a common finding to
have outbreaks of gastro-enteritis and diarrheas, as summer approaches. This is seen
in rural and urban areas. Corroded water pipes lead to contaminated water being
supplied in the city supplies. The Bangalore Water Supply and Sewerage Board and
the Karnataka Urban Water Supply and Drainage Board can help to prevent outbreaks
of diseases, by ensuring safe drinking water in cities and towns. The panchayats must
ensure the same in the rural areas. The Health department can monitor the quality of
water and alert the water supply system to take prompt action.
Water borne diseases: There are many water-borne diseases still prevalent in the
State, even though we have the technical know-how to prevent such diseases.
Water related diseases: Vector (mosquito; flies) borne diseases are still very
common; community participation is essential to reduce, if not eliminate these
diseases.
5.8.
Sanitation and Health
Good sanitary arrangements can reduce the prevalence of diarrhoeas and worm
infestations, such as round worms and hook worms that lead to anaemia and under
nutrition. There is need for sanitary latrines. Proper use of latrines, including washing
of hands after defecation, has been shown to be an important factor in removing fecaloral infectious diseases.
-4-
Waste disposal is essential, whether it be solid or liquid waste. Hospital waste is a
special category, where there is added problem of microbiological and other
contaminants.
5.9.
Social Welfare and Health
There has to be co-ordination between Social Welfare and Health. This is particularly
so with respect to disadvantaged sections of the people. Persons with disabilities,
women and children and elderly need such co-operation.
5.10. Tobacco Control
Intersectoral action is needed on almost all issues in health. One of the emerging
issues in health is the control of tobacco use. Control requires legislation (political
will; legislature), taxation (tax reforms), prevention of smoking and abuse of tobacco
in other forms (education), agriculture (reduction in growing tobacco and alternate use
of land), labour (women and child workers) and media (advertisement).
5.11. Poverty and health
Poverty has been defined by UNDP as " the denial of opportunities and choices basic
to human development". Poverty has economic, social and political dimensions. It
produces helplessness, insecurity and powerlessness. Poverty breeds ill – health and ill
– health leads to poverty. Any attempt at alleviation or eradication of poverty will have
its impact on health. So also, improving the health of the people is one sure way of
reducing poverty.
5.12. Development and Health
Many developmental activities affect directly or indirectly health. An example would
be digging canals to provide for irrigation. The water may partly be used for drinking
purposes and thus improve health. But it may also breed vectors (like mosquitoes) and
lead to vector – borne diseases (like malaria). Health Sector must develop the capacity
to undertake studies and collect data to measure and estimate the possible health
impacts of developmental activities. The death and disease burden of development
activities should be measured with an estimation of the contribution that the social and
environmental factors are making to the health problems, as also the health
opportunities presented by developmental programmes.
" Human beings are at the centre of concerns for sustainable development. They are
entitled to a healthy and productive life in harmony with nature"
-
6.
U. N. Agenda 21. Programme of Action for Sustainable Development, Rio
declaration on Environment and Development, Rio de Janeiro Brazil, 1992.
Critical pre-requisites for intersectoral action for health
Few or no mechanisms are available to enable health professionals and health policy makers
to have any significant role in the process of developmental policy making, which needs
intersectoral collaboration. Among the critical pre – requisites are:
-5-
•
conviction among health professional that a key strategy for improving health is to work
together with other sectors;
•
governments, State and local, should make health central to the development policies;
•
a general recognition by all that better health is an integral part of community
development; and
•
developing the technical capacity to advise other sectors about modifications to their
activities that would improve health of the people and actively listening to suggestions of
other sectors and acting upon them.
Recommendations
•
The State must establish administrative machinery and Co-ordination committees at the State,
district and local levels for intersectoral action for health. These groups must be involved in the
preparation of the State plan.
•
Have a High Power Core Committee (intersectoral) headed by the Chief Secretary at the state
level and committees at the district level with participation by D.Cs and C.E.Os. The
Committees should have representations from Health, Education Women and Social Welfare,
Agriculture, Horticulture, Animal Husbandry. Irrigation, Housing , Industry, Pollution Board
and Environment. Subcommittees can be formed to reflect and take action on specific matters.
•
All developmental programmes must have inputs from the health sector to make use of the
opportunity to improve health and prevent problems.
•
Health personnel (Public Health) should be trained to anticipate and find solutions to possible
health hasards of developmental programmes. They should continue their association during
implementation, monitoring and evaluation of the programme.
-6-
22. THE KARNATAKA STATE INTEGRATED HEALTH POLICY 2001
(Draft)
CONTENTS
1.
1.1
1.2
1.3
2.
3.
4.
5.
5.1
5.2
5.3
5.4
5.5
5.6
5.7
5.8
5.9
5.10
5.11
5.12
5.13
5.14
5.15
5.16
5.17
5.18
6.
6.1
6.2
6.3
6.4
6.5
6.6
6.7
6.8
6.9
7
7.1
7.2
8
9
Introduction
Health Gains
Health gaps
Health policy approach
Karnataka: Vision for better health and health care
Karnataka: Mission statement on health and health care
Karnataka health policy perspectives and goals
Karnataka health policy components
Scope of policy-comprehensiveness and integration
Public health approach and primary health care strategies
Equity in health and health care
Quality of care
Multisectorality and intersectoral coordination
Private, public and voluntary sector partnerships
Health Financing
Health Planning
Health Management and Administration
Environmental health
Nutrition
Population Stabilisation
Education for health personnel
Rational drug policy
Medical Industry (Diagnostics, medical equipment, health accessories)
Medical and health research
Indian systems of medicine and homeopathy
Health promotion
Policy components on priority health problems and issues
Communicable / infectious diseases
Women's Health
Children's Health
Mental Health
Prevention and control on non-communicable diseases
Disability
Occupational health and safety
Dental health / Oral health
Emergency Health Services and Trauma Care
Cross-cutting Policy Issues
Medical and Public Health Ethics
Policy Process and Implementation factors
Outcome and Indicators
Conclusions
1. Introduction
1.1
Health gains
During the past century and particularly after Independence in 1947, several gains
have been made in health and health care in Karnataka. Life expectancy at birth
(LEB) has increased from 26 years in 1947 to 66.3 years for women and 65.1 years
for men in 1998. The Infant Mortality Rate (IMR) declined from 120 in 1951-60, to
81 in 1981, and further to 58/1000 live births in the late 1990s (SRS, 1998).
Smallpox has been eradicated. The state has become free of plague and more recently
of guinea worm infection. The incidence of polio has been reduced to just 6 cases in
2000. A widespread infrastructure of health and medical institutions has been
developed through government policy measures. A large pool of trained health
personnel has also been created through support to training institutions in the public
and private sector.
1.2 Health gaps
However, gaps remain. Large rural-urban differences remain, exemplified by IMR
estimates of 70 for rural areas and 25 for urban areas (SRS, 1998). Despite overall
improvements in health indicators, inter district and regional disparities continue.
The five districts of Gulbarga Division (Bidar, Koppal, Gulbarga, Raichur, Bellary)
and Bijapur & Bagalkot districts of Belgaum division continue to lag behind. Under
nutrition in under five children and anaemia in women continue to remain
unacceptably high. Women’s health, mental health and disability care are still
relatively neglected. Certain preventable health problems remain more prevalent in
geographical regions or among particular population groups. Decision making and
financial powers are insufficiently decentralized or exercised, to develop swift and
effective local responses to health problems.
The public lack confidence in public sector health services, particularly at primary
health centres. Lack of credibility of services, adversely affects the functioning of all
programmes. Underlying reasons for implementation gaps need to be understood and
addressed.
1.3 Health policy approach
The State has so far followed policy guidelines through the framework of successive
Five Year Plans developed by the Planning Commission, decisions of the Central
Council of Health and Family Welfare, central health legislation and national health
programmes developed by the Central Government. Over time, separate policies at
national level have developed for health (1983), education for health sciences (1989),
nutrition (1993), drug policy (1988 and 1994), Medical Council of India (MCI)
guidelines (1997), blood banking (1997), the elderly (1998), and population (2000).
All these have served the State well in developing its health system, and will
continue to be used as a standard for further growth.
Health however is constitutionally a state subject. Health needs, defined socioepidemiologically, vary between states and even districts, requiring more specific
planning. Health expenditure is met largely by the State budget, with 82% of public
sector expenditure on health from the State Government of Karnataka and 18% from
2
Central Government. A comprehensive Karnataka state policy for the integrated
development and functioning of the health sector is therefore being articulated
explicitly, for the first time in 2000-2001, at the turn of the millennium. The policy
with a strong emphasis on process and implementation will be an instrument for
optimal, people oriented, development of health services.
•
It will build on the existing institutional capacities of the public, voluntary and
private health sectors.
•
It will pay particular attention to filling up gaps and will move towards greater
equity in health and health care, within a reasonable time frame.
•
It will use a public health approach focussing on determinants of health such as
food and nutrition, safe water, sanitation, housing and education.
•
It will expand beyond an excessive focus on curative care and further strengthen
the primary health care strategy.
•
It will encourage the development of Indian and other systems of medicines and
healing.
•
It views health as the right of every citizen and will work within a framework of
social justice and decentralization as envisaged in the 73rd and 74th Constitutional
Amendments.
•
Most importantly it is intended to be a guiding document that needs to evolve and
be changed in response to changing situations.
This policy evolution derives from intense, interactive discussions organized at all levels
through the Karnataka Task Force for Health, throughout 2000 and early 2001.
2.
The Karnataka vision statement for better health and health care
2.1. Karnataka State recognizes the immeasurable value of enhancing the health and
well being of its people. The State’s developmental efforts in the social, economic,
cultural and political spheres have, as their overarching goals, improved well being
and standards of living, better health, reduced suffering and ill health, and
increased productivity of its citizens. It is recognized that health and education are
central to development. Health is a basic human right, an entitlement, and an
individual and collective responsibility. The constitutional mandate, role and
responsibility of the state (government) in giving direction, in creating a policy
framework, in health care provision and related endeavours including maintenance
of standards of health care, is of critical importance in meeting these social
development objectives.
The understanding of health was articulated by the World Health Organisation
(WHO), 1948 as “a state of complete physical, mental and social* well-being and
not merely the absence of disease or infirmity” creating the ability to lead a
“socially and economically productive life” (WHO 1978). This is the ideal
towards which individuals and institutions in society strive. While India and
Karnataka accepted the goal of the World Health Assembly of 1978, of Health for
All by 2000, it is acknowledged that this has not been achieved. The State will
3
work with a sense of greater urgency and commitment to a renewed goal of Better
Health for All, Now, particularly for the underprivileged.
Karnataka reaffirms the relevance of the strategy of Primary Health Care, and the
importance of practising the principles of Public Health in order to reach this goal.
The state is supported in its health and health related efforts by the Constitution of
India, which states in its Directive Principles that,
“The enjoyment of the highest attainable standard of health is one of the
fundamental rights of every human being, without distinction of race, religion,
political belief, economic or social condition.”
The 1983 National Health Policy recollected the aim of the Constitution of India
for “the elimination of poverty, ignorance and ill health”, and its direction to the
State, ”to regard the raising of the level of nutrition, the standard of living of its
people and the improvement of public health as among its primary duties, securing
the health and strength of workers, men and women, especially ensuring that
children are given opportunities and facilities to develop in a healthy manner”.
The United Nations Universal Declaration of Human Rights, 1948, of which India
is a signatory, states that “Everyone has the right to a standard of living adequate
for the health and well-being of himself (herself) and his (her) family” (words in
brackets have been introduced).
2.2.
The State and her people are proud of the several achievements made in terms of
improved health and better access to health care. However, the State also a
recognizes that some goals have not been met. The State expresses certain current
concerns and commitments.
•
•
•
•
•
It is concerned about the current inequalities and inequities in health status by
region, urban / rural location, gender, social and economic groupings.
It is also concerned that good quality health care services are unevenly
distributed and are inaccessible and unaffordable to a significant proportion
of its citizens.
It is aware of the escalating prices of diagnostics, medical therapeutic
technologies and pharmaceutical products that are occurring as a result of
globalization.
It also recognizes the health impact and consequences of broader policies that
affect employment, income, purchasing capacity, food security, education and
pollution.
The State accepts that public sector expenditure for health, while growing,
does not meet recommended norms and is inadequate to support health
services to respond to basic health needs. Out of pocket expenditure by
people, largely in the private sector, while fairly substantial, has not produced
requisite health gains and also results in adverse economic consequences to
families, especially the poor. Judicious investment in health brings major
gains in terms of human well being, development and economic productivity.
--------------------------------------------------------------------------------------------* Addition of the word ‘spiritual’ was suggested by India, but was not accepted by others, who argued
that it was included in social.
4
•
•
•
•
3.
It acknowledges the growing recognition, that access to comprehensive health
care has a poverty alleviating effect.
It also recognizes the urgent need to address poverty and inequality, and the
social forces that underpin them, as poverty and ill-health linkages are strong,
having been adequately researched and documented.
It is committed to pursuing social development policies and increasing
intersectoral coordination to accelerate improvement of health of all sectors of
society in an equitable manner.
It recognizes the critical role of the state to initiate and steer policies;
- to ensure equity and quality of care;
- to promote the sustainable development of public health services;
- to promote community/ peoples’ participation in the governance of health
service;
- to facilitate private and voluntary health sector growth as augmenting
health care while maintaining professional and ethical standards and
keeping in mind distributive justice;
- to provide adequate resources to different levels of health care and to
maintain accountability and transparency in functioning.
Karnataka – Mission Statement on Health & Health Care
3.1
Karnataka State, through a process of planned policies and strategies, and through
ongoing reflection, research and learning, aims to respond to the aspirations of its
people for better health and for improved access to good quality health care. It will
do this by using policy mechanisms and instruments to create and support an
enabling environment for further development of the entire health sector – public,
private and voluntary. It will foster active participation of people through
decentralized systems to take part in the governance and social control of the
medical and health sector.
3.2
Karnataka state has rich spiritual, philosophical and cultural traditions. In keeping
with these, the development and functioning of the health sector will be guided by
values of equity, ethics, accountability, concern and respect for all people,
participatory democratic functioning and respect for local health knowledge and
culture. Principles of integration, decentralized governance, working in partnership,
social inclusiveness, community participation, empowerment and gender sensitivity
will be actively promoted through all its health sector interventions.
3.3
The Karnataka State Government will foster the further development of living and
working conditions that improve the health status of all its people, particularly of
the poor and marginalised. It will work, in the next five years, towards ensuring
that all citizens have access to the basic determinants of health. These include
nutrition, housing, employment, safe water, sanitation and education, recognizing
that many of these lie outside the health sector. It will provide an enabling
environment for the equitable growth and development of good quality health care
services in the public, private and voluntary sectors, based on humane moral and
ethical values. It will actively encourage a spirit of collaboration and cooperation
between the different sectors and also with elected bodies and citizens' initiatives. It
will put into practice the principles of public health and the primary health care
approach, including the education of health personnel. It will govern and nurture
the vast number of personnel working in its network of health services in the
Directorate of Health and Family Welfare, in urban municipal and other bodies.
5
4.
Karnataka health policy perspective and goals
4.1
Building on strengths of the system evolved over the years, specific will be
undertaken at various levels and within a reasonable time frame, to further improve
health status and increase people’s access to health care, particularly for women,
children, disadvantaged communities and regions, the disabled and the elderly in
Karnataka.
4.2
A comprehensive integrated approach will be used to develop the health care
sector, so that it is responsive to the health needs of the community, defined socioepidemiologically.
4.3
There will be a strengthening of public health systems, using the primary health
care approach, with an emphasis on community participation and inter sectoral
coordination. Functioning referral systems will be built with secondary and tertiary
health care services. Health management and hospital administration will be
further developed.
Building institutional capacity, including leadership,
professional competence, communication skills, managerial skills and teamwork
will be encouraged and fostered at all levels.
4.4
While efforts will be made to increase financial and human resources to the health
sector, from public and private sources, issues of sustainability, cost-effectiveness,
self-reliance, accountability and transparency will receive serious consideration.
4.5
Human resource development will be ongoing, through appropriately designed
basic and continuing education and accreditation systems, which will be introduced
in a phased manner for all grades of health and allied professionals. Social and
community orientation will be a major focus.
4.6
Partnerships will be built with institutions and practitioners from the private and
voluntary health sectors, also ensuring maintenance of acceptable professional and
ethical standards.
4.7
Health promotion and empowerment will be a thrust area with active involvement
of the education sector, media and civic society.
4.8
Indian systems of medicine, homeopathy, local health traditions, Tibetan medicine
and other systems of healing will receive greater recognition, resources and
support, to contribute to overall health goals.
4.9
Decentralized planning and functioning within the health system, and decentralized
governance through the Panchayat Raj system will be developed further with
professionalism, accountability and fairness.
4.10 Values of equity, gender sensitivity, accountability, transparency, fairness, selfreliance, humaneness, respect for local health knowledge and culture and
participatory democratic functioning will form the guiding principles, with explicit
efforts made towards internalizing them.
Indicators and systems for monitoring and evaluation will review and assess
progress towards achieving specific objectives that derive from the goals.
6
5.
Karnataka Health Policy Components
5.1
Scope of policy – comprehensiveness and integration
To facilitate the balanced development of health systems and services, responsive
to health needs and aspirations of people, Karnataka State considers it necessary to
have a comprehensive health policy statement in which different elements are
integrated together and viewed as a whole. Various units and sub-sectors may
evolve more detailed policy guidelines. However, this comprehensive statement
will allow each one to be placed in the context of others. A comprehensive
approach is important, since at the point of delivery of services or the point of
contact between the public, the patient and the provider, there is need for horizontal
integration.
The need for development of comprehensive health care was first identified by the
Bhore Committee in 1946. The importance of integrated health services was
reiterated by the National TB Programme in 1962. The damage caused by vertical
programmes was recognized by the Kartar Singh Committee in 1973. It
recommended integration, as did the Srivastava Committee Report in 1975. The
State will undertake measures to operationalise a comprehensive, integrated health
service, with promotive, preventive, curative and rehabilitative health care services
at primary, secondary and tertiary levels, linked together with good referral
systems.
5.2
Public health approach and primary health care strategies
The practice of public health principles was strong in the State till the sixties. These
unfortunately declined since the seventies. The state recognizes the value of
practicing public health and primary health care, for the common good of all
citizens. It has committed itself to revitalizing these aspects. While the clinical or
curative approach to health is focused on individual persons and their disease
problems, public health tries to protect, promote, restore and improve the health of
all people, through collective action. Programmes, services and institutions give
priority attention to disease prevention and health promotion, responding to the
health needs of the population as a whole, particularly the deprived. Public health
addresses the basic determinants of health. Epidemiology is one of the basic
sciences of public health, studying the distribution and determinants or risk factors
of disease and ill health in society. Public health interventions address
communicable disease transmission and attempt to reduce risk factors for other
diseases. An evidence based approach using action research and other sources will
help develop and fine tune strategies. This will be supplemented by feedback from
the public, from patients and from frontline implementers or health personnel. This
will enable the development of a problem solving approach that is locally specific.
Public health and primary health care work in synergy, particularly emphasizing
principles of,
7
a)
b)
c)
d)
intersectoral coordination at all levels, especially at the district and below;
community participation through panchayati raj institutions and other
mechanisms and fora for involvement in decisions making concerning their
own health care;
equitable distribution of good quality care; and,
use of appropriate technology for health.
The primary health care strategy does not focus only on the primary level of care
but also on the secondary and tertiary levels.
The new public health recognizes and attempts to address the socio-cultural and
political economy factors that affect health status and implementation of health
programmes.
5.3
Equity in health and health care
Equity will be a key policy thrust, encompassing four main parameters, namely,
region, disadvantaged groups (Scheduled Castes and Tribes), gender and
vulnerable groups (street children, elderly).
a)
Region
The state is deeply concerned by recent data analyses that reveal continuing
regional disparities in health status, in distribution of primary health care
facilities and in their utilization. The districts of Bidar, Gulbarga, Raichur,
Koppal, Bellary, Bijapur and Bagalkot scored the lowest on all indicators.
These districts will receive priority attention through a special package of
services inclusive of infrastructure development, additional personnel, a good
management structure and special efforts at community empowerment for
health, particularly with women, through women sanghas and NGOs.
The districts of Belgaum, Gadag and Chamarajnagar have negative indices at
a lower level, while Dharwad and Bangalore Urban lack government primary
health care services. These districts also require attention.
The districts of Kodagu, Uttar Kannada, Chikmagalur, Udupi, Dakshin
Kannada, Shimoga and Bangalore Rural have better indices regarding health
determinants, health status and utilization of health facilities. However,
specific pockets and population groups within them are more disadvantaged
and vulnerable. Services here will be maintained with a focus on vulnerable
groups and taluks or areas.
Taluk level disparities have also been identified in all divisions of the State.
These will be factored into the planning process.
b)
Disadvantaged groups
Persons from Scheduled Castes and Scheduled Tribes will receive priority
attention. Besides primary care, access to complete treatment, follow up and
referrals, to secondary and tertiary care services at very subsidised costs, will
be assured. The camp approach will be replaced by ensuring good quality
care for vulnerable groups within the health care system. For indigenous
people a package with nutrition communicable disease control, care for
8
specific diseases such as sickle cell anaemia and special norms for health
services will be implemented.
5.4
c)
Gender
The poor status of women's health, the declining gender ratio and poor
coverage and quality of mother and child health services are areas of concern.
Measures to improve women's health status and access to care will be
implemented and closely monitored. Efforts will be made to increase the
number of women doctors, senior health assistants (LHVs and ANMs) by
providing adequate residential facilities and personal security. This will be
done, particularly at Primary Health Centres and Community Health Centres.
The districts with poor health indicators currently, namely Bidar, Koppal,
Gulbarga, Raichur, Bellary, Bijapur and Bagalkot will receive high priority.
Quality of maternal health services will improve, in particular emergency
obstetric care. Widely prevalent conditions affecting women, such as
anaemia, low backache, cancer of the cervix, uterine prolapse and
osteoporosis will be addressed. Services for psychosocial problems and
emotional distress will be developed. Empowerment of women for health will
be encouraged and supported. Programmes for the special needs of adolescent
girls and boys will be developed in collaboration with the department of
education.
d)
Vulnerable groups
Innovative, flexible and collaborative approaches for meeting the health needs
of street children, out of school and working children, persons with disability
and the elderly, will be used.
Quality of care
Having developed an extensive statewide health care infrastructure over the past
five decades, an important policy thrust area in the next phase will be improvement
in quality of care and patient satisfaction. Standards of care for different levels of
health institutions will be developed. Mechanisms will be established to assure
good quality medical and public health care in public institutions and to facilitate
and ensure similar standards in the private and voluntary sector. Mechanisms may
include accreditation, repeat registration, legal measures, mandatory continuing
education for all health care personnel, patients charters and grievance redressal
systems. Provisions of good care to patients will be the primary concern.
5.5
Multisectorality and intersectoral coordination
Intersectoral coordination has been inadequate even though its importance was
recognized since the late 1970’s. Working links, joint programmes and regular
communication will be institutionalised between the Directorate of Health and
Family Welfare and the Departments of Women and Child Development,
Education, Rural Development and Panchayati Raj, and the Public Distribution
System in particular. Links with the Water Supply and Sewarage Boards, Pollution
Control Boards will be developed with clarity regarding the roles of each
department and areas of shared responsibility. Functional mechanisms at
village/ward level, taluk, district and state will be developed.
9
5.6
Public, private and voluntary sector partnerships
Though already existing in an adhoc and often informal manner, public private and
voluntary partnerships will be further developed in a planned, systematic manner in
order to develop in spirit and practice a collective, community ownership for better
health care and also for optimal utilization of health resources. District and Taluk
health action networks and issue based networks will be encouraged with active
participation from the public sector in such voluntary sector initiatives.
5.7 Health Financing
Greater attention will be paid to equitable health financing systems in view of the
rising costs of medical care and the large out of pocket payments that often have
adverse consequences on the poor. Social insurance schemes, prepayment
schemes, selection of cost effective strategies including use of generic drugs and
central purchasing will all be tried out.
State government spending on health will be brought up to acceptable norms, as
investments in the social sector are recognized to produce gains in human
development. Equitable proportions of spending will be in the primary, secondary
and tertiary levels and between rural and urban areas. Resource flows will help
increase access to quality health care in rural areas. Allocation and spending on
health promotion will be enhanced. The indigenous systems of medicine and
homeopathy will receive a higher share of resources.
A system for state health accounts with necessary data bases will be developed to
monitor health revenue and expenditure, including those from externally assisted
projects and centrally sponsored schemes. District wise health expenditures will be
analyzed, reported in annual reports and made available to people on request. A
larger proportion of funds will be allocated to the Panchayati Raj Institutions,
including some untied funds to enable district authorities to respond to local needs.
Districts with a lower ranking on the Human Development Index need more funds
for health, but may also a lower capacity to utilize it. Besides increased resource
flows, financial management and administrative capacity will also need to be
strengthened in these districts. Systems of transparency and accountability will be
established.
Pilot studies will be undertaken and encouraged to experiment with innovative
health financing schemes such as community financing and social insurance, with
particular focus on the rural and urban poor.
Since the Government of India has opened up the health insurance sector to private
and foreign investment, the state government will introduce mechanisms to ensure
that they operate in an equitable manner seeing that the interests of consumers/
patients, particularly the underprivileged are protected. Regulation of health
insurance through appropriate authorities will be undertaken. Public sector
insurance companies will be promoted.
10
5.8
Health Planning
Health planning will be undertaken at state level more and more, keeping in view
national policy and programme guidelines. The state will institutionalize a strategic
planning monitoring and review unit, into the Directorate/ Secretariat. The unit
will use an evidence base whenever necessary and possible.
Epidemiological units will be developed alongside the surveillance units, at district
level and state level. Descriptive and analytical work will be undertaken, by the
epidemiological units, in priority diseases and health problems. They will help to
improve the quality of data collected through the surveillance systems and HMIS.
The Strategic Planning Cell (SPC) will have a multidisciplinary team including
economists, sociologists and anthropologists. Studies will be undertaken by them
and also contracted out to other institutions, including educational institutions. The
SPC will need to be supported by adequate facilities, such as computers, library
and online information systems. Over time, a medical and health research body or
council will be established at the State level with links with the State Institute of
Health and Family Welfare and the Rajiv Gandhi University of Health Sciences.
The council would undertake relevant research to support decision making and
planning by the Health Directorate. This will make planning more systematic,
rational and responsive to local needs and situations.
Health financing and health personnel planning will be a critical and ongoing part
of the state health planning.
5.9
Health Management and Administration
Through a process of recruitment of trained personnel and in service training, skills
in health management and administration will be strengthened. Two streams of the
health cadre are being envisaged for medical care and public health respectively.
The public health stream of the health cadre will have programme management and
implementation skills. In the medical care stream, hospital administration,
especially for hospitals above 50 beds, will be professionalised.
The Health Management Information System will be an important means for
decision making and for introducing correctives at institutional and higher levels.
Issues such as leadership, governance, strengthening institutional capacity,
developing efficient communication systems, within and between tiers and levels,
will receive priority attention, with the help of experts and institutions such as the
Indian Institute of Management.
Sections for engineering, construction and infrastructure maintenance; equipment
procurement and maintenance; drug procurement and transport, will be
strengthened in-house and developed further into specialized units. These are
critical support areas for health systems to function optimally.
The newly introduced systems, under the Karnataka Health Systems Development
Project (KHSDP), for contracting out non-clinical services such as cleaning,
laundry, security, dietary department etc., will be reviewed and the positive aspects
11
internalized. Minimum wages and working conditions of staff under these systems
will be ensured.
5.10 Environmental Health
Evironmental health is an important issue of concern with increasing pollution of
air, water and soil due to rapid and sometimes unplanned industrialization,
inadequate compliance with pollution control regulations, poor monitoring and
control systems. Motor vehicle fumes also add to the toxic chemicals in the air.
Excessive use of chemical pesticides including those, which are banned, are
causing pollution of the food chain. The State will introduce measures to control
exposure to these sources of pollution in order to protect its citizens from these
health hazards. Environmental and health impact assessment studies will be
undertaken around industrial and power plants, dams, mines etc. and clearances
will be required before new plants are commissioned.
The health sector will also take responsibility to ensure the improvement of
drainage and sullage systems and solid waste management in keeping with the
guidelines of the committee set up by the Supreme Court of India.
The government will ensure water quality through a monitoring and surveillance
system according to accepted norms and standards.
Health education and health promotion activities will promote personal hygienic
practices and methods to safeguard against environmental health hazards.
5.11 Nutrition
The magnitude of undernutrition and deficiencies in Karnataka revealed by recent
data, place nutrition as a major public health problem in the state.
The state policy reflects the National Nutrition Policy (NNP) adopted by the Govt.
of India in 1993 and the National Plan of Action in Nutrition (NPAN) developed in
1995 by the National Standing Committee on Nutrition.
The goals to be achieved by 2007 are:
(a) Reduction of under nutrition (Gomez classification) among pre-school children
as follows - severe undernutrition to 3% from 6.2% (1996); moderate
undernutrition to 30% from 45.4% (1996). (b) Reduction in anemia among women
from 42% (1998) to 30%. (c) Reduction in anemia among children from 66%
(1998) to 50%. (d) Reduction in new borns with low birth weight from 35% (1994)
to 10%. (e) Elimination of blindness due to Vit. A deficiency and elimination of
iodine deficiency in goiter prevalent districts. (f) Promotion of balanced, low cost
diets using locally available foods for different age groups including children,
adolescents, pregnant and lactating mothers and the elderly. (g) Improving
household food security through poverty alleviation programme.
The short-term interventions envisage district wise goals and targets will be
developed, nutrition interventions for vulnerable groups, particularly:
12
(a) Focussing on under-twos with supplementary foods. (b) Expanding the nutrition
intervention net (ICDS, UIP, ORT)* with wider coverage, regularity and better
quality, with special attention to girls and underprivileged social groups. (c)
Empowering mothers and families with nutrition and health education, with
emphasis on caring for children and on low cost, locally available nutritious foods.
(d) Control of iron deficiency anemia, Vit. A deficiency and iodine deficiency.
To achieve the above, the state will enhance its investment in nutrition
interventions, will fill up vacancies and ensure full capacity of staff, strengthen
supportive supervision and improve/ develop nutrition monitoring systems.
The indirect, long term institutional and structural changes, as also
recommended by the National Nutrition Policy, 1993, are:
(a) improved food security; (b) increased production of nutritionally rich foods
such as pulses, oilseeds and ragi, and protective foods such as vegetables, fruits,
milk, poultry, fish and meat; (c) improved purchasing power by active
implementation of poverty alleviation programmes; (d) strengthening the public
distribution system; (e) preventing food adulteration; (f) improving the status of
women; (g) ensuring community participation.
5.12 Population Stabilization
Population stabilization through fertility decline has long been a goal of the state
government, in consonance with national priorities. It is widely recognised that the
public sector in particular has generated awareness, demand for services and has
also provided widespread access to contraceptive and family welfare services,
especially terminal methods, and to health care. There have been resultant gains
with declines in birth rates from 41.6 (1951-60) to 22.1 (1998-99), death rates from
22.2 (1951-50) to 7.9 (1998-99), and growth rates from 2.2 (1951) to 1.8 (2000
estimate). The Total Fertility Rate (TFR) is 2.13 and the effective Couple
Protection Rate (CPR) is 60%. Thus the State is fairly near to reaching
replacement levels of fertility.
Data indicates declines in growth rates,
particularly after 1981 in all districts except Gulbarga division (with slower or
stagnant declines). This momentum of decline is likely to continue. Expert
analysis suggests that improvement in social development, quality of life and
gender development will hasten the process of demographic transition. This
will be an important component of the state strategy, with emphasis on
districts in greater need.
Drawing from the guidelines of the National Population Policy 2000 the State will
follow certain basic principles.
a)
It will promote the spirit of voluntarism and will protect human rights. It will
not adopt coercive strategies in any form.
----------------------------------------------------------------------------------------*
Integrated Child Development Services (ICDS), Universal Immunization Programme (UIP), Oral
Rehydration Therapy (ORT).
13
b)
It will provide good quality contraceptive services, integrated with primary
health care throughout the state. Reproductive technologies that are safe and
effective will be used. Quality of care will be further improved with
screening, follow-up services, managing and minimizing side effects.
Spacing methods will be made more available and more popularized. Male
methods will be increasingly used, reducing the burden from women only.
The government is committed to providing for informed choices and to
seeking the consent of citizens.
c)
Responding to the specific situation in Karnataka the State will develop a
special package for districts with greatest unmet need in terms of health and
family welfare services. It will endeavor to increase the utilisation of these
services by making them user friendly, being particularly sensitive to the
special needs of women.
The objectives of the state in terms of population stabilization are:
•
•
•
To provide good quality family welfare services integrated with general health care
services to all sections of the population, particularly in areas of greater need, though
strengthened health care infrastructure and health personnel and by developing
partnerships and coordination within and between government departments, with
industries, the private sector and voluntary sector.
To bring the Total Fertility Rate to replacement levels in all districts at the earliest, by
2005.
To achieve a stable population by 2030.
Strategies and Steps to be taken will include:
•
•
•
•
•
•
•
Setting up a State Commission for Population and Social Development.
Making all efforts to ensure adequate facilities for good quality mother and child health
care.
The State will attempt to develop a good civil registration system, working towards
100% registration of births, deaths and marriages. It will pilot this in a few districts and
then expand. This will help provide accurate information regarding population
dynamics.
The State is concerned about increasing son preference that is adversely altering the
gender ratio. It will implement legal measures such as The Prenatal Diagnostic
Techniques (Regulation and Prevention of Misuse) Act 1994 to prevent female foeticide.
It will also strengthen norms about the intrinsic value of girl children.
Introducing life-skill and population education for adolescent girls and boys, using
methods that capture their interest and responding to their needs.
Promoting delayed marriages for girls in particular and boys, delaying of the first
pregnancy and spacing of the second child.
The equitable and sustainable social development dimensions of a people centered
population policy, including the education for all children; enhancing programme,
implementation for basic amenities (and rights) such as safe water supply, sanitation and
health care; increasing employment; and empowerment of women. Given the broad
scope of interventions, implementation of the Population Policy would not be the sole
responsibility of the Department of Health and Family Welfare, but will involve
14
considerable intersectoral coordination for which working mechanisms will be
established.
5.13 Education for Health Personnel
Learning and education in Indian tradition are accorded an almost sacred place and
role. Karnataka has many achievements in the realm of education for health
personnel, including medical and all allied health professionals. Institutions of
high quality have developed. The private sector has been encouraged and a vast
network of educational institutions has been established. The relatively new Rajiv
Gandhi University for Health Sciences is working towards ensuring better
academic and professional standards and norms.
Institutes and systems for education, training and continuing education play a
critical role in the formation of medical and allied professionals, and in the
maintenance of this human resource as a well-informed, up to date and motivated
force. This is particularly important in a profession on whose decision-making
abilities and practices depend the life, health and well being of people. The
regulation of the profession including of its educational systems and institutions
and the role of the state therefore are issues of great importance.
A situation analysis reveals many ills in the health personnel educational system
and institutions and in professional practice and conduct. These include a rapid
expansion in quantity, namely numbers of educational institutions and seats, at the
expense of quality. There is an overproduction and supply particularly of medical
graduates. In post-graduation, there is a mismatch between the specialties, with
certain specialties remaining underrepresented. Growing commercialisation and
corruption in student selection, during examinations, and in the professional
practices of teachers, cause double standards, with dilution of professional
standards and ethics. Student and patient interests are compromised with
inadequate numbers of teaching staff, inadequate and poor quality infrastructure
and equipment. Professional councils are often not playing strong roles to regulate
their respective disciplines.
Keeping these and other factors in view, the health policy has evolved certain principles
and strategies for education for health personnel.
a)
The focus will not be only on medical education of doctors but on all allied health
professionals and on Indian Systems of Medicine and Homeopathy. The
functioning of a variety of health professionals in teams makes for better health
care services to respond to people’s needs. Conducting team training will be
encouraged.
b)
Norms regarding number of institutions and number of seats will be respected.
Issuing of essentiality certificates and University affiliation for new medical,
dental, nursing, pharmacy and physiotherapy colleges will be stopped for the next
3 years, with an exception for nursing colleges in the under-served areas of
Karnataka. The distribution of institutions will receive greater attention. The
number of students per college will be stipulated (e.g. maximum of 100 per
batch in a medical college) in order to maintain quality.
15
c)
Similarly the moratorium on new Ayurvedic, Homeopathic and Unani Colleges
will continue for two more years.
d)
Efforts will be made to improve the infrastructure and functioning of existing
colleges (all systems, all levels) bringing them up to acceptable norms laid down
by professional councils. The State will in particular initiate measures in this
regard for government teaching institutions and hospitals. It will allocate
resources for repair, maintenance and where justified extensions of buildings.
Similarly systems for regular equipment repairs, and maintenance will be
established. Staffing will be according to norms in the teaching and non-teaching
category. Essential Services will be maintained round the clock especially
emergency services, casualty, accidents, burns, X-ray, laboratory, blood bank etc.
Uninterrupted supply of drugs required for such institutions will be made
available.
e)
A study of financial and other resource requirements for these institutions will be
made, with various options for raising of resources and for ensuring sustainability
of these institutions.
f)
Closer working links will be encouraged between the University, educational
institutions and health services for mutual advantage and development. Health
Service professionals can undertake some teaching responsibilities, while a part
of the teaching of undergraduates and postgraduates could be based in district and
taluk hospitals, with postings to CHC and PHC’s as well. Teaching staff also
will be exposed to the reality of situations in such institutions so their teaching
and research could be relevant. Teaching institutions, will work in collaboration
with the Department of Health and Family Welfare in service provision in a
specified number of PHC’s / CHC’s / Wards etc.
g)
Improvements will be made in the pedagogy of health science institutions. The
University and Para –Medical Board will organise Teacher Training Programmes
on Teaching Methodology for health sciences suited to adult learners. It will be
mandatory for teachers to undertake these courses. Learner centred, problemsolving approaches will be used, moving away from the banking system of
education. Each institution will be encouraged to initiate and run educational
units with the specific objective to improve teaching capacity. Systematic
feedback from students will help to modify training programmes. Performance
appraisal of teaching faculty will help to further develop their competence.
h)
State Councils, such as the Karnataka Medical Council, Dental Council, Nursing
Council, Pharmacy Council etc. need to be strengthened and professionalised.
They should also to provide for community representation through consumer
groups, NGOs and then professionals being nominated or co-opted in order to
reflect social and community concerns. The Councils could develop a good
information and knowledge base and also a database regarding their membership.
A Commission at State level will bring together representatives from different
councils, including Indian Systems of Medicine and Homeopathy along with
government policy makers and University / board representatives to address
issues raised by the National Education Policy for Health Sciences. The
Commission will need to be alert to trends in the sector including negative trends
mentioned earlier and make suggestions for regulations and correctives.
16
i)
The State Institute of Health and Family Welfare will be developed into a high
quality centre for training and continuing education, especially in the fields of
public health, management and ethics, linked with the Rajiv Gandhi University of
Health Sciences. It will provide orientation and in-service training to personnel
from the department of health. It will be linked with the district and health
worker training centres. Its infrastructure will be upgraded especially, library,
teaching halls with audiovisual equipment and computer facilities, as also
personnel. It could offer certificate and diploma courses. It will be encouraged
to develop links with other educational and specialized institutions, including the
Indira Gandhi Open University. It will also undertake research studies
5.14 Rational Drug Policy
The government is aware of the advances and developments made by the
pharmaceutical industry in the country and in the state, with good technological
and production capacity, high turnovers and exports. However it is concerned that
essential drugs of good quality are not available in adequate quantities to many,
particularly in rural parts of the State. The rising cost of drugs especially in recent
years, and adulterated substandard drugs are also areas of concern.
The State has developed a public sector pharmaceutical concern, the Karnataka
Antibiotics and Pharmaceuticals Ltd (KAPL), which has been functioning well and
at a profit over the years. There are also several small scale producers and larger
Indian companies, besides foreign and multinational companies in the state. The
public sector, organised Indian private sector and small scale sector are the major
producers of bulk drugs, while the others operate in formulations and in production
of inessential drugs which are more lucrative.
There are over 60,000 formulations of medicinal drugs in the market. The essential
drug list of the World Health Organisation (WHO) has listed about 300 drugs
necessary for secondary care, while only about 25 – 30 drugs are required for
primary care. However these drugs, are produced much below requirements
estimated according to epidemiological need and also below licensed capacities,
resulting in shortages. These are drugs required for common diseases such as
tuberculosis, worms, filaria, typhoid, anaemia etc. On the other hand there is
abundant production of vitamins, tonics, health drinks, cough and cold
preparations, over the counter preparations (OTCs), tranquilizers, antacids etc. The
production and sale of irrational and hazardous drugs is another area of concern.
The State recognizes its responsibility as to ensure that all people are able to obtain
the drugs they need or required at a price that they and the state can afford; that
these drugs are safe, effective and of good quality. It will implement this
responsibility through various measures, including better drug selection, pooled
procurement, quality assurance, management and transparency in procedures, using
resources in a socially productive way, and encouraging participation and
discussion from the public and professionals in this vital area concerning lives and
health of citizens.
1.
The Government supports the concept of essentiality based on criteria of
therapeutic need, efficacy, safety and value for money. Essential drugs only
17
are selected for the Rate Contract lists. Essential drug lists for different levels
of institutions will be adopted.
Spreading of information concerning essentiality and essential drug lists to
medical professionals, pharmacists and to citizens will be promoted in
consumer and patient interests. The patients / citizens right to information
will be protected by making available information about harmful, hazardous,
irrational and essential drugs.
2.
The government supports the system of monitoring Adverse Drug Reactions
(ADR) already initiated by the Karnataka State Pharmacy Council. It will
increasingly get all its institutions linked to the system. Early detection of
ADRs will allow for corrective actions to be initiated.
3.
The state through its technical bodies will keep abreast of latest developments
regarding drugs and therapeutics and will initiate suitable action to withdraw
hazardous drugs from the market in consumer interest e.g. baralgan (a
hazardous antispasmodic), novalgin (a hazardous analgesic), enteroquinol (a
hazardous antidiarrhoeal). Outside experts, the pharmacy council and
consumer activists will be inducted into technical bodies. The names and lists
of banned drugs and their formulations and trade names will be widely
publicized.
4.
Drug package labeling and package inserts will be made to carry unbiased
drug information and cautions to consumers of warnings for drugs not to be
taken during pregnancy, drugs not recommended for the elderly, for children,
for people with liver or kidney impairment etc. This should be made
available in Kannada also and in print large enough to read. The state
recognizes its responsibility in protecting the health of its citizens against
iatrogenic problems, since health is of higher value than profits to companies.
In this it will also endeavor to enhance the knowledge of medical and allied
professionals through professional and other bodies. The ethical and legal
aspects of the need for rational therapeutics will also be highlighted.
5.
It will strengthen the Drug Control System by providing for adequate staff
with the required qualifications.
It will introduce inspection of good
manufacturing practices as recommended by WHO.
Systems will be
established wherein prescribers can send drugs they suspect to be substandard
for testing. Random samples of drugs will be sent for testing in recognised
laboratories in the state and in different parts of the country.
6.
Key staff and doctors will be trained in rational drug policy issues and in how
to identify and solve problems relating to drug prescription, dispensing and
consumption. Newsletters and updates on drug categories, cautions,
contradictions, side effects, dosage for different age groups etc., will be made
available to improve quality of service to consumers.
7.
Monitoring and studies of prescription practices, pharmacy practices etc. will
be encouraged to provide regular feedback for continuous improvement in the
area of rational therapeutics
18
8.
Rational drug policies for the Indian Systems of Medicine and Homeopathy
will also be introduced following discussions with their Councils and experts.
9.
Measures to increase effectiveness of drug procurement, warehousing and
distribution are also being undertaken.
10.
Expert groups will look at drug pricing issues and issues relating to access to
drug for persons with HIV / AIDS with psychiatric illnesses and other
diseases requiring new drugs which fall under the new patent laws and are
therefore out of the reach of the majority of people.
The State will study the impact of the new patent regime on the pricing,
production patterns and availability of pharmaceuticals. Necessary measures
will be taken to protect the interests of patients and consumers.
11.
The State will support strategies in collaboration with professional and
consumer bodies to ensure safe drugs and rational drug use for people. It will
be alert to implementation of drug policies, including bans. Problem drugs or
unsafe drugs will not be allowed to be marketed or used e.g. pediatric
preparations of loperamide or diphenoxylate, unnecessary combinations of
antibiotics with antidiarrhoeals, analgesics, irrational over use of second line
antimalarials (mefloquin) and antitubercular drugs, growth stimulants,
harmful contraceptives, hormone replacement therapies and psychotropics.
12.
A State drug formulary and therapeutic guidelines will be developed, adopted
and regularly updated. Use of generic prescribing will be promoted.
13.
The Directorate of Health and Family Welfare will take responsibility for the
drug policy and will not leave it only to the Departments of Petrochemicals or
Industry. Forums for intersectoral working will be made functional.
14.
Pharmaceutical Companies will need to follow nationally and internationally
accepted codes of marketing practices, registration and re-registration of
drugs for production will also have to follow acceptable norms especially
with regard to advertisements, sponsorship, indirect promotional methods,
and availability of unbiased information.
15.
Drug donation guidelines will be developed and implemented.
16.
fforts will be continued to attain and retain self-reliance in the production of
all essential drugs and vaccines. The economy of scale will help these to be
available at low cost. Modernization and upgradation of public sector
facilities including infrastructure and personnel will be undertaken so that
they can contribute to contain drug and vaccine prices and to maintain gold
standards.
5.15 Medical Industry (diagnostics, biomedical equipment, health accessories)
The production, procurement and marketing systems for diagnostics, medical
equipment, health accessories and educational material will be regulated, keeping
19
in mind need, quality, cost effectiveness, safety and ultimately patient and
consumer interests.
There is need for a body to lay down standards and for production to be brought
within the purview of a legally binding act. Necessary action will be taken in order
to safeguard consumer interest.
5.16 Medical and Health Research
Research and the spirit of enquiry upon which it is based provides the critical
questioning and thinking required in the quest for new solutions to old and new
problems. Rapid social, technological and environmental changes are posing new
disease and health problems. There is a need to actively study these changes and
evolve our own ways of addressing them.
Karnataka State prides itself of having premier scientific, technical and research
institutions in various fields. It will partner with these institutions and actively
foster systematic data collection and research in the public health services and
educational institutions so as to inform the planning process. It will develop the
necessary bodies and facilities for a purpose. A research advisory group would
steer the research process, raise funds and review technical quality and
achievements.
5.17 Indian Systems of Medicine and Homeopathy (ISM&H)
The country and Karnataka have evolved and cherished a rich heritage of
traditional Indian systems of medicine and healing. These classical systems of
Ayurveda, Siddha and Yoga have the world's earliest written texts and
pharmacopia. They have survived through the centuries and are currently gaining
increasing global recognition and respect for their insights and holistic approach to
healing and efficacy. They have a large number of practitioners, educational
institutions, and pharmacies/centres where medicines are prepared. They are linked
to local health traditions and practices. Other systems such as Unani, Tibetan
medicine and homeopathy also contribute to health care in the state.
However, ISM&H have been neglected in health planning and provisioning of
resource by the state. In future this will be compensated for and reversed. They
will receive increased state support and resources to promote optimal growth
according to their own genius. They will be involved more in health decision
making and in provision of health services, possibly being located within the same
premises as modern medicine, so that people can freely exercise a choice.
5.18 Health Promotion
Health education and Information, Education and Communication (IEC) activities
have in the past few decades been fragmented. They are linked to specific
programmes each of which has an IEC component. It is envisioned that health
promotion will receive a major thrust and become the most important health
intervention in future. It will move focus from communicating information to
promoting positive behaviour change and from being instructive to becoming
empowering. It will address health determinants, diseases, prevention and control,
using appropriate methods and idioms to different settings and varied groups such
as school children, youth, women, workers/farmers etc. It will enable people to
20
increase control over and participate actively in improving the health. Local folk
media will be used.
The state will allocate adequate resources for health promotion and take measures
to build capacity for health promotion, using talent available from all sectors and
promoting creativity.
6.
Policy Components on Priority Health Problems and Issues
6.1
Communicable / infectious diseases
The State recognises that communicable diseases such as water borne diseases, air
borne diseases particularly tuberculosis and acute respiratory infections; vector
borne diseases namely malaria, filaria, dengue fever, Japanese Encephalitis and
Kyasanur Forest Disease; sexually transmitted diseases, HIV / AIDS, Hepatitis B
and C ; among others, still account for the largest share of the burden of disease in
Karnataka, resulting in both avoidable preventable morbidity and mortality.
People’s demand for better and effective services that can control these diseases,
has been articulated several times.
The state will accord highest priority to reducing and preventing the transmission
of these diseases by allocating adequate resources for the purpose and by using
strategies based on the principles of public health and primary health care. It is
aware that cost effective methods for control of these diseases are well known. It
also feels that investments in health and health care today, produce gains in terms
of reduced preventable suffering, better health, well-being and improved
productivity. Besides resources and technical inputs, the state recognises that
governance, leadership, management and good administration are critical in
achieving these goals.
The state though an inter-sectoral approach will invest in nutrition, in safe water
supplies, in sanitation and waste disposal, in housing and education, in
interventions to improve women’s status, recognising that addressing these
determinants of health are part of a public health approach and have deep and long
lasting gains in health. The entire state will be covered by these basic services in a
phased manner.
The communicable disease control programme will be integrated horizontally into
the general health services. Particular attention will be paid to the centres closest to
the homes of people namely the 1685 primary health centres and their associated
sub centres. Special care will be taken to develops and nurture the personnel
working in these peripheral centres and in the anganwadi’s.
A disease surveillance system, with district epidemiological and microbiological
units will be made functional statewide within 5 years. Diagnostic equipment, drug
supply and communication systems will be made more efficient. Continuing
education will update peripheral health personnel on new information and
developments.
21
a.
Tuberculosis
The State will work towards the following (a) increased case detection to
75% of expected cases; (b) early case detection, with an emphasis on sputum
microscopy. Developing an acceptable ratio between sputum positive and
sputum negative cases; (c) good recording and reporting systems, with
possibly notification of TB. Research and analysis will be encouraged; (d)
ensuring uninterrupted drug supplies; (e) complete treatment with cure rates
of at least 85%.
It will cover the entire state at the earliest with the Revised National TB
Control Strategy, particularly emphasizing the preparatory training of all staff
and setting up of supervisory mechanisms for diagnosis and treatment.
Provision of microscopes and filling of all vacancies will be undertaken.
Directly observed or supervised therapy will be used judiciously where
necessary. Active involvement of patients and their families in the treatment
process will be fostered.
Recognizing that TB is an important co-infection will HIV / AIDS, special
attention will be paid to providing diagnostic and treatment facilities to all
persons with HIV / AIDS.
The state recognises that poor implementation of the RNTCP will result in
increased drug resistance and even to Multi Drug Resistance. It accepts its
responsibility in minimizing this by ensuring good treatment practices in the
public and private sector. It will also monitor the situation by setting up
facilities for culture and sensitivity in laboratories at the earliest.
b.
HIV / AIDS
The State will take proactive steps to create public awareness regarding this
rapidly growing problem. Preventive education, will be undertaken with
adolescents through life skill education, with workers in the organised sector;
with women through Sanghas and women’s organisations; with young adults
in particular; and through the general mass media.
•
District based voluntary counselling and testing centres (VCIC) will be
established in all district hospitals.
•
Lack of access to treatment is a difficult ethical issue which will be
addressed by attempts to reduce prices of antiretroviral drugs, through
negotiation and collaboration with various agencies.
•
Treatment to reduce mother to child transmission will be introduced.
•
Home based care would be encouraged and supported.
•
There will be no discrimination in providing treatment facilities in all
public sector hospitals. Private sector institutions will also need to be
non-discriminatory
•
Training of staff will be undertaken.
•
Treatment facilities for Reproductive Tract Infections (RTIs) and
Sexually Transmitted Diseases (STDs) will be expanded, with
conscious efforts to maintain privacy and professional confidentiality.
•
Measures will be enforced reduce transmission of HIV through blood
transfusion and blood products.
•
Strong advocacy and social mobilisation efforts will be made at all
levels.
•
Surveillance and operational research will inform the development of
the programme.
22
•
•
•
•
c.
NGO and philanthropic organisations will be supported to run care
centres for patients where home care is not possible.
The State will be responsive to problems such as children with HIV /
AIDS, orphaned children, abandoned patients, legal issues etc.
The State will promote collaboration between public, private and
voluntary sector, all departments and with citizens groups in responding
to the problems of HIV / AIDS.
The control of HIV / AIDS is closely linked to control of sexually
transmitted diseases (STDs) and Reproductive Tract Infections,
Hepatitis B and C. The overlapping elements in strategies will be made
convergent and all will be operationalised through general health
services.
Vector borne diseases
Vector control strategies for the different diseases (e.g. malaria, filaria,
dengue fever etc.) will be made coherent and integrated, retaining specificity
required for different vectors. A judicious mix of bioenvironmental methods
and use of pesticides, including neem, will be utilized and popularized. The
adverse effects of pesticides are documented and of concern. Caution will be
exercised in selection and use of pesticides.
For malaria, early diagnosis and prompt treatment through active and
passive surveillance; good laboratory diagnosis and reporting systems; vector
control with an emphasis on bio-environmental methods; personal protection;
prediction, early detection and effective response to outbreaks; health
promotion and most importantly involvement of people through proactive
social mobilization efforts will be sustained. Epidemiological mapping and
study of time trends will help in identifying areas needing specific attention.
For filariasis especially in endemic districts, in addition to the general
principles of vector control and the guidelines of the National Filaria Control
Programme, treatment of acute and chronic filariasis, detection and treatment
of microfilaira carriers will be undertaken. Single dose mass (diethyl
carbamazine) DEC therapy will be considered after expert review.
The increasing spread of dengue fever is being recognised as a public
health problem. The new expanded disease surveillance system, backed by
the public health laboratory service, will help to record emerging
epidemiological patterns. Facilities for diagnosis and treatment will be made
available; health promotion for households regarding peri-domestic measures
to reduce vector breeding; adoption and implementation of urban, municipal
bye-laws to control vector breeding grounds will be initiated.
6.2
Women’s Health
The State has several ongoing schemes for girl children and women. These will be
expanded, strengthened and developed further.
The State recognises several societal factors that influence and affect women’s
health, such as lower social status, social exclusion and isolation; lower access to
and utilisation of health and other services especially in some districts; poverty,
leading to overwork, fatigue, stress, undernutrition, and a host of effects;
environmental degradation reducing access to water and fuel; migration for
23
economic reasons increasing risk of ill-health; violence in the family, at the
workplace and in public places; along with education, employment, mobility,
empowerment and political participation which have positive influences. The state
is committed to women friendly policies in all these areas. It will also undertake
reviews of the implementation of schemes addressing these issues and studies of
their impact.
More specifically, in health, policies will work towards the following:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
6.3
A focus on the entire life course or life cycle of women from conception to death.
This means ensuring adequate nutrition and physical and social conditions for
mothers during pregnancy, providing access to good mother and child health
services, implementing measures to prevent female foeticide and female
infanticide. Women will have access to the entire gamut of services till old age
and death.
Focus on the woman/women as a whole including physical, psychosocial and
emotional aspects. This will mean a major shift from the predominant focus on
family planning and reproductive health, to conceptualizing and responding to
women as persons of dignity and worth and not only on their role as procreators
and mothers.
Using strategies empowering women for health, where women are important
agents for change.
Using a community health and community development approach that facilitates
community mobilisation, community participation, community organisation and
community action, wherein the role of men is also important. As many health
problems of women have social roots, this strategy will allow for social
interventions rather than medical interventions only.
Health promotion for women focussing on empowerment and community action.
Access to care for women will be enhanced by increasing the number of women
health professionals, particularly at primary care levels and in the first referral
units. Provision of adequate living facilities, equipment and drugs will also be
ensured at these centres. Priority attention will be given to Bidar, Koppal,
Raichur, Gulbarga, Bellary, Bijapur and Bagalkot districts.
Gender and age disaggregated data to improve the database and analysis of
problems, and the impact of interventions. Qualitative and quantitative indicators
will be developed and used.
Special attention will be given to developing counselling and mental health
services for women at district and taluk level with trained professionals and by
short term training of health workers at primary care levels to respond to needs at
community level.
Facilities for diagnosis and treatment of STDs and RTIs will be made available at
the primary care level supported by a referral system.
Education regarding reproductive health will be given higher priority.
Children’s Health
Karnataka State has a special interest in and commitment to the health and well
being of children during their intrauterine period, infancy, toddler years, school age
and adolescence. Its interventions reach out through MCH programmes, through
anganwadis of the ICDS scheme through schools and colleges. A policy document,
“The State Programme of Action for the Child” brought out in 1994, reiterated the
state’s commitments, in keeping with the spirit of the National Policy for Children
24
in 1974, the World Summit for Children in 1990, the four sets of Rights of
Children (to survival, protection, development and participation), and the National
Plan of Action: A commitment to the Child, adopted in 1992. The State will be
guided by the principle underlying the national plan, namely “first call for
children”, wherein the essential needs of children will be given highest priority in
allocation of resources at all times. This will also be applied specifically to the
spheres of health and nutrition, as recent data reveal unacceptably widespread high
levels of undernutrition and anaemia in Karnataka, which leads to illhealth and
stunted growth and development. Specific efforts will be made to reach children,
especially from socially deprived groups, who are still unreached by the IDCS
system and who are out of school. A multisectoral approach will be used to
provide services for working and street children, and to address underlying issues
that result in their having to work.
a)
The state will undertake all efforts to ensure child survival with no damage to the
processes of growth, maturation and development. Continuing efforts will be
made to reduce infant and neonatal mortality.
b)
The coverage and quality of services of the Integrated Child Development
Services (ICDS) with regard to health, nutrition and care will be improved by
providing adequate resources and training of all levels of personnel. Supervisory
and monitoring systems will be strengthened. Recognizing the importance of the
child care, responsibilities of anganwadi workers, who are volunteers on an
honorarium, caution will be exercised in adding additional responsibilities that
may be detrimental to their prime responsibility. Constructive partnerships with
gram panchayats and parents will be developed and linkages with Primary Health
Centre staff will be made more functional and regular. Quality of food given to
children will be ensured and health promotion and nutrition education will be
undertaken more proactively and professionally. The most needy children,
including scheduled castes and scheduled tribes, will receive particular attention.
Disaggregated data by age, sex, taluk, and social grouping will be regularly
validated and analysed.
c)
School health programmes will be developed, being initiated by the public
sector in partnership with parents, voluntary organisations and the private sector.
The goal is that a health promoting school will provide a healthy environment,
health and nutrition education, school health services, physical education and
recreation/ extra – curricular activities. Through health promotion, preventive
health, screening and early detection it helps prevent disease and disability.
School age children account for about 25% of the population. The school health
programme will help attain their full potential in physical, psychosocial,
emotional and intellectual growth and development. The two-fold purpose is
improvement of health and health promotion. Key strategic interventions include
training of over 3.15 lakh teachers in the 58,000 schools through a training of
trainers; school curriculum review of health related topics; health promotion
using activity based learning principles; a focus on life skill education to prepare
children for life; ensuring universal coverage with good quality school health
services including follow up treatment.
Schools will be seen as community institutions and will be centres from where
out of school children will also be reached.
25
d)
6.4
The adolescent age group has been relatively neglected and currently faces
greater risk during this phase of rapid social transition. Adolescent care and
educational programmes will be designed and implemented with sensitivity.
These will include family life education, life skill education, basic understanding
of sexuality, interpersonal relationships, conflict resolution, coping capacities for
dealing with stresses of increasing responsibilities and expectations from others.
Mental Health
The burden of suffering due to mental illness is large. Research work done over
the years by premier institutions have helped to quantify this in Karnataka. At least
2% of the population suffer from severe mental morbidity at any point of time and
an additional 10% suffer from neurotic conditions, alcohol and drug addictions and
personality problems. A large proportion of outpatients (20-25%) in general health
services have somatoform disorders and come with multiple vague symptoms.
Unsupported and untreated mental illness has an impact on families as well. Mental
ill health is thus an issue of public health importance, requiring proactive, sensitive
interventions, particularly since more effective and better management is now a
reality.
However, there continue to be shortages of trained personnel in Karnataka,
compounded by maldistribution of facilities and staff with a greater urban
concentration in big cities.
The state will make systematic and sustained efforts to enhance mental health
services by:
a) Improving training in psychiatry and psychology in the undergraduate
medical and general nursing courses.
b) Introducing district mental health programmes in a phased manner by
strengthening psychiatric teams and services at district hospital level and
planning for counselling services at taluk hospital level.
c) Ensuring minimum standards of care for mentally ill patients.
d) Providing for mental health care at primary care level by training primary
health centre medical officers and staff, using manuals already prepared by
NIMHANS.
e) Encouraging and making provision for care facilities for persons with chronic
mental illness, through NGOs and other organizations.
f)
Introducing the mental health component into school health services on a
pilot basis in different districts and later expanding it.
g) Supporting broader societal strategies that address violence, particularly
against women; discrimination in any form; substance abuse; poverty and
destitution.
h)
i)
Establishing institutional mechanisms at the State level through which mental
health care services can be promoted.
Caring for and nurturing health care personnel, who are carers working under
difficult conditions.
26
6.5
Prevention and control of non-communicable diseases
Karnataka and India, along with other developing countries, carry a double burden
of communicable and non-communicable diseases. The latter include, in
particular cardiovascular diseases, including hypertension, cancers and diabetes.
These have on the whole received less public sector and policy attention due to the
magnitude of other problems and issues. However with a future perspective,
especially considering rising life expectancies, growing urbanisation and
industrialisation in the state, and rapidly changing life styles including diets, the
state will provide greater support to the prevention and control of noncommunicable diseases.
a)
It will use a public health approach by adopting strategies to reduce the risk
factors for these diseases and by using health education to promote healthier life
styles.
b)
It will initiate policies to stem the rapid increase in production, advertisement,
aggressive marketing and use of Tobacco and Alcohol products. Over 25 serious
diseases are associated with the use of tobacco and several diseases and social
problems are linked to alcohol. These are described as communicated diseases.
They are both addictive substances and once hooked, their manufacturers are
assured of consumers for life, event though for shortened lives. Policies required
for their control are broad and include bans on sponsorship of sports and
entertainment; bans on direct and indirect advertising; higher taxation; sales to be
permitted to only over-18s; sales barred within certain distances from
educational institutions; and public education, especially among children and
youth as part of life skills education; education of health personnel.
In the case of tobacco, measures include banning smoking in public places to
prevent passive smoking and working towards alternative crops and alternative
employment. Chewed tobacco in particular is a growing problem with
widespread use among women (40-60% in different groups) and even among
children as its addictive nature is not widely known. Comprehensive Tobacco
Control includes smoked and chewed tobacco.
In the case of alcohol there is a need for strategies to help women and children
cope with men who drink heavily. De-addiction strategies using group therapy
such as alcoholic anonymous groups will need to be supported, besides individual
therapy and counselling.
Education regarding tobacco and alcohol will be included in school and college
curricula.
c)
Diagnosis and treatment for non-communicable diseases will be made available
at primary health care level. This will require preparation of treatment guidelines
and supply of diagnostic equipment and drugs.
d)
Recording and reporting of non-communicable diseases as per the International
Classification of Diseases will be introduced into the diseases surveillance
system.
27
e)
6.6
The cancer control programme will also be strengthened by tobacco control,
health education, early detection and provision of treatment. Facilities will be
made available at regional level and later in a phased manner in some districts
where medical colleges exist. Grants provided by the national programme will be
fully utilised.
Disability
It is estimated that about 2-3% of the total population of Karnataka consists of
disabled people with 76% in rural areas and 58% men. Disabilities include
locomotor, visual and learning disabilities, hearing and speech impairment, mental
illness, mental retardation, multiple disabilities, etc.
An inclusive approach will be used for persons who are differently challenged or
persons with disability, with their full participation in decision making and
implementation.
The Department of Health and Family Welfare will increase its role and
responsibility in respect to disability, which has been largely under the Directorate
of Welfare of the Disabled, under the Department of Women and Child
Development.
The Persons with Disabilities (Equal Opportunities, Protection of Rights and Full
Participation) Act of 1995 will be made more widely known and implemented.
Interventions will need to include medical, social and environmental components.
The different steps would be:
(i)
Disability prevention -- through universal immunization, good nutrition,
MCH, accident prevention through drink and not drive policies, helmets for
two wheelers and car-seat belts etc.
(ii) Disability limitation – through prompt treatment, particularly at primary care
levels.
(iii) Reducing the transition from disability to handicap – by rehabilitation.
Establishing rehabilitation units at district hospitals.
(iv) Actively supporting Community Based Rehabilitation.
(v) Providing access to aids and appliances to those who cannot afford them.
(vi) Using apex and specialized institutions in the state for training of levels of
health workers.
(vii) As per the Medical Council of India recommendations, starting Physical
Medicine and Rehabilitation departments in every medical college.
6.7
Occupational Health and Safety
Though services exist in some large public sector and private sector units,
this specialty needs greater support. The focus will be on the agricultural and
unorganised sectors who comprise the largest proportion of the work force
and who are at risk because few safety devices and precautions are used. The
services of institutions like the Regional Occupational Health Centre and
experts will be utilised to evolve a strategy.
28
6.8
Dental Health/ Oral Health
Oral health has so far received little policy attention. However, the state recognises
that peridontal diseases and dental caries are widespread in the population. These
impact on general health as well. Fluorisis is prevalent in certain taluks and
districts (North Karnmataka, Kolar, Pavagada). Oral cancers are one of the
commoner cancers. The state has the largest number of dental colleges in the
country, numbering 41, of which 40 are private. However, there are concerns
regarding substandard quality and the lack of impact on oral health in the state.
Karnataka will integrate oral health within its health care services by providing
equipment and trained personnel at CHC level and services at PHC level through
the medical officers and dental/oral hygienists. School health programmes will
have dental/oral health as an important component both for
services and health promotion.
6.9 Emergency Health Services and Trauma Care
Initiatives to develop this area will be strengthened and expanded. Besides
accidents and injuries this will include emergency obstetrics care; snake/insect and
dog bites and stings; and other medical emergencies. Existing centres of
excellence in the state will be utilised to train expand services statewide. Transport
and communication links will be established and 24 hour services provided in
selected institutions. Training in first aid and life support systems will be imparted
to children, teachers, factory workers, drivers and conductors and paramedics.
Preventive measure such as helmets and seat belts will be encouraged. The right of
the citizen as determined by the Supreme Court to access emergency care in any
hospital and to received the first line of critical care will be publicised.
7.
Cross-cutting Policy Issues
7.1
Medical and Public Health Ethics
The state is aware of public dissatisfaction and loss of confidence in the health
services, particularly of the public sector. The state takes cognizance of expressions
of dissatisfaction through the media, elected representatives, people organizations
and movements and through the issues of concern raised by the Task Force on
Health in its Interim Report. In keeping with its constitutionally mandated
responsibility and in collaboration with professionals and the people it represents
and works for, it will initiate and make functional institutional mechanisms to
provide for checks and balances to protect public interest; and human rights
including the right to health and health care.
a)
The state will promote the principles and practice of medical ethics in all its
institutions, in all sectors and in all systems of medicine.
b)
The state will ensure the practice of public health ethics in its decision making,
resource allocation and in implementation of policies and programmes.
29
7.2
Policy Process and Implementation Factors
The policy document is just one step in the overall ongoing policy process that
makes explicit the current concerns, intentions and priorities concerning health
by government.
The competence and attitudes of implementers, especially at the point of contact
with patients or people is critical in giving life to policies and programmes.
Human resource development to develop competencies and capability and caring
attitudes will be a priority with a focus on front line implementers and just not on
leadership. Energising the primary health centres and all health institutions is our
goal. Good communication, supportive supervision, regular updates, small group
work, decentralistion of decision making and financial powers, participatory
methods, better governance and accountability systems, along with strategic
planning at all levels will be the strategic approaches to better implementation.
Strong politico-economic and social forces also influence implementation in
directions most often against the interests of the poor and marginalized groups.
Certain groups are more organized and powerful with closer access to
These include professional bodies and interests; industrial and business interests
of pharmaceutical, diagnostic and medical equipment manufacturers; the media;
donor agencies; International agencies and others. On the other hand, patients
and people, particularly the poor, are relatively unorganized and most often
unheard in the policy process. The state recognises that it represents this public
interest and it commits itself to undertaking this responsibility to improving
health and health care of its citizens.
30
8. Outcomes and Indicators
Quantity indicators of improved health and nutrition status and goals for 2007 are shown in the
Table below.
Sl.No.
Present
situation
M=61.7, F=63.5
Expected Outcomes
Year
Goals for 2007
1998
M=67, F=69
1.
Life expectancy at birth
2.
Crude birth rate
22
1998
17/1000 Pop
3.
Crude death rate
7.9
1998
7/1000 Pop
4.
Infant mortality rate
58
1998
40/1000 LB
5.
Under-five mortality rate
69.4
1994-98
55/1000
6.
Maternal mortality rate
195
1998
150/100000LB
7.
Nutrition status of children
7.1 Severe under nutrition
6.20%
1996
3%
7.2 Moderate undernutrition
45.40%
1996
30%
Gomez
39%
1996
50%
Classification
9.40%
1996
17%
7.3 Mild undernutrition
7.4 Normal
8.
Anaemia among women
42%
1998
30%
9.
Anaemia among children
66%
1998
50%
10.
Newborns with low birth weight
35%
1994
10%
11.
Immunisation coverage with maintenance
of cold chain
60%
1998
85%
12.
Safe deliveries with access to Emergency
Obstetric Care
51%
1998
>80%
13.
Case detection and cure rates in TB
68% / Not
Available
1999-
75% and 85%
respectively
2000
9. Conclusion
In conclusion, through this policy document Karnataka state is placing health high on its agenda.
It reaffirms the wisdom of the sages who said that health is wealth. It will translate this into
action by allocating adequate human and financial resources, by good governance and
institutional capacity building. "Better health for all now" can only be achieved if it is seen as a
common endeavour of all sections of society. The state will play a facilitating role in harnessing
resources, energies and ideas from the private and voluntary sector. It will stay committed to its
mandate and will work towards equity, integrity and quality in health and health care.
31
Recommendations
•
The draft Integrated Health Policy should be finalised after dialogue with Directorate of
Health and Family Welfare Services, other Government Departments, Voluntary
Organisations and Public.
32
23. VISION 2020
"The journey of a thousand miles begins with one step."
- Lao Tse
HEALTH OF THE PEOPLE OF KARNATAKA
The emerging picture of the health of people of Karnataka, 2020, is a bright one, though with many
patches of varying shades of gray. The gains made have been possible because of the political will
and action taken at all levels to improve health and health care. People's awareness and
participation have contributed considerably to improve health status. Conscious efforts by the
Government to meet the needs of all the people have helped in the betterment of health. The overall
development of the State has improved the health determinants. The availability, accessibility and
utilisation of health care and public health have led to improvement of the health of all the people.
Karnataka can take up the challenge of 'health for all'. It is now in a position, with the reforms and
restructuring in place, to make the health system work. Some of the health indicators have shown
that the efforts to improve the health of the people are already bringing forth the desired outcomes.
However the people of the State have visions and dreams of going beyond where we are. To move
forward towards these shared aspirations, a vision 2020 is being articulated with goals and
indicators to strategise and focus our collective energies. They will also become a referral point for
us to review our progress.
1. Infant Mortality Rate
The Infant Mortality Rate in 2020 will come down to less than 25 from the present figure of 51
(in 2001). Proactive measures will need to be taken to achieve these. This goal is being set
keeping in mind the stagnation and even slight worsening of IMR occurring over the past 5
years in 10 states. The process will include the availability of the second birth attendant,
recommended by the Task Force for Health and Family Welfare. She will look after the
newborn, ensuring spontaneous breathing and preventing hypothermia and other problems, thus
reducing neonatal deaths, an important component of infant mortality. Improved birth weight as
a result of better nutrition of the mother starting from her adolescent period and avoidance of
infection are other factors helping in the reduction of infant mortality. Better quality and
complete coverage of antenatal care, access to emerging obstetric care, implementation of the
universal immunisation programme, health promotion including nutrition, education of mothers
and families and a focus on caring for infants are all part of the intervention required to achieve
lower IMRs.
2. Under – Five Mortality Rate
There will be reduction in the under – 5 mortality from 69.4 (1994-98) to 40-45. The child is
healthier as a result of certain measures taken: commencement of breastfeeding immediately
after the birth of the child (benefiting from the goodness of colostrums); exclusive breast
feeding for the first 6 months; better universal immunization coverage (with a good cold chain
system) including immunization against measles; better nutrition with weaning (supplementary)
food from 6 months (food being given free to the poor), child care and psychosocial stimulation.
-1-
This will be achieved through working collaboration between anganwadis and primary health
centres / subcentres.
3. Maternal Mortality
Maternal mortality has been unacceptably high. Even the statistics available are questionable.
There will be reduction because of better health of the mother preventing undernutrition and
anaemia (especially the common iron deficiency anaemia with intake of iron-folic acid tablets),
availability of prenatal check-ups and of the services of trained birth attendants at all deliveries,
and better management of high risk pregnancies at the first referral units (Community Health
Centres and Taluka Hospitals as also urban maternity homes); who will be equipped to manage
problems like post partum haemorrhage and other obstetric problems. Action taken will reduce
the maternal mortality rate by 50% or more by 2020.
4. Crude Birth Rate and Crude Death Rate
Both the indices have fallen. The Crude Birth Rate has come down to 14 in 2020 from 21 in
2001; the Crude Death Rate has come down to 7.0 from 8.0. The Total Fertility Rate is down to
1.6; the Couple Protection Rate has gone upto 75%. Population stabilization is in sight. We need
to achieve this with gender equity, guarding against sex selection practices unfavourable to girls.
5. Equity
Having been accorded high priority, it is considered that by 2020 there would be a measurable
reduction in inequities as shown by disaggregated data analysis.
The regional (district, taluka) disparities would be reduced, with respect to the provision of
primary health care facilities, utilisation of health services by people, the determinants of health
(through developmental activities), and improved health status.
Gender disparities will show a reduction through the process of sensitization of all people,
including the health care staff at all levels to gender related issues and action by providing
access to women's health, professionally by increasing the number of women health
professionals and through women's health empowerment programmes.
Much work will need to be done with respect to removal of disparities in health due to socioeconomic (class / caste) inequalities.
6. Quality of Health Care
Quality will be the watchword with all personnel taking pride in the quality of their work.
There is increased awareness of the need to focus on quality, maintaining structural, process and
outcome standards in all health care interventions. The legislation on quality assurance and
registration of health care institutions has helped to improve quality. The process of
accreditation of all health care institutions is gaining momentum.
7. Integrity
A major factor which has been eroding public health care services has been corruption. Services
which were supposedly free can be obtained only after satisfying the demands made by the
health professionals and other staff. This is reduced through steps taken by the Department to
make known to patients and the public the rights of patients, the citizen's charter and the Right
to Information Bill. Increasing emphasis on ethics and integrity in the training programmes,
better governance, supervision and creation of the vigilance cell will all help in reducing
-2-
corruption in health care services. The balancing role of civic society organisations will be
encouraged by involving people's organisations, NGOs and elected representatives in various
capacities.
Action taken with respect to recruitment, postings and transfers of doctors and others has
reduced corruption. These steps will be continued.
There were many complaints of corruption by examiners in University examinations. Action by
the University to remove such examiners has produced the desired results.
8. Community Participation
One of the requirements for improved primary health care is community involvement. There is
greater degree of participation of the people in all matters affecting health and health care. This
has been helped by the institution of health committees from the village level onwards.
9. Water Supply and Sanitation
By 2020, we envisage complete coverage of the entire population with safe potable water
supply, and coverage of 80% of the population with sanitation facilities, through an intersectoral
effort.
There is improvement in water supply, an important determinant of health. The Bangalore
Water Supply and Sewerage Board and the Karnataka Water Supply and Drainage Board are
working towards improved water supply in cities and towns. The Department of Rural
Development and Panchayati Raj is spearheading service provision in rural areas, supported by
a variety of externally assisted schemes. There is also improved supply of drinking water, both
in quantity and quality, through the activities of the panchayats and village committees. There is
better monitoring of drinking water supply by the Health Department, using simple devices and
improved chlorination and other measures to assure better quality. These will be carried out by
the male health workers who are trained for the purpose and the work will be supervised. The
scarcity of water is tackled by better harvesting of rainwater and better management of surface
water, bore wells and hand pumps, Fluorosis and other problems are also being tackled.
Sanitation receives greater attention in the cities, towns and villages. This includes disposal of
garbage, sewage and human and industrial waste. There are more latrines but not sufficient.
People are encouraged to have sanitary latrines attached to their dwelling places, instead of
women having to wait until its is dark to relieve themselves in the open.
Hospital wastes are receiving greater attention, with segregation of the waste and appropriate
disposal.
10. Environment
Everyone has the right and responsibility to live and work in healthy environments. Many
people, especially those living in urban slums are compelled by circumstances to live in unsanitary conditions. The situation becomes worse in rainy seasons. The slum dwellings are often
below the road level and filthy water flows into the houses. Work environment particularly for
the unorganised and small-scale sector is suboptimal. Housing, living and working conditions
have to improve, through the efforts of all sections of society enabled by the state. Bodies set up
by the state will also look at action required at state level to study and respond to broader
environmental issues as depletion of the ozone layer; global warming; air, water and soil
pollution; and others; all of which impact on health.
-3-
11. Nutrition
The percentage and absolute numbers of severely and moderately undernourished children will
be significantly reduced, as a result of better nutrition awareness and action. Mid-term goals
stated in the health policy document will be improved by a further 50% by 2020.
12. Immunisation
There are many achievements by 2020. There is better coverage of children under the Universal
Immunisation Programme. Paralytic polio has been eradicated. The number of vaccine
preventable diseases is reduced. However coverage is still incomplete, especially in backward
districts. There are still problems of maintenance of cold chain with frequent breakdown of
electric supply. There is need for dependable refrigeration system. By 2020, this basic
preventive health strategy will have universal coverage with good quality.
13. Transition Stage
Karnataka is still in the epidemiological transitional stage. It still has a large share of infectious
diseases, characteristic of the underdeveloped world, as well as the degenerative and other
diseases of industrialised and affluent societies. The old scourges of tuberculosis and malaria
continue. It is envisaged that by 2020 the burden of preventable infectious diseases will be
contained keeping alert to newer and re-emerging diseases that continue to remind us of the
need to address deeper underlying socio-cultural, behavioral and political economy factors.
Health promotion regarding risk factors and healthier lifestyles will be actively undertaken with
creativity, professionalism and broad based participation.
HIV infection has been contained to some extent; anti-retroviral drug combinations are being
used against HIV infection.
14. Medical Services
Primary, Secondary and Tertiary Care Services are available through Public, Voluntary and
Private Sectors. But there are problems due to commercialistion of medical care. With a middle
class mindset, policy and decision makers do not see the needs of the poorest of the poor. With
globalization of medical care, the cost of care has gone up. The affluent can afford the care but
the very poor continue to be outside the medical care in the private sector. There is need for
social security, ensuring that the poorest can get the needed medical and health care.
15. The Non-Communicable Diseases:
The non-communicable diseases are on the increase. Diabetes Mellitus continues to be a serious
condition. A very large number of people are affected in urban and rural areas. 8-10% of males
and females of 20 to 80 years are affected. The disease leads to many complications.
Management and control of blood sugar level are absolutely essential.
High blood pressure is also prevalent in a large proportion of the population. Cardio-vascular
diseases are very common. Primary, secondary and tertiary prevention are necessary; changing
life styles have added to the problem. The state has a large number of patients with asthma and
chronic bronchitis.
-4-
16. Cancer
There is not enough community-based data on the prevalence of cancer in the State. Cancer
registry data may not reflect the true cancer situation. Changes in life style, longevity and use of
tobacco in various forms are some of the important causes leading to increase in cancer. The
increase in treatment centers has not been able to cope with the demands.
17. Sight for all
The number of the visually impaired continues to be high. The major cause (80%) is cataract.
This is curable. It is unfortunate and unacceptable that Karnataka has not been able to cope with
the need for cataract surgery (mostly intraocular lens implantation) even though we have the
required trained eye surgeons and the cost of IOL has come down drastically. Other causes of
impaired vision like corneal ulcers and opacities, glaucoma, refractive error, trauma and diabetic
retinopathy continue. Vision 2020 works towards coverage of the backlog, with attention paid to
other.
18. Substance Abuse
Alcohol consumption continues to be high, resulting in various kinds of diseases, affecting
almost every organ of the body. Not enough is being done to reduce the demand or supply of
alcoholic drinks and the harmful effects from their abuse.
Tobacco is another substance which has widespread harmful effects on the body, including
cancer, cardiovascular diseases and other problems.
19. Indian Systems of Medicine
Not enough is being done to improve the functioning of the health care institutions belonging to
the Indian Systems of Medicine. The people continue to use the systems of Ayurveda, Unani,
Siddha, Homeopathy, Yoga and Naturopathy.
Herbal medicine is very popular.
Other healing practices such as Tibetan Medicine, acupuncture, acupressure, pranic healing,
Reiki, magnetotherapy and many others continue to be popular with the public.
20. Panchayat Raj
There is greater co-operation between the Panchayat Raj Institutions and Health Services. The
Panchayat Raj Institution members are more aware of their responsibilities and powers. They
are involved in the planning and implementation of the development programmes including
health at various levels. This is making a substantial impact on the improvement of health
services at the periphery.
21. Medicinal drugs
The use of drugs has become more rational. Most of the essential drugs are available at the
health care institutions in the public sector. But some of the drugs, under the new patent laws are
not easily available because of the increased cost. The patent laws have affected the production
of some of the drugs in the country.
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22. Informatics Technology
Karnataka has made vast strides in Informatics Technology and this has made its impact on
Health Care. There are four main areas where informatics technology can be useful.
•
•
•
•
Patient care (diagnostic and therapeutic decisions)
Medical education, training and research
Public health
Health Systems management.
Patient care, both diagnostic and therapeutic, has benefited from telemedicine in secondary and
tertiary care with cardiac monitoring and ECG evaluation via a telephone line. ECGs and
sonograms are transmitted to experts and their advice obtained. It can be expected that these
facilities will be extended in due course to primary health care in remote areas. Computerized
ECGs, stress test equipment and scanners can be linked to computer networks and opinions of
experts (situated in the cities) can be obtained.
Medical education can benefit from computer assisted instruction. Visual information (images)
can be very useful. Computer animation can be added to it. MEDLARS has been helpful in
promoting education, training and research in health.
Health Management Information System has been developed and has been in place for some
time. It helps in better management of health care systems. Hospital Information System has
also been developed. Improving the utilisation of the facilities available and bringing out
lacunae and mismatches.
Public health can benefit enormously. Disease surveillance has been computerized. Early
information leads to early and effective interventions and containment of disease out breaks.
The vision is promising. The need is to have a mission to achieve that vision, where there is
equity, integrity and quality in health and health care.
-6-
KARNATAKA VISION 2020
Indicators
Infant Mortality Rate
Source / Year
SRS 1999
2020
25 / 1000 live births
NFHS – 2
35 / 1000 live births
SRS 1999
Male
2001
58 / 1000 live
births
69 / 1000 live
births
22.3 / 1000
population
7.7 / 1000
population
195 / 1,00,000
live births
61.7 years
1996-2001
13 / 1000
population
6.5 / 1000
population
90 / 1,00,000 live
births
70.0 years
Female
65.4 years
1996-2001
75.0 years
2.13
51.1
NFHS – 2
NFHS – 2
1.6
75
59.2
35 %
86.3
NFHS – 2
1994
2000
> 95
10%
100
59.7
2000
70%
60
NFHS – 2
90
70.6%
NFHS – 2
40.0%
Under –5 Mortality Rate
Crude Birth Rate
Crude Death Rate
Maternal Mortality Rate
Life Expectancy at Birth
Total Fertility Rate
Percentage of Institutional
Deliveries
Percentage of safe deliveries
Newborns with Low Birth Weight
Percentage of mothers who
received ANC
Percentage of eligible couples
protected
Percentage of children fully
immunised
Anaemia among children (6 – 35
months)
Severe under
nutrition
Nutritional
Moderate under
Status of
nutrition
children
Mild under nutrition
Normal
Sex (Gender) ratio
Sex (Gender) ratio, 0-6 years
SRS 1999
SRS 1998
6.2%
45.4%
39.0%
9.4%
964F / 1000M
949F / 1000M
-7-
2.0%
Gomez, 1996
2001 census
2001 census
25.0%
43.0%
30%
975F / 1000M
970F / 1000M
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24. IMPLEMENTATION OF THE REPORT
The Task force had the unique opportunity of considering the entire health system of the State.
Consequently, the recommendations of the Task Force are wide ranging and impact on almost
all aspects of the health system. At first sight the recommendations may seem too many and too
detailed. However, it would be evident that in the effort to cover all aspects of the health system,
all issues had to be considered and inter-relationships both within this system and the links with
other social and development activities had to be included. Obviously, it would be necessary
while considering and implementing these recommendations to prioritize them by urgency for
change, feasibility within a set time frame and need to ensure a smooth transition.
The recommendations could be broadly said to consist of three types.
•
Those that relate to the changes in the basic structure of the health services and involve
formulation of new Cadre and Recruitment Rules and associated elements;
•
Those that relate to “governance” issues such as training, moral building, transparent
transfer polices; personal appraisal system , monitoring of finances, administrative and
technical aspects of work; disciplinary systems; relationship with the Panchayat
institutions and other elements of management;
•
Those that relate to enhancement of equity, quality and coverage and building in
emphasis on new elements in the health services provided. These include the elements
such as expansion and addition of services, better surveillance, better access and reach of
services and the like.
It must be emphasized that these are not exclusive. On the other hand, they are inter-connected
since they together seek to re-engineer the health system for higher efficiency and productivity
and greater equity. However, these three sets of recommendations would need special expertise
appropriate to the character of the category of recommendations. Such expertise would range
from administrative, financial, legal and management experience to knowledge of the
professional content of both public health and medical (clinical) services. The structures for
examination of the recommendations would, therefore, have to be based on these special
requirements.
A two-tier structure is suggested for this purpose. The first could be a Implementation
Committee. The second would be subject matter Sub Committees whose reports would be
considered by the Implementation Committee and, in due course, by the final decision making
level in Government. It is suggested that the recommendations be considered by an official
Implementation Committee (for Health Systems Reform) which could include:
Principal Secretary for Health & FW, Secretary Medical Education, Commissioner for Health,
Project Administrator, KHSDP, who has been Member Convenor of the Task Force, Secretary,
Department of Personnel and Administrative Reforms, Director, Health & FW, a representative
of the Finance Department, a representative of the Law Department.
The Implementation of recommendations for change is essentially the responsibility, the
prerogative and the privilege of the Department of Health and Family Welfare. It is to be done in
an atmosphere of freedom, innovation and creativity. The government need to provide the
department with the best officers to lead and steer this important and challenging process of
change, ensuring them adequate time, space and support. The Task Force has refrained from
-1-
detailing implementation plans but expresses its willingness to be a sounding board in this
regard, if required.
To initiate implementation of recommendations at the earliest a small core group of young
energetic doctors be selected to function under the Commission for Health to study the
recommendations and evolve plans. This group could function on a short-term basis. the work
would be later continued by the Planning and Monitoring Division The Core group may first
process the recommendations for consideration of Government, prioritize them and set realistic
time frames for implementation. Some of the recommendations can be implemented early by the
Department. The attempt must be to expedite the process of implementation. Therefore, the time
frame should preferably be as short as possible.
Other experts could be co-opted for specific issues by this Committee or the Sub Committees
The Implementation Committee would need the assistance of a small but efficient secretariat, by
way of a Cell, to process the recommendations, prepare notes for the Committee and the Sub
Committees and follow up all action points. It is recommended that this cell be constituted of
full time officers drawn from within the Department and other connected Departments.
Expertise from outside could also be inducted with advantage.
The number of such officers and experts and the supporting staff may be determined and the
positions filled by selection of capable persons. This cell may be placed under the Commissioner
and will function till the Planning and Monitoring Division is fully established.
The Implementation Committee could set up Sub Committees for specific aspects. Priority
would have to be given to the reorganization of the health services. This would include basic
issues such as setting in place through Government orders the suggested system, transition
provisions, establishing the District Cadres and the procedures for allocation of existing
personnel and future recruitment procedures, preparation of the separate seniority lists for the
two Cadres of Public Health and Medical, determination of time scales for those who prefer to
remain as doctors at the PHC level, preparation of the new Cadre and Recruitment Rules, etc. It
would be useful to list out all these issues and develop a calendar of operations, with
specification of the Sub Committees that would deal with each issue. It must be reiterated that
the effort should be to implement the recommendations in as short a time frame as possible. If
these recommendations are implemented, there would be little doubt of the future of the health
services of the State in terms of efficiency and professional excellence and, most important of
all, ability to serve the people of the State to their full expectations and satisfaction.
The woods are lovely, dark and deep,
But I have promises to keep
And miles to go before I sleep,
And miles to go before I sleep.
- Robert Frost
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25. MAJOR RECOMMENDATIONS AND EXPECTED OUTCOMES
" Our main business in life is not to see
what lies dimly at a distance
but to do what clearly lies at hand"
-Dale Carnegie
The Task Force on Health and Family Welfare had made some short-term recommendations to
improve health of the people and strengthen health care services in Karnataka, with special focus on
Primary Health Care and Public Health. The Task Force is happy that these short term
recommendations have found acceptance by the Government and many of them have been
implemented or, are in the process of implementation. The Final Report takes cognisance of the
acceptance of the short term recommendations and builds on them with the medium and long term
recommendations. Implementation of these recommendations would yield good dividends by way
of improved health and human – centred development.
The overall thrust of the short term recommendations had been Equity With Quality. These
continue to be the major thrusts. During discussions with various groups and individuals, and
observations in the field, another important focus became clear: Integrity. It deals with corruption
which is widespread and must be tackled. There is increasing corruption in health services; if the
newborn baby is to be seen by the mother or close relatives, a bribe has to be paid. If an operation is
to be done, a bribe is demanded. It is true that there are many, many health professionals and health
workers who do their work honestly. But there are others who are unethical in their practice and
hold the public to ransom.
The hallowed precincts of the University and teaching institutions are not free of this lack of
integrity. Bribes are demanded if a pass is to be given. Even a good student has to pay to ensure that
the student does not fail.
But integrity goes beyond these. It deals with failure to do one's duty. Non-performance has come
out as a major issue.
There have been failures of the individual and the system. There is need for improvement. Better
training and overall capacity building can help in improved performance; so also, reorganisation of
the services can help in the utilization of resources with better accountability.
There are a large number of recommendations given under each chapter or subchapter. These are all
important. But in order to highlight the more important recommendations, they have been brought
together as "Major Recommendations". We have also given the expected outcomes" against each
recommendation, even though, in the majority of the recommendations, the outcomes are selfevident within the recommendations themselves.
-1-
Sl.
No.
1.1
Major Recommendations
Outcome expected
1. EQUITY IN HEALTH CARE
All policies of the Government (State and local), likely to All people have equal
have direct or indirect effect on health, should be opportunity to meet their
governed by the principle of equitable access to effective health needs.
care to meet the needs of the people; they should be
formulated such that disadvantaged are addressed to
reduce inequity. Monitor inequities in health based on
social, economic and health care services, disaggregated
with respect to age, gender, socio economic status,
geographical regions and others.
1.2
The Health System must improve availability and access
to quality health care (particularly primary health care
and public health) in the underserved talukas / districts
and for the poor and vulnerable population. Ensure better
utilization of the primary health care services by making
the facilities fully functional and people friendly and
through monitoring and supervision improve the quality of
service.
The State Government and the local governments should
take special steps to bring up the health status in areas
where the health status is below the State average.
1.3
In the large and undivided districts like Gulbarga and The quality of health care will
Belgaum the districts should be divided into two and a improve with better
post of Additional DHO / DMO should be created with supervision.
Additional team of Programme Officers.
2. QUALITY OF HEALTH CARE
Have minimum acceptable standards worked out by Standards are worked out for
independent committees for health care institutions at health care institutions at
different levels and locations and for public health different levels and locations
measures.
and for public health
measures.
2.1
2.2
The Joint Directors, Medical and Public Health, will be
designated as the persons in charge of Quality Assurance.
The Administrative Medical Officer in charge of each
hospital will be responsible for ensuring quality of care in
each institution.
-2-
Quality health care is
available to the poor and the
disadvantaged and in
underserved areas,
considering talukas and
districts as the base
Nodal officers and
administrative medical
officers assigned the
responsibility for quality
assurance.
3.1
3.2
3. PRIMARY HEALTH CARE
Have the philosophy of comprehensive primary health Priority is given to
care accepted through training and advocacy and comprehensive primary
implemented by all concerned: the people and the health health care, as distinct from
services.
selective primary health care
and in preference to
secondary and tertiary health
care.
All existing vacancies of doctors, nurses, pharmacists, All posts at PHCs and
laboratory technicians and ANMs in the primary health subcentres are filled up
centers and subcentres must be filled up immediately. promptly with qualified
Appointments made on contract basis must be regularized. personnel, appointed
Have regular appointments made based on needs for regularly, improving service.
which there must be a continuous assessment and
monitoring of vacancies likely to occur in the PHCs and
subcentres.
3.3
Appoint staff nurses at all PHCs, creating posts where Qualified staff nurses are
there are none at present.
available regularly.
3.4
All essential staff, including doctors, pharmacists, nurses All essential staff are
and ANMs attached to the Primary Health Centres must available for service at all
stay at headquarters.
times.
3.5
Have a construction and renovation programme such that
every PHC will have a suitable building within the next 5
years and quarters for the essential staff within the next 10
years. In the interim period, take suitable buildings on
rent for PHCs and staff quarters.
Every PHC will have its own
building over a time frame.
Buildings will also be
available for the stay of all
essential staff.
3.6
Consider the possibility of making available rural medical
practitioners / physician assistants / nurse practitioners /
nurse obstetricians available for service in the rural
areas, where qualified MBBS doctors are not available.
Where MBBS doctors are not
available for service at PHCs,
other trained practitioners are
available.
3.7
Have telephones at the PHCs installed without delay for Communication and transport
better communication. Make arrangements for the speedy are assured
transport of patients to the referral centers by provision of
ambulance vans or funds to hire available transport, in
the case of the poor.
3.8
There is need to have fully functional laboratory services, Diagnostic services are
with trained technicians.
assured
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3.9
Have Village Health Committees at Gram Panchayat
level. Two representatives each of the committees will be
members of the PHC level co-ordination committees,
which will have representatives of voluntary
organisations, professional bodies and elected
representatives. The Department of Health must stipulate
the working hours of PHCs and subcentres to suit the
community needs.
Community involvement is
assured at the village and
PHC levels. More convenient
working hours of PHCs.
3.10
PHCs must have round the clock service. Make available
the services of Lady Medical Officers. Progressively
increase the number of lady medical officers at PHCs such
that, in the course of the next 10 years, every PHC will
have one male and one female medical officer.
PHCs must provide round the
clock service. The services of
lady medical officers are
assured.
3.11
An appropriate referral system and linkages between An efficient and effective
PHCs and Secondary Care Institutions must be put in referral system is in place.
position to make primary health care more efficient and
effective.
3.12
Have Urban Primary Health Centres, one for 50,000
population in cities and towns, converting the existing
resources such as health centers, urban family welfare
centers and maternity homes. While these Urban Primary
Health Centres will be the responsibility of the local body
(Corporation or Municipality), technical guidance will be
provided by the Directorate of Health and Family Welfare
Services.
3.13
Every PHC will display prominently a Charter of Rights of Greater transparency and
patients and citizen's charter.
better appreciation of the
rights of patients are assured.
3.14
Distribute the male health worker, one for each Gram
Panchayat, redefining his job responsibilities. He will
belong to the District Cadre. The technical control will be
with a designated PHC medical officer.Or Male Health
Worker could be given the responsibilities of 2 Subcentres.
Better utilization of the
services of male health
workers with defined
responsibilities.
3.15
Reorganise and restructure the PHCs, PHUs and
subcentres (including staffing) considering the population
and area covered and accessibility.
Provide interest free loans for the purchase of two
wheelers for the transport of Medical Officer and health
workers at PHCs and subcentres.
Improved functioning of
PHCs, PHUs and subcentres.
3.16
-4-
Comprehensive primary
health care in urban areas
comes to function,
administratively under the
local bodies, with technical
guidance from the
Department of Health and
Family Welfare Services
Improved mobility and
availability of functionaries at
the first contact level.
4.1.1
4. SECONDARY AND TERTIARY HEALTH CARE
4.1 SECONDARY AND TERTIARY HOSPITALS
Make the secondary and tertiary health care institutions The needs of the people for
fully functional, with the required staff (avoiding secondary and tertiary care
mismatch) and equipment in good working condition. are better met.
Appoint an expert committee to examine the needs of the
State with respect to the specialities and their rational
distribution in the districts and talukas, together with
requirements of personnel, equipments, etc.
4.1.2
Make the hospitals under the Indian Systems of Medicine The hospitals under ISM&H
and Homeopathy function well. Standards for these provide quality care.
hospitals must be worked out and implemented.
4.1.3
Steps must be taken during training (in-service) Improved functioning of the
programmes to inculcate the feeling of 'ownership' of the hospitals.
hospitals by the staff at every level, with good 'supervision'
and 'facilitation'.
4.1.4
CHCs need the post of anaesthetists for the functioning of Improved surgical, obstetric
the Departments of Surgery and Obstetrics & & gynaecological procedures.
Gynaecology
4.1.5
The equipments must be maintained in good working Better utilization of the
condition; the downtime must be reduced to the absolute equipments
minimum.
4.1.6
The Administrative Medical Officer must be trained in Improved hospital
Hospital Administration.
administration; better service
to the patients.
4.1.7
The Secondary Care Hospital must have a social worker Improved facilities for the
and a Dharmashala for the care of the patients and patients and better patient
attendants.
satisfaction.
4.2 EMERGENCY HEALTH SERVICES
4.2.1
Develop Emergency Medicine and Trauma Care Centres Improved emergency care,
to provide comprehensive medical care, including reducing death, disease and
medical, surgical, obstetric, paediatric and trauma care. disability.
To start with there will be 44 such centers developed by
the Karnataka Health Systems Development Project. This
will be expanded gradually to include more hospitals,
spread throughout the State. Each center will have 10
beds for emergency medicine and trauma care. The
Centres will have trained personnel, all necessary
equipment and furniture.
-5-
4.2.2
A good and working communication system will be All available delay is
developed. This will include telephone facilities and removed. Patients get the best
wireless sets. Well-equipped ambulance services with possible care at the earliest.
trained personnel will be provided. The help of the police
will be taken to ensure early and easy communications. A
system of community insurance will be developed.
4.2.3
Helmet wearing should be made compulsory for two Improved safety on the roads.
wheeler users (including pillion riders). Seat belts should
be worn while driving cars. First aid training should be
mandatory to drivers and conductors of buses, trucks and
other vehicles. These vehicles will carry functional first
aid boxes.
4.2.4
The Additional Director, (Medical) will be the Chief A designated person is given
Nodal Officer for coordinating all work with respect to the responsibility for coEmergency Medicine and Trauma Care.
ordination.
4.3 DIAGNOSTIC SERVICES
4.3.1
The Public Health Institute must be redesigned and A State level laboratory with
strengthened to encompass Epidemiology and laboratory necessary expertise and
components. This State Level Laboratory should have facilities is available.
expertise in Bacteriology, Virology, Mycology,
Parasitology, Medical Entomology and Toxicology. Its
functions include Supervision, Training, Quality
Management, Reagent preparation and Standardisation.
4.3.2
The District Hospital Laboratory and the District Health District, Taluka and PHC
Laboratory will be integrated; the District Laboratory will level laboratories are
fulfill both functions – diagnostic service for health care, provided.
and for public health. The District Laboratory should be
supervised by one MD / DCP (Microbiology) and MD /
MSc (Biochemistry) and one MD / DCP (Pathology), and
adequate respective staff, technical and administrative.
The Taluk Hospital Laboratory should be supervised by
one specialist of DCP qualification, supported by other
staff. CHC and PHC laboratories will be managed by
Trained Technicians.
4.3.3
Imaging and miscellaneous investigative services will be Imaging and other diagnostic
provided to meet the requirements for diagnostic tests at services are available
various levels.
according to needs and
feasibility.
-6-
4.4.1
4.4 BLOOD BANKING AND TRANSFUSION SERVICES
All blood banks should have the required equipment, and All blood banks are of the
be supplied with adequate reagents and testing kits in a required standards and
timely manner. They should have adequate number of quality.
trained staff. All blood banks should put in place a quality
assurance programme.
4.4.2
A comprehensive plan to motivate and mobilize voluntary Availability of safe blood is
and relative blood donors to ensure adequate supply of assured
safe blood throughout the year and all over the state
should be developed with their help.
4.4.3
The medical community should be sensitized to make Optimum use is made of the
optimal & rational use of blood. Every hospital should blood.
have a blood transfusion committee to ensure this.
4.4.4
A pilot project to study the logistics, management and Information on management
monitoring of the centralized 3-tier system comprising – of the blood banking system
“Blood Component Center- blood collection -blood becomes available.
storage & issue points” should be initiated in Bangalore;
and this model replicated later in other major cities, if
found feasible.
4.4.5
An adequate number of well-equipped (Whole Blood) A system is in place to
blood banks will have to be set up, keeping the blood needs provide for the requirement
and regional disparities in mind.
of blood throughout the
State.
4.5 BIO-SAFETY
Radiation Protection programmes must be strictly followed Health professionals and
by the X-ray equipment users.
patients will be protected
from radiation hazards.
Adequate consumables for barrier protection like aprons, Health professionals and
masks and gloves should be provided to staff.
patients will be protected
All health care workers who are at potential risk for from nosocomial infections.
infections which may be transmitted through blood and
body fluids should be immunized against Hepatitis B.
4.5.1
4.5.2
5. PUBLIC HEALTH
5.1.1
5.1 PUBLIC HEALTH AND PRIMARY HEALTH CARE- A SYNERGY
All the staff of the Department of Health and Family Public Health is given due
Welfare Services must appreciate the importance of Public importance.
Health and the synergy between primary health care and
public health.
-7-
5.2 WATER AND SANITATION
While other departments are responsible for storage, treatment and distribution of water,
the department of health, has specific responsibilities for monitoring quality.
5.2.1
Set standards for water quality and ensure regular testing to Standards are set for
ensure that they are maintained. This information should be quality of water and
made available to the public.
periodically monitored.
5.2.2
Undertake, supervise and be responsible for water
purification treatment e.g. chlorination of wells in rural
areas by junior health assistants in collaboration with the
panchayats / local bodies. Undertake periodic testing for
microbial contamination. New water sources will need an
initial detailed testing for chemical contamination.
5.2.3
Undertake surveillance and notification of the concerned Waterborne diseases are
authorities regarding early outbreaks of waterborne controlled.
diseases, as part of the disease surveillance system.
Initiate rapid action in suspected outbreaks.
5.2.4
Integrate health promotion activities concerning water and Health promotion activities
sanitation related problems at all levels - through schools, with respect to water and
panchayats, women's sanghas, the print and audio visual sanitation.
mass media and folk culture groups. The linkage between
health status and water supply, sanitation and drainage
needs to be highlighted. Positive messages regarding
personal hygiene practices, environmental hygiene and how
to utilise government schemes.
5.2.5
Ensure availability of toilets in schools and public places Improved sanitation, with
and in individual households.
decrease in water borne
diseases.
-8-
Junior health assistants
carry out periodical testing,
chlorination and other
measures.
5.3.1
5.3.2
5.3 POLLUTION AND WASTE MANAGEMENT
General Waste Management:
- Set up a working group to look at the recommendations
of the Supreme Court Committee for management of
solid waste in Class I cities and draw up an Action Plan
for implementation in Karnataka.
- Learn from experiences in Bangalore regarding primary
(door-to-door) collection of garbage and expand it to the
other cities and towns.
- Accelerate the process of identifying and utilising the
Landfill sites.
- Delineate the elements of an Integrated Waste
Management Policy at the State Level.
- Identify mechanisms for improving the functioning of
the local self-governments with regards Solid Waste
handling (Financial and Technical expertise including).
- The government should provide certain common
facilities like collection & transport, incineration,
sanitary landfill sites etc., for all Towns and Cities and
support private initiatives for common waste
management facilities including recycling units.
A policy for waste
management becomes
available and action taken
to dispose off solid waste.
Hazardous Waste
Pollution of the
- Steps to be taken to publicise and bring in greater environment reduced.
transparency in the functioning of the State Pollution
Control Board including the punitive measures taken
against the polluting industries.
- Set up the working group to examine the existing
provisions of the Environment related acts (Water Act,
Air Act and Environment Protection Act) and the impact
of the 73rd and 74th Amendment to the Constitution of
India (Nagarapalika and Panchayath Raj Acts).
- Regulate the use of Plastics including the
implementation of the ban on plastics less than 20
microns thick.
- Steps to be initiated to regulate the use of Mercury and
other heavy metals in industries.
-9-
5.3.3
5.3.4
Natural Resources depletion and Pollution abatement:
- Study the recommendations of the Eco-committee
report under the chairmanship of Sri A N Yellapa
Reddy and draw up of an Action Plan for
implementation.
- Health Impact Assessment to be made mandatory
along with Environment Impact Assessment for
developmental projects.
Initiate steps to address the abatement of indoor air
pollution within households (efficient and effective use
of firewood and other fossil fuels; popularising the use
of LPG).
Bio-Medical Waste
- The Andhra Pradesh experience (Task Force for
independent monitoring and reporting), and Tamilnadu
experience (Development of Model centres in each
district) towards development of systems for safe
management of health care waste to be studied and
appropriately incorporated into the working of the
Advisory committee to the Appropriate Authority on
Bio-medical Waste Rules in Karnataka.
- The waste management initiatives at the KHSDP
Hospitals should be strengthened and extended to all
health care institutions.
- Ensure proper segregation of waste and total waste
management at all health care institutions. The
segregated waste streams should not get mixed up with
general solid waste.
The segregated waste should be disinfected; sharps
should be destroyed / disfigured and plastics shredded
before final disposal through discharge into sewage
systems, land-fills etc.
Recyclable material should be sent for recycling.
Ensure training of Healthe Care Personnel for proper
waste management practices.
Reduction in pollution.
Development projects are
cleared after considering
their impact on health.
Bio-medical waste disposal
is improved after learning
from our own and
neighbouring States
experiences. Health care
personnel are trained in
proper separation and
disposal of waste.
5.4 COMMUNICABLE DISEASES
5.4.1 VECTOR-BORNE INFECTIOUS DISEASES
5.4.1.1
Establish programmes for control of all vector borne Control of vector borne
diseases, including Malaria, Filariasis, Japanese diseases.
Encephalitis and Dengue fever / Dengue Haemorrhagic
Fever and Dengue Shock Syndrom, and KFD. Emphasise
bio-environmental methods of control.
5.4.1.2
Establish a District Level Disease Surveillance System and Control of communicable
a State Level Diagnostic and Reference Laboratory for diseases
mosquito borne infections and other communicable
diseases of public health importance.
- 10 -
5.4.1.3
Kyasanur Forest Disease
Strengthen the existing disease surveillance system for Early detection of outbreak
Kyasanur Forest Disease with every case of human of KFD.
infection or monkey death being reported and investigated.
5.4.1.4
Vaccination of the population at risk. Production of Prevention of KFD.
adequate quantities of KFD vaccine must be ensured as
also timely supply through cold chain.
5.4.1.5
The latest method for diagnosis like ELISA test should be Improved an early
introduced for quick and correct diagnosis.
diagnosis.
5.4.2
5.4.2.1
The quality of implementation of the Tuberculosis control Improved diagnosis and
programme in all districts, including urban areas, under care.
both the National Tuberculosis Programme (NTP) and the
RNTCP needs to improve within the next year. All staff
involved will need to be held accountable for performance.
The primary health centres should provide access to good
quality TB care for all, and should have
5.4.2.2
TUBERCULOSIS
laboratory technicians, whose skills are updated and
whose slides are cross checked regularly;
microscope, stains, all records and registers;
uninterrupted drug supplies;
medical officers are trained by the District TB officers
regarding the organisation and functioning of the
NTP/RNTCP;
close supportive supervision from the taluk health
officer and DTC in particular with problem solving in
the field.
The District TB Centre should have a qualified person in The District TB Centre
public health or with a diploma in TB and chest diseases. becomes functional and
DTOs should undergo the training at National effective.
Tuberculosis Institute (NTI). Two medical officers are
required at the DTC – one to run the clinical service and
the other to undertake training in the field and to analyse
reports etc. The DTC is the referral centre for all aspects
of the NTP/ RNTCP and should undertake orientation and
training of institutions and General Practitioners in the
private, voluntary and public sector regarding the
programme. A medical college department cannot replace
the DTC.
- 11 -
5.4.2.3
The state should work towards
Improved case detection
Increased case detection to 75% of expected cases. and completion of
This will include cases detected by the public, private treatment.
and voluntary sector for which a system of notification
may be required. The expected number of cases may
also have to be recalculated based on recent
epidemiological data. Targets should not be used.
Early case detection, with emphasis on sputum
microscopy for diagnosis. The use of x-rays should be
rationalised to reduce over diagnosis and unnecessary
treatment. There should be an acceptable ratio
between sputum positive and sputum negative cases
(1:1).
Completion of treatment with cure rates (measurable
in sputum positives) of at least 85%. Two drug
regimes should be discontinued.
• Recording, reporting and analysis at DTC level to
be used for monitoring and planning the
programme.
• Paediatric dosage forms of drugs to be made
available. Anganwadis could be centres for followup of young children with TB.
• Supervised or directly observed therapy to be used
only when necessary. Active involvement of patients
and their families in the treatment process with
adequate patient education.
5.4.2.4
The State TB Centre to be a model centre that is also used The State TB centre
for training and operational research, including social conducts training &
science research into patients and peoples’ perspectives. research.
Networking and training with NGOs and the private sector
to be facilitated by this unit along with the Karnataka State
TB Association.
5.4.2.5
The state should make greater use of the services and
advice of the National TB Institute.
Given the co-infection of HIV and TB, training for
physicians and health personnel regarding specifics of
presentation, access to treatment, developing working links
with the Karnataka State AIDS Society.
5.4.2.6
5.4.2.7
Services of NTI used
better.
Health personnel trained
for tackling co-infection.
The State TB Society should include professionals and More effective functioning
NGOs and regularly (annually) review the implementation of the State TB Society.
of the programme.
- 12 -
5.4.3.1
5.4.3 VACCINE PREVENTABLE DISEASES
Review periodically the
Immunisation Policies and
Practices with the help of experts. Establish Disease
Surveillance System to measure the outcome of the
Universal Immunisation Programme. Any occurrence of
vaccine-preventable disease, especially in a cluster of two
or more cases, must immediately attract public health
attention, and improve vaccination coverage locally
Improved planning,
monitoring and evaluation
of the Universal
Immunisation Programme
and follow-up action.
5.4.3.2
Include Hepatitis B vaccine, under Universal Protection of children from
Immunisation Programme for the immunisation of Hepatitis B infection.
children.
5.4.3.3
Production of vaccine in the State to be modernized using
the latest technology, under guidance of a Technical
Steering Committee for a) Kyasanur Forest Disease b) Cell
Culture Anti Rabies vaccine and vaccines against typhoid,
Japanese Encephalitis and other vaccine preventable
diseases in collaboration with the Department of Animal
Husbandary .
5.4.3.4
Maintenance of cold chain and utilising it for all drugs and Better coverage and
vaccines that require cold chain.
effectiveness of the
Immunisation Programme.
5.4.4 FOOD AND WATER BORNE DISEASES
The Health System must establish a functional disease Early control of food and
surveillance system and develop epidemiological, water borne epidemic out
microbiological and chemical analysis and expertise and breaks.
facilities for early outbreak control.
5.4.4.1
5.4.4.2
Self-reliant, efficient and
effective vaccine
manufacture system will be
established in the state.
The health system must establish routine periodic Provision of safe, adequate
monitoring of water for coliforms and chlorine content. and acceptable drinking
Each local area health authority must develop its own plan water to the public.
of action to monitor water quality. At any point when
coliform is found in supplied water, that information must
be immediately made available to the local government,
the water supply agency and also to the public
(consumers). Health System will also provide technical
advice for correcting the deficiencies and to monitor
progress.
- 13 -
5.4.4.3
The Health Department must review and revise the Enhanced food safety.
regulations and legislative measures governing food
safety. Regulations must include all food serving facilities
including street vending. They must check and prevent
adulteration and contamination of foods at various stages
of production, processing, storage, transport and
distribution..
5.4.4.4
The Health Department should develop guidelines for the Enhanced food safety.
health check-up and immunisation of food handlers against
typhoid fever and hepatitis A.
Control measures recommended include, training and
certification of food handlers in restaurants, hostels, hotels
etc.
5.4.5 HIV / AIDS, REPRODUCTIVE TRACT INFECTIONS & SEXUALLY TRANSMITTED
INFECTIONS
Integration of HIV/AIDS Prevention & Control program fully with other programmes of
Health & Family Welfare Services should be effected at the earliest.
5.4.5.1
Prevention: Health education especially targeting Prevention of sexually
adolescents, women’s groups etc. -The ‘men make a transmitted diseases.
difference’ campaign, attempting to make men more
responsible in the control of the epidemic. The male and
female health workers should promote condom use as an
infection preventive measure in addition to their use for
spacing of pregnancies.
5.4.5.2
STD services: Laboratory diagnosis and treatment of Improved diagnostic and
STI/RTI from PHC upwards. HIV diagnostic facilities in treatment facilities
each of the 27 districts to run as Voluntary Testing Centres
with counsellors and social workers. Training of Medical
Personnel on counseling of the STD / HIV patients as well
as their sexual partners.
5.4.5.3
Early diagnosis and treatment of Opportunistic Treatment of HIV and
Infections. Treatment and admission should be possible at apportunistic infections.
all district hospitals. Provision of ethical and effective
antiretroviral therapies – antenatal, Post-ExposureProphylaxis & for HIV infected. The state/country could
use provisions under WTO for indigenous production,
which would lower costs.
- 14 -
5.4.5.4
A multi-tier system of networked continuum of care, Continuum of care.
modeled on the Bangalore experience of NIMHANS,
Bowring Hospital, NGO-network based day care &
hospice care and home based care, including use of herbal
medicine and other systems of healing with back-up
support from referral hospitals.
5.4.5.5
Capacity building within the Health & Family Welfare Improvement in the
Departments
including
training,
Public-Private management of sexually
partnership etc. to effect prevention, treatment and transmitted diseases.
continued management of sexually transmitted diseases
should be undertaken.
5.4.6. LEPROSY
5.4.6.1
The Department of Health should maintain the expertise Expertise and skills
and skills developed and sustained over the years in the retained.
detection and management of leprosy even after
integration of leprosy into primary health care.
5.4.6.2
The Leprosy incidence must be closely monitored so that
under-diagnosis, if any, due to the integration with the
primary health care system, may be identified and rectified
without losing ground.
5.4.6.3
Rehabilitation of leprosy cured persons with disability to Leprosy cured persons with
be taken up seriously.
disabilities rehabilitated.
There is a view that
incidence continues. Care
can be exercised by
monitoring.
5.4.7 RABIES
5.4.7.1
The responsibility of dogs on the streets belongs on the Intersectoral collaboration
legally correct agency. The health authority should for prevention of rabies.
immediately call a meeting of the relevant agencies: those
who manage roads, veterinarians, health personnel, local
administration, Vaccine Institute, SPCA, animal activist
lobbies, ministry of environment etc. and prepare a
comprehensive action plan, within 6 months, defining
responsibilities. The plan of action must be put to action,
which should include education of the public on rabies.
5.4.7.2
Decision to discontinue the use of animal brain rabies Availability of cell culture
vaccine, and to replace with a cell culture vaccine. Design vaccine, with much less
the transition from animal brain ARV to cell culture ARV. complications.
Evolve a method to give cell culture vaccine at no payment
to poor people but leave the private sector patients to
purchase it. The price of cell culture vaccine may come
down drastically, if bulk orders are placed. Explore
manufacturing of cell culture vaccine.
- 15 -
5.4.7.3
5.4.8.1
Continuing Medical Education for correct management of Improved management of
animal bites to all registered practitioners / hospitals, and animal bites.
other personnel. State Institute of Health & FW to be in
charge. Material to be professionally prepared.
5.4.8 OTHER INFECTIOUS DISEASES
Active search to be conducted in the erstwhile endemic Complete elimination of
districts with Guinea worm disease, to ensure its complete Guinea worm diseases.
elimination, and the result to be reported in the 2000-2001
Annual Report of the Department of Health and Family
Welfare.
5.4.8.2
The expanded laboratory in the Public Health System, at Control of Leptospirosis,
the State level, must develop expertise in the microbiology Brucellosis, Anthrax and
of the following diseases and develop training, reagents Plague.
and standardisation of laboratory test for the District
Laboratories; Leptospirosis, Brucellosis, Anthrax, Plague.
5.4.8.3
After a disease surveillance system is established, a Control of infectious
laboratory based information system must be developed in diseases.
order to pool and collate laboratory generated information
in infectious and parasite diseases. This will give the
geographic prevalence of specific infectious diseases so
that intervention can be designed and applied.
5.4.8.4
A mechanism to coordinate public health activities
between the Departments of Animal Husbandry and Health
and Family Welfare must be created. Such a mechanism
will help in epidemiological investigations, development of
laboratory skills, vaccine manufacture and development,
health education, and preventive intervention.
5.4.8.5
It is recommended that all primary health centres and even All essential drugs are
sub-centres are provided with simple drugs to treat skin available
infections.
5.4.8.6
Provision of antibiotics at PHCs and referral facilities for Impairment of hearing
other interventions at taluk hospital level. Audiometry at prevented.
least at district hospital level.
5.5.1
Co-ordination of Animal
Husbandary and Health
Departments to prevent
infectious diseases.
5.5 DISEASE SURVEILLANCE
An epidemiological disease surveillance system to be Disease Surveillance
initiated in two districts in 2001 and then progressively System in place.
expanded to cover the entire state over a period of two
years. The purpose of the system is for public helath
action.
- 16 -
5.5.2
The State Public Health Institute (PHI) will be adequately The State Public Health
staffed and equipped with the State and District public Institute is fully functional.
health laboratories reporting to it.
5.6. NON-COMMUNICABLE DISEASES
5.6.1. DIABETES MELLITUS
5.6.1.1
Epidemiological surveys may be undertaken in rural, and Better planning for control
urban areas to understand the "burden" of Diabetes and prevention of diabetes
mellitus and for proper planning for control and mellitus.
prevention of Diabetes mellitus. The help of specialist
association / NGO's may be sought. The survey may be
confined to the age group between 20-90 group using
fasting blood sugar level above 126mg/dl as the criterion.
using the glucometer. (The survey of hypertension,
coronary artery disease and stroke may be undertaken
along with diabetic survey).
5.6.1.2
Laboratory facilities: It is essential to provide minimum Improved diagnosis of
necessary facilities to diagnose Diabetes mellitus even at diabetes mellitus.
PHC level. This includes, a colorimeter, glucostrips or
Benedict's solution. (The calorimeter may also be used for
estimating Blood Urea & Creatinine).
5.6.1.3
Constant supply of essential drugs like insulins and oral Essential drugs and
hypoglycemic compounds are necessary. The conventional available.
insulin may be used instead of costly ones like purified /
Human Insulins except in certain special circumstances.
5.6.1.4
Continuing Medical Education (CME) & other training
programmes: Doctors / nurses and technicians must be
exposed to CME programmes regarding the early
detection, treatment and preventive measures. The course
may be of 3-5 days duration.
5.6.1.5
Referral System: Most of the patients can be treated at Patients are managed at
PHC level itself and occasionally patients need to be appropriate levels.
transferred to the CHC / Taluka hospital for specialist
opinion and treatment. The patients with emergencies like
Diabetic Coma and gangrene should be transferred to the
higher level of care.
Other patients with chronic
complications may be referred or specialist's visits may be
organised at PHC's on regular basis. Some guidelines
may be formed for referral / treatment.
- 17 -
The capacities of health
personnel in the
management of diabetes
mellitus improved.
5.6.1.6
Health Education: The health education is promoted with Better awareness of the
regard to the early symptoms and complications especially disease leading to action.
foot care and diet; prevention of disease & its
complications. There is a need for orientation course for
health workers / IEC staff regarding various aspects of
Diabetes mellitus with special emphasis on diet, exercise
and foot care.
5.6.1.7
Develop "District Diabetic Control Programme". One There is a designated
Specialist for all non communicable diseases at the district Officer and a district
may be designated for supervision, detection, drug supply programme.
and health education programme.
5.6.2. CARDIOVASCULAR DISEASES
CORONARY ARTERY DISEASE (CAD)
5.6.2.1
Epidemiological sample survey regarding the risk factors Prevention of coronary
may be conducted especially for diabetes mellitus, high artery disease.
blood pressure, positive family history and smoking which
will help in prevention strategie. Preventive measures may
be initiated now itself based on available data. Health
education programmes to be strengthened to reduce risk
factors.
5.6.2.2.
Case detection and emergency management of ischaemic Management of ischaemic
heart disease, to be done at PHC / general practitioner's heart disease.
level. The person has to be transported to CHC / Taluka
Level Hospital for confirmation of diagnosis and further
management.
5.6.2.3
The essential drugs like Nitroglycerine Tablets, Pethidine, Improved patient
Morphine, parenteral diuretics, oxygen etc must always be management.
available. The well-equipped Ambulance services to shift
the patient to referral centres should be available.
HYPERTENSION
5.6.2.4
There is need for multiple sample surveys to be conducted, Better management of
to have some idea of the "burden" of the disease, for proper persons with hypertension.
planning of our strategy for the management of
hypertension. There is need to take co-operation of NGO's
and specialist organisations. Estimation of blood pressure
must be a part of routine examination by the doctor.
5.6.2.5
Facilities: There is a need for well maintained standard Improved facilities for
mercury sphygmomanometer and with standard, cuff in all diagnosis.
centres. For investigations like ECG and chest X-ray the
cases may be referred.
- 18 -
5.6.2.6
5.6.2.7
Constant supply of antihypertensive drugs must be
maintained. Less expensive drugs with minimum frequency
of dosage are preferred which increases the patients
compliance.
Health education programmes are very essential for both
primary and secondary prevention. Special stress on
control of smoking, restriction of salt, saturated fat intake
and reduction of weight has to be laid.
Improved availability of
essential drugs.
Health promotion,
avoiding risk factors.
RHEUMATIC FEVER / HEART DISEASES
5.6.2.8
Rheumatic fever may be detected at PHC level and treated. Detection and
Benzathine Pencillin should be supplied to PHC's for management of rheumatic
Rheumatic fever prophylaxis programme. (It is advisable fever at PHC.
to give penicillin upto 25yrs).
5.6.2.9
Patients with Rheumatic Heart Disease are referred to Patient with rheumatic
specialist / tertiary care hospital for special investigations, heart disease gets
surgery and other interventions.
specialist treatment.
THROMBO ANGITIS OBLITERANS (BERGER'S DISEASE)
5.6.2.10 Discourage use of tobacco (a definite measure to prevent Prevention of thrombodisease).
angitis obliterans.
5.6.3.1
5.6.3.2
5.6.3 CHRONIC BRONCHITIS and ASTHMA
Every health centre / practitioner must have the drugs and Availability of essential
facilities always available to treat asthmatics. Drug drugs assured to manage
supply should include injections of Deriphylline, patients with asthma.
Aminophylline, Adrenaline, Steroids and tablets of
Salbutomol, terbutaline. It is desirable to supply
pressurised aerosol nebuliser in every health centre, so
that an acute attack may be relieved, even at subcentre
levels.
Preventive measures and health education may be Reduction in attacks of
addressed individually. Lowering environmental / asthma
industrial pollution should be taken up as a part of wider
health issues. Preventive measures, health education
regarding smoking and control of air pollution are
important from individual / community angle.
- 19 -
5.6.4 CANCER
5.6.4.1
5.6.4.2
Primary prevention
Prevention of use of
- Health promotion programmes in schools and tobacco
colleges to reduce use of tobacco and intensive antitobacco campaigns by doctors, nurses, paramedicals,
teachers, social worker and anganwadi workers and
voluntary organsiations
- Orientation programmes in the problems of tobacco
use for all people's representatives and other
decision makers.
Legislation to reduce tobacco use
Secondary prevention: Have cancer detection camps Early detection of cancer.
with the help of voluntary organisations to create
awareness and detect cancers at early stage and have
cancer detection units in hospitals
5.6.4.3
Tertiary prevention: Have multidisciplinary treatment Effective treatment of
facilities at Kidwai and other identified centers: surgical, cancer patients.
medical, radiation oncology and supportive systems
5.6.4.4
Palliative care for terminally ill cancer patients.
5.6.4.5
Have a District Cancer Control Programme, consisting Early detection of cancer
of a field unit and a clinical team, with staff trained at and management
Kidwai Memorial Institute of Oncology and located at
the District Hospital.
5.6.5
Palliative care
OTHER NON-COMMUNICABLE DISEASES
5.6.5.1 FLUROSIS
5.6.5.1.1
Make available alternate drinking water with less than
1ppm of fluoride to people living in areas where the
fluoride content is more than 1ppm.
Fluoride poisoning
controlled.
5.6.5.2 HANDIGODU DISEASE
5.6.5.2.1
5.6.5.2.2
5.6.5.2.3
Vacancies at the Handigodu Disease Unit at Sagar
Hospital to be filled up and made fully functional along
with the mobile unit. Disease surveillance system should
be introduced for Handigodu Syndrome.
All vacancies are filled up
resulting in improved
quality of care.
A special component of the
Disease Surveillance
System.
Genetic counseling regarding marriage, child bearing, Prevention of the disease.
risk estimates on the basis of pedigree analysis.
Rehabilitation facilities are to be provided to all the Handigodu patients
affected, especially in Chikkamagalur district where rehabilitated.
there are none. Patients with Handigodu Disease should
be provided with supplementary calcium in dietary and
tablet forms.
- 20 -
5.7 ORAL HEALTH
5.7.1
Have oral (dental) health promotion activity at every level of
health care and as part of the school health programme.
Improved oral (dental)
health
5.7.2
All vacancies of dental health officers to be filled up by
suitably qualified persons. All dental clinics should have the
necessary equipments and facilities, which should be
maintained in good working condition
Improved facilities at all
dental clinics.
5.7.3
A designated post of Deputy Director to be in charge of
Dental Health Services and Dental Education, at the
Directorate.
A designated officer at the
Directorate made
responsible for oral (dental)
health.
5.8 OCCUPATIONAL HEALTH
5.8.1
The use of pesticides must be reduced to the minimum. Only Harmful insecticides
such insecticides as are found to be not harmful within the eliminated.
recommended dosage should be allowed to be manufactured
/ imported and used. The cumulative effects should be
considered. Monitor continuously the effect of the use of
pesticide. If found harmful, withdraw it.
5.8.2
Ensure pre-employment and periodical health check-ups of Detect occupational health
all workers.
problems at the earliest.
5.9 CONTROL OF BLINDNESS
5.9.1
Strengthen the State Ophthalmic Cell, filling up vacancies, Improved activities of the
and long term continuity of Joint Director.
State Ophthalmic Cell.
5.9.2
Ensure accountability of the ophthalmologist and ophthalmic Improved performance.
units.
5.9.3
Integrate school eye screening with the health check-up of Improved eye check up.
school children
5.9.4
All Medical Colleges Eye Departments should take up in- Better blindness control.
reach base hospital programme
5.9.5
All taluk hospitals (upgraded by KHSDP) should be made Increased number of
base hospitals for conventional cataract surgery and be cataract surgeries.
allotted a fixed geographical area.
All districts should have at least two Government base
hospitals where IOL surgery is available.
The District Medical Officer should co-ordinate and depute
the available surgical manpower to fixed surgical centers on
the operation days in the districts.
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5.9.6
Screening in the community by the health worker to identify Improved early
and refer persons at risk of developing glaucoma to management of glaucoma.
ophthalmologist for evaluation and management.
5.9.7
Prevention, early diagnosis and intervention in persons Better management of
liable for corneal opacities causing blindness.
corneal opacities.
5.9.8
Establish speciality clinics: glaucoma, vitreo-retinal and Improved management of
corneal grafting centre, one each for each region.
eye problems.
5.10 TOBACCO
5.10.1 BAN OF TOBACCO CONSUMPTION: Complete ban on Smoking is reduced
smoking in public places such as:
including passive smoking
a. Hospitals and all other health care facilities and
Educational
Institutions
(Schools,
Colleges,
University).
b. Transport facilities, including Air travel (domestic),
Buses and Trains: Separation of smoking and nonsmoking compartments.
c. Waiting areas: Airports: Segregation of smoking
areas from non-smoking areas and Hotel lobbies:
Segregation of smoking areas from non-smoking
areas.
d. Theaters / Cinemas and Restaurants
e. Sports
f. Museums, libraries and closed areas of Tourist
Interest:
g. Work site (segregated area for smoker at recreational /
eating facilities).
5.10.2 BAN ON TOBACCO SALE: Ban on sale of tobacco and Tobacco use by children
tobacco containing products to minors (below 18 years of and adolescents is reduced.
age) and in the immediate vicinity of educational institutions
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5.10.3 BAN ON TOBACCO ADVERTISMENT / PROMOTION: All Demand for tobacco
hoarding / poster advertisement to be banned, including in / products is reduced.
on all transport facilities.
Radio and Television ban on tobacco advertising should be
continued.
Advertisement in Cinema halls / Videocassettes / audio and
in print media.
Point of sale advertising should be prohibited. Warning
symbols and health warning should be prominently
displayed at the point of sale.
Ban on all forms of sports and arts sponsorships or linkage
with sports goods / accessories should be effected. This ban
should apply to all tobacco products and to other products
with the same brand name. Indirect sponsorship through
setting up of trusts, etc., should be banned
All promotional activities for any tobacco product such as
free distribution, mailings, discount offer etc., should be
banned
5.10.4 STATUTORY WARNING ON PACKAGING / NICOTINE AND Demand for and use of
TAR CONTENT:
tobacco is reduced.
Notification of nicotine and tar content on all packages of
the cigarettes and beedies and all products with tobacco
should be made compulsory. Size of the statutory warning
should be as large (in letter size) as the brand name and in
the local (regional) language
5.10.5 Nicotine and tar content of cigarettes should
progressively reduced, in a specified time frame.
be Adverse effects reduced.
5.10.6 TAXATION: Taxes on all tobacco products should be
increased. A specified percentage of the tax revenue from
tobacco should be set aside for health education on tobacco
related diseases.
5.10.7 INCENTIVES: Farmers who change over, from tobacco, to
alternate crops should be provided monetary and other
incentives for three years.
Demand for and use of
tobacco is reduced.
5.10.8 Promote diversification of tobacco industry into other
industries such as information technology.
Availability of tobacco
products reduced.
Availability of tobacco is
reduced.
5.10.9 ENVIRONMENTAL LEGISLATION:
Deforestation is reduced.
Environmental legislation to provide for a targeted
compulsory compensatory reforestation programme by
tobacco producers and industry to make up for a tobacco
curing related deforestation. A specific tax may be levied for
this purpose.
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5.10.10
MISCELLANEOUS: Improve working condition of beedi
5.10.11
Investment of public sector funds in the tobacco industry No encouragement to
must be stopped.
tobacco industry.
5.11.1
Improvement of health of
workers. Industry must provide for medical care of the the workers.
workers.Have alternate employment for beedi workers and
labourers now working in tobacco growing, curing, etc.,
5.11 ALCOHOL
Training of all Medical Officers and especially at the
Primary Health Care level on screening the patient for
alcohol abuse problem with a simple questionairre, early
detection and interventions for alcohol-related health
problems. The training should include sensitization
regarding association of alcohol use with violence in the
family, and association with STDs & HIV/AIDS.
Medical officers are skilled
in the detection and
interventions for alcohol
related problems.
5.11.2
Referral centres for treatment of alcoholism should be Alcoholism is managed
identified or set up at district levels. The treatment effectively.
programme should include detoxification, treatment of
withdrawal symptoms, psychological therapy and longterm relapse-prevention programmes
to ensure
abstinence
5.11.3
Referral to local self-help groups like Alcoholics Alcoholism is reduced.
Anonymous should be encouraged as part of the relapse
prevention programmes for treatment of alcoholism.
5.11.4
The model of “camp-approach” for treatment of Relapse of alcoholism is
alcoholics which is being successfully implemented by prevented.
TTK Hospital, Chennai, in some centres in Tamil Nadu
could be tried in Karnataka. Involve the local community
in the relapse-prevention programme.
5.11.5
The departments of Excise (Finance), Health, Education, Better enforcement of
Social Welfare and Police should work together to regulations controlling
implement and enforce the existing regulations and alcohol.
measures applying to production, sales, retail, taxation
and advertising of alcohol.
5.11.6
A differential Tax structure with a higher taxation on Discouraging drinking of
liquors than on beer or wine will help in discouraging the beverages with higher
drinking of beverages with higher alcohol content.
alcohol content.
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5.11.7
A general awareness about “drinking and driving” Alcohol related road
should be undertaken by the Transport department. This accidents are reduced.
should specify the type and amount of drink over which the
person should not drive, explained in lay terms and not as
percentage of alcohol. The laws against drinking and
driving should be strictly implemented and exemplary
punishment must be awarded to offenders.
5.11.8
Measures to prevent production and sale of illicit liquor Harmful effects of illicit
should be enforced.
liquor are avoided.
5.11.9
Health education programmes for children and Children and adolescents
adolescents should include substance (including alcohol) learn to avoid alcohol.
abuse as well as Life Skills Education.
5.11.10
Community level interventions by Government and by Domestic violence
NGOs should include community awareness, Health following drinking is
Education, social support for battered women and children reduced.
following
alcohol
consumption
and
vocational
rehabilitation for reformed alcoholics.
5.11.11
Advertising agencies and media should be encouraged to Demand for alcohol is
self-regulate and avoid even covert messages.
reduced.
5.12 HEALTH ASPECTS OF DISASTER MANAGEMENT
5.12
The Government of Karnataka should commission a
competent group of experts, administrators and policy
makers including those in the field of health, to prepare a
multi hazard plan for all districts in the state of Karnataka.
This Plan should be completed before the end of the year
2001.
Disaster management is a
large issue which must be
tackled with intersectoral
cooperation.
6. MENTAL HEALTH & NEUROSCIENCES
6.1 MENTAL HEALTH
6.1.1
Train the medical officers and others at the Primary Mental health problems are
Health Centres to recognize mental health problems early, recognised early and
manage them effectively or refer them.
managed effectively.
6.1.2
Have District Mental Health programmes in all districts Every district has an
on the model of Bellary District Programme. All district effective mental health
hospitals to have mental health units with qualified programme.
psychiatrists and other trained staff and facilities for
outpatient and inpatient care of the mentally ill persons.
6.1.3
Ensure availability of essential drugs for the management Effective management of
of mental disorders. Have counseling centers with mental disorders.
qualified and trained personnel.
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6.1.4
All medical colleges should have qualified psychiatrists Training of medical
and facilities for teaching medical students and for students and service is
outpatient and inpatient care of mentally ill persons.
improved.
6.1.5
Upgrade the Dharwad Mental Hospital, converting it to a The only state institute has
centre of active treatment in a humane way.
upgraded facilities and
patient - centered care.
Encourage community based rehabilitation of persons with Community based
mental disorders, who have recovered from acute illness. rehabilitation of persons
Encourage community based rehabilitation of persons with with mental retardation or
mental retardation, integrating them into the society.
chronic mental disorder.
6.1.6
6.2 NEUROLOGICAL DISORDERS
6.2.1 EPILEPSY
6.2.1.1
Epilepsy Education: It is a key area that needs immediate
attention. These programmes should aim at relieving
stigma, and improving the compliance of the patient in
taking drugs. It must also highlight DO's and DONT'S and
focus on positive outlook on epilepsy. Recognise different
types of epilepsy, including hot water epilepsy. Awareness
should be created on Hot Water Epilepsy particularly in
Chamarajanagar, Mysore and Mandya District.
6.2.1.2
The primary care physicians (both PHC doctor and private Improved early diagnosis
practitioner) and auxiliary staff have to be trained by a and treatment.
short term course, regarding diagnosis, treatment, epilepsy
education record keeping and monitoring. There must be a
continuous supply of anti-epileptic drugs.
6.2.1.3
Establish and strengthen epilepsy services at district Improved management of
hospitals through out-patients clinics with adequate supply epilepsy at the districts.
of drugs. The district medical officers, physicians and
paediatricians may be trained by a short course as it is
done at NIMHANS under epilepsy control programme.
Have a District Epilepsy Control Programme for
planning, implementing, supervising and evaluating,
epilepsy services. The programme officer may be incharge
of all non-communicable disease.
6.2.2
6.2.2.1
Better awareness of the
problem and improved
compliance with prolonged
medication.
STROKE
Control of hypertension, discouraging smoking, reducing Stroke is prevented.
intake of saturated fats, and control of obesity are
important measures to be instituted at all levels of health
care. Antiplatelet drugs like aspirin 100-325mg are
prescribed, to prevent further attacks. It may be used as
primary prevention in a person who has a strong family
history and risk factors.
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6.2.2.2
Nearly 80% of stroke may be managed at PHC level with Effective management of
well-trained staff and certain specific cases to referred to patients with stroke.
secondary / tertiary level as an emergency
6.2.2.3
Training programmes for the management of all causes of Improved training to deal
neurological disorders to be instituted at NIMHANS for with 'stroke'.
primary care physicians, both private and public. The
training should be practical and should include
physiotherapy.
6.2.3. NEUROLOGY AND NEUROSURGERY SERVICES IN GOVERNMENT
MEDICAL COLLEGES
6.2.3
The Government of Karnataka must initiate immediate and
energetic steps to establish Neurology and Neurosurgery
services in all the four government medical colleges.
Train physicians and general surgeons at taluka and district
hospitals to manage neurological disorders and head injuries
and refer patients, when necessary to the Medical Colleges /
NIMHANS, Bangalore.
Improved services in
neurology and
neurosurgery available at
the Medical Colleges.
6.2.4. HEAD INJURIES AND TRAFFIC ACCIDENTS
6.2.4
The law regarding compulsory wearing of crash helmet by
riders and pillion riders of two wheelers must be reintroduced to protect them from severe head injury. It is
essential to educate the public regarding the road safety
measures and benefits of wearing the helmet.
Riders of two wheelers
are better protected from
the effects of head
injury.
7. NUTRITION
7.1
Supplementary food supply to pregnant mothers be Improved nutrition status
increased, based on the need; this can be assessed based on of the mother and the
the gain in weight, after excluding other causes.
unborn child.
7.2
Breast feeding to commence soon after delivery, to use the Breast milk is wholesome
highly beneficial colostrums. Exclusive breastfeeding during food and nourishes the
the first 6 months. Breastfeeding to continue for 18-24 child.
months (Method: education of the mother).
7.3
Semisolid weaning (supplementary) food, adequate in Supplementary food
quantity and quality, be given to the infant under the ICDS ensures adequate
scheme. In the case of the poor, weaning food be supplied nutrition.
free to the infants above 6 months (Department of Health
Family Welfare services with the help of the departments of
Women and Child Welfare and Food Supplies).
7.4
Growth monitoring to detect growth faltering, based on Early detection of under
weights taken by anganwadi workers, with well-calibrated nutrition and
balances; follow-up action by the medical officers of PHC. intervention.
If malnutrition is severe, admission and management.
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7.5
Free mid-day meals (nutritious) to poor school children. Improved nutrition and
(Department of Education).
performance at school.
7.6
PDS must be strengthened. More foods like ragi, other Improved nutrition of the
pulses and oil to be supplied to the green card holders (Food poor.
and Civil Supplies).
7.7
Ensure supply of iron-folic acid to pregnant mothers. Micronutrients are made
Ensure vitamin A prophylaxis. Calcium tablets to be available.
supplied if indicated, to lactating and older women.Iodised
salt in goiter prevalent districts.
7.7
Nutrition and Health Education (Health and Family Welfare Improved awareness
Services, Medical and Nursing Colleges and schools, leading to action to
University departments of Nutrition and Home Sciences); reduce malnutrition.
Nutrition education of the public.
7.9
Prevent infection. If infection occurs, treat promptly.
Improve access to health care of infants, children and
pregnant mothers to PHCs and CHCs with the help of
Paediatricians and Obstetricians and Gynaecologists.
Safe drinking water and improved sanitation to prevent
diarrheas and worm infestation. Periodical (once in a year)
deworming.
7.10
The District Nutrition Officer will co-ordinate the nutrition A designated officer is
programmes in the district.
given the responsibility
to monitor and take
corrective action.
7.11
Encourage use of green leafy vegetables. Every house to Improved nutrition at low
have a kitchen garden. The Department of Horticulture to cost.
help with supply of seeds, seedlings, etc and promote the
development of kitchen (nutrition) garden with drumstick
plants, green leafy vegetables, etc. Every PHC to consider
possibility of developing a demonstration plot.
7.12
Constitute an interministerial co-ordination committee Improvement in nutrition
(Health, food and civil supplies, agriculture, education, rural requires multi sectoral
development and social welfare) to tackle the problem of coordination.
malnutrition.
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The additve effect of
infection on
undernutrition is
prevented; so also the
effect of other diseases.
8. WOMEN AND CHILD HEALTH
8.1 WOMEN'S HEALTH
While general recommendations regarding Nutrition, STD & HIV/AIDS; Cancer control
among women etc, are incorporated in the chapters on these topics, some specific issues
are emphasized here.
8.1.1
All Health -care personnel should be sensitized on issues
relating to gender inequalities. The curriculum for Medical
Education and for training programs for health care personnel
should include gender perspectives.
All health care personnel
become aware of and
sensitive to gender
issues.
8.1.2
Gender dis-aggregated data and gender sensitive indicators
to evaluate gender equity should be integrated in all plans &
programs. Examples of gender disaggregated data would
include birth and death details, actual consumption of the food
and micro-nutrients supplied to pregnant women through the
RCH / ICDS programmes; admissions & attendance at
schools, hospital in-patient & out-patient records,
immunization details, salary patterns for the same jobs and so
on, should be monitored.
Disaggregated data on
various issues affecting
the health of the people
become available for
suitable action.
8.1.3
Violence against women and girls at societal and household
levels to be eliminated through strengthening of institutional
capacity (especially Health, Police and Judicial Sectors);
involvement of women, and review of certain existing legal
provisions
Action to be taken to
eliminate violence
against women.
8.1.4
8.1.5
Health Sector:
Privacy is essential when interviewing clients about domestic
violence and this should be ensured. Health personnel should
be trained adequately and sensitively to recognize and treat
signs of domestic violence, sexual abuse & violence associated
with alcohol abuse; give legal advice and counseling. The
hospitals should be made women friendly.
Violence and sexual
abuse are recognized and
appropriate advice is
given.
Long term psychological support for sexually abused children Services of a counselor/
of a trained counseller / psychologist / psycho-social worker / psychologist/
psychiatrist should be identified within the Health system.
psychosocial worker is
made available to
sexually abused children.
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8.1.6
8.1.7
Female foeticide & infanticide:
Actively look for female foeticide & infanticide.. Gender ratio Female foeticide and
at birth and other indicators to show trends, underlying causes infanticide are reduced
should be used for community-level control programmes. The and finally eliminated.
services of religious leaders can be used to strengthen the
programme against foeticide and infanticide. IMA and other
professional bodies should be encouraged to sensitize doctors
to the legal and ethical aspects; self-regulate and socially
boycott known offenders.
The Prenatal Diagnostic Techniques Act,1994, should be Female foeticide is
enforced strictly.
reduced.
8.2 CHILD HEALTH
8.2.1
8.2.2
Have an additional health worker appointed by the Gram
Sabha and trained to receive and resuscitate the newly born
along with other duties as an experimental measure in the 7
northern districts found to have lower health status and
extended, if found useful.
Health education for children and adolescents should be the
responsibility of the Health as well as Education department.
This should be integrated into the formal school system and
should include nutrition; sanitation; reproductive health,
RTI/STI; HIV/AIDS; substance abuse, values & life skills and
gender issues; Alternate mechanisms to reach school dropouts
should be identified.
Neonatal deaths are
reduced.
School health education
for children and
adolescents brings about
responsible behaviour.
8.3 REPRODUCTIVE & CHILD HEALTH PROGRAMME
8.3.1
8.3.2
8.3.3
Quality of Services
The general quality of RCH services should be improved; a
Quality Assurance programme should be developed and
implemented. Changes in the procedure, equipment
specifications, new techniques etc. should go through a
specified evaluation process before being accepted for
implementation. The patient’s comfort and dignity are of first
consideration. So the tilted laproscopy tables and other such
inconsiderate methodology should not be used.
The attitude of doctors and other staff should be positive and
helpful. This can be ensured through periodic internal audits,
patient satisfaction studies and accreditation system with an
external audit. Periodic auditing of maternal and infant deaths
should be implemented to institute preventive strategies.
Quality and patients
convenience and
satisfaction are assured
Periodic audits are in
place to ensure quality
care.
Availability of safe abortion (MTP) services for all women Safe MTPs are assured.
should be ensured. Sterilizations and MTPs should be carried
out only at first referral units (Fixed-Day strategy) and not at
camps.
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8.3.4
8.3.5
8.3.6
Infrastructure-Staff:
The system of deliveries by Dais should be supported, with
enhanced training. Initial as well as periodic reorientation
training for all birth attendants to ensure quality should be
implemented. There should be periodic evaluation and upgradation of the training courses.
To solve the problem of safety and timely attendance of ANMs:
as far as possible, ANMs should be posted in their home
villages; given loan facility to buy a two wheeler. Their
workload needs to be rationalized- less paper work and better
use of their expertise and talent
Ensuring availability of trained staff: Government may
consider approved, training courses to provide services in the
absence of a Medical Office:, Nurse-Obstetrician Practitioner
at the PHC level and Short-term (6m to 1yr) training in
anaesthesia for Medical Officers at the CHC level.
The details of the course, feasibility etc. should be worked out
by an expert team.
Improved performance
by the trained birth
attendant, resulting in
safe delivery.
ANMs have greater
mobility and are able to
carry out their functions
more effectively.
In the absence of Lady
Medical Officer at PHC,
have a nurse-obstetrician
trained anaesthetist helps
in performing surgical,
obstetric and
gynaecological
operations.
8.3.7
Disposable delivery kits with good quality cost effective Improved delivery
components - with the expectant mothers.
8.3.8
Subsidised menstrual cloth /pads may be supplied to the poor, Improved menstrual
to promote personal hygiene and should be supported with hygiene.
awareness programmes to ensure correct usage.
8.3.9
Male Health Workers should be given adequate training and Male participation
skills to tackle gender issues and to ensure male participation improves in the
through individual counseling as well as community education programme.
programmes.
9. POPULATION STABILIZATION
9.1
The unmet needs for family planning services should be met, The needs for family
with options of choice and assured quality;
planning services are
met.
9.2
Information, education and communication activities should be IEC programme in place.
enhanced to convey messages of the advantages of postponing
the second child, of a two child norm, and of the health and
familial advantages of spacing births and of raising age at
marriage.
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9.3
There has to be regular and effective follow up of acceptors
after they adopt any of the family planning methods to ensure
that complications, if any, are attended to expeditiously. Such
follow up would also encourage the increasing acceptance of
family planning
Regular follow-up
reduces complications; if
complications occur, they
are attended to
immediately.
9.4
There should be no element of compulsion or pressure,
particularly through camps or “pulse approach”. The services
should be such that their quality and availability, with
regularity and at all times, with choice encourages voluntary
adoption of family planning;
New family planning technology should be adopted only after
careful consideration of the ethical aspects of use of such
technology, safety issues and cost effectiveness.
Voluntarism and quality
improve acceptance.
9.5
Ethics, safety and costeffectiveness considered
before adopting new
technologies.
9.6
Ensure legal requirement of registration of all marriages. This All marriages are
would enable the stricter application of the law relating to registered.
restriction of age at marriage and assist in organizing outreach services;
9.7
The community, particularly women’s groups, should be Community needs are
closely associated, in consultative and operational terms, with met.
family planning programmes to reflect the perceptions and
needs of the local community
9.8
The Population Policy for the State as part of Integrated
Health Policy should be drafted. The draft policy would have
to be widely publicized for public awareness and response,
before it is finalized;
9.9
Districts may be prioritized on the basis of evaluation of the Districts are prioritized to
current status of the family planning services available and provide family planning
related social criteria, for enhancing the scale of the services.
programme;
9.10
For ensuring inter-sectoral coordination and monitoring of the
programmes relating to family planning and related sectors, a
Committee on Social Development and Population Issues may
be established at the official level, while at the Cabinet level a
Commission on Social Development and Population may be
established.
- 32 -
A State Population
Policy as part of the
Health Policy becomes
available.
A Commission on Social
Development and
Population is established
at Cabinet level and a
Committee at official
level.
10. FOCUS ON SPECIAL GROUPS
10.1 PERSONS WITH DISABILITY
10.1.1 Establish the role of the Health department in Disability
Prevention, Early detection, Intervention, corrective surgery
and physiotherapy. Sensitise health-care workers on
identification, classification, records of progress and
evaluation, referral and home-based stimulation training. Staff
from Leprosy control programs may be trained first.
The staff of the
Department of Health are
sensitive to the issues in
disability.
10.1.2 Utilise Media to create awareness and training of parents and Awareness is created
other caregivers on specific disabilities.
among all caregivers
10.1.3 Shift from institutional approach to a Community Based Community Based
Rehabilitation-home-(parent) based approach; and from approach is adopted.
single to a multi-disability approach.
10.1.4 Networking initiatives – Get all people, Government as well All people are involved
as NGOs, from all sectors to meet at a common platform and in the programme for
plan out strategies.
rehabilitation.
10.1.5 Make provision for the manufacture, distribution and repair Aids and appliances are
and maintenance of aids and appliances. Have an orthotic available as required.
and prosthetic centre at every district hospital (as in Tamil
Nadu).
10.1.6 Develop and implement a policy of inclusive education. Train Inclusive education is
teachers for early detection and management of learning available.
difficulties. Include evaluation and management of speech and
hearing and other impairments in school health programmes
10.1.7 Ensure access to all health care institutions and other Improved access to all
buildings, transport, water supply, sanitation etc., by buildings
incorporating necessary provisions in the statutes, rules, etc.
10.1.8 Implement the provisions of the existing legislation, including
Persons with Disabilities Act, 1995 with respect to protection
of the rights of persons with disabilities. Ensure equal
opportunities in employment and training for persons with
disabilities, by enforcing current legislation; enhance the
provision for training and employment
- 33 -
Provisions of the Persons
with Disabilities Act are
applied, ensuring equal
opportunities.
10.2 HEALTH OF THE TRIBAL PEOPLE
10.2.1 A rapid survey of the health status of the tribals should be Health status of the tribal
carried out. Region specific and tribe specific health plans people is known.
should be made.
10.2.2 The norms for Primary Health Centres and Subcentres in Improved primary health
tribal areas should be based on geographical and population care services.
basis and they should be flexible.The mobile units should be
made functional.
10.2.3 Tribal girls should be selected and trained as tribal ANMs and Improved health care.
they should be posted in tribal subcentres. They should also be
trained in traditional medicine and health practices.
10.2.4 Traditional healing systems must be encouraged and
documented in tribal areas and there should be integration of
Allopathic medicine with the Traditional systems. Promote
herbal gardens in tribal areas.
Preservation of
traditional healing
systems and use for the
benefit of the people.
10.2.5 Genetic diseases like Sickle Cell Anaemia, G 6 PD Improved health of the
Deficiency, which are specific to tribals should be given tribal people.
special importance with adequate funds and expertise, for
their treatment, research and rehabilitation. Secondary and
tertiary care, transport facilities for emergency services and
obstetric care are essential.
Community financing for
emergency transport and referrals Health education, PRA
exercises and micro planning, Convergent community action,
training in communication skills and mobilisation of local
health resources.
10.2.6 Ensure food security and encourage growing of nutritionally Better nutrition.
rich food crops. Public Distribution System should distribute
cereals like ragi, bajra and pulses instead of polished rice and
sugar. Promote kitchen gardens.
10.2.7 A HMIS of the health infrastructure, human resources, vital Health Management is
statistics and other health indicators specially for the tribals is improved.
mandatory and should be an on-going process.
10.2.8 There should be increased collaboration between the
government and the NGOs in tribal areas. The voluntary
agencies must be involved in the development activities
undertaken by the government.
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Collaboration between
Government and
Voluntary Organisations
for improved health of
the tribal people.
10.3. THE ELDERLY
10.3.1 A policy for the elderly should be formulated, with particular A policy for the elderly is
safeguards for women. The administrative Department available.
responsible for implementation of this policy should be
designated. The management of both public and private
institutions would need to be sensitized to the special needs of
the elderly. Single point counters to avoid multiple trips to
various counters in an institution, elimination of long waits
and personal interaction.
10.3.2 The scale of user fees for health services, if charged, should be The burden on the family
reduced in the case of the elderly patients, so as to lessen the because of medical care
burden on the household in availing of medical assistance for of the elderly is reduced.
the elderly
10.3.3 Geriatric care facilities should be provided at the secondary Specialised care of the
and tertiary level levels. In addition, private health institutions elderly is available.
should be encouraged to provide such facilities, and a perpatient payment system by Government could be considered.
10.3.4 For sensitization to the health issues of the elderly and Improved care of the
training in providing health services to this group, (a) in-house elderly.
training in geriatric care should be instituted within the
Department, (b) the associations of private institutions could
be requested to conduct similar courses, and (c) the content of
medical, nursing and paramedical courses to be reviewed so
as to train them in geriatric issues.
10.3.5 Health insurance schemes for the elderly need to be Health Insurance of the
introduced. The formulation of such schemes could be elderly in place.
assigned to the public sector Indian insurance companies,
including the Karnataka Government Insurance Department.
10.3.6 A scheme for provision of old age pensions to those below the Old age pension as part
poverty line with suitable safeguards to ensure that the right of social security
beneficiaries receive the amounts should be formulated;
10.3.7 Non-government organizations could be assisted in utilizing Elderly people become
the elderly in productive activities as teachers / guards and the productive members of
like and establishing of care centers and counseling centres to the society.
advise the elderly andz their families.
Panchayat institutions could be encouraged to promote the
welfare of the elderly and induct them, on fixed honoraria
basis, for specific work in the community.
- 35 -
10.3.8 The introduction of legal provisions to ensure that the family Law to ensure
takes the responsibility of looking after the elderly could also maintenance of the
be considered as has been attempted through the Himachal elderly by the family.
Pradesh “Maintenance of Parents and Dependents Act”,
1966.
11. HEALTH PROMOTION AND ADVOCACY FOR HEALTH
11.1 HEALTH EDUCATION (IEC)
11.1.1 All the vacant posts in the different units/divisions of the
Health Education Bureau must be filled up. Bring all IEC
activities in the Department of Health & Family Welfare
Services under Health Promotion; at the same time, ensure
that the individual programmes do not suffer. Integrate the
two sections of the Health Education Bureau into a division of
Health Promotion.
11.1.2 The Block Health Educators must be fully trained and should
have the necessary qualification (Diploma in Health
Education); 50-60 Block Health Educators may be deputed
annually for the training. An important part of the training
must be skills development in community organization and
involvement of the local people in health promotion and
education. Strengthen community action.
The Health Education
Bureau becomes fully
functional.
Integration of all IEC
activities under Health
Promotion.
The Block Health
Educators are qualified
and competent.
11.1.3 Encourage and support Mahila Swasthya Sanghas in health Community participation
promotion. Have Village Health Committees; health is ensured.
promotion and education will be a major responsibility of
these committees.
11.1.4 Have health committees attached to Doordharshan and AIR to Improved use of media
actively help in health promotion.
Have a watchdog
committee to prevent wrong messages and 'unhealthy'
advertisements.
11.2 HEALTH PROMOTION IN SCHOOLS
11.2.1 Medical examination of all students (1-10 standards) by the Improved health of all
medical officers and the team of PHCs must be taken up school children.
seriously and the performance monitored by the District
Health Officers.
If necessary, the services of general
practitioners may be taken and they be paid a suitable
honorarium.
11.2.2 The Block Health Educators (2-3) may be attached to the Health education
Taluk Health officer. They must carry out health education in activities improved.
every school in the area and for the population covered by the
PHCs to which they are attached. District Health Education
Officers must monitor the programme.
- 36 -
11.2.3 Intensify the training of teachers for health; they should be
enabled to detect diseases or disability at the earliest;
corrective action should be taken by the PHCs doctors and the
students must be followed up.
Teachers are able to
detect health problems
among the school
children at the earliest.
11.2.4 The programme of health promotion among school children is Collaborative efforts of
the combined responsibility of Health and Education the departments of health
departments
and education produce
improvement in health.
12. HUMAN RESOURCE DEVELOPMENT FOR HEALTH
12.1 EDUCATION:
12.1.1 The issuing of Essentiality Certificates by the Government and Improved quality of
affiliation by the University for new Medical, Dental, Nursing, education of health
Pharmacy and Physiotherapy Colleges should be stopped for professionals.
the next two years, the exception being Colleges in
underserved districts of Karnataka. This is to ensure quality of
education, with adequate teaching staff and other facilities.
Extend the moratarium on new Ayurvedic, Unani and
Homeopathy Colleges for two more years.
Fill up all vacancies of teaching staff by suitably qualified
persons
12.1.2 Take up urgently the repairs of the building of the colleges, Better facilities for the
hospitals, hostels, equipments and vehicles of the Government education of health
teaching institutions. All equipments must be maintained in professionals.
good working condition.
12.1.3 Improve the emergency and casualty services. There should Improved emergency
be available round the clock diagnostic (x-ray and laboratory) care
services.
12.1.4 Medical Colleges should take up 3 PHCs for training and Improved training of
service. Dental and Nursing Colleges should take up 1-3 students and better
PHCs for the same purpose.
service to the people.
12.1.5 Extra vigilance is necessary at the University examinations. Corruption is eliminated.
Corrupt examiners should be debarred from examinerships.
12.1.6 Monitoring and evaluation (performance appraisal) of Performance is
teaching and other staff in the health professional colleges and monitored and action
affiliated institutions should be carried out once a year; the taken.
performance should be taken into consideration for promotion
and other benefits.
- 37 -
12.1.7 Appropriate training and re-training of Heads of Depts,
Resident Medical Officers, Medical Superintendents,
Principals and Directors in management, (personnel,
financial, materials and time) should be taken up on priority
basis.
The possibility of appointing qualified and trained hospital
administrators in teaching hospitals to be considered.
The hospital
administration is
improved with better
utilisation of facilities.
12.1.8 Every professional college should have an education unit to Teachers are better
improve the teaching capability of teachers. RGUHS should trained; quality of
organize teacher-training programmes. Make use of the education improves.
facilities at the National Teacher Training Institute at
JIPMER, Pondicherry.
12.1.9 The possibility of bringing the non-teaching staff in Medical
College Hospitals under the control of Department of Medical
Education may be studied and action taken to implement the
decision.
The Officers in the Department of Medical Education should
have sufficient powers to take suitable disciplinary action even
on staff who are on deputation from the health department. An
administrative manual setting out the powers and duties may
be brought out.
The Officers of the
department of Medical
Education have sufficient
administrative and
disciplinary control over
the staff seconded to the
department.
12.2 TRAINING
12.2.1 Have a detailed survey of the need for training of paramedics There is co-ordination
and take appropriate action. Review the job oriented between the needs and
paramedical courses.
the availability of trained
personnel.
12.2.2 Auxiliary nurse midwives training to be taken up seriously. Auxiliary nurse midwifes
Whether there is need for extension of period of training to 24 are key personnel in
months (from 18 months) must be examined.
health and they are
trained well.
12.2.3 Use developments in Information technology for continuing Improved training
education of all health and allied professionals and
paramedical personnel.
12.2.4 The State Institute of Health and Family Welfare should be
upgraded to become the apex training institute, making it an
institute of excellence.
- The State Institute will be an autonomous body, with
adequate funds for its activities and maintenance allocated
from the State Health and Family Welfare Department
Budget directly.
- 38 -
The State Institute
becomes the nodal
institute for all training
and has upgraded
facilities.
-
The post of Director of the Institute will be selection post.
The tenure will be 5 years. The Director will be medically
qualified and will have training and experience in
education technology and training of trainers. It would be
preferable to have persons with some experience of having
worked in the Department of Health and Family Welfare
Service.
- The Institute will have full complement of training,
research, administrative and supportive staff with
appropriate qualifications.
- Considering the importance of social sciences and
communication skills, the Institute will have either full-time
/ part-time staff for these departments or engage the
services of experts as and when required for the training
sessions.
- The Institute will have all the necessary equipment and
facilities including teaching / learning space and identified
field practice areas.
- The Institute will have an up-to-date digital library and
documentation centre.
The State Institute will conduct induction and orientation
programems for medical officers and other staff and arrange
for continuing education for all the staff of the Department of
Health and Family Welfare Services and the Department of
Indian Systems of Medicine and Homeopathy.
12.2.5 The Regional Health and Family Welfare Training Centre The Regional Centres are
will be administratively under the State Institute.
able to meet the specific
- The regional centers will plan and execute the training needs of the region.
programmes based on the needs of the region; these will
be supervised and co-ordinated by the State Institute.
- The Regional Centres should have adequate staff with
requisite qualifications, competence and suitability, as
also all necessary equipment and facilities.
12.2.6 All Districts will have their own District Training Centres to The District Centres meet
meet the training needs of the district.
the training needs of the
- The District Centres would be under the State Institute district.
administratively
- The State Institute will plan (along with the District
Centre), supervise and co-ordinate the training
programmes.
- The District Centres will oversee the functioning of the
ANM training centers.
- Adequate staff with necessary qualifications and
competence and all necessary equipment and facilities will
be provided to the District Centres.
- 39 -
12.2.7 The State Institute will, along with the Strategic Planning Cell
of the Directorate of Health and Family Welfare Services,
identify the training needs and draw up a master plan for the
training of staff at all levels. The training should be in the
State mostly. Fellowships / scholarships offered by WHO,
Commonwealth and other similar organizations must be
availed of.
The State Institute and the Planning and
Monitoring Division should work together to get the relevant
information and have the staff deputed according to the needs
of the State and the suitability of the staff member.
The needs of the State for
training are planned and
offers for training
utilised.
12.2.8 The State Institute must plan and conduct courses in Public Public Health regains its
Health:
importance in improving
- short term orientation courses (2 weeks?) for all medical the health of the people.
officers and selected other staff;
- longer certificate courses (6 months?) for all medical staff
in the public health cadres, for the period of transition till
sufficient number of persons with DPH or higher
qualification are available.
DPH and higher courses, in collaboration with the Rajiv
Gandhi University of Health Sciences, to be started in 3
years.
13. RESEARCH IN HEALTH
13.1
Develop Vision, Mission and Strategy Statement on research The process helps the
at the primary health care level as also at the secondary and State to plan the research
tertiary levels and in public health.
activities.
13.2
Study the status of research projects (completed and ongoing) The study helps to
managed by the Department of Health and Family Welfare, improve the quality of
Medical Education and Indian Systems of Medicine and research.
Homeopathy.
13.3
Set up a Research Board and a think tank to identify the Improved quality of
problems. Invite experts to brainstorm, allocate funds and research and adequate
resources from Government (state and central), Universities, funds.
Indian Council of Medical Research, Department of Science
and Technology (ICMR, DST) and Pharmaceutical Industries.
13.4
Create infrastructure for digital library, information and
documentation center. Set up access to the Internet and
databases. Make available leading research journals and
publications.
- 40 -
Services of
information are
increased.
14. HEALTH SYSTEMS MANAGEMENT
14.1 ADMINISTRATION
Structure of Health Services:
14.1.1 The emphasis on public health should be revived and its Public Health gets its due
essentiality recognized; two separate cadres may be importance.
constituted relating to Public Health and Medical (clinical)
based on integrated and common functions.
14.1.2 The Directorate of Health Services would be in charge of a More efficient and
Commissioner / Director General of Health Services. This post effective functioning.
would be filled by a senior IAS Officer of the State Cadre or
through contract appointment of an eminent professional from
within the department or outside it.
14.1.3 The levels of health personnel up to the district level should
constitute district cadres, selection to State cadres being made
from these cadres on the basis of merit cum seniority.
Appropriate transitory mechanisms for exercise of options by
the present staff.
A suitable recruitment mechanism should be established for
appointment of doctors and others at the basic level: either a
District Recruitment Committee or a State level Local Services
Recruitment Board, depending on the level / grades of staff to
be recruited;
14.1.4 Recruitment doctors would be at the level of the PHC,
assignment to the Public Health or Medical Cadres being
made after a certain period and subject to qualifications and
training.
District and State cadres
come into effect.
14.1.5 A Taluka Health Team under the Taluka Health Officer may
be constituted which includes the Block Health Educators,
Senior Health Inspector, the Refractionist and the Senior Lady
Health Visitor;
14.1.6 The District Health Officer and the District Medical Officer
would be designated as the district health chiefs and be made
responsible for all concerned activities in the district;
General Administrative Issues:
14.1.7 The restructuring of the health services would call for
amendment of the Cadre and Recruitment Rules and for
consideration of the transitory arrangements. A Committee
with the Commissioner as Chairman should be set up for this
purpose, with a mandate to complete the process in a specified
time so that the new structure is in position in a year’s time.
A Taluk Health Team is
created
- 41 -
Initial recruitment and
subsequent career in two
streams.
The District health chiefs
are identified.
Amendments to C & R
rules to enable the reorganisation of the health
services.
14.1.8
14.1.9
14.1.10
The present system of annual appraisal reports needs to be
reviewed and made performance specific. Also, a system of
medical audit should be instituted for assessing performance
of hospitals;
Private practice by health personnel would be subject to the
following conditions:
a) Hours of duty will be stipulated in all health / medical
institutions of the Directorate and prominently displayed
for public knowledge. The hours of work would take
regional, seasonal and other factors into consideration.
All personnel should adhere to these hours and the
responsibility to ensure this would be that of the superior
officer;
b) Doctors may be allowed private practice outside these
stipulated duty hours and only when not on call or
required for emergency service, subject to the remission
every month to Government of one-third the basic pay of
the staff member who so practices;
c) The Directorate would identify and notify those posts
where private practice is banned, based on criteria to be
evolved. The incumbents of these posts would be paid a
monthly “non-practicing allowance” of one-third the
basic pay of the post;
d) All doctors in the Directorate, at all levels, would
provide an affidavit at such periodic intervals as may be
specified affirming whether they are or are not carrying
on private practice. This would form part of the service
record;
Those found contravening the affidavit would be subject
to disciplinary actions as may be prescribed in the
relevant rules.
Internal institutional mechanisms for detection of and
enquiry in cases of corruption should be set up for
expeditious detection and punishment;
Improved performance
appraisal so that action
can be taken to
improve performance.
Conditions under which
private practice by
doctors in government
service is permitted are
set out
Corruption is reduced
significantly
14.1.11
All externally aided projects would be within the structure of The Department owns
the Department, even if implemented by a distinct Division the projects
within the Department, as suggested in the restructuring of
the Department;
14.1.12
Morale needs to be built up by adoption of transparent The morale of the staff is
procedures with regard to transfers, selection for training or improved
courses, regularization of contract doctors, providing soft
loans for transport to PHC doctors and field personnel and
the like.
- 42 -
14.1.13
The orders relating to delegation of powers, both financial Better delegation of
and administrative, need review. The Commissioner may powers leading to early
carry out such a review.
and appropriate action.
14.1.14
All vacancies should be filled expeditiously. Vacancies in a Health services function
“service” Department result in serious reduction of quality efficiently and
and availabilty of health facilities;
effectively.
Budget cuts for health services should not be made since
these not only reduce the scale of the services but also result
in deterioration of existing ones. Such cuts are counter
productive.
14.1.15
It is necessary to extend the technical authority of the
Director, Public Health / Director, Medical over health
matters in urban areas that are under the control of the
municipal authorities. This could be done through the issue
of orders under the existing Municipal Acts.
14.1.16
The existing mechanisms should be used effectively to Improved co-ordination.
monitor and interact with the specialty institutions, including
the Central ones;
14.1.17
The possibility of contracting out non-clinical services in Improved efficiency
increasing degree should be explored;
14.1.18
The Population Centre may be redesignated as the Centre The Centre for
for Population and Health Studies, and its role expanded. It Population and Health
may be placed under the Commissioner.
Studies becomes a centre
for evaluation and
research.
The system of registration of births and deaths needs to be Improved vital statistics
reviewed to enhance its accuracy, coverage and utility.
14.1.19
The Department of
Health Services provide
technical guidance to the
local administration
14.2 PLANNING AND MONITORING
14.2.1
A Planning and Monitoring Division should be organized
incorporating the Strategic Planning Cell and vested with
the authority to call for information from all other Divisions.
This Division should be responsible for strategic planning of
activities of the entire health system, including long term
planning, coordination with the Zilla Panchayats to ensure
that the health plans of the districts, talukas and Gram
Panchayats are integrated into the State Health Plan, and
assessing budget resources for current and future needs,
taking into consideration population, level and norms for
services and other relevant parameters, and assessing
human resources and all material resources on a continuing
- 43 -
A planning and
monitoring division
comes into function to
plan, prioritise, workout
budget resources,
monitor and evaluate the
activities of the
Department.
basis.
- The Division would have to include a Reporting and
Monitoring Section, a Geographical Information System,
a Computer Division and a Perspective Planning
Section.
14.2.2
-
All reporting activities with regard to the HMIS should
be vested in this Division. The analysis of information
and generation of monitoring reports for various levels
would be the responsibility of this Division, to enable
assessing performance and initiating corrective action;
-
A website would have to be developed and maintained
with all information relating to health services, including
financial and performance details;
-
This Division would function as the secretariat for the
Commission on Health that has been recommended to be
established.
The statistical (HMIS) offices in the districts may be District planning and
established with adequate computer facilities. District level monitoring are effected
monitoring reports must be produced for enhancing
management capacity at the district level;
14.3 HEALTH MANAGEMENT INFORMATION SYSTEM (HMIS)
14.3.1
A comprehensive Health Management Information System
(HMIS) should be put in place by end of the year 200I to
enable the Health and Family Welfare Department to
improve its service delivery. This should include the
following elements:
- Adequately fulfill human power requirements and avoid
mis-matches especially in the posting of Medical officers,
details regarding all personnel, at all levels, (viz.
Number of sanctioned posts & number filled;
recruitment, transfers, leave etc) should be computerised
and monitored.
- Details regarding infrastructural facilities – buildings,
equipment; etc. should be monitored continually to
ensure adequate availability, timely repairs, civil works
and so on.
- A comprehensive Disease surveillance system should be
evolved. This should continually scrutinize, monitor,
evaluate and plan for control & / or eradication of
diseases, especially diseases of Public Health
importance and should be useful at grass roots levels for
prevention and management of disease outbreaks.
- 44 -
Comprehensive Health
Management Information
System comes into place
to effectively assist all
activities of the
Department.
-
The HMIS should be an effective monitoring tool to
assess the performance of the system and which provides
for informed planning and decision by the DHS. At the
same time it should also support micro-planning and
management at all levels where action is essential. The
performance indicators & protocols required for
objective monitoring of all health activities up to the
subcentre level should be worked out.
14.3.2
To increase the efficiency and validity of reporting Reporting improves
mechanisms, the minimum required data that has to be
collected should be identified; integrated reporting formats
should be developed and adequate supply of registers/forms
especially at the subcentre level should be ensured.
14.3.3
The Human power and Infrastructure data, Disease All data are
surveillance system and a geographical information system computerized helping
(GIS) should be .integrated into one computerized system
prompt and easy action.
Computerization which is envisaged at the District and State
level initially, should be extended to the Taluka and PHC
levels at the earliest.
The staff at decision- making levels should be trained to use
the HMIS & GIS effectively for micro-level action and
planning.
Training in basic computer literacy including GIS System
and data entry and analysis of all categories of staff involved
should be effected.
Connectivity and communication systems between the
different health institutions, offices and levels should be
established. To start with all 27 Districts and Directorate
should be connected. Later all Talukas could be connected.
An expert panel should monitor and upgrade the system to
keep up with the constant and rapid evolution in IT.
14.3.4
The present system concentrates on information on
communicable diseases. It should also get geared up for
management of non-communicable diseases, especially
with the changing patterns of diseases due to urbanization,
industrialization, pollution, changing life styles and life
expectancy.
14.3.5
The web page of the department should be constantly up- The information is made
dated. It should be maximally utilized not only for awareness available to all
and information but also as a means for promotion of
transparency.
- 45 -
All information regarding
communicable and noncommunicable diseases
become available.
14.3.6 In the long run mechanisms to utilize the computer networking
for “Distance-Learning” programmes, “Tele Medicine” etc.
for the health personnel, and for Health Education and Health
Promotion activities for the community could be identified and
implemented
The information is
utilised effectively for
education and promotion
of health.
15. HEALTH FINANCING
15.1
A study of the availability and financing of health services Reliable data become
provided by the State, by local authorities and by the private available of the financing
sector should be carried out;
of health services.
15.2
Parameters should be evolved for rational allocation of funds Greater equity is assured
to districts and sub-regions to ensure a degree of equity in
availability of services, with flexibility being built in for
special circumstances, taking into account the health plans of
the Zilla Panchayats;
An internal review of specific allocations is necessary to Improved allocations to
reflect the needs of certain essential activities in a realistic critical areas.
manner. This would be particularly necessary in the case of
supporting and infrastructure services. Some of the critical
areas which would need enhanced allocations would include
repairs of vehicles, equipment and buildings, touring for better
supervision and administrative charges of the PHCs;
15.3
15.4
Budgetary cuts should not be made in allocations for health Continuity of services at
services. Such cuts destroy continuity and levels of services optimum level is assured.
built up over time and only prove counterproductive in the
long run;
15.5
It should be ensured that release of funds and sanction orders
are issued well in time and that the quantum of funds released
should be adequate since such releases, in combination with
sufficient financial delegations, would ensure maintaining and
improving health services;
15.6
It is necessary to ensure coordination in the budgeting of the Improved budgeting
various Departments and Divisions of the health and medical
services. This responsibility may be assigned to the
Commissioner as a coordinating officer, with authority to call
for information from associated Departments / Directorates.
The Planning and Monitoring Division to be established
directly under the Commissioner may be assigned this role. To
assist this Division a post of Financial Adviser be created in
this Division. This post could be filled by a health economist or
by selection, based on experience, from the State Accounts
Department or Planning cadres of Government;
- 46 -
Improved utilisation of
finances in time and,
therefore, optimum
services.
15.7
The need for the current large number of distinct accounts
offices in various Directorates / Departments of the health
services results in lack of coordination. The possibility of their
integration would have to be studied.
15.8
The adequacy and implementation of financial delegations
within the health services would need review. This may be
done by a Committee under the Chairmanship of the
Commissioner.
Nonperformance due to non-utilization of delegated authority
should be one of the parameters for assessing annual
performance;
15.9
Internal procedures for monitoring expenditure, particularly
in the case of acquisition of equipment and infrastructure,
would need to be reviewed to ensure expeditious utilization of
allocations in the best manner possible;
The reporting system and formats prescribed for the field level
officials, particularly the ANMs, would need to be reviewed to
rationalize them and reduce workload.
15.10
The study will bring out
information, based on
which action can be
taken on integration of
the accounts offices
Delegation of financial
powers appropriate to the
level of responsibility;
the officers will be
accountable for
performance.
Better utilisation of the
funds.
Rationalisation of the
reporting system at the
field level
15.11
A comprehensive review of the financial reporting system is A rational financial
necessary so that it becomes part of the HMIS that has been reporting system is in
recommended;
place.
15.12
The system of user fee is a good feature and should be
periodically reviewed to enhance both the base and the scale
of fees, if called for. It would be necessary to reiterate that the
collection of user fee by a hospital would be exclusively meant
for its improvement;
15.13
Schemes for community insurance based on Self Help Groups Community insurance to
for non-hospitalization cases or with involvement of national be tried out on a pilot
insurance companies for hospitalization cases should be basis.
formulated and tried out on a pilot basis to develop a
replicable model;
15.14
A scheme for liability insurance for doctors in the
Department, including group insurance schemes, needs to be
formulated in consultation with public sector insurance
companies, including the Karnataka Government Insurance
Department. The scheme may stipulate that doctors meet half
the costs of the premium;
- 47 -
Periodical review and
revision of user fee to be
used by the hospital,
where the fees are
collected
A scheme of insurance
against claims of
damages to be worked
out.
15.15
Norms for health services based on adequacy of services and Norms would be
quality should be developed as guidelines for formulation of available for budgeting
budget requirements. These norms would also provide and other requirements.
guidance for assessment of the financial elements of the
perspective plan for health services;
Norms in terms of both quality and adequacy, with regard to
expected outcomes of expenditure need to be evolved for
monitoring of efficiency of use of funds. Such norms must be
developed for various functional levels, including the Zilla
Panchayats;
The long-term requirements of health services would need to
be assessed on the basis of the norms suggested above and on
the basis of the perspective plan for health services. In
assessing these requirements, the requirements to sustain the
assets and services created at considerable cost through
externally aided projects must be built in.
15.16
Test audit through chartered accountants may be tried on a
pilot basis for evaluating the performance of health services at
PHC and taluka levels and also to induce a sense of financial
discipline. A pilot audit could be instituted in consultation with
the Institute of Chartered Accountants. The Planning and
Monitoring Division could be the nodal office for this pilot
study;
A study is necessary of the scale of health services and the
financial outlays on such services in Municipal Corporations
and other municipal bodies to assess the total health
expenditure on health in the public domain. Such a study
would help in assessing the needs in urban areas.
15.17
15.18
15.19
15.20
Auditing of PHC would
be done, first as a pilot
study and extended if
found feasible and useful.
The financial and other
needs of the urban areas
become known.
A study of costs on health services to families may be
conducted, after an evaluation of the results of studies already
available, for guidance regarding enhancement of services for
the economically weaker section of society at affordable costs;
A major part of the
health expenditure is met
by the family, which
makes the family
impoverished;
affordability of services
must be known.
The staffing pattern would need to be reviewed at intervals to Adequate staffing is
determine both adequacy and excess and critical shortages. A critical in the optimum
Staff Inspection Unit trained in Organization and Management functioning of health care
principles could be assigned this task;
services.
A financial database may be built up as part of the composite The financial needs and
HMIS that has been recommended for the health services. The utilisation will be known.
system of computerization of financial information and of the
accounts should be built up without delay.
- 48 -
16. RATIONAL DRUG MANAGEMENT
16.1
Procedures should be established for quantifying the essential
drugs required for the State, to optimize the pooled
procurement through the Rate Contract.
The Zilla Panchayats may make use of the rate contract for
90% of their requirements, reserving 10% for discretionary
purchase.
16.2
Procedures should be established for developing, Standard Treatment
disseminating, utilizing & revising Standard Treatment Guidelines are worked out
Guidelines.
to improve the outcome
of treatment.
16.3
Procedures should be established for developing & revising
Essential Drug Lists and a State Formulary based on
treatment of choice for the level of expertise- primary,
secondary, tertiary, speciality and teaching.
16.4
Every hospital should have a Pharmacy & Therapeutics Rational Use of Drugs
Committee for monitoring & promoting quality use of will be assured.
medicines. Specific guidelines for Rational Use of drugs,
especially, Antimicrobials and Analgesic are a must.
Use Generic names of drugs for procurement, supply and
prescribing.
Implement problem based training in pharmacotherapy in
undergraduate medical & paramedical education based on
Standard Treatment Guidelines to promote Rational use of
Drugs.
Encourage problem-oriented in-service educational programs
by professional societies, universities, & the ministry of health
& require regular continuing education for licensure of health
professionals..
Stimulate an interactive group process among health
providers and consumers to review & apply information about
appropriate use of medicines. Train pharmacists to be more
active members of the health care system & to offer better
advice to consumers about health & drugs.
The concept of Drug Information should be popularized
among the health care professionals & the public. Drug
Information Centre must be accessed for unbiased, objective
information.
The Services of the State Karnataka Pharmacy Council may
be utilized for all the above purposes.
- 49 -
The quantity of the
essential drugs required
are known to get
advantage of the bulk
purchases through the
Rate Contract System.
Essential Drug Lists
based on level of
expertise available and
Formulary for institutions
at different levels become
available.
16.5
16.6
Monitor adverse drug reactions so that appropriate and early
measures can be taken to ensure safe use of drugs.
Encourage active involvement by consumer organizations in
public education about drugs and allocate government
resources to support these efforts.
Procedures should be established to ensure proper labeling of
drugs. The packages and the inserts should be adequately
labeled to enable people to use drugs properly. It should also
mention most common side effects and danger signals, special
precautions in case of children, pregnant and lactating
mothers, and old people. The labeling should be printed in
adequately bold size. The labeling in case of O.T.C. drugs
should be more detailed, giving all indications,
contraindications, common side effects and danger signals.
The labeling should be made in English, Hindi and the
regional language.
The Government Medical Stores and the District Stores to be
re-organised to ensure proper and on-time distribution of all
essential drugs. Monitoring of drugs to be received from the
centre, their actual receipts and supply to be monitored
vigorously.
Improved safety in the use of
drugs.
The Medical Stores at the
State headquarters and
districts are re-organised for
greater efficiency and
effectiveness.
16.7
The Drug Control Department to be re-organised with The Drug Control
sufficient number of Drug inspectors and Drug testing Department is able to
laboratory. Regulation of Drug Company's Promotional perform its duties better.
Activities is important.
Promotional literature for
pharmaceuticals, guidelines for sponsorship of Symposia and
Other Scientific Meetings, Advertisements, Free samples of
prescription drugs for promotional purposes, Post-marketing
scientific studies, surveillance and dissemination of
information should conform to guidelines.
16.8
A strategic approach is to be developed to improve
prescribing in the private sector through appropriate
regulation & long-term association & collaborations with
professional associations.
In view of the trends in increased use of traditional medicines,
it is essential to facilitate the establishment of regulation and
registration of traditional medicines.
16.9
16.10
More rational use of drugs in
the private sector also.
Better regulation of the use of
traditional medicines.
The services of the Karnataka Antibiotics and Better use is made of the
Pharmaceuticals Limited to be made full use of, for the facilities of Karnataka
production of quality drugs needed by the State.
Antibiotics and
Pharmaceuticals Limited.
- 50 -
17. LAW AND ETHICS
17.1
Implement effectively the existing laws affecting health and Effective implementation
health care, and especially the laws such as the Human of the existing laws is
Organs Transplant Act, 1994 and the Prenatal Diagnostic assured.
Techniques Act, 1994.
17.2
Renew the registration of health professionals in the State Prevention of
once in 5 years, with evidence of sufficient credits of having obsolescence and
participated in approved continuing education programmes.
upgrading of competence.
17.3
The respective professional councils should ensure that the
members of the profession practice ethically, following their
codes of conduct.This may be done through an amendment of
the respective Acts.
Enact a comprehensive law to ensure registration and quality
assurance of all health care institutions in the state, on the
lines suggested by the Task Force and forwarded to the
Government. Promote accreditation.
17.4
17.5
17.6
It is the duty of the
professional councils to
ensure that the members
practise ethically.
Quality assurance and
continuous quality
improvement.
Enact a comprehensive Public Health Act, based on the An effective and
Model Public Health Act (1987) with suitable modifications.
comprehensive Public
Health Act is in place.
Examine in depth the problem of quackery and take effective Quackery, which is a
steps to stop it.
hazard to the health of the
people, is reduced.
17.7
Arrange for monitoring of the activities under the Human
Organs Transplant Act, by an independent agency, to stop the
sale of organs.
The Appropriate authority for Organ Transplantation may be
reconstituted with inclusion of representatives of voluntary
organisations.
17.8
Every health care institution to have a Charter of citizens Greater transparency and
rights and rights of patients. The Charter should be displayed integrity. Rights of
prominently.
patients are honoured.
17.9
Update the "Prohibition of Smoking Act". Ensure the welfare Use of tobacco is reduced
of tobacco growers when cultivation is restricted and of beedi and thereby, the harmful
workers when manufacture and use are reduced.
effects on the health of
the people.
- 51 -
The sale of organs is
reduced; more cadaveric
transplants are
encouraged.
17.10
Make the teaching/learning of ethics as part of health The health care personnel
professions education.
practise ethically.
Make the health personnel aware of the codes of conduct.
Have training programmes in medical ethics for all health
care personnel and particularly the doctors and nurses.
18. INDIAN SYSTEMS OF MEDICINE AND HOMOEOPATHY
18.1
The sanctioned post of Joint Director is to be filled. In the
absence of C & R rules the senior person may be placed in
charge and duties may be assigned. Existing senior doctors
may be designated as District level officers of the respective
districts. In 11 districts where there are already hospitals, it
can be implemented immediately. These district level officers
posts are to be filled by selection based on merit-cumseniority.
18.2
Dispensaries and hospitals are to be renovated after a survey Improved facilities in the
by the Department. Develop uniform norms for dispensaries units of ISM&H.
and hospitals, with regard to plan, space, infrastructure and
staff.
Construct special wards with all amenities atleast in the major
hospitals attached to teaching institutions at Bangalore,
Mysore and Bellary.
18.3
Establish or relocate units of ISM&H with necessary Availability of modern
infrastructure at CHCs, Taluka and District hospitals.
medicine and Indian
Systems of Medicine and
Homeopathy, at the same
place; choice is left to the
people.
Establish herbal gardens in ISM&H units, PHCs and CHCs Improved use of herbal
for utilisation and demonstration for the public with the help medicines.
of forest department (social forestry).
18.4
A senior, experienced
experienced person is in
charge, at the same time
ensuring competence.
18.5
Provide residential accommoation near the place of work for Availability of doctors of
physicians of ISM&H. If Government accommodation is not ISM&H is improved.
available, houses may be taken on rent.
18.6
There is an urgent need to make available the facilities for Improved availability of
investigative procedures with qualified and technical staff in diagnostic procedures.
all the hospitals. This can be done in collaboration with the
hospitals of modern medicine at various levels.
18.7
The services of contract doctors need to be regularized, based Improves the morale of
on performance appraisal
the doctors.
- 52 -
18.8
The Boards of Visitors are to be re-constituted immediately in Better people's
order to improve the functioning of the hospitals.
involvement.
18.9
Provide all dispensaries and hospitals with a working Improved
telephone
communication.
18.10
Establish the speciality units of panchakarma and Have speciality treatment
ksharasutra in all district hospitals first and then taluk available. Major
hospitals.
Hospitals are upgraded.
The major hospitals are to be upgraded and enlarged to meet
the requirements and demands with adequate human force,
equipments and other accessories, after a need assessment.
Well-planned OP blocks in all the major hospitals of
Bangalore, Mysore and Bellary.
18.11
Fill up the vacant post of Siddha Physician in the 10-bedded The post of Siddha
Siddha ward at Sri. Jayachamarajendra Institute of Indian Physician is filled.
Medicine, Bangalore.
18.12
There is a need to enhance the budget provision for Increased availability of
procurement of medicines in dispensary atleast to a sum of essential drugs.
Rs.36,000/- p.a.
18.13
Steps have to be taken to provide hostel facilities in all the Improved
major medical colleges.
accommodation for the
students.
The disparity in pay scales of doctors and stipend for Disparity reduced.
internees of ISM&H and modern medicine may be studied and
action taken to remove the inferiority feeling or low esteem
prevailing amongst doctors and students of ISM&H
18.14
18.15
Study the need for developing appropriate training courses Paramedical staff become
with special modules for paraclinical staff such as Masseurs, available, with improved
Nurses ,Health extension workers and pharmacists and take quality and numbers.
necessary action
18.16
The facilities of the State Institute of Health & Family Welfare Improved training in all
should be made use of for the training of ISM&H personnel. aspects including
The training should include hospital management for those in management.
charge of hospitals.
18.17
CME courses must be periodically conducted to update Constant upgrading of
knowledge and skills of the practitioners of ISM&H. Sufficient the knowledge and skills
credit hours must be earned for the renewal of registration by of the doctors.
Karnataka Ayurveda and Unani Practitioners Board and
Karnataka Council for Homeopathic Medicine. Professional
and Technical support may be obtained from the teaching
institutions (Both Private and Government).
- 53 -
18.18
18.19
10 seats may be reserved in MBBS course in the Government
Medical Colleges for eligible ISM&H graduates, 7 for
Ayurveda, 2 for Homeopathy and 1 for Unani, to bring about
integration.
There is greater
integration and
possibility of research
into the efficacy of
different systems of
medicine.
All the teaching inst itutes of ISM&H must take up defined Improved involvement of
geographic areas in order to effectively execute public ISM&H in primary
awareness programmes and for primary health care (through health care.
the dispensaries and mobile units). The need for trained
ISM&H health workers for extension work may be studied and
action taken so that they can take up health promotion work in
the periphery.
18.20
Introductory lessons on ISM&H systems viz., Ayurveda,
Unani, Naturopathy, Yoga, Siddha and Homeopathy should be
included in the curriculum of schools and colleges, which
would create awareness among the children. The institutes of
ISM&H should take up school health programmes in the
neighbouring schools.
18.21
An expert committee may be appointed to consider the Greater availability of
upgradation of the Government Pharmacy after studying quality medicines.
TAMPCOL of Tamil Nadu or AUSHADHI of Kerala.
A Homeopathic Drugs Manufacturing Unit may be started to
make medicines in sufficient quantities to meet the demands of
the entire state.
18.22
To meet the increasing needs of ISM&H, a post of Assistant Quality assurance of the
Drug Controller may be created and filled up by suitably drugs under ISM&H.
qualified candidate
Qualified homeopathic doctor may be appointed as drug
inspector to inspect the Homoeopathic manufacturing units.
The department of ISM&H must prepare essential drug lists
for each system. A medicinal plant board may be established
which would ensure quality, consistency and price.
- 54 -
Greater respect for all
systems of medicine;
improved health of
school children.
18.23
Encourage research. Appoint a Senior Research Officer in Research in ISM&H is
ISM&H. Reconstitute the research advisory committee. Rajiv improved.
Gandhi University of Health Sciences may be requested to
establish interdisciplinary research board, comprising of
experts of ISM&H, modern medicine and scientists of basic
sciences. RGUHS may be requested to frame standard
guidelines for protocols for thesis / dissertations for
postgraduate courses in ISM&H.
The financial support to PG researches may be enhanced to
Rs.2,500/- p.a.
Encourage research in ISMH through financial support for
interested and dedicated practitioners and private academic
institutions.
18.24
Government should provide about 50-100 acres of land for Improved availability of
ISM&H in each district for cultivation of medicinal plants, medical plants.
which should be harvested and utilised by the Government
Central Pharmacy.
18.25
The government should effect immediately the promotions that Improved morale and
are due and implement time bound promotions
better functioning of the
department.
Appoint a qualified person competent in editing / publishing to Publications are brought
effectively bring out publications including health promotion out on time.
materials
18.26
18.27
Doctors qualified in particular system of medicine should Doctors practise only that
practice only that system; cross practice must stop in the system in which they are
interest of the public and to develop the particular system of competent.
medicine.
18.28
Have a comprehensive HMIS for all the institutions and Improved availability of
services under ISM&H.
information for better
management.
19. PANCHAYATI RAJ AND EMPOWERMENT OF THE PEOPLE
19.1
The involvement of the Panchayat institutions and of the
community in providing health services should be encouraged
for improvement and enhancement of these services based on
real needs. For enhancing such involvement, information
should be available to the community and a forum must be
developed. It would also be necessary to sensitize the officials
in this regard;
- 55 -
Greater involvement in
Panchayat Raj
institutions and people
for improved health
services.
19.2
Sec. 61 of the Karnataka Panchayat Raj Act may be amended The committee
to establish a separate Committee for health, sanitation and concentrates its attention
education in the Gram Panchayat;
on health, sanitation and
education.
19.3
Training courses in health for empowering women members
of the Panchayats and women community leaders need to be
organized. Such empowerment would improve the effectiveness
of programmes such as RCH, children’s and women’s health
in the community;
19.4
Model health plans need to be formulated by the Panchayat Improved health plans as
institutions. Such model plans would assist in developing the part of Development
health component of the District Development Plan;
Plan.
19.5
The health hierarchy needs to be oriented regarding its role in
the Panchayat system and its relationship with these bodies;
monitoring of implementation of State funded activity,
supervision and inspection continue to be a direct
responsibility of the hierarchy;
A system of monitoring the health activities of the ZPs by the
Commissioner needs to be established;
Improved involvement of
women members in
health and family
welfare.
Better co-ordination
between the department
of Health and Family
Welfare Services and the
local authorities, with
clear responsibility of the
department in all
technical matters.
The Rural Development and Panchayat Raj Department and
the Health Department may develop a system of feedback from
the health hierarchies in order to render the mutual interactive role between the Health Department and the Panchayat
bodies more productive;
It would be necessary to conduct orientation courses /
workshops for the health hierarchy so that there is a better
understanding of both their role and responsibility in the
Panchayati Raj system. The Rural Development and
Panchayati Raj Department could organize such courses.
19.7
19.8
The meetings of the ZPs may be regulated according to the
circulars of the Department of Rural Development and
Panchayti Raj regarding frequency, so as to permit district
health personnel, particularly the DHO, to carry out
inspections and supervision more intensively;
Village communities should be encouraged to form Village
Health Committees with wide membership, including
representatives of women’s groups, the youth, the ANMs, the
Anganwadi Workers, and others. The Gram Panchayat is
empowered to constitute such committees under Sec. 61 – A of
the Act.
These Village Health Committees would have to be trained in
the conduct of meetings, prioritizing local health issues,
preparation of health plans, etc. Institutions such as the
- 56 -
The DHOs can plan and
implement their other
activities effectively.
Greater involvement of
the people in all health
activities.
Institute for Social and Economic Change could be assigned
this function;
The formulation of a pilot project for the formation of such
Committees, developing necessary training material and
sensitization could be assigned to the Institute for Social and
Economic Change, Bangalore. The State Institute for Health
and Family Welfare should also be involved in the process of
sensitization of the official hierarchies.
20. STRENGTHENING PARTNERSHIPS
PRIVATE / CORPORATE SECTOR, GENERAL PRACTITIONERS AND VOLUNTARY
ORGANISATIONS
20.1
The over all strategy of the government should be to recognise and appreciate the
importance of voluntary and private sectors in health care and to create an atmosphere of
trust and foster public-private partnership in delivering comprehensive health care
Enhance the scope/importance of collaboration with the Improved collaboration
private and voluntary sectors in primary, secondary and between public,
tertiary level of health care.
voluntary and private
Involve private sector in preventive and promotive care in sectors in all aspects of
addition to curative care.
health care.
Promote partnership between public, private and voluntary
organisation.
20.2
Evaluate and monitor quality of services in the private and Quality assurance is a
voluntary sectors.
must whichever be the
sector.
20.3
All the voluntary agencies working for the health sector should
have a central cell. The cell should register all organisations
and bring out the annual report of the activities of voluntary
organisations. The grant-in-aid procedures must be simplified
and the bottlenecks removed, to help better collaboration and
remove the feeling of frustration.
Co-ordination and
credibility. Greater
involvement of credible
voluntary organisations
in health and
development.
The logistics of partnership concept between the government
and voluntary organisation has to be worked out by the central
cell and the government. Voluntary agencies should be invited
to participate in the preparation of health policies by the
Government.
20.4
The agencies, have to be used more and more for the effective Better performance of the
implementation of National Programmes, spread of health National and other
education and act as a watch-dog over the provision of health programmes.
services within the public/private sectors.
- 57 -
21. MULTISECTORALITY AND INTERSECTORAL COORDINATION
21.1
The State must establish administrative machinery and Co- Better collaboration
ordination committees at the State, district and local levels for between all health related
intersectoral action for health. These groups must be involved sectors
in the preparation of the State plan.
Have a High Power Core Committee (intersectoral) headed
by the Chief Secretary at the state level and committees at the
district level with participation by D.Cs and C.E.Os. The
Committees should have representations from Health,
Education, Women and Child Welfare, Agriculture,
Horticulture, Animal Husbandry.
Irrigation, Housing,
Industry, Pollution Board and Environment. Subcommittees
can be formed to reflect and take action on specific matters.
21.2
All developmental programmes must have inputs from the
health sector to make use of the opportunity to improve health
and prevent problems.
Health personnel (Public Health) should be trained to
anticipate and find solutions to possible health hazards of
developmental programmes. They should continue their
association during implementation, monitoring and evaluation
of the programme.
Some development
programmes might have
adverse effects on health;
these can be avoided by
action during planning,
and implementing.
22. THE KARNATAKA STATE INTEGRATED HEALTH POLICY 2001
22.1
22.2
The draft integrated health policy should be finalised after Wide circulation and
dialogue with Directorate of Health and Family Welfare debates
among
all
Services, other Government Departments and Public.
stakeholders can improve
the policy and its
implementation for better
health for all.
A Commission on Health would be constituted to provide Enhancing
policy inputs and expert guidance to the Directorate of Health responsiveness of
Services.
health Services to meet
current needs and
expectations.
- 58 -
- 59 -
ANNEXURE 1A
GOVERNMENT ORDER APPOINTING THE TASK FORCE
Proceedings of the Government of Karnataka
Sub: Constitution of Task Force on Health and Family Welfare – reg.
Ref: Note No SCM / 516 / 99, Dated 10-11-1999
PREAMBLE:
In order to propose measures to improve the public health care system in the State of
Karnataka, it has been felt necessary to set up a Task Force, consisting of eminent persons in
various fields, which would examine the issues involved and propose measures which could be
adopted by Government.
Hence the following order.
Government Order No. HFW 545 CGM 99, Bangalore, Dated 14-12-1999
A Task Force on Health and Family Welfare is hereby set up consisting of the following
persons:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Dr. H. Sudarshan, Karuna Trust, B.R. Hills
Sri P. Padmanabha, Former Registrar General, India
Dr. Chandrashekar Shetty, Vice Chancellor, Rajiv
Gandhi University of Health Sciences
President, Indian Medical Association, Karnataka Branch
Dr. Jacob John, C.M.C., Vellore
Dr. C. M. Francis, Bangalore
Dr. S. Nagalotimutt, Rtd. Director, Karnataka Institute of
Medical Sciences (KIMS), Hubli
Dr. Latha Jagannathan, T.T.K. Blood Bank, Bangalore.
Dr. Jayaprakash Narayan, M.D. (Ayurveda), Bangalore
Swami Japananda, Chairman, Swami Vivekananda
Integrated Rural Health Centre, Pavagada, Tumkur
Dr. M. Maiya, Physician, Bangalore
Dr. S. Subramanya, Project Administrator, Karnataka
Health Systems Development Project
Chairman
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member Convener
The following shall be the Terms of Reference of the Committee:
1. The Task Force shall propose to the Government various policy measures to be adopted
for improving the public health care system in the State.
2. The Task Force shall propose measures to stabilize the population at a Net Reproductive
Rate of 1 and suggest the time frame by which this should be achieved.
3. The Task Force shall also make recommendations regarding improvements necessary in
the management and administration of the Department of Health and Family Welfare for
this purpose.
4. The Task Force shall also recommend changes in the education system covering both
clinical and public health areas keeping in view the improvements envisaged above.
5. The Task Force shall not only make recommendations with regard to the above issues but
is also expected to monitor the impact of the recommendations especially in the initial
stages of implementation. Hence the Task Force may set out specific outcomes to be
achieved by the Department of Health and Family Welfare after the implementation of the
recommendations.
The terms and conditions regarding the sitting fees, etc. are at Annexure-I to this order.
By order and in the name of the
Governor of Karnataka
Sd/(SIDDALINGAIAH)
Under Secretary to Government
Health & Family Welfare Department
To,
1. Dr. H. Sudarshan, Karuna Trust, B.R. Hills
2. Sri P. Padmanabha, Former Registrar General, India
3. Dr. Chandrashekar Shetty, Vice Chancellor, Rajiv Gandhi University of Health Sciences
4. President, Indian Medical Association, Karnataka Branch
5. Dr. Jacob John, C.M.C., Vellore
6. Dr. C.M. Francis, Bangalore
7. Dr. S. Nagalotimutt, Rtd. Director, Karnataka Institute of Medical Sciences (KIMS), Hubli
8. The Accountant General in Karnataka, Bangalore
9. The Commissioner, Health & Family Welfare, Bangalore
10. The Director, Health & Family Welfare, Bangalore
11. Dr. Latha Jagannathan, T.T.K. Blood Bank, Bangalore
12. Dr. Jayaprakash Narayan, M.D, (Ayurveda), Bangalore
13. Swami Japananda, Chairman, Swami Vivekananda Integrated Rural Health Centre, Pavagada,
Tumkur
14. Dr. M. Maiya, Physician, Bangalore
15. Dr. S. Subramanya, Project Administrator, Karnataka Health Systems Development Project
Copy to:
1. P.A. to Principal Secretary to the Government, Health & Family Welfare Department
2. P.A. to the Deputy Secretary (H), Health & Family Welfare Department
ANNEXURE 1B
PROCEEDINGS OF THE GOVERNMENT OF KARNATAKA
Sub: Constitution of Task Force on Health and Family Welfare – Nomination of
additional Members
Read: G.O. NO. HFW 545 CGM 99 dt. 14.12.99
PREAMBLE:
In order to propose measures to improve the public health care system in the State, a Task
Force has been constituted vide Government order referred above.
It has been considered necessary to include some more members in the Task Force to
represent their respective fields. Hence, the following order.
GOVT.ORDER NO.HFW 545 CGM 99 BANGALORE DT.20.1.2000
In continuation of constitution of Task Force vide Govt. order dt. 14.12.1999, the
following additional members are nominated as against their names.
1.
Dr. Kamini Rao, Gynaecologist
Member
2.
Dr. Thelma Narayan, Community Cell,
A Health Policy NGO
Member
The terms and conditions regarding the sitting fees etc., are at Annexure – I of Govt. order
dt. 14.12.99 remains the same.
By order and in the name of the
Governor of Karnataka
Sd/(SIDDALINGAIAH)
Under Secretary to Government
Health & Family Welfare Department
To
1. Dr. H. Sudarshan, Vivekananda Girijana Kalyana Kendra (Karuna Trust) B.R. Hills-571 441,
Yelandur Taluk, Chamarajanagar District
2. Dr. S. Subramanya, Project Administrator, Karnataka Health Systems Development Project,
Seshadri Road, Bangalore – 560 001
3. The concerned (through Member Convener, Task Force, Project Administrator, KHSDP,
Seshadri Road, Bangalore – 560 001.
4. The Secretary to the Chief Minister
Copy to:
1)
2)
P.S. to Principal Secretary
P.A to P.S-1 & 2
ANNEXURE 1C
PROCEEDINGS OF THE GOVERNMENT OF KARNATAKA
Sub: Constitution of Task Force on Health and Family Welfare, reg.
Read: 1) G.O. NO. HFW 545 CGM 99 dt. 14.12.99 and 20.1.2000
2) Notification No. DFAR 133 CAS 2000 dt. 6.3.2000
PREAMBLE:
In the Government order read at (1) above, sanction was accorded to set up a Task Force
on HFW Department consisting of 12 eminent persons and with Dr. S. Subramanya, Project
Administrator, KHSDP, Bangalore as Member Convener.
In the Notification read at (2) above on returning from leave Dr. S. Subramanya is
transferred and appointed as Secretary to Government (Mines, SSI & Textiles) Commerce and
Industries Department, Bangalore and Sri. Arvind G Risbud is appointed as Project Administrator,
Karnataka Health System Development Project and Special Secretary to Government, Health &
Family Welfare Department, Bangalore, vice Dr. S. Subramanya IAS transferred.
Now, it is considered necessary to appoint / nominate Sri Arvind G Risbud as Member
Convener of above said Task Force with immediate effect and until further orders.
GOVERNMENT ORDER NO. HFW 545 CGM 99, BANGALORE Dt. 16.3.2000
In the circumstances explained above, Government is pleased to nominate The Project
Administrator, Karnataka Health System Development Project and Special Secretary to
Government, Health and Family Welfare Services Department as Member Convener of Task force
on Health & Family Welfare Department, with immediate effect and until further orders.
The other conditions mentioned in the said Government Order small remain unaltered.
By order and in the name of the
Governor of Karnataka
Sd/(SIDDALINGAIAH)
Under Secretary to Government
Health & Family Welfare Department
To:
1. Dr. H. Sudarshan, Karuna Trust, B.R. Hills
2. Sri P. Padmanabha, Former Registrar General, India
3. Dr. Chandrashekar Shetty, Vice Chancellor, Rajiv Gandhi University of Health Sciences,
Bangalore.
4. President, Indian Medical Association, Karnataka Branch
5. Dr. Jacob John, C.M.C., Vellore
6. Dr. C. M. Francis, Bangalore
7. Dr. S. Nagalotimath Rtd. Director, Karnataka Institute of Medical Sciences (KIMS), Hubli
8. The Accountant General in Karnataka, Bangalore
9. The Commissioner, Health & Family Welfare, Bangalore
10. The Director, Health & Family Welfare, Bangalore
11. Dr. Latha Jagannathan, T.T. K. Blood Bank, Bangalore
12. Dr. Jayaprakash Narayan, M.D. (Ayurveda), Bangalore
13. Swami Japananda, Chairman, Swami Vivekananda Integrated Rural Health Centre.
Pavagada, Tumkur
14. Dr. M. Maiya, Physician, Bangalore
15. Dr.S.Subramanya, Project Administrator, Karnataka Health Systems Development Project,
Seshadri Road, Bangalore.
Copy to:
1. P.S to Principal Secretary to the Govt. HFW Dept.
2. P.A. to DS-I-II, HFW Dept.
ANNEXURE 2
SCHEDULES OF THE MEETINGS AND CONSULTATIONS BY THE
TASK FORCE ON HEALTH AND FAMILY WELFARE
SL
NO.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
MONTH
December
January
February
March
April
May
June
July
August
September
October
November
December
January
February
March
YEAR
1999
2000
2000
2000
2000
2000
2000
2000
2000
2000
2000
2000
2000
2001
2001
2001
DATES
21st
3rd, 4th, 5th, 10th, 11th, 12th, 27th, 28th, 29th
8th, 14th, 15th, 16th, 21st, 25th, 28th, 29th
1st, 6th, 7th, 8th, 11th, 13th, 20th
6th, 8th, 19th, 24th, 26th
8th, 13th, 27th,
20th
18th,
23rd
25th
23rd
15th, 20th, 28th
13th, 14th
9th, 22nd, 23rd, 29th
7th, 14th 20th, 21st, 26th, 27th, 28th
5th, 8th, 13th, 21st, 27th
Total = 59 working days
Sub Group Meetings
1. Task Force Sub-Committee meeting on HIV/AIDS- 24th August 2000
2. Task Force Sub-Committee meeting on Cancer- 24th August 2000
3. Task Force Sub-Committee meeting on PHC- 11th August and 29th Sept. 2000
ANNEXURE - 3
SUBGROUPS AND TEAM MEMBERS
1
2
3
4
Equity in Health Care
1.1
Regional disparities: Health status; Infrastructure & Human
Resources
1.2
Gender disparities
1.3
Socio economic (Caste and Class) disparities
Quality of Health Care
2.1
Standards
2.2
Quality Assurance
2.3
Accreditation
Primary Health Care
3.1
Rural health
3.2
Urban Health
3.3
Referral Services
Dr. C.M. Francis
Dr. C.M. Francis
Secondary and Tertiary Health Care
Dr. C.M. Francis
4.1
Secondary / Tertiary Hospitals
Dr. C.M. Francis
4.2
Emergency Health Services
Dr. C.M. Francis
Diagnostic Services
Dr. T. Jacob John / Dr. M.
Maiya
Blood Banking & Transfusion Services
Dr. Latha Jagannathan
Bio-Safety
Dr. Latha Jagannathan / Dr.
B. S. Ramesh
4.3
4.4
4.5
5
Dr. C.M. Francis
Public Health
Dr. Thelma Narayan
5.1
Public Health and Primary Health Care - Synergy
Dr. Thelma Narayan
5.2
Water Supply & Sanitation
Dr. Thelma Narayan
5.3
Pollution & Solid Waste Management
Dr. Latha Jagannathan / Dr.
N. Girish
5.4
Communicable Diseases
Dr. T. Jacob John
Vector borne diseases – Malaria, Filaria,
Kyasanoor Forest Disease (KFD), Dengue and
Japanese encephalitis (JE)
Dr. T. Jacob John
5.4.1
5.4.2
Tuberculosis
Dr. T. Jacob John
5.4.3
Vaccine Preventable Diseases
Dr. T. Jacob John
5.4.4
Food and Water borne diseases
Dr. T. Jacob John
5.4.5
RTI, HIV/ AIDS & STDs
Dr. Latha Jagannathan
6
5.4.6
Leprosy
Dr. T. Jacob John
5.4.7
Rabies
Dr. T. Jacob John
5.4.8
Other communicable diseases
Dr. T. Jacob John
5.5
Disease Surveillance
Dr. T. Jacob John
5.6
Non Communicable Diseases
Dr. M. Maiya / Dr. B.S.
Ramesh
5.6.1
Hypertension & Cardiovascular diseases
5.6.2
Diabetes Mellitus
5.6.3
Cancer Control
5.6.4
Bronchitis & Asthma
5.6.5
Other Non-communicable diseases:
5.7
Oral Health
Dr. M. Maiya / Dr. B.S.
Ramesh
5.8
Occupational Health
Dr. B.S. Ramesh / Dr. C.M.
Francis
5.9
Blindness control
Dr. Chandrashekar Shetty /
Sri Swami Japananda
5.10
Tobacco
Dr. C.M. Francis / Dr.
Latha Jagannatha
5.11
Alcohol
Dr. Latha Jagannathan / Dr.
C.M. Francis
5.12
Health aspects of Disaster Management
Dr. T. Jacob John
Mental Health & Neurosciences
Dr. C.M. Francis
6.1
Mental Health
Dr. C.M. Francis / Dr.
Sreenivasmurthy
6.2
Neurological disorders
Dr. M. Maiya
6.2.1
Epilepsy
6.2.2
Stroke
6.2.3
6.2.4
7
Neurology and Neurosurgery services in
Government Medical Colleges
Head injuries and traffic accidents
Nutrition
7.1
Vulnerable groups
7.2
Integrated Child Development Services
Dr. C.M. Francis
7.3
8
Public Distribution System (PDS)
Women & Child Health
8.1
Women's Health
8.2
Child Health
8.3
Reproductive & Child Health Programme
9
Population Stabilization
10
Focus on Special groups
11
12
Dr. Latha Jagannathan
Dr. Jacob John
Mr. Padmanabha
10.1
Persons with disability
Dr. C.M. Francis
10.2
Health of the Tribal People
Dr. H. Sudarshan / Dr.
Deepak M.G.
10.3
Health of the elderly
Mr. P. Padmanabha
Health Promotion and Advocacy for Health
11.1
Health education (IEC)
11.2
Health promotion in schools
11.3
Advocacy
Human Resources Development for Health
12.1
Education
12.2
Training
12.3
Continuing Education
Dr. C.M. Francis
Dr. Chandrashekar
Shetty / Dr. C.M. Francis
13
Research
Dr. C.M. Francis / Dr.
Hrishikeshavam
14
Health Systems Management
Mr. P. Padmanabha
15
14.1
Administration
14.2
Planning and Monitoring
14.3
Health Management Information System (HMIS)
Health Financing
16.1
Allocations and Expenditure
16.2
External Aid
16.3
Management Structure
16.4
Budget Planning and Control
16.5
Information for Health Financing
Dr. Latha Jagannathan
Mr. Padmanabha
16.6
16
17
18
Community Financing and Insurance
Rational Drug Management
15.1
Procurement and Distribution
15.2
Testing and Quality Control
15.3
Rational Use of Drugs
Law & Ethics
17.1
General
17.2
Quackery
17.3
Ethics
Indian Systems of Medicine & Homeopathy
18.1
Department of ISM&H
18.2
Medical Education
18.3
Drug Controller
18.4
Problems
18.5
Folk & Traditional Medicine
18.6
Other healing practices
Dr. C.M. Francis / Dr. H.
Sudarshan / Dr. Deepak
M. G. / Ms. Sunitha
Srinivasan
Dr. C.M. Francis
Dr. Jayaprakash Narayan
19
Panchayat Raj & Empowerment of People
Mr. Padmanabha
20
Strengthening Partnerships
Dr. M. Maiya
20.1
Voluntary Organisations
Dr. M. Maiya
20.2
General practitioners
Dr. B.S. Ramesh
20.3
Private & Corporate Hospitals
Dr. M. Maiya
21
Multisectorality and Intersectoral Coordination
Dr. C. M. Francis
22
The Karnataka State Integrated Health Policy 2001
Dr. Thelma Narayan
23
Vision 2020
Dr. C.M. Francis
24
Implementation of the Recommendations of the Report
Dr. C.M. Francis
25
Major recommendations and expected outcome
Dr. C.M. Francis
ANNEXURE - 4
LIST OF RESEARCH STUDIES CONDUCTED BY THE TASK FORCE
1. Proposal for Review of Organisation Structure and Design of Job Responsibilities for Health
and Family Welfare Department.
Dr. Kishore Murthy, Advisor Health, A.F. Ferguson & Co.
2. Review of Externally Aided Projects in the context of their integration into the Health
Services Delivery in Karnataka.
Dr. Ravi Narayan, Community Health Advisor, Community Health Cell
3. Training Programmes for Health Personnel in Government Service in Karnataka – A
Review Proposal.
Dr. Pankaj Mehta, Director, Medical Education, Manipal Hospital
4. Public Health Care Services under Panchayat Raj System in Karnataka: A Review
Dr. Ramesh Kanbargi, Director, Centre for Social Development
5. Disparities in Health and Health care Services
Mr. As Mohammed, Prof. of Statistics, St. Johns Medical College
6. Proposal for Review of Role of Private Sector in Health Services (Access and Quality).
Dr. Kishore Murthy, Advisor Health, A.F. Ferguson & Co.
7. Health Expenditures in the State Budget
Dr. Vinod Vyasulu, Director, Centre for Budget and Policy Studies
8. Peoples Perceptions of Public Health Care Services and Indigenous System in Karnataka
9.
Dr. Ramesh Kanbargi, Director, Centre for Social Development
Research Study on the Feasibility and Modalities of application of principles of Health
Promotion and its integration with Health Education.
Dr. K. Basappa, President, Karnataka Chapter, International Union for Health Promotion
and Education
1
2
ANNEXURE 5
List of Individuals /Organisations/ Associations who interacted with the Task Force
1. Ministry of Health, Government of Karnataka
1. Dr. Maalaka Raddy, Honourable Minister of Health and Family Welfare
2. Smt. Nafees Fazal, Honourable Minster of State for Medical Education
3. Sri Abhijit Sen Gupta, IAS Formerly Principal Secretary,
4. Sri A K M Naik IAS, Principal Secretary
5. Sri Sanjay Kaul, IAS Health Commissioner
6. Sri Jyothi Ramalingam, IAS Formerly Medical Education Secretary
7. Sri. Thangaraj D, IAS Medical Education Secretary
8. Dr. Subramanya S, IAS Formerly Project Administrator, KHSDP
9. Sri Arvind G Risbud, IAS Project Administrator, KHSDP
10. Sri Shivasailam, IAS Formerly Project Director, IPP IX
11. Sri. Sadashiviah, IAS Formerly Project Director, IPP IX
12. Sri G.V.K. Rao IAS Project Director, IPP IX
13. Prof. B.K. Chandrashekar, Hon.Minister for Information, Bangalore.
14. Sri. Gautam Basu, Joint Sector (RCH), Ministry of H & FW, Govt. of India, New Delhi.
II. Directorate
A. Health and Family Welfare Services:
1. Dr. P N Halagi, Director of Health and Family Welfare,
2. Dr. Seetha Lakshmi, Director of Medical Education, Directorate of H&FWS
3. Dr. Dr. G.V. Nagaraj, Director, Health & Family Welfare Services
4. Dr. Makapur, Director, State Institute of Health and Family Welfare
5. Dr. Shivaratna Savadi, Formerly Director of Medical Education
6. Dr. Nagaraj G V, Project Director, RCH
7. Dr. Murugendrappa, Additional Director (CMD), Dir of H&FWS, Bangalore.
8. Dr. Kurthkoti, Additional Director, Health Education and Training
9. Mr. B. Guruswamy, Director, ISM&H
10. Dr. K. Sharadamma, Additional Director (SPC), KHSDP
11. Dr. Bhattacharjee, Director, Population Centre
12. Dr. Kumaraswamy, Joint Director, Ophthalmology
13. Dr. Janguay, Joint Director, Leprosy
14. Dr. H.G. Narayana Murthy, Joint Director, Tuberculosis
15. Dr. Jayadev, Joint Director, HET
16. Dr. Jalaja Sundaram, Joint Director, Nutrition
17. Smt. H.S. Susheela, Joint Director (IEC)
18. Sri Prakasham, Joint Director, Demography
19. Dr.V. S. Rajamma (HMIS), Deputy Director, KHSDP
20. Dr. B.Y. Nagaraj, Joint Director (Lab), PHI Building
21. Dr. K R Kamath, Deputy director, PHI
22. Dr. M. Dhananjaya Reddy (CMD), Deputy Director
23. All the District Health Officers
24. All District Surgeons
25. Dr. D.M. Koradhanyamath, Training Officer, IPP-IX
26. Shri P. Mahadev, Asst. Leprosy Officer,
27. Smt. D. R. Jayashri, Systems Analyst,
28. Sri Veeranna, Assistant Director, Nursing Services
29. Dr.M. Mallikarjunaiah, Deputy Director (Medical), Directorate of H&FWS
30. Dr.K.P. Damodar, Chief Supervisor, Govt. Medical Stores, Bangalore.
31. Dr.B.Y. Nagaraj, Joint Director (Lab), Bangalore.
32. Mr. D.S.Murali Krishna, Deputy Secretary, Health & Family Welfare Dept. Bangalore.
33. Dr. M. Mallikarjunaiah, Deputy Director (Medical), Directorate of H &FWS, B'lore.
34. Mr. M.E. Shivalingaiah, CAO, Dir of H&FWS, Bangalore.
35. Dr. P.K. Srinivas, District Malaria Officer, Mysore.
36. Dr. G.B. Desai, Director, State Institute of Health & Family Welfare, Bangalore.
37. Dr. C.S. SiddeGowda, Additional Director (PHC), Dir of H&FWS, Bangalore.
38. Dr. Thimmaiah, Additional Director (AIDS), Dir of H&FWS, Bangalore.
39. Dr. A.S. Thambakad, Joint Director (GMS), Dir of H&FWS, Bangalore.
40. Dr. N.D. Mukunda, Joint Director (IPP), Dir of H&FWS, Bangalore.
41. Dr. Chandrashekar Naik, Joint Director (AIDS), Dir of H&FWS, Bangalore.
42. Dr. Rama Jayaram, Joint Director (H&P), Dir of H&FWS, Bangalore.
43. Dr. Dhanya Kumar, Deputy Director, KHSDP
44. Dr. Rajamma. V. S, Deputy Director, KHSDP.
45. Prof C. V. Nagaraj, Officer on Special Duty, SPC, KHSDP.
46. Dr. Vishwaradya, Deputy director (Equipment), KHSDP.
B. Indian Systems of Medicine and Homoeopathy
47. Dr. S M Angadi, Director of Indian Systems of Medicne,
48. Dr. Malini, Principal, Government Ayurvedic College,
49. Dr. Prakash, Principal, Government Homeopathic Medical College
50. Mr. B. Guru Swamy, Director, ISM&H, Bangalore.
51. Dr. Sangamesh Kalahal, Medical Officer, Govt. Ayurvedic Dispensary, Kinnal, Koppal
District.
52. Dr.G.B. Patil, Principal, DGM Ayurvedic Medical College, Gadag.
53. Dr. Mohammad Rafi H. Hakeem, Physician, GR-II, G.A.D., Chitiwadgi, Bagalkot District.
54. Dr.K.C. Ballal, Member, K.A.G.P. Board, Bangalore.
C. Drugs Control Department
55. Dr. Ananada Rajashekar, Drugs Controller
56. Mr. Prabha Chandra, Deputy Drugs Controller
57. The Chief Pharmacist, Government Medical Stores
58. Dr. K.P. Damodar, Chief Supervisor, Govt. Medical Stores, Bangalore
III. Bangalore Mahanagara Palike
1. Dr. Siddegowda, Health Offcier, Bangalore Mahangara Palike
2. Dr. M. Jayachandra Rao, Project Director, IPP 8
3. Dr. Mala Ramachandran, Programme Officer (Health and Administration), IPP8
IV. Professional Bodies
1. Dr. Chikkananjappa, Karnataka Medical Council
2. Dr. K B Naggor, Dr. Hanumegowda, Karnataka Council for Indian Systems of Medicine and
Homeopathy
3. Smt. Sunitha Srinivas, Deputy Director, Drug Information Centre, Pharmacy Council
4. Dr.V. Brahmacharya, President, Homeopathic Board
5. Representative, Karnataka Dental Council
6. Dr. Sheela Bhanumathy, Dr V C Shanmuganandan, Indian Medical Association
7. Dr. Mallikarjunaiah, Dr. Shantaraj, Dr. Hanumanthrayappa, Karnataka Government Medical
Officers Association
8. Dr. Shivananda, Dr. R Chandrashekara, Dr. Narasimhaswamy K R, Karnataka Government
Medical and Dental Teachers Association
9. Dr. C. Muralidhar, President, Ayurvedic Physicians Association
10. Dr. K.C. Ballal, Dr. C. Muralidhar, Dr. K.V. Joshi, Dr. L.K. Rauannavar, Dr. J. Aprameya
raman and Dr. Padmanabha, Integrated Medicine Practitioners Association
11. Dr. Nityananda, Dr. Srinivas D R, Junior Doctors Association
12. Dr. Malikarjuna R, Dr. Veerabhadraiah, Dr. Sanath Kumar, Dr. Ravishankar, Karnataka
Government Contract Doctors Association
V. Voluntary Organasations
1. Dr. Jayashree Ramakrishna, AIDS Forum Karnataka
2. Smt. Neerajakshi T, Voluntary Health Association of Karnataka
3. R. Balasubrammaniam, Swami Vivekananda Youth Movement
4. G. Mallappa, Folk Practioner
5. Dr. Shobha Yohan, Christian Medical Association of India, Karnataka
6. Sr. Elise Mary, Catholic Health Association of India, Karnataka
7. Dr. Ravi Narayan, Community Health Cell
8. Sri Jayakumar Anagol, SOSVA
9. Sri Auxin Thomas, FEVORD (K)
10. Dr. Pruthvish, Action Aid, Bangalore.
11. Dr. Chapel Khasnabis, Mobility India, Bangalore.
12. Smt. Indumati Rao, CBR Network, Bangalore.
13. Dr. Sangamitra Iyengar, Project Officer, SAMRAKSHA, Bangalore.
14. Mr. Ashok Rao, Freedom Foundation, Bangalore.
15. Mr. Elango, KNP+, Bangalore
16. Dr. Glory Alexander, Asha Foundation, Bangalore
17. Dr. James Parayil Joseph, CHC, Bangalore.
18. Mr. Vinay Kulkarn, PRAYAS, Pune
19. Ms. Jayashree Kotvale, NGO Advisor, KSAPS
20. Dr. Sampath K. Krishnan, Policy Fellow, CHC, Bangalore.
21. Dr. Pruthvish. S. Co-ordinator, Disaility Training and Research Unit, Action-Aid, India.
VI. National Institutes and Premier Institutions
1. Mrs. Dr. Jogota The Director National Tuberculosis Institute
2. Dr. Mohan Issac, Prof & Head, Dept. of Psychiatry
3. Dr. Shastry, Neuro Surgeon & HOD of Neuro Surgery, NIMHANS
4. Dr. Nagaraj C, Regional Office of Health and Family Welfare
5. Dr. H. R. Raj Mohan, In-Charge Director, Regional Occupational Health Centre.
6. Dr Raju and Dr Rayappa, Institute of Social and Economic Change,
7. Dr. Shymal Biswas, I/c, Director National Institute of Communicable Disease
8. Dr. Prasanna, The Office-in-Charge, National Institute of Virology
9. Dr. Ghosh, The Regional Director, Malaria Research Centre
10. Dr. Nanda Kumar, Project Officer, National Cancer Registration Prg
VII. Outside the health Sector
1. Sri M Jothi, Director, Department of Agriculture
2. Sri Krishna Kumar IAS, Principal Secretary, Urban Development
3. Sri G V K Rao IAS, Food and Civil Supplies
4. Smt Meera Saxena IAS, Women and Child Development
5. Smt Anita Kaul, IAS, Education
6. Sri Ganjigatti, Member secretary, Karnataka State Pollution Control Board
7. Dr. Sharma, Regional Director, Central Pollution Control Board
8. Sri Krishna Murthy. H.V, Song and Drama Division, Government of India
9. The Director, Information & the, Secretary Information, Bangalore.
10. The Chairman, Tax Reforms Commission, Bangalore.
11. The Secretary and Members of Tax Reforms Commission, Bangalore.
12. Sr. Sreenivasamurthy, Secretary, Rural Development & Panchayati Raj, Govt. of Karnataka,
Bangalore.
13. Sri. R.K. Raju, CEO, B'lore Rural Zill Panchayat.
14. Sri. Kariyamma, MLA and Chairman, Scheduled Castes and Scheduled Tribes Welfare
Committees.
VIII. Interaction with Press
1. Sri Chennakrishna, Reporter, Samyukta Karnataka
2. Sri. G.D. Yatish Kumar, Reporter, Prajavani
3. Sri. P.K. Lenis, Janavahini
4. Sri. B. S. Satish Kumar, Deccan Herald
5. Reporter, Asian Age
6. Smt. Padmini, The Hindu
7. Sri B N Chandrakumar, Programme Officer, Doordarshan Kendra
IX. Health Organisations
1. Sri G.S. Bhatt, Family Planning Association of India, Mysore
2. Mr. Raj Mathur, Family Planning Association of India, Bangalore
3. Mrs. Subhadra Venkatappa, Family Planning Association of India, Bangalore
4. Mr. Muniswamy, Family Planning Association of India-Bangalore
X. Citizens / Consumer Groups
1. Mr. Leo Saldhana, Environment Support Group
2. Ms Vijaya, CIVIC
3. Mrs Anjana Iyer, Mr. Govardhan and Mrs Sheela Prema Kumar, SWABHIMANA.
4. Mr. Surya Shetty, Mangalore Parisarasaktha Okkuta
5. Y.G. Muralidhar, Consumer Rights Education and Awareness Trust.
6. Dr. Sulata Shenoy, Jayanagar, Bangalore.
XI. Women’s Group
1. Ms Ruth Manorama and Mrs Shan Taj, National Alliance of Women, Women’s Voice
2. Mrs. Prema David, Ms Padma Priya, Vimochana
3. Mr. Vimalanathan, NESA
4. Mrs. Anitha Reddy, AVAS
XII. Peoples Organisations
1. Sri Sridhar and Sri Basavaraju, Bharatiya Gnana Vignana Samiti
XIII. Corporate Bodies
1. Mr. Tallam Venkatesh, Federation of Karnataka Chamber of Commerce and Industry
2. Dr. Subbaswami and Sri Jatish N. Sheth, Karnataka Drugs Pharmaceuticals Manufactures
Association
3. Ms. Manjusha Nair, A.F. Ferguson & Co.
4. Mr. K.M. Prabhu, A.F. Ferguson & Co.
5. Mr. Ramaditya, A.F. Ferguson & Co.
6. Dr. Satish, WOCKHARDT Hospital, Bangalore.
7. Dr. Kishore Murthy, Advisory Health, A.F. Ferguson & Co.
XIV. Voluntary, Private and Corporate Hospitals
1. Dr. Pankaj Mehta, Manipal Hospital, Bangalore
2. Dr. K.S. Shekar and Dr. Shiva Prasad, Bangalore Hospital, Bangalore
3. Dr. Devi Shetty and team, Manipal Heart Foundation, Bangalore
4. Dr. Diwakar and Dr. Hema Diwakar, Diwakar’s Hospital, Bangalore
5. Sri P.K. Davison, WOCKHARDT Hospital, Bangalore
6. Dr. P R Desai, Dr. Chikkananjappa, Association of Private Hospitals and Nursing Homes,
Karnataka,
7. Dr. Nandini Mundkur and Sri S Akbar Basha, Bangalore Childrens Hospital and Research
Centre
8. Dr. B.S. Srinath, Bangalore Institute of Oncology.
9. Dr. Anil Thomas, Bharath Charitable Cancer Hospital, Mysore.
XV. Teaching Hospitals
1. Dr. M.R. Sandhya Belwadi, M S Ramaiah Medical Teaching Hospital, Bangalore
2. Dr. Chikka Moga, Victoria Hospital
3. Dr. Chandramma, Bowring and Lady Curzon Hospital
4. Dr. Anil Hegde, St. John’s Medical College, Bangalore.
5. Dr. T. Murali, Head, Dept. of Rehabilitation, NIMHANS, Bangalore.
6. Dr. Shylaja Nikam, Director, All India Institute of Speech & Hearing, Manasa Gangothri,
Mysore.
7. Dr. N. Janaki Ramaiah, Prof. of Psychiatry, NIMHANS.
8. Dr. Vivek Benegal, Associate Prof. of Psychiatry, NIMHANS.
9. Dr. Prathima Murthy, Associate Professor, Dept. of Psychiatry, NIMHANS.
10. Dr. Sreenivas Murthy, Associate Prof. Dept. of Psychiatry, NIMHANS.
11. Dr. P.S. Prabhakaran, Director, KIDWAI Memorial Institute of Oncology, Bangalore.
12. Prof G. Kilara, Curie Institute of Oncology, St.John's Medical College Hospital, Campus,
Bangalore.
13. Dr. V. Ravi, HOD, Department of Virology, NIMHANS
14. Dr. Jayashree Ramakrishna, Department of Health Education, NIMHANS.
15. Dr. Reynold G. Washington, Associate Professor, Department of Community Health, St.
John's Medical College.
16. Dr. M.K. Sudarshan, HOD of Community Medicine, KIMS, Bangalore.
17. Dr. Dara Amar, Prof. & HOD of Community Health, St. John's Medical College Hospital,
Campus, Bangalore.
18. Dr. Nagesh, Principal, R.V. Dental College, Bangalore.
19. Sr. Annie Marie, Principal, College of Nursing, St. Martha's Hospital, Bangalore.
20. Dr. Padma Rao, Kasturba Medical College, Manipal.
XVI. Autonomous Hospitals
1. Dr. Ballal, Sanjay Gandhi Accident Relief and Rehabilation Center
2. Dr. Benakappa, Indira Gandhi Institute of Child Health
XVII. World Bank
1. Mr. Chris Lovelace, Director, Health Nutrition Population, Human Development Network,
2. Ms. Hnin Hnin Pyne, World Bank.
3. Dr. David Peters, Member, World Bank.
XVIII. Invited Guests / Experts
4.
Dr. Phadke, St. John’s Medical College Hospital, FORTE
5.
Dr. Philip Thomas, St. John’s Medical College Hospital, FORTE
6.
Dr. Venkatesh, Bangalore Kidney Foundation.
7.
Sri. D.K. Bhatt, Consultant Health System Management
8.
Sri. P.V. Bhat, Principal System Analyst; Smt. K. Padmavathi, Secretary Systems Analyst,
National Informatics Centre
9.
Sri Manjot Deol, Manager, Sri S Mani, Business Manager; Sri Sanjeev, Vice President,
Wipro GE Medical System
10. Justice D.M. Chandrashekar
11. Dr. Hema Reddy, Formerly Director of Health Services
12. Dr. Vinod Vyasulu and Dr. Indira, Centre for Budget and Policy Studies
13. Dr. Sathyanarayana, Centre for Symbiosis of Technology, Environment and Management
14. Dr. Darshan Shankar, Foundation for Revitalisation of Local Health Tradition
15. Dr. R.M. Varma, Consultant Neuro Surgeon
16. Dr. R L Kapoor, Consultant Psychologist
17. Sri P G R Sindhia, MLA and Formerly Health Minister of Karnataka
18. Sri Suryanarayana Rao, Trade Union Leader, CPI (M)
19. Sri Nagaraj G N, Secretariat member, CPI (M),
20. Dr. N.H. Antia, The Foundation for Research in Community Health, Pune
21. Dr. Rajaratnam Abel, RUSHA, Christian Medical College and Hospital, Tamil Nadu
22. Dr. Muraleedharan, Indian Institute of Technology, Chennai
23. Dr. Sridhar, SEWA, Wardha
24. Dr. Almas Ali, Project Officer, South Asia Poverty Alleviation Programme, UNDP
25. Sri Srinivasan, Formerly Health Secretary, Government of India
26. Dr. S.K. Chaturvedi and Sri Sudha Murali, UNICEF.
27. Dr. Alok Mukyopadhay, Voluntary Health Association of India.
28. Mr. V. Shantappa, Director, CESCON
29. Dr. K.N.B. Raghavesh, CESCON
30. Mr. Dharmapuri Vidyasagar, M.D. Director of Neonatology, Prof. of Pediatrics, University
of Illinois, Chicago.
31. Mrs. Archana Dutta, Deputy Director, Directorate of Field Publicity, Regional Office
(Karnataka).
32. Dr. B.C. Rao, Family Physician, Bangalore.
33. Ms. Sunitha Srinivas, KSPC, Bangalore.
34. Sri Chaluvarayaswamy N, Member, Karnataka Legislative Assembly, Nagamangala.
35. Sri Chikkamada Nayaka, Member, Karnataka Legislative Assembly, Bannur.
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49.
50.
51.
Sri. Neelakantha Rao Deshmukh Garmpathi, President, Zilla Panchayat, Gulbarga.
Dr. K.S. Mani, Epileptologist, Bangalore.
Dr. Munichoodappa.C, Consultant Diabetologist, Bangalore.
Dr. Parameshwara V, Consultant Physician and Cardiologist, Bangalore.
Dr. Hegde B.M. Vice-chancellor, Manipal Academy of Higher Education.
Dr. Basappa.K, Professor of Preventive and Social Medicine and Former Dean.
Dr. Shivaram C. Emeritus Professor in Community Medicine, M.S. Ramaiah Medical
College.
Sri. S.V. Rama Rao, Consultant in Health, Bangalore.
Dr. Ramakrishna V, Health Education Consultant, IUPHE
Prof. Joga Rao S.V, Director, TILEM, National Law School of India University.
Mrs. Sudha Tewari, Managing Director, Parivar Seva Sanstha, New Delhi.
Dr.N. Shantaram, President, Karnataka Association of Community Health.
Ms. Amrita, Mahila Samakhya, Karnataka.
Ms. Anita Gurumurthy, Indian Institute of Management, Bangalore.
Mr. Sabu George, CHC, Bangalore.
Dr. Elizabeth Vallikad, St. John's Medical College.
ANNEXURE - 6
ANNEXURE - 6 a
LIST OF SUGGESTIONS BY POST - KANNADA
Name of the Individual
Organisation
1. Mr. Abdul Mujeeb S
2. Administrative Medical General Hospital, Soraba
Officer
3. Mr. Anjanappa
4. Anonymous
5. Anonymous
6. Mr. Asthulekhan E Lodi
7. Dr. B. Ashoka Reddy
Karnataka State Government Doctor’s
Association ®
8. Mr. N.Y. Badager
9. Mr. Bahubali
10. Mr. Banada S S
11. Mr. Basava Raju
12. Mr. Bhat G .S
FPAI
13. Dr. Chandrappa Gowda
14. Ms. Chandrika S Y
15. Mr. Dakappa Muddhol
16. District Health and
Family Welfare Officer
17. Deputy Medical Director District Cholera Control Team
18. Dr. Dharwad S C
District Malaria Office
19. Mr. Eerappa M Hulihalli
20. Mr. Guruswamy
21. Medical Officer
Mobile Doctor’s Unit
22. Mr. Heggade V S
Taluka Industrial Centre
23. Hony Secretary
Teachers Association, Government
Polytechnic
24. Mr. Kaashivappa A
Thotagi
25. Karyadarshi
Taluk Soliga Abhivruddi Sangha (Regd.)
26. Mr. Keshvappa M G
27. Mr. Krishnamurthy B R
28. Mr. M.D. Krishnayya
Karnataka State Yaadhava Vani Sangha
29. Dr. Kulakarni S S
30. Kumari Shwetha M
Revalkar
31. Mr. Laksmana Rao T K
32. Dr. M B Rudrappa
Health and Family Welfare Training
Place
Tumkur
Shimoga
Bangalore
Bangalore
Bangalore
Gadag
Chitradurga
Belgaum
Belgaum
Bidar
Tumkur
Mysore
Shivamogga
Davanagere
Belagaum
Chamarajanagar
Gulbarga
Dharwad
Haveri
Bellary
Kollegal
Bidar
Bidar
Belgaum
Chamarajanagar
Shivamogga
Bangalore
Bangalore
Belgaum
Davanagere
Bangalore
Hubli
Centre
33. Mr.Mahadeva Shetty K
34. Dr. S.B. Maheshwara
35. Dr. Muralidhar
36. Mr. Nagappa R Tiger
37. Mr. Nagaraja. A
38. Mr. M.S. Nagaraj
39. Mr. Nanjundaiah
40. Mr. Nataraj
Mysore
Dudee Organisation for Rural
Reconstruction (Regd.)
Karnataka State Government Indian
Health and Homoeopathy Contract
Doctor’s Association (Regd.,)
Karnatak Dalita Sangharsha Samiti
Jai Bheem Youth Union (Regd)
Karnataka State Pharmacist’s (Allopathy)
Association
FEDINA - VIKASA
Sri Guruboodhi Swamigala Vidhyathi
Nilaya
41. Mr. Nirvani Gowda
42. Mr. Patil N S and 40
Chalakulu, Mattanuru, Malkarna and
others
Shosa
43. Smt. Philomena Joy
Rural Literacy and Health Programme
44. Mr. Prabhakar N P
45. Mr. Prabhakar Rao and 6
others
46. Dr. Raju
47. Mr. Ramachandra I.
Pavar
48. Dr. Ramachandra K.
49. Dr. S B Maheshwara.
Dudee Organisation for Rural
Reconstruction
50. Mr. Sanga N R
51. Dr. Sangamesh Kalahal Karnataka State Govt. Indian Systems’
Medical Officers’ Association
52. Mr. Sattar S.A and 6
others
53. Secretary
Taluk Soliga Abhivridhha Sangha
54. Mr. Seetharamaiah and Government Nurses Association,
Dasegowda
Karnataka
55. Ms. Shashikala
56. Mr. Shabbir Ahmad
Athaar
57. Mr. Shena Shetty
Aadhivaasi shikshana kendra
58. Sidharameshwar Guruji Revansidheshwar Prasanna Education
Society
59. Mr. Sidheshwaran G.N. Chitradurga District Health Supervisor
Association
60. Mr. Srinath. N. Navale
Gundlupet
Bellary
Gulbarga
Bangalore
Bangalore
Mysore
Hunusur
Hassan
Belgaum
Mysore
Bidar
Bidar
Shivamogga
Belagaum
Mandya
Gundlupet
Bagalkot
Bangalore
Bhalki
Kollegal
Bangalore
Belagaum
Gokak
Bantwal
Bidar
Chitradurga
Belgaum
61. Dr. P. S. Upaadhyaaya
Taluka Medical Office
62. Mr.H.Venkataramanayya Shri Venkateshwara Kendra Trust ®
63. Ms. Sheena Shetty
Adivasi Sikshana Kendra
64. Mr. Shettar M S
65. Mr. Siddappa
Haralenneyavar
66. Mr. Siddaramappa and
Ajjampura, Singtagere, Sakhrayapatna
20 others
67. Dr. P.K. Srinivas
District Malaria Officer
68. Mr. Srinivas Murthy
69. Mr. Subramanya R
70. Taluka Health Officer,
General Hospital
71. Taluka Health Officer
72. The President
Ramamurthy Nagar Welfare Association
73. Mr. Thimmiah H D
74. Mr. ThyaraMallesh S M
75. Mr. Venkatesh K R
K R Pete General Hospital
76. Mr. Venkatesh R
77. Mr. Veerabhadrappa H
78. Ms. Vijayalakshmi Yella
79. Dr. Yamanur Saheb B P Karnataka Rajya Nadaf / Pingara Sangha
80. Mr. G.R. Yogendra
Nayak
81. Taluka Health Officer
82. Dr. R Venkatesh
83. Smt Vatsala
C/o T S Sridhar
84. Dr. M Chandrashekar
Ex Chief Judge
85. Dr. Dharmaraya Ingle
Medico legal Expert
86. Dr. Hallera .C.M
Taluk Health Officer
87. Jeevajala Kendra
Nagavalli
88. Dr. Ravikant .S
89. Dr. K. Thippayya
Retd. District Health Officer
90. D. R. Chikkoppa
Health Guide, Surebaan
91. Sri. Mohan .K. Shetty
MLA
92. Dr.V. R. Krishnamurthy Medical Officer, CHC
93. Mr. Satya
94. Mr. A. P. Chandrashekar
95. G.A.M.C.M. Teachers
Association
96. Taluk Health Officer
97. Administrative Medical
Officer
98. Dr.A. S. Upadhyaya
99. Dr. M .R. Gayathri
Jagriti Vedike
Shivamogga
Bangalore
Bantwala
Gadag
Kunsi
Chikkamagalur
Mysore
Bangalore
Bangalore
Chintamani
Yadhagiri
Bangalore
Chitradurga
Chitradurga
Mandya
Bangalore
Bhadravathy
Chitaguppa
Bellary
Shimoga
Udipi
T Narsipura
Yelahanka
Mangalore
Bijapur
Byadagi, Haveri
Chamarajnagar
Hubli
Chitradurga
Belgaum
Kumta
Gandasi,
Hassan
Mysore
Mysore
Mysore
Crawford Hospital
Kundapur
Sakaleshpur
Taluk Health Officer
Medical Officer, PHC
Theerthahalli
Arasurali
100. Medical Officer
PHC, Konandur
Theerthahalli
ANNEXURE – 6 b
LIST OF SUGGESTIONS BY POST – ENGLISH
Name of the
Individual
1. Anonymous
2. Justice Avadhani K K
3. Mrs. Banerjee
4. Dr. N. D. Bendigeri
5. Mr. E. Basavaraju
6. Dr. Chandrashekar N
M.
7. DHO
8. Mr. Farooqui M A H
9. Mr. Gangamalliah
10. Mr. Giri A T S
11. Dr. Govindaraju
12. Mr. Guttal M C
13. Dr. Hanumanthappa T.
14. Medical Officer
15. The Head Master
Organisation
Associate Professor, K.I.M.S.
Bharath Gyan Vigyan Samithi
Homeopathic Forum
Health & Family Welfare Dept.
Bangalore City District Youth Congress (I)
K R Hospital
Directorate of Health and F W Services
Primary Health Centre
Manikappa Bandeppa Khashapura Higher
Primary and High School
16. Dr.Jayanth G Paraki.
17. Dr.K Taranath Shetty NIMHANS
18. Mr. Krishna Murthy G
19. Kumari Sandhya
20. Mr. G. Krishna Swamy President, Garuda Seva Samaj
21. Dr. M H Baig
District Hospital
22. Dr. Mahendranath K M Indian Rheumatism Association, Karnataka
State
23. Dr. Maliyappa G H
Shoba Nursing Home
24. Dr. Marekannavar S N
25. Mr. Murthy S N S
HAL II Stage Civic Amenities and Cultural
Association
26. Mr. Narayana H S
27. Mrs Nassema Banu
Government Urdu Middle and Higher
Primary School
28. Dr. Prakash C Rao
Drugs Action Forum, Karnataka
29. Mr. Rangaswamy K.L.
30. Mrs. Rajanna N
Formerly Member, Karnataka Legislative
Assembly
31. Mrs. Rajarama K E T Population Research Centre
32. Mr. Rajesh
Place
Bangalore
Uttar Kannada
Bangalore
Hubli
Bangalore
Bangalore
Bangalore
Belgaum
Bangalore
Bangalore
Mysore
Bangalore
Chinakurali
Shimoga
Bidar
Bangalore
Bangalore
Bangalore
Bellary
Bidar
Bangalore
Arsikere
Mysore
Bangalore
Bangalore
Tumkur
Bangalore
Bangalore
Bangalore
Dharwad
Humnabad
33. Dr. S.V. Rama Rao
Prof. of Community Medicine
34. Mr. Ramesh Kumar
Member, Karnataka Legislative Assembly
Pande
35. Dr.Ranganath T
36. Mr. Reddy C R
37. Mr. Roy David V S
Coorg Organisation for Rural Development
38. Mr. Sagar K S
Citizens Forum
39. Ms. Sangeeta C M
40. Dr.Sanjeevi Shayana
41. Mr. Shakeel Ahmed
42. Mr.Sharshchandra H D
43. Dr. Shivarama Shastry PHC Savalanga
44. Mr. Shivasharanappa Akkamahadevi Womens College
Chitta
45. Mr. Srinath P L
46. Mr. Srinivasa Rao
47. Students
Diploma Physiotherapist Youth Forum
48. Dr.Sumanth Goel
49. Dr.UdayaKumar
50. Mr. Varadaraj B K
51. Dr. U.S. Vanahalli
President, Dr. Hahnemann’s Rural Homeo
Medical Practitioner’s Associtation ®
52. Mr. Venkatesh
53. Mr. Vishwanath
Ashturey and others
54. Dr. R.S. Wali
Assoc. Prof., B.L.D.E.A’s Medical College
55. Mr. Yogesh G
56. Mr. Ziauudin Alvi
57. Dr. Jagadish
CEO, Consulting Engineering Services
India Ltd.
58. Dr. Shashikala M
Community Health Specialist, St Martha's
Hospital
59. Dr. M B Rudrappa
Epidemiologist, Health and Family Welfare
Training Centre,
60. Dr. B T Basanthappa
Professor, Government College of Nursing
61. Dy Chief Medical
CHC
Officer
62. Dr. B N Brahmacharya Hony Secy. Prakruti Jeevana Kendra ®
Trust
63. Dr. Ramkrishna B
PG in Community Medicine, MSRMC
Goud,
64. Dr. P. K. Srinivas
District Malaria Officer
65. Mrs. Laila Ullapally
Advocate, Citizen's Action group
66. Dr N. S. Deodhar
Consultant in Health Sciences
67. Mr. B. Raghava Shetty
Bangalore
Bidar
Mysore
Bidar
Kodagu
Bangalore
Humnabad
Raichur
Tumkur
Bangalore
Dhunnali
Bidar
Mysore
Mysore
Bangalore
Bagalkot
Bangalore
Bangalore
Mahalingpur
Chamarajanagar
Bidar
Bijapur
Bangalore
Bidar
Hubli
Bangalore
Mulki
Bangalore
Bangalore
Mysore
Bangalore
Pune
Saligrama
68. Dr. P. N. Halagi
69. Dr. B. C. Rao
70. Dr. Philip. G. Thomas
71. Dr. Mahadanthappa
72. Prof. Tara Gopaldas
73. Dr. T. L. Devaraj
74. Dr. N. Santharam
75. Dr. Vasant Kumar
76. Dr. K. S. Mani
77. Dr. H. V.
Parashwanath
78. Dr. M. K. Mani
79. Dr. M. R. Raju
80. Dr. Rajesh Surgihalli
81. Mr. Harshavardhan
82. Mrs. Parvathi
Subramanian
83. Dr. L. Chandramma
84. Dr. Chakko. K. Jacob
85. Dr. Padma Rao
86. Mr. B. M. Kumara
Swamy
87. Mr. Seshagiri Rao
88. Medical Officer
89. Dr. P. R. Desai
90. Dr. Kavitha Bhatt
91. Dr. C. Shivaram
92. Convener
Director, DHFWS, (Retd)
HOD of Surgery, St. John's Hospital
Chairman, Doctor's in Service Sub
Committee
Director, Tara Consultancy Services
Dy. Dir of Ayurveda (Rtd)
HOD of PSM, Sri Devaraj Urs Medical
College
Prof of OBG, Guntur Medical College
Neurological Clinic
Chief Executive Officer
Nephrologist, Apollo Hospital
Mahatma Gandhi Memorial Medical Trust
Medical Officer, PHC, Ulavi
Bangalore
Bangalore
Bangalore
IMA. Bangalore
Bangalore
Bangalore
Kolar
Guntur
Bangalore
Bangalore
FPAI, Bangalore Branch
Chennai
Bhimavaram
Shimoga
Bijapur
Bangalore
Medical Superintendent, Bowring Hospital
Depatment of Nephrology, CMC
Obstetrician & Gynaecologist
Secretary, FPAI
Bangalore
Vellore
Manipal
Shimoga
Secretary General, FPAI
PHC, Kunavalli
Association of Nursing Homes and Private
Hospitals in Karnataka
Paediatric Endocrinologist, Manipal
Hospital
Chairperson. Health Care Waste
Management Cell
Jayanagar, Citizens Forum
Mumbai
Shimoga
Bangalore
Bangalore
Bangalore
Bangalore
ANNEXURE – 7
THE KARNATAKA PRIVATE HEALTH CARE ESTABLISHMENTS BILL, 2000
A Bill to provide for the Promotion and Monitoring of Private Health Care Establishments in the State
of Karnataka and matters connected therewith or incidental thereto.
Whereas it is expedient in the public interest of quality health care to promote and monitor by law the
running of Private Health Care Establishments in the State by stipulating minimum standards for
quality of service in keeping with principles of medical ethics,
Be it enacted by the Karnataka State Legislature in Fifty first year of the Republic of India, as follows:
1.
Short Title, Commencement and application.
(1)
(2)
(3)
2.
This Act may be called the Karnataka Private Health Care Establishments Act 2000.
It shall come into force on such date as the State Government may, by notification, appoint
and different dates may be appointed for different provisions of the Act.
This Act shall apply to all health care establishments.
Definitions. In this Act, unless the context otherwise requires:(a)
(b)
(c)
(d)
(e)
(f)
(g)
(h)
(i)
‘Accreditation /Registration means accreditation'/ registration granted under section 5;
‘Accreditation / Registration Authority’ means the Authority constituted under section 4;
‘Appellate Authority’ means an authority appointed by the State Government, by
notification, to be the Appellate Authority for the purpose of this Act;
‘Appointed day’ means the date appointed under sub-section (2) of section 1;
‘Bangalore Metropolitan Area’ means the Bangalore Metropolitan area as defined in
Bangalore Development Authority Act, 1976 (Karnataka Act 12 of 1976).
‘Clinical Laboratory’ means an establishment where(i) biological (pathological), bacteriological, radiological, microscopic, chemical or other
tests, examinations or analysis, or
(ii) the preparation of cultures, vaccines, serums or other biological or bacteriological
products in connection with the diagnosis or treatment of diseases, are or is usually
carried out;
‘Department’ means the Department of Health and Family Welfare or the Department of
Indian Systems of Medicine and Homeopathy, Government of Karnataka as the case may
be
‘Health Care Establishment’ means a Hospital or dispensary with beds or without beds, a
Nursing Home, Clinical laboratory, Diagnostic Centre, Maternity Home, Blood Bank,
Radiological Centre, Scanning Centre, Physiotherapy Centre, Clinic, Polyclinic,
Consultation Centre and such other establishments by whatever name called where
investigation, diagnosis and preventive or curative or rehabilitative medical treatment
facilities are provided to the public and includes Voluntary and Private Establishments.
‘Medical Practitioner’ means a Medical practitioner registered under the Homeopathic
practitioner Act, 1961 (Karnataka Act 35 of 1961), Ayurvedic, Naturopathy, Sidda, Unani
and Yoga practitioners Registration and Medical practitioners Miscellaneous Provisions
Act, 1961 (Karnataka Act 9 of 1962), Medical Registration Act, 1961 (Karnataka Act 34 of
1961), Indian Medicine Central Council Act, 1970 (Central Act 48 of 1970), Homeopathy
Central Council Act, 1978 (Central Act 59 of 1973) and Medical Council Act, 1956
(Central Act 102 of 1956) to practice the system of medicine which he has studied,
-1-
qualified and registered and includes a Dentist registered under the Dentists Act, 1948
(Central Act 16 of 1948).
(j) ‘Local Inspection Committee’ means the committee appointed under section 8;
(k) ‘Manager’ in relation to a Health Care establishment means the person, by whatever name
or designation called, who is in charge of, or is entrusted with, the management or running
of the Health Care Establishment;
(l) ‘Maternity home’ means an establishment where women are usually received or
accommodated or both for the purpose of confinement and antenatal or post-natal care in
connection with child-birth and includes an establishment where women are received or
accommodated for the purpose of sterilization or medical termination of pregnancy;
(m) ‘Medical treatment’ means systematic diagnosis and treatment for prevention or cure of
any disease, or to improve the condition of health of any person through allopathic or any
other recognised systems of medicine such as Ayurveda, Unani, Homeopathy, Yoga,
Naturopathy and Siddha; and includes Acupuncture and Acupressure treatments.
(n) ‘Nursing Home’ means an establishment where persons suffering from illness, injury or
infirmity (whether of body or mind) are usually received or accommodated or both for the
purpose of treatment of diseases or infirmity or for improvement of health or for the
purposes of relaxation or for any other purpose whatsoever, whether or not analogous to
the purposes herein before mentioned in this clause;
(o) ‘Physiotherapy establishment’ includes an establishment where massaging, hydrotherapy, remedial gymnastics or similar work is usually carried on, for the purpose of
treatment of diseases or infirmity or for improvement of health or for the purposes of
relaxation or for any other purpose whatsoever, whether or not analogous to the purposes
herein before mentioned in this clause;
3.
All Private Health Care Establishments to be Registered:
On and after the appointed day, no private health care establishment shall be established, run or
maintained in the State except under and in accordance with the terms and conditions of
Registration granted under this Act:
Provided that a private health care establishment in existence immediately prior to the appointed
day shall apply for such registration within ninety days from the appointed day and pending
orders thereon may continue to run or maintain till the disposal of the application.
4.
Registration authority for the State of Karnataka consisting of 12 Members as under:
(1) Commissioner for Health and Family Welfare, Karnataka
(2) Director of Health Services, Karnataka
(3) Director, Indian System of Medicine & Homeopathy
(4) President, Karnataka Medical Council
(5) President, ISM Council
(6) President, Homeopathy Council
(7) President, Indian Medical Association, Karnataka State
(8) President, Association of Nursing Homes and Private Hospitals Karnataka
(9) One General Practitioner (allopathic) – nominated
(10) One representative of private establishments of Ayurveda
(11) & (12) Two representatives nominated by the Nursing Homes to represent different regions
of the State.
-2-
5.
Application for Registration:
(1)
6.
Disposal of applications:
(1)
(2)
(3)
7.
Every person or institution or organisation desiring to establish, run, maintain or continue
to run and maintain a health care establishment shall make an application to the concerned
Registration authority in such form and in such manner along with such fees as may be
prescribed and different fees may be prescribed, for different class or classes of Health
Care Establishment.
On receipt of an application under section 5, the Registration Authority, having regard to
the provisions of section 7 and after such enquiry as may be necessary, by Local Inspection
Committee, either grant Registration subject to such conditions as may be prescribed or
reject the application:
Provided that the Registration Authority shall not reject the application without giving an
opportunity of being heard to the applicant and after recording the reasons for such
rejection. If no communication is received within 90 days of application, the application is
deemed to have been accepted.
Every order passed under sub-section (1) shall be communicated to the applicant forthwith.
Every Registration granted under sub-section (1) shall be valid for a period of five years
and may be renewed once in five years on an application made in such form, in such
manner and on payment of such fees, as may be prescribed.
Factors to be taken into account while disposing of applications under section 6:
In disposing of applications under section 6, the Registration Authority shall have regard to the
following namely:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
8.
that the premises housing the health care institution is located in hygienic surroundings and
otherwise suitable for the purpose for which it is established or sought to be established;
that the health care establishment is adequately staffed with qualified doctors, qualified /
trained para medical personnel;
that the health care establishment has the necessary buildings with adequate space for
performing its various functions, equipments and other infrastructure facilities;
that such institution is in a position to provide such facilities, possess such skilled
manpower and equipment and maintain such standards as may be prescribed;
that the health care establishment conforms to the standards referred to in section 9 and;
that the special provisions have been taken into account in certain categories of health care
establishments such Radiotherapy, Nuclear Medicine Centre and Ultrasound Clinics.
such other factors as may be prescribed.
Local Inspection Committee:
There shall be a Local Inspection Committee for each of the Districts consisting of 6 Members as
under:
1. District Surgeon
2. President or Secretary Indian Medical Association of the District
3. One representative of Private Nursing Homes in the District-nominated
4. Representative of Indian System of Medicine of the District
5. One General Practitioner of the District, to be nominated.
6. One senior nurse, to be nominated
-3-
Local Inspection Committee for Bangalore Metropolitan Area consisting of –
9.
1.
2.
3.
4.
5.
6.
7.
Health Officer B.C.C.
Representative of Karnataka Medical Council
Secretary, Indian Medical Association, Karnataka.
President of Association of Nursing Homes and Private Hospitals, Bangalore
Deputy Director, Dept. of Indian System of Medicine & Homeopathy
President, Indian Association of General Practitioners.
One senior Nurse, to be nominated.
(1)
The Local Inspection Committee, either with prior intimation or on receiving a
complaint, may at reasonable time, inspect, a Health Care Establishment to satisfy itself
that the provisions of this Act or the rules made there under and the conditions of
Registration are being duly observed. The Manager of the Health Care establishment
shall be responsible to provide all reasonable facilities for such inspection.
(2)
If any defects or deficiencies are noticed during inspection, the Local Inspection
Committee shall report to the Registration Authority which may direct the Manager of
the Health Care Establishment to remedy the same within such reasonable time as may be
specified in the order. Thereupon the Manager shall comply with every such direction
and report the compliance to the Registration Authority within the time so specified.
Standards:
(1)
(2)
10.
Fee chargeable to be notified:
(1)
(2)
11.
Every Health Care Establishment shall conform to the standards laid down by or under this
Act or any other laws, regarding the staff and their qualifications, operation theatre,
buildings, space requirements, equipment, facilities to be provided to the patients and their
attendants, maintenance and the like matters.
The standards have to be set separately for different groups (urban / rural, size, other
categories), as determined by the Registration Authority. Expert Committees will be
constituted by the Registration Authority for setting standards for each group. The
composition, terms and conditions, powers and responsibilities, etc, will be laid down by
the Rules.
Every Health Care Establishment shall for the information of the patients and general
public make available the structure of fees charged by it for different medical treatment and
other services through Brochures / Booklets.
No Health Care Establishment shall charge or collect from the patient or his relatives, any
amount in excess of the fee printed in the brochure / booklet, and without issuing proper
receipt for every amount charged or collected.
Obligations of Health Care Establishments:
Every Health Care Establishment shall:
(a) Administer necessary first aid and take other life saving or stabilising emergency measures
in all medico-legal or potentially medico-legal cases such as victims of road accidents,
accidental or induced burns or poisoning or criminal assaults and the like which present
themselves at the establishment;
-4-
(b)
(c)
(d)
12.
Actively participate in the implementation of all national and State health programmes in
such manner as the State Government may specify from time to time; and furnish
periodical reports thereon to the concerned authorities;
Maintain proper medical records in such form and in such manner as may be prescribed;
Perform statutory duties in respect of communicable diseases to prevent the spread of the
disease to other persons and report the same to the concerned public health authorities
immediately.
Suspension or cancellation of registration:
The Registration authority may on the basis of a complaint and if a Prima Facie case exists about
the breach of any of the provisions of this Act or the rules made there under, or conditions of
Registration issue notice to any health care establishment to show cause why its registration
should not be suspended for the reasons mentioned therein.
13.
Appeal:
(1)
(2)
(3)
Any health care establishment whose application for Registration is rejected or deemed to
have been rejected or whose Registration has been suspended or cancelled or is otherwise
aggrieved by any original order made under this Act, may prefer an appeal to the Appellate
authority in such manner and on payment of such fees as may be prescribed by the
appellate authority (authority to be specified in the Rules).
Every such appeal shall be preferred within thirty days from the date of receipt of the order
appealed against;
The Appellate Authority may, after holding an enquiry pass such order as it deems fit as far
as possible within a period of sixty days from the date of filing of the appeal.
14.
Penalties:
First Offence – Warning
Second Offence – Fine not exceeding Rs.5000/Third Offence – Suspension of Registration.
15.
Power of entry, Inspection, etc:
(1)
Subject to such rules as may be prescribed, the State Government may, specially authorise
any officer of the State Government (hereinafter referred to as authorised officer) to(a) enter, at all reasonable times, and with such assistants if any, being persons in the
service of the State Government as he thinks fit, any place which is, or which he has
reason to believe is being used as a health care establishment.
(b) Make such examination of the premises of a health care establishment and of any
register, record, equipment, article or document found therein and seize any
document or record as he may deem necessary for the purpose of examination,
analysis or investigation and retain them as long as he thinks it necessary to do so for
such purpose, provided the authorised officer after seizing documents and records
shall intimate the reason for such seizure to the Manager of the Health Care
Establishment as early as is practicable.
(c) Make such enquiry and take on the spot or otherwise the statement of any person as
he deems necessary:
(d) Exercise such other powers as may be necessary; for carrying out the purposes of this
Act.
Provided that no person shall be required under this sub-section to answer any
question or give any evidence tending to incriminate himself;
-5-
(2)
16.
Provided further that, no residential accommodation (not being a private health care
establishment–cum-residence) shall be entered into and searched by the authorised
officer except on the authority of a search warrant issued by a Magistrate having
jurisdiction over the area and all searches and seizures under this Section shall so far
as may be, made in accordance with the provisions of the Code of Criminal
Procedure, 1973 (Central Act 2 of 1974).
The authorised officer shall make a report to the Registration Authority regarding the result
of the inspection, searches and seizure made by him under sub-section (1), and the
Registration Authority shall take necessary action on the said report under this Act.
Offences by a Company:
(1)
(2)
Where an offence against any of the provisions of this Act or any rule or order made
hereunder has been committed by a company, every person who at the time the offence was
committed, was incharge of and was responsible, to the Company, for the conduct of
business of the company, as well as the company shall be deemed to be guilty of the
offence and shall be liable to be proceeded against and punished accordingly.
Notwithstanding anything contained in sub-section (1) where any such offence has been
committed by a company, and it is proved that the offence has been committed with the
consent or connivance of or is attributable to, any negligence on the part of the Director,
Manager, Secretary or other officer of the company, such Director, Manager, Secretary or
other officer of the company shall be deemed to be guilty of that offence and shall be liable
to be prosecuted and punished accordingly.
Explanation: For the purpose of this section:(a)
(b)
“a company” means any body corporate and includes a trust, firm, a society or other
association of individuals:
“the director” in relation to:
(i) A firm means a partner in the firm;
(ii) A society, a trust or other association of individuals means the person
entrusted under the rules of the society, trust or other association, with
management of the affairs of the society, trust or other association, as the case
may be.
17.
Cognizance of offences:
No Court shall take cognizance of any offence punishable under this Act, except upon a
complaint in writing made by the Chairman of the Local Inspection Committee with the prior
approval of the Registration Authority.
18.
Powers of State Government to give directions to the Registration Authorities: The State
Government may give such directions to the Registration Authorities as are in its opinion
necessary or expedient for carrying out the purposes of this Act. Government shall record the
reasons necessitating issuance of the said directions and it shall be the duty of the Registration
Authority to comply with such directions.
19.
Protection of action taken in good faith:- No suit, prosecution or other legal proceeding shall
lie against the State Government or any officer, authority or person in respect of anything which
is in good-faith done or intended to be done in pursuance of the provisions of this Act, or any
rule or order made there under.
-6-
20.
Removal of difficulties:- If any difficulty arises in giving effect to the provisions of this Act the
State Government may, by order published in the Official Gazette, make such provisions not
inconsistent with the provisions of this Act as appear to it to be necessary or expedient for
removing the difficulty:
Provided that no such order shall be made after expiry of a period of two years from the date of
commencement of this Act.
21.
Power to make rules:
(1) The State Government may, by notification and after previous publication, make rules for
carrying out the purposes of this Act.
(2) In particular and without prejudice to the generality of the foregoing provisions such rules
may provide for all or any of the following, namely:
(a) the manner in which an application for Registration shall be made and the fee which
shall be accompanied under section 5;
(b) the conditions subject to which, the form in which and the period for which
Registration may be granted under section 6;
(c) the manner and form in which the period for which and the fee on payment of which
Registration may be renewed under section 6;
(d) factors to be taken into account by the Registration Authority under section 7;
(e) the standards to be enforced by the Registration Authority under section 9;
(f) the manner in which an appeal may be preferred under section 13;
(g) any other matter which is required to be or as may be prescribed.
22.
Rules and orders to be placed before the State legislature:- Every order made under section
18 and every rule made under section 19 shall be laid as soon as may be after it is made, before
each House of the State Legislature while it is in session for a period of thirty days which may be
comprised in one session or in two or more successive sessions, and if, before the expiry of the
session immediately following the session or the successive sessions aforesaid both Houses
agree in making any modification in the rule or order both houses agree the rule or order should
not be made, the rule or order shall thereafter have effect only in such modified form or be of no
effect, as the case may be; so however, that any such modification or annulment shall be without
prejudice to the validity of anything previously done under that rule or order.
23.
Repeal and Savings:
(1) The Karnataka Private Nursing Homes (Regulations) Act. 1976 (Karnataka Act 75 of
1976) is hereby repealed.
(2) Notwithstanding such repeal:
(a) Anything done or any action taken under the repealed Act shall be deemed to have
been done or taken under the corresponding provisions of this Act;
(b)
All applications made under the repealed Act for registration or renewal prior to the
commencement of this Act and pending consideration on the date of commencement
of this Act shall abate and the fee paid, if any, in respect of such application shall be
refunded to the applicant. Such applicant may apply afresh for Registration under the
provisions of this Act.
-7-
STATEMENT OF OBJECTS AND REASONS
It is considered necessary to bring a comprehensive legislation in place of the Karnataka Private
Nursing Home (Regulation) Act. 1976 to have effective control over Private Health Care
Establishments in the State. The Bill, among other things provides for:(i)
(ii)
(iii)
(iv)
(v)
(vi)
Registration of private health care establishment and Suspension and cancellation of
Registration;
constitution of Registration Authority and Local Inspection Committee;
classifying health care establishment with reference to different standards and to require the
health care establishments to conform to the standards regarding staff, operation theatre,
buildings, equipment etc.
requiring every private health care establishment to notify the fees structure charged by it for
different medical treatment and other services;
obligations of private health care establishments,
penalties for contravention of the act and the rules.
Certain other consequential and incidental amendments are also made.
Hence the Bill.
MEMORANDUM REGARDING DELEGATED LEGISLATION
Clause 5
:
Empowers the State Government to make rules regarding the form and manner in
which the application has to be made and the fee to be paid along with the
application for Registration of Health Care Establishments.
Clause 6
:
Empowers the State Government to make rules regarding;
(i) Conditions of grant of Registration
(ii) The form and the manner of application and payment of fees.
Clause 7
: Empowers the State Government to make rules regarding the facilities to be
provided, possession of skilled manpower and equipment by Private Health Care
Establishments and such matters.
Clause 9
:
Clause 11
: Empowers the State Government to make rules regarding the form and the manner
in which the medical records of the Private Health Care Establishments have to be
maintained.
Clause 13
: Empowers the State Government to make rules regarding the manner and fee for
preferring an appeal to the Appellate Authority by the Private Health Care
Establishment aggrieved by any original order made under this Act.
Clause 14
: Empowers the State Government to make rules for carrying out the purposes of
this Act and any other matter which is required to be made.
Empowers the State Government to make rules regarding the different standards
for different categories of Private Health Care Establishments.
The Proposed delegation of the legislative power is normal in character.
-8-
ANNEXURE 8
REPORT ON JANAAROGYA SABHE PROCESS IN KARNATAKA
March 2000-February 2001*
1. Background: To support the People’s Health Assembly, Dhaka (Dec2000), a National
Coordination Committee (NCC) of 18 National Networks emerged in the November 1999November 2000 phase to mobilise and prepare for the event. The NCC decided to facilitate the
organisation of district and state level meetings and initiatives to culminate in a National Health
Assembly called Jan Swasthya Sabha at Calcutta in Dec 2000, a few days before the Global Health
Assembly at Dhaka (4th – 8th December 2000). A National Working Group (NWG) was formed to
catalyse this massive mobilisation. Community Health Cell was an active member of National
Coordination Committee and National working Group and the whole planning process. At a
National Level AIPSN / BGVS were identified as a lead organisation to coordinate / facilitate this
process in close collaboration with all the other networks
The Goal
The goal of the Peoples Health Assembly to re-establish health and equitable
development as top priorities in local, national and international policymaking, with Primary Health Care as the strategy for achieving these
priorities. The Assembly aim to draw on and support people’s movements in
their struggles to build long-term and sustainable solutions to health
problems.
The Focus of the Campaign
The 6 prerequisites to enable People’s Health in People’s Hands are:
1. Reversing Structural Adjustment and Globalisation, which clearly is
worsening the quality of life of the majority of the Indian people.
2. Decentralisation and democratisation of health care along with adequate
resources to ensure its effectiveness.
3. Bringing the community to the centre stage of the health planning and
health care process.
4. Ensuring the provisioning of basic needs to all citizens through
decentralised planning and appropriate technology transfers.
5. Curbing the unregulated and unethical commercialisation of the health
profession and promoting the growth of rational, ethical and competent
professional practice.
6. Bringing together Voluntary Organisations and People’s Movements to
build a powerful force to work to lessen disparities, promote organisations
of weaker sections, and build people’s capabilities.
*Submitted to Karnataka Task Force in Health and Family Welfare.
2. Janaarogya Sabhe Organisational Framework: The Process in Karnataka was called
‘Janaarogya Sabhe’ and activities in Karnataka related to it were started in March 2000 with
meeting of 6 networking agencies in Karnataka (Bharat Gyan Vigyan Samiti (BGVS), Community
Health Cell (CHC), Mahila Samakhya (MS), Catholic Health Association of India- Karnataka
(CHAIKA) Karnataka Rajya Vigyan Parishat (KRVP) and Drug Action Forum – Karnataka (DAFK). This was followed by a series of discussions and deliberations in the state with various
organisations who agreed to join the collective initiative. These included Vivekananda Foundation
(VF), Voluntary Health Association of Karnataka (VHAK), Federation of Voluntary Organisation
For Rural Development Karnataka (FEVORD-K), Christian Medical Association of India (CMAI),
National Alliance for People’s Movement (NAPM-K), New Entity for Social Action (NESA),
Society for Service to Voluntary Agencies (SOSVA), Family Planning Association of India (FPAI),
Campaign against Child Labour (CACL), Forum For Street Children, Foundation For Revitalisation
of Local Health Traditions (FRLHT), and Joint Women’s Programme (JWP). Others also joined in
later and these included Dalit Sangharsh Samithi (DSS), Democratic Youth Federation of India
(DYFI), Karnataka Prantha Raitha Sangh (KPRS), Karnataka Rajya Raitha Sangh (KRRS), and
Karnataka State Medical and Sales Representatives Association (KSMSRA).
A State Coordination Committee was formed in the month of May 2000, with Dr. H.sudarshan,
(Vivekananda Girijana Kalyana Kendra), Chairman, Karnataka Health Task Force and respected
development activist as Chair Person and Ms. Ruth Manorama of Women’s Voice as vice
chairperson. Dr. Prakash Rao of DAF-K and Mr Basavaraju of BGVS were asked to be the
Technical and Organisational Convenors respectively. A small working group was formed to help
the above to monitor, train and communicate with various groups working both at state and district
levels.
3. National launch workshop at Hyderabad-April 5-7, 2000: In the month of April 2000, eight
(8) members from Karnataka who were active in state level activities attended the National People’s
Health Assembly launch workshop in Hyderabad. This workshop gave proper insight to the
participants about the whole ideology of the PHA process. In the workshop, draft materials were
given to the participants, to enable the participants to carry out the activities at the state level. These
included four evolving booklets on the themes a) Globalisation and Health, b) Whatever happened
to Primary Health Care, c) Caring for the vulnerable and d) Basic Needs for all and also e) A draft
of a People’s Health Charter and f) Some initial ideas for block level Health Surveys / Enquiries.
Dr. Zafarullah Choudary of Gono Shasthya Kendra also participated in this workshop.
4. State Level Orientation Workshop: A State level Orientation Workshop for District level
facilitators was organised by CHC and BGVS at Indian Social Institute, Bangalore between 26-28
June 2000. 82 participants from 19 districts participated in the workshop. The Health Minister Dr.
Malaka Reddy, who inaugurated the workshop, assured all cooperation from the Government for
this programme. The others who attended were Mr. Abhijit Sen Gupta; Health secretary Dr. G.V.
Nagaraj: Director of H and FW services, and, Dr. Chandra shekar Shetty vice-chancellor of Rajiv
Gandhi University of Health Sciences (RGUHS). Background materials for this workshop were
some of the draft materials that were given at the National workshop at Hyderabad. A few topics
relevant to Karnataka situation were added to these topics. During this 3-day workshop participants
were also oriented on how to initiate district level activities.
5. District level Initiatives: After this workshop various agencies in the state showed increased
interest in these activities and joined the process at State and District level. Activities were planned
for 20 out of 27 districts. This was decided on the basis of stronger base at District level of the
organisations represented in State workshop.
District committees were formed and district activities were initiated. Ultimately district initiative
took place in 18 out of 27 districts. Bangalore (R), Shimoga, Davanagere, Raichur, Koppal, Bidar,
Bijapur, Tumkur Kolar, Gulbarga, Bangalore (U), Chitradurga, Uttar Kannada, Dakshina Kannada,
Belgaum, Mandya, Mysore, and Chamarajanagar. Most of these initiatives were completed by
second week of November so that they could feed into the state level convention, which was held
on 26th to 27th November.
6. Publications and materials: 5 books which were published by the NCC in English for the Jana
Swasthya Sabha mobilisation process were translated into Kannada by state working group and
have been used for all the deliberations during district level workshops. Along with these the draft
People’s Health Charter and People's Health Dialogue (block level enquires) were also translated
into Kannada and circulated to all the districts. In addition a book on Kalajatha materials, which
included songs, skits and street plays, was also prepared and published by SCC. These songs and
skits were evolved in a Kalajatha preparation workshop held from 18th to 20th of October, at a
CHAI-KA centre where resource persons who were well-versed in these low cost communication
methods – folk media participated to produce the material.
7. Kalajatha workshop: Kalajatha workshop was organised between 2nd-5th of November 2000.
After this, trainers of the Kalajatha team were instructed to go around the district to spread the
message of the PHA to the Community. The districts represented in the workshop were Kolar,
Shimoga, Dharwad, Raichur, Bangalore (Rural), Bellary, Chamarajanagar, Mysore, Koppal,
Bijapur, Bidar, Mandya, Davangaere, Tumkur, Belgaum, Chitradurga, and Gulbarga. Teams
enacted the role-play, street plays, songs and various folk methods for the purpose. Details of the
messages of the mobilisation were given during the workshop to the participants. Before this 2 day
orientation for the resource persons about Janaarogya Sabhe was given to 5 persons at Navajeevan
Mahila Pragathi Kendra in Bangalore between October 18- 19, 2000.
Kalajathas were finally organised in the following districts: Mysore, Chamarajanagar, Mandya,
Davanagere, Belgaum, Raichur, Koppal, Bidar and Bijapur.
8. People’s Health Dialogue: Discussions on format and methodology of People’s Health
Dialogue was carried out on 31/10/2000 at Honnali. Eight districts (Shimoga, Tumkur, Chitradurga,
Davanagere, Koppal, Raichur,Kolar, and Bellary) were represented in the discussion and the
participants were oriented to the objectives and methodology of such a dialogue. Apart from these
eight districts, 2 other districts (Bidar and Bijapur) showed interest in carrying out the dialogue
though they could not attend the discussion. At the end of the process, they were asked to carry out
the dialogue in a few of the villages in which they were working. Finally the districts, which carried
out the dialogue, were Bijapur, Koppal, Tumkur, Raichur and Kolar.
9. State Level Convention: The State level convention was held on 26th and 27th of November at
Davanagere which gave opportunity to all field level workers and people to voice their concern on
PHA issues including the deteriorating health situation and the growing commercialisation of health
care. 357 participants from all over the state attended this convention. From among them 178
participants went to Calcutta to attend The National Health Assembly. These 178 participants
including 14 who participated on behalf of Karnataka at the PHA in Dhaka were identified
democratically by consulting all the groups. Of these 178 delegates 65 were women. They also
belonged to 22 different organisations, which were working at State or District levels and
represented 20 districts.
10. People’s Health Train: The train journey started from Bangalore soon after the state assembly
at Davangere was over on 27th November 2000. About 150 people were flagged of in special buses
from Davangere and reached Bangalore city station where 28 more people joined them. The Health
Commissioner flagged off the journey and wished all success to the Karnataka contingent. The
Karnataka contingent changed train at Chennai, and got on the 5th People’s Health train (The
Coramandel express to Kolkata on 28th November 2000). During the journey discussions and
interactions continued about the Shamiana sessions and sub conferences themes planned in the
National Health Assembly (NHA ) Kolkata in which Karnataka delegates were going to participate.
These discussion were based on the Materials provided by NCC for the train workshops just before
the delegates began the journey. The Karnataka delegates also raised Health slogans and sang
Health song during the journey and at some stations on the way. In a few stations in Andhra and
Orissa local reception committees also felicitated the team. The Karnataka team arrived in Kolkata
on 30th November after a very interesting journey.
11. Jana Swasthya Sabha Kolkata: The Karnataka delegates were active participants in all the
programmes of Jana Swasthya Sabha They were especially good at songs and slogans and helped to
liven up the proceedings. They made presentations in 13 Shamiana sessions through representatives
selected by the group of which 9 belong to Northern Karnataka district. The assembly was a great
opportunity to network and learn from such a massive mobilisation of State delegates and resource
persons.
12. People’s Health Assembly, Dhaka: This was attended by 1350 participants from 116
countries. In People’s health Assembly at Dhaka, 15 participants belonging to seven different
organisations represented Karnataka. Along with these Karnataka also had a representation through
resource persons. Few important things needs to be mentioned here, were there was large
opposition to presentation by World bank representative and whole hearted supported for the Cuban
delegation. Another important features of this assembly were entire hospitality esp. cooking and
serving was done by women.
13. Other Complementary Activities: In addition to initiatives organised by the state coordination
committee various participating organisations also organised PHA related events as part of their
own organisational activity. These included a PHA presentation in the annual general body meeting
of VHAK; a session at the annual general body meeting of VHAI; a scientific session on PHA
themes at the annual general body meeting of CHAI; a PHA session during the NAPMS national
convenors meeting and the consumer group (CREAT) meetings – all at Bangalore. In addition
CHAIKA organised PHA discussions at Shimoga, Hassan and Mysore and a presentation to
Janwadi Mahila Sanghatane district level meeting at Belgaum. CHC provided resource persons for
all these meetings.
14. Advocacy : 3 Press meets were called specifically for this mobilisation process. First was in
June 2000 just before the State level workshop. The next one was in November 2000 when the
national leaders of the PHA process Dr. N.H. Antia ,Dr. D. Banerjee, Dr. Sundarraman and few
leaders from state addressed the press at Bangalore and the last one was addressed by Dr,
Sudarshan, state chair person, the day before the state level convention at Davanagere.
15. Financial Resources: A lot of the activities spread over 20 districts were carried out by the
financial support from organisations involved in the programme and local mobilisation at district
level. The Government of Karnataka agreed to support the programme by providing half of the
projected amount required for this purpose.
The Jana Arogya Sabha process has been a very interesting networking process in Karnataka
bringing together a large number of organisations many of whom had not worked together in the
earlier years, since all of them very busy with their own focus and agenda. This broad based
networking of health groups, science movement groups, women’s groups, Development groups and
people’s movements has been a very significant experience. This networking has been very good
and should not be wasted and efforts have to be made to continue this effort and widen its scope
with ultimate benefits to the Health of communities particularly in the disadvantaged areas of the
state.
Another significant strength has been the production of 6 Booklets in Kannada on health issues
which is a major demystification process to increase the health awareness of the people and
empower them to take health responsibilities and demand health as a right.
CONCLUSION: The Jana Arogya Sabhe process has been an interesting experience especially for
all those organisations who have been actively involved. It is now necessary to evolve better
coordination and greater clarity in our collective efforts to make ‘People’s health in People’s hands’
a reality in the state. A creative collectivity can ensure the development of a truly authentic
“Janaarogya Andolana ”. It is now in everybody’s hand to see this network doesn’t end up as the
few movements earlier. We need to gear up for this now and together with true commitment. The
time for Health for All is Now !
Prepared for State Coordination Committee- Janaarogya Sabhe- K
By Mr. Prahlad,
Community Health Cell,
Ms. Amrutha,
Mahila Samakhya Karnataka,
Mr. Chegareddy, Bharat Gyan Vigyan Samiti, and
Dr. Ravi Narayan Community Health Cell.
ANNEXURE 9
INFORMATION ON KARNATAKA
GENERAL INFORMATION
1.
2.
3.
4.
5
6.
7.
Area in Sq Km
Number of districts
Revenue divisions
No. of Taluks
No of towns and Urban Areas
No of inhabited villages
No of Gram Panchayats
191791
27
4
175
254
27066
5692
DEMOGRAPHIC FEATURES
1.
2.
3
4
5.
6.
7
8.
9.
10
Total Population*
52,733,958
Males
26,856,343
Females
25,877,615
Decadal Growth Rate (1991 – 2001)*
+17.25%
Annual Growth rate (1981 – 91)
1.9%
Population density (2001)*
275/ sq km
Sex (Gender) Ratio*
964 females / 1000 males
Percentage of population in the 0-6 age
12.94
group*
Percentage of births registered (1997)
Rural
63.3
Urban
163.4
Combined
92
Total
67.04%
Literacy*
Males
76.29%
Females
57.45%
(Population in age group 0-6 is excluded)
Percentage of SC / ST
SC
16.38
population to Total Population
ST
4.26
(1991 Census)
Per capita income at current
Rs. 13,621.00
prices (1997-98)
* Census of India 2001, Provisional Population Estimates
HEALTH INDEX
1.
2.
Crude Birth Rate (SRS, 1999) Combined
Urban
Rural
(NFHS – 2)
Crude Death Rate (SRS, 1999)
-1-
22.3 / 1000 population
19.2 / 1000 population
23.7 / 1000 population
20.4 / 1000 population
7.7 / 1000 population
3.
4.
Infant Mortality Rate (SRS, 1999)
Life Expectancy at
Birth (1996-2001)
Urban
Rural
(NFHS –2)
Male
58 / 1000 live births
24 / 1000 live births
69 / 1000 live births
51.5 / 1000 live births
61.7
Female
5.
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
Under 5 Mortality Rate (NFHS 2)
Neonatal Mortality Rate (NFHS 2)
Post-Neonatal Mortality Rate (NFHS 2)
Perinatal Mortality Rate (1994)
Rural
Urban
Percentage of children fully vaccinated
(NFHS- 2)
BCG
DPT (3)
Polio (3)
Measles
Child Mortality Rate (NFHS –2)
Anaemia among children (6-35 months)
Nutritional status of children (Gomez
Classification), 1996
Severe Undernutrition
Moderate Undernutrition
Mild Undernutrition
Normal
Total Fertility Rate
(SRS, 1997)
(NFHS-2)
Percentage of Institutional Deliveries
(NFHS – 2)
Percentage of safe deliveries (NFHS – 2)
Anaemia among women in 15 – 49 years
age group (NFHS-2)
Newborns with Low Birth Weight (1994)
Percentage of mothers who received ANC
(NFHS-2)
Percentage of Eligible Couples protected
as on March 2000
Maternal Mortality Rate (SRS, 1998)
Percentage of currently married women
using (NFHS – 2)
a. Any contraceptive method
b. Sterilization
Unmet need for family planning(NFHS 2)
a. For spacing
-2-
65.4
69.8 / 1000 live births
37.1/1000 live births
14.4/1000 live births
47.8/1000 live births
49.2/1000 live births
44.3/1000 live births
60
84.8
75.2
78.3
67.3
18.3 / 1000 children
70.6%
6.20%
45.40%
39%
9.40%
2.5
2.13
51.1
59.2
42.4%
35%
86.3
59.7
195 / One lakh live births
58.3
52.1
8.3
23
b. For limiting 3.2
c. Total
11.5
Percentage of women reporting a
18.8
reproductive health problem (NFHS-2)
TRENDS IN KARNATAKA
1. Crude Birth Rate, Crude Death Rate and Infant Mortality Rate, 1971 to 1999
1971
1975
1980
1985
1990
1992
1994
1995
1996
1997
1998
1999
Crude Birth Rate
Total
Rural Urban
31.7
34.6
25.3
17.7
29.7
22.5
27.6
28.9
24.4
29.6
30.9
26.2
28.0
29.0
25.0
26.3
27.4
23.3
25.0
26.0
22.7
24.1
25.1
22.1
23.0
24.2
20.3
22.7
23.9
20.1
22.1
23.1
19.4
22.3
23.7
19.2
Crude Death Rate
Total
Rural Urban
12.1
14.0
7.2
11.1
12.5
7.5
9.6
10.7
6.6
8.8
9.8
6.1
8.1
8.8
6.1
8.5
9.4
6.0
8.3
9.3
6.0
7.6
8.5
5.6
7.6
8.6
5.4
7.6
8.5
5.4
7.9
8.9
5.6
7.7
8.7
5.5
Infant Mortality Rate
Total
Rural Urban
95
105
54
80
86
60
71
79
45
69
80
41
70
80
39
73
82
41
67
73
50
62
69
43
53
63
25
53
63
24
58
70
25
58
69
24
2. Nutrition Status: Percentage Weight for Age; (12-71 months) by Sex and Time
Year
1975 -79
1996-97
Sex
M
F
M
F
<60
5.7
6.8
13.9
12.5
60-75
45.2
45.5
52.1
47.8
75-90
37.9
40.1
30.3
31.9
>=90
11.2
7.6
3.7
5.6
3. Prevalence of Vitamin A deficiency (Percentage of Bitot's spots in the age group 12-71
months)
Year
1975-79
1996-97
Rural
2.3
0.5
-3-
Urban
7.1
1.1
4. Population distribution, percentage decadal growth rate, sex ratio and population density*
Sl State/District
No
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
Belgaum
Bagalkot
Bijapur
Gulbarga
Bidar
Raichur
Koppal
Gadag
Dharwad
U. Kannada
Haveri
Bellary
Chitradurga
Davangere
Shimoga
Udupi
Chikmagalur
Tumkur
Kolar
Bangalore
Bangalore
(Rural)
Mandya
Hassan
D. Kannada
Kodagu
Mysore
Chamrajnagar
Karnataka
Population 2001
Percentage
decadal
growth rate
2,059,518
816,548
880,313
1,533,479
730,695
815,860
591,470
478,160
780,379
666,273
697,553
996,761
737,578
872,373
810,230
587,953
564,829
1,267,575
1,242,253
3,100,313
916,081
198191
20.30
20.79
22.94
24.10
26.12
30.53
28.05
15.56
19.64
13.66
20.53
26.84
20.51
23.07
15.11
9.42
11.57
16.58
16.34
38.44
15.23
19911991 2001
01
17.40
954
964
18.84
982
977
17.63
948
948
21.02
962
964
19.56
952
948
21.93
978
980
24.57
981
982
13.14
969
968
16.65
935
948
10.90
966
970
13.29
936
942
22.30
966
969
15.05
951
955
14.78
942
951
12.90
964
977
6.88 1134 1127
11.98
977
984
11.87
959
966
13.83
965
970
34.80
903
906
12.21
945
953
874,411
862,696
958,752
272,112
1,289,070
474,380
25,877,615
15.96
15.67
15.98
5.75
24.84
14.99
21.12
7.14
9.66
14.51
11.64
15.04
9.16
17.25
Persons
Males
Females
4,207,264
1,652,232
1,808,863
3,124,858
1,501,374
1,648,212
1,193,496
971,955
1,603,794
1,353,299
1,437,860
2,025,242
1,510,227
1,789,693
1,639,595
1,109,494
1,139,104
2,579,516
2,523,406
6,523,110
1,877,416
2,147,746
835,684
928,550
1,591,379
770,679
832,352
602,026
493,795
823,415
687,026
740,307
1,028,481
772,649
917,320
829,365
521,541
574,275
1,311,941
1,281,153
3,422,797
961,335
1,761,718
1,721,319
1,896,403
545,322
2,624,911
964,275
52,733,958
887,307
858,623
937,651
273,210
1,335,841
489,895
26,856,343
* Census of India 2001, Provisional Population Estimates
-4-
Sex ratio
963
999
1020
979
953
963
960
985
1005
1023
996
965
968
964
Population
density
1991
2001
235
211
147
159
231
198
133
184
333
119
263
196
156
263
171
268
141
218
270
2210
288
275
251
172
193
276
241
166
209
376
132
298
240
179
302
193
286
158
243
307
2979
323
331
230
363
119
333
173
235
355
253
416
133
383
189
275
HEALTH AND MEDICAL INSTITUTIONS IN KARNATAKA AS ON 31.3.1998
Sl.
No.
Institutions by
Management
I. Hospitals
1.
State Government
2.
Central
Government
3.
E.S.I
4.
Autonomous
5.
Other Departments
6.
Local Body
7.
Private
Total
II. Dispensaries
1.
Central
Government
2.
E.S.I.
3.
Other Departments
4.
Local Body
5.
Private
Total
III. Primary Health Units
(PHUs)
IV. Primary Health
Centres (PHCs)
V. Urban Primary Health
Centres
Grand Total
1.
2.
3.
4.
5.
6.
7.
8
9
10
Rural
Urban
Total
Institutions
Beds
Institutions
Beds
Institutions
Beds
8
1
417
25
168
12
22806
1829
176
13
23223
1854
2
14
25
26
2547
3015
7
4
7
28
42
268
1125
1228
310
714
7452
35464
7
4
9
28
56
293
1125
1228
336
714
9999
39485
2
-
11
-
13
-
11
25
3
7
48
48
21
4
73
118
5
22
4
160
4
44
48
129
30
25
11
208
52
65
4
121
511
786
72
336
583
1122
1591
12702
85
2384
1676
15086
-
-
9
54
9
54
2175
16576
594
38286
2769
54862
Urban Family Welfare Centres
Rural Family Welfare Centres
ANM Subcentres
CHCs
Post Partum centres
MTP Centres: Government
Health & Family Welfare
Training Centres
District Training Centres
ANM Training Centres
No of ICDS projects
87
269
8143
249
103 (16 merged with UFWC)
325
5
27
19
185
-5-
INDIAN SYSTEMS OF MEDICINE AND HOMOEOPATHY
No. of Institutions in the State as on 31.3.1999
I. Colleges
No. of Ayurvedic Colleges
Government
Private
No.
3
35
Seats
160
1465
No. of Homoeopathic colleges
Government
Private
1
11
40
510
No.of Unani colleges
Government
1
50
No. of Nature Cure / Yoga
colleges
Government
Private
1
2
12
80
No. of P.G. Courses college in
Ayurveda
Government
Private
5
4
38
16
II. Hospitals and Dispensaries:
Sl.
No.
System
1.
2.
3.
4.
5.
6.
Ayurveda
Unani
Homoeopathy
Siddha
Yoga
Nature Cure
No. of
Hospitals
61
10
5
1
3
3
83
No. of
beds in
Hospitals
1035
167
80
10
15
26
1333
-6-
No. of
Dispensaries
509
45
25
5
584
A COMPARISON
1. Human Development Index and Gender Related Development Index Ranks
State
Kerala
Punjab
Maharashtra
Haryana
Gujarat
West Bengal
Karnataka
Tamil Nadu
Andhra Pradesh
Assam
Orissa
Rajasthan
Bihar
Madhya Pradesh
Uttar Pradesh
HDI
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
GDI
1
4
2
9
3
7
5
6
8
10
11
13
14
12
15
Source: A K Shivakumar (1991-92) quoted in Human Development in Karnataka, 1999 pp 12
2. Rural Health Services
Average Rural
Area (Sq. KM)
covered by a
Sub Centre
23.03
Andhra
Pradesh
25.54
6.97
Tamil
Nadu
14.27
PHC
117.13
202.18
36.98
86.27
136.22
CHC
774.88
1303.93
443.76
1720.58
1,154.82
Average Radial
Distance (KM)
covered by a
Sub Centre
2.71
2.85
1.49
2.13
2.70
PHC
6.10
8.02
3.43
5.24
6.58
CHC
15.70
20.37
11.88
23.40
19.17
Average Number
of Villages
covered by a
Sub Centre
3.32
2.52
0.27
1.82
4.29
PHC
16.91
19.91
1.44
11.02
25.54
CHC
11.84
128.43
17.30
219.75
216.53
Number of Sub Centres per PHC
5.09
7.92
5.31
6.05
5.95
Number of PHCs per CHC
6.62
6.45
12.00
19.94
8.48
Number of MPW (M) Per HA (M)
5.0
5.3
3.9
1.3
3.3
Number of MPW (F) per HA (F)
8.1
7
5.3
6
6.9
Average Rural Population (1991)
covered by a MPW (F) / ANM
3837
4466
4748
4305
4707
Particulars
Karnataka
Kerala
All India
22.89
Source: Rural Health Statistics in India, June, 1998: Bureau of Health Intelligence, Government of India
-7-
Position: 4739 (1 views)