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KARNATAKA
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TOWARDS EQUITY WITH QUALITY IN HEALTH
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Focus on
Primary Health Care
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Interim Report
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April 2000
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Government of Karnataka,
TASK FORCE ON HEALTH AND FAMILY WELFARE,
Ground Floor, Public Health Institute Building Annexe,
Sheshadri Road, Bangalore - 560 001
Phone: 2271021; Fax: 2277389;
emai,: kl~isdp@vsnl.com / healthtaskforce@indiatimes, com
website: http//www.dhskhsdp.com
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Preface
The Constitution of India places the responsibility of providing for the
health of the people, on the State. Article 47 of the Directive Principles
stipulates that the State shall raise the level of nutrition and standard of
living of the people and improve public health.
It was always recognised that health care and public health could not be
viewed in isolation but had to be seen as one of the elements within a
package of social welfare measures that would include Nutrition,
Drinking water supply and Sanitation, Literacy and education,
entitlements of women and children and empowerment of the
community. Unfortunately, over the years this holistic approach that all
such activities of the State should converge in the creation of a welfare
state has been eroded and development facets have tended to get
“departmentalised”. However, in recent years the emphasis on integrated
development has been revived and as part of this process the need to
take a close look at the organisation of the Health Services in the State
has been recognised by the Government of Karnataka.
Karnataka State has had an impressive record of development and has
indeed been a pioneer. The present basic structure has evolved from the
system in vogue in the Princely State of Mysore. It has been among the
earliest administrations to establish and actively support water supply
and sanitation systems, health units and local self-government units in
the urban areas. That system was remarkable for its approach to Primary
Health Care (with the concept of Primary Health Units) and Public Health
(using bio-environmental methods of malaria control since the 1930s,
establishment of Birth Control Clinics at Vani Vilas Hospital in Bangalore
and Cheluvamba Hospital in Mysore, and health personnel being sent for
training in Public Health in India and abroad). The addition of other
geographic areas following the reorganisation of the States and concepts
and structures brought about by the Centre has produced changes. But,
the basic structure remained and this has been a strength of the system.
It has also been in the forefront of establishing the Panchayat Raj system.
The same spirit has guided its approach to the Health System and the
State has an impressive health administration combined with a network
of health facilities and educational institutions for health professionals.
The Chief Minister, in keeping with the forward looking role of the
Government of Karnataka in development, considered that there should
be a review of the current state of Health System so as to ensure “Health
for All , with equity and quality, for the people of the State within as
short a span of time as possible. This concern has been reflected in the
constitution of the Task Force.
li
Many features of the Health System today are the result of historical
processes. The character of these Health Services has moved away from a
public health perspective to one with major emphasis on clinical
(curative) services. This imbalance needs to be rectified. There are also
other important issues that merit attention. These include the state of
accountability of Health Services to the people, and the need to ensure
equity in accessibility, adequacy and quality of services. A review must
address several aspects of the Health System. These range from the
organisation and management of the health services to the location of
service facilities ensuring access to these services without hidden costs,
management of the drug supply system and ensuring availability of
trained personnel. There are related issues such as of the content of
medical education so, as to inculcate an appropriate value system in
personnel, the providing of choice for the people between Indian Systems
of Medicine & Homeopathy and Allopathy.
Active involvement in the monitoring and management of the health
system by the community would make the official mechanisms more
responsive and responsible in the discharge of their duties. In this
context, the panchayat system has a crucial role to play. How best such
an inter-face could be developed would engage the attention of the Task
Force.
It is also recognised that the health system cannot function in isolation.
Health issues cannot be narrowly defined and confined to merely
preventive and curative services. The health of a nation is closely
dependent on the nutrition status of the population, the special
measures necessary to enhance reproductive and child health and the
need to ensure equity in distribution of all social services to the
disadvantaged groups. The ability to take advantage of the entitlements
in the system is dependent on the ability to access information, which
itself is dependent on literacy. The health of future generations depends
on the networking of various sectors of development. The mechanisms for
such inter-sectoral coordination would also merit attention.
The Task Force is conscious of the duty cast on it. It has set for itself
three main tasks.
1. a review of the present health system to determine if it meets its
objectives and to recommend measures for improvement,
2. to revitalise and reinstitutionalise the public health character of
health services
3. to render operative the mechanisms for involvement of the
community in the management of the health services.
In doing so it would assess the current scene and determine courses of
action that would go a long way in improvement of the health system.
The prime objective would be to commence a process that would result in
d
the system being able to deliver, with quality and equity, the health
entitlements of the people.
This report is an interim report. It deals mainly with the short-term
recommendations, which can be implemented within a period of 6
months. It gives also indications of areas of concern, which can be
accomplished in the medium (6-24 months) and long term (2 to 5 years).
These will be reflected on further. The approach is to ensure
sustainability of the initiatives. The interim report will be the basis for
wider discussions. A final comprehensive report will then be made. This
Final report will contain in addition to the recommendations on specific
issues, a Draft State Health Policy and a Perspective Plan. It will also
have a Vision Statement.
(Dr. H Sudarshan)
Chairman
(Sri Arvin G Rispud)
Member Convenlp r
(3-3-2000 till date)
Members:
(Dr. Chandrashekar Shetty S)
r. Jacob John T) o
I h'vvx^'v,
(b r. Kamini Rao)
(Dr. Maiya M)
(Sri Padmanabha Pj
(Dr. Francis C M)
(Dr. Jayaprakash Narayan)
UM
(Dr. Latha Jagdnnathan)
Xx
(Dr. Nagalo
(Dr. Suresh B
ulkarni)
KJ CX YVvC
(Swami Japananda)
(Dr. Thelma Narayan)
Member Convenors
('
/
(Dr
Subramanya)
(Sri A K M Nayak)
(21- 12-1999 to 14-2-2000)
(15-2-2000 to 3-3-2000)
Contents
Page
Preface
The Process
i
An Over view
Strengths and Achievements: Karnataka Health Care Services
Issues of Concern
Key Messages
v
v
Towards Equity with Quality - an agenda for action
vn
ix
xi
1
Introduction
1
2
Disparities
3
3
Primary Health Care
7
3.1
3.2
3.3
3.4
3.5
3.6
4
Rural Health
Urban Health
Referral Services (Secondary and Tertiary Health Care)
Emergency Health Services
Laboratory Services
Blood Banking and Transfusion Services
Public Health
7
8
8
9
9
10
12
Water Supply and Sanitation
Waste Management
Communicable Diseases
Non Communicable Diseases
12
14
15
16
18
22
5
Maternal and Child Health
28
6
Population Stabilisation
31
7
Focus on Special groups
33
7.1
7.2
7.3
Women and Health
Persons With Disability
Tribal Health
33
34
37
4.1
4.2
4.3
4.4
4.5
4.6
Strengthening Public Health
Nutrition
8
Health Education
39
8.1
8.2
Health Education
School Health
39
40
9
Health Human Resources Development
42
10
10.1
10.2
10.3
10.4
10.5
10.6
Health System Management
45
11
Indian Systems of Medicine and Homeopathy
11.1
11.2
Administration
Planning
Financing
Health Information Management System
Medicines - Procurement and Supply
Law and Ethics
Ayurveda, Unani and Homeopathy
Folk and Traditional Medicine
45
48
48
50
51
53
56
56
57
58
58
59
12
12.1
12.2
Panchayat Raj and Empowerment of People
13
Strengthening Partnerships
61
13.1
13.2
Voluntary Organisations
Private and Corporate Sector
62
63
14
Panchayat Raj Institutions and Health
Peoples Empowerment for Health
Short Term Recommendations and Plan of Action
64
Annexures
1.
2.
3.
4.
5.
6.
7.
8.
Government Order Appointing the Task Force
Schedules of the Meetings and Consultations
Sub Groups and Team members
List of Individuals / Organsiations / Associations who
interacted with the Task Force
List of Invitees for Suggestions / Comments
List of persons who responded by Post ( Kannada / English)
Suggested role and responsibilities of the Commissioner of
Health and Family Welfare
Information on Karnataka
78
83
84
85
90
92
97
98
GLOSSARY
AIR
ANM
CNA.
CBO
GBR
CDR
CFTRI
CHC
DD
DHO
DHFWS
DISM & H
DME
DHF/ DSS
FOGSI
FRU
GMS
HIV/AIDS
HIMS
ICDS
IEC
I FA
IMR
ISEC
ISM&H
JD
JE
KMIO
All India Radio
Auxiliary Nurse Mid-wife or Junior
Health Assistant (Female)
Community Needs Assessment
Community Based Organisation
Crude Birth Rate
Crude Death Rate
Central Food Technology and
Research Institute
Community Health Centre
Doordarshan
District Health Officer
Directorate of Health and Family
Welfare Services
Directorate of Indian Systems of
Medicine and Homeopathy
Directorate of Medical Education
Dengue Haemorrhagic Fever and
Dengue Shock Syndrome
Federation of Obstetrics and
Gynaecologists Societies of India
First Referral Unit
Government Medical Stores
Human Immunodeficiency Virus /
Acquired Imuuno Deficiency
Syndrome
Health Information Management
System
Integrated Child Development
Services
Information, Education,
Communication
Iron and Folic Acid
Infant Mortality Rate
Institute of Social and Economic
Change
Indian Systems of Medicine and
Homeopathy
Joint Director
Japanese Encephalitis
Kidwai Memorial Institute of
Oncology
LEB
MLA
MLC
MCH
NFHS
NGO
NIMHANS
NRR
NTI
NTP
OOD
ORS
PD
PDS
PHC
PHU
PLA
PRA
RCH
RDPR
RGUHS
RNTCP
RTI
SC &ST
SGARRC
SIHFW
STI / STD
TFR
UTI
UGC
VO
ZP
Life Expectancy at Birth
Member of Legislative Assembly
Member of the Legislative Council
Maternal and Child Health
National Family Health Survey
Non Governmental Organsiation
National Institute of Mental Health
Amd Neuro Sciences
Net Reproduction Rate
National Tuberculosis Institute
National Tuberculosis Programme
On Other Duty
Oral Rehydration Solution
Project Director
Public Distribution System
Primary Health Centre
Primary Health Unit
Participatory Learning and Action
Participatory Rapid / Rural
Appraisal
Reproductive and Child Health
Rural Development and Panchyat
Raj
Rajiv Gandhi University of Health
Sciences
Revised National Tuberculosis
Control Programme
Reproductive Tract Infection
Scheduled Castes and Scheduled
Tribes
Sanjay Gandhi Accident Relief and
Rehabilitation Centre
State Institute of Health and Family
Welfare
Sexually Transmitted Infection /
Sexually Transmitted Disease
Total Fertility Rate
Urinary Tract Infection
University Grants Commission
Voluntary Organisation
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
(Annexure 1).
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 28 sittings starting on 21st December 1999 (Annexure 2). 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 (Annexure 3). 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 (Annexure 4). 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) The Principal Secretary (Health), Government of Karnataka; The Secretary, Medical
Education, Government of Karnataka; The Commissioner for Health and Family Welfare;
i
The Project Administrator - Karnataka Health Systems Development Project; The Project
Director - India Population Project IX; The Deputy Secretary, Health.
c) 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.
d) Health Officials from Bangalore Mahanagara Palike - The Health Officer and the Project
Co-ordinator, India Population Project VIII.
e) Representatives from the Professional Bodies - Karnataka Medical Council, State Councils
for Indian Systems of Medicine and Homeopathy, Dental, Nursing and Pharmacy, Indian
Medical Association, Associations of Karnataka Government Medical Officers, Ayurvedic
Physicians, Medical and Dental Teachers Association, Contract Doctors, Integrated System
of Medicine, Federation of Obstetrics and Gynaecological Societies of India, Indian
Academy of Paediatrics.
f) Representatives from Voluntary Organisations and Associations networking in the area of
Health - Voluntary Health Association of Karnataka, Catholic Health Association of India-
Karnataka, 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.
g) 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 Relief and Rehabilitation Centre.
h) Representatives of Corporate Hospitals, Teaching Hospitals, Private Hospitals and
Association of Nursing Homes and Private Hospitals.
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,
ii
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 (Annexure 4). 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 (Annexure 5).
Experts both within the State and outside were invited to share their concerns and suggestions for
improvement of health.
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,
MFCs 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,
i
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.
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
iii
District Health Officers and District Surgeons during their monthly meeting. Members of the Task
Force also visited some of the institutions.
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 would have long term implications.
Recognising and realising that each one of us can immediately contribute towards ensuring equity
with quality in health for all of our people, this Interim 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. An agenda for immediate action has been drafted. An
indicative Plan of Action towards implementation of the short-term recommendations is given as
the last chapter of this report. A comprehensive Plan of Action for the implementation of all the
recommendations (including medium and long term) and monitoring the outcome will be drawn up
in consultation with the Directorate of Health and Family Welfare Services.
Over the next 6 months, the members of the Task Force will identify for themselves specific
monitoring components, the objective being to enable and empower the system to deliver better
health care services. The endeavour would primarily focus on working with individuals and
structures in the system and arriving at desirable outcomes.
The Task Force intends to incorporate all the recommendations of facilitation in the final report. It
is hoped that this process will result in a comprehensive State Health Policy, which will include
the components of Health, Population, Nutrition, and Rational Drug Use.
iv
X
An Overview
X
X
y
X
¥
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x
X
X
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X
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 ot 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.
A
X
x
STRENGTHS AND ACHIEVEMENTS OF THE KARNATAKA’S
HEALTH CARE SERVICES
X
x
The Government of Karnataka has over the last few decades taken measures to improve the health
¥ and wellbeing of its citizens iin line with the constitutional pledges, National Health Policy
¥
y
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
X has achieved a great deal. By recognising them the Task Force hopes to indicate the context and
X
base on which a comprehensive and people oriented Health Policy can be enunciated and put into
action.
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X
X
X
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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.
x
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.
X
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x
X
X
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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 humanpower have been trained. The establishn|ent of the Rajiv Gandhi
University of Health Sciences has brought under one umbrella over 240 educational
institutions training health humanpower for the State. This augurs well for the evolution of a
more relevant, rational and need based Health humanpower 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
x
J
X
4
v
A
X
•
Increased Life Expectancy at Birth from 26 years in 1947 to 66.3 years for women and
65.1 years for men in 1997.
y
•
Decline in Crude Birth Rate from 41.6 to 22.7 / 1000 population from 1961 to 1997.
X
X
X
•
Decline in Crude Death Rate from 22.2 to 7.6 / 1000 population from 1961 to 1997.
•
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.
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y.
x
X
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.
Family Welfare
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X
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5. Some of the other policies and initiatives in the State:
•
•
The State has been entering into partnership with Voluntary Organisations for
the more efficient and effective running of Primary Health Centres
Y
•
The State has also recently made available anti-tubercular drugs to fight the
menace of Tuberculosis in the entire State.
?
X
•
I
X
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X
IX
X
X
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The Externally Aided Projects have contributed to the infrastructure available for X
health care delivery and to the efficient and effective work cultures.
X
X
X
The Community Mental Health initiative in Bellary
X
X
I
X
I
The effective Couple Protection Ratio has increased from 23.8% in 1981 to 57.7% in
1997
•
X
X
X
y
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.
Ix
x
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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.
X
X
X
X
|
X
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.
X
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IX
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ISSUES OF CONCERN
The Task Force had a very wide ranging interaction with a large number of health care providers,
¥ decision makers, policy
' makers,
' representatives
- of- professional
-........................
• •
associations, voluntary and. private
X
X
sector organisations and representatives of civic society. The discussions were open, frank, in a
spirit of dialogue and very constructive. Concerns were shared and suggestions and ideas to
improve the health care system in Karnataka were freely given.
I
Some issues of general concern emerged from all these interactions.
X
1. Neglect of Public Health:
There was an overall neglect of public health principles in planning, organisation and
management of health care services with not enough emphasis on preventive, promotive and
rehabilitative care; and even less on the determinants of health including nutrition, water
supply and sanitation and the social determinants.
A
2 . Distortions in Primary Health Care :
¥
Y
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The promotion of Primary Health Care as a policy thrust was distorted by various factors.
which included:
I
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Inadequate efforts at community partnership and ownership of programmes including
effective decentralisation to Panchayat Raj Institutions.
Increased verticality and selectivisation of programmes at the cost of horizontal
integration and comprehensive approaches.
Lack of intersectoral coordination and convergence of health and development
programmes at the community level.
Lack of adequate partnerships with General Practitioners, Voluntary Organisations,
civic society and the private sector.
(a)
(b)
X
A
(c)
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X
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(d)
3. Inadequate Attention to Quality:
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There seemed to be an overall lack of quality orientation and inadequate attention to
establishment and maintenance of quality of care standards.
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I 4. Lack of Focus on Equity and Regional Disparities:
Regional disparities and differences were being inadequately addressed. The monitoring of
equity as a policy imperative was insufficient - be it regional inequities, gender inequality or
class/caste inequities, at least partly due to absence of monitoring health indicators dis
aggregated by equity related factors.
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5. Lack of Leadership and low Morale of Health Team:
The leadership at the Health Department seemed to be inadequate leading to a low morale at
various levels. Visionary and inspirational leadership to reach the stated goals with the full
involvement of the health team and community as partners was lacking.
X
6. Corruption:
?
There was widespread and growing 'corruption' at various levels of the system, which seemed X
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to be compromising
quality,
efficiency and management.. The areas affected included |
monetary consideration for appointment, promotions, transfers; corruption within the selection X
.
.
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of candidates as well as the examination
systems; and monetary
factors distorting
access and X
utilization of health care services at different levels. The "canker" seemed to be widespread
and well entrenched into the system.
.
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7. Lack of Political Will:
Health did not seem to figure high on the political agenda of governance. Health budgets were
stagnant; often under utilized; and the political will to get plans off the ground and reach those
who need to be reached was lacking. Especially, the continual of key and critical vacancies not
being filled up. Individual agendas rather than collective good predominated.
I
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8. Poor Governance:
The planning administration, monitoring and evaluation of the health system was poor, often
adhoc, and not always evidence based. Problem solving oriented leadership development at all
levels was seriously needed. There was an overall lack of comprehensive perspective or
vision, too much compartmentalisation of programmes and initiatives, often leaving the forest
for the trees.
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X
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9. Human Resource Development Inadequately Addressed:
There was a neglect of planning and policy for human resource development and deployment types of health team, qualities and complete team development; continuing education;
promotion and career development policy; accountability and maintenance of morale. The
commercialisation of Professional education has led to poor quality of training and
mushrooming of educational institutions.
10. Lack of Integration of Externally Aided Projects into Health System Planning:
A range of externally aided projects, through grants and loans, have been inadequately
integrated into the overall health system planning due to compartmentalisation; parallel system
development; inadequate monitoring of potential distortions; policy and conditionalities of
funding partners; inadequate policy reflection on issues of sustainability, accountability and
transparency.
4
X
I
I
Y
viii
XX
KEY MESSAGES
X
A reflection on the interaction-deliberations of the Task Force has brought forth Key Messages
addressing the concerns and building on the strengths.
1.
State Health Policy
Need for a State Health Policy which is comprehensive and integrates Health, Population,
Rational Drug Use and other concerns; which is located in the context of a long term
perspective planning process and built into the Health System.
2.
The Equity Imperative
Need for urgently tackling regional disparities in Health with an equity focus on the rights,
status and access for women, children, Scheduled Castes and Scheduled Tribes,
marginalised groups, the Persons With Disabilities and the aged.
2
Revaluing Public Health
Need for strengthening Public Health competence and skills at all levels of the system to
improve Health for All without distinction or discrimination and tackling the determinants
of Health rather than only responding to the biomedical aspects.
4.
Making Primary Health Care work
Making Primary Health Care work by improving quality of the primary Health services
through strengthening of human power resources, services and referrals. At the same time
strengthening the community partnership and ownership of programmes through
decentralised Health action through Panchayat Raj Institutions, civic society mobilisation
and devolution of administrative and financial powers.
5.
Quality Assurance
Quality improvement in the management of Health services through training and
continuing education of the Health teams; increasing competence and quality of care;
increasing focus on efficient supplies and logistic support; preventing duplication and/or
compartmentalisation of services and strengthening quality monitoring systems.
6.
Investing in Health
Making optimum utilisation of the allotted financial resources and increasing budget
allocation as necessary for needs and Health for All goals, supplemented by raising the
value of Health in the political agenda.
X
X
X
7.
X
4
X
i1
Increasing Accountability and Transparency.
X
Recognising the constitutional and policy obligations of evolving a comprehensive Health y
policy and Health care system development; ensuring accountability and transparency to
I
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ix
?
t
prevent distortions and deviations due to extraneous influences of market economy,
lobbies, social and political agendas and money power.
8.
Establishing New Partnerships
Evolving meaningful partnerships to improve Health and quality of life of the people of the
State, through planned involvement of voluntary agencies, general practitioners, private
sector and the sections of civic society.
9.
Strengthening Medical Pluralism:
Strengthening the functions of the Indian Systems of Medicine and Homeopathy and
supporting them to widen the choices for the people, particularly at Primary Health Care
level.
10.
Exploring greater Intersectorality of Health Development:
Recognising the intersectorality, central to Health development, and evolving meaningful
partnerships with other sectors and ministries of the government which impacts on the
determination of Health as well as contributes to the improvement of health development.
<•
X
i
X
V
I
X
y
I
I
I-X
Y
x
I
■■■
TOWARDS EQUITY WITH QUALITY
- AN AGENDA FOR ACTION
x
Major Recommendations For Implementation In The Next Six Months
The deliberations and interactions-discussions of the Task Force have brought forth issues and a
concerns and resulted in its recommendations. The recommendations aim at initiating changes in
health system towards ensuring Equity and Quality in service delivery. The 12 Point Agenda focus /
and highlight the actions for immediate implementation based on major recommendations.
X
1. Strengthening Primary Health Centres and Sub centres
XX
X
IX
I
I
Y
I
Y
X
I
1. All vacancies of Doctors, Laboratory Technicians and ANMs must be filled up
immediately.
A.
Y
The allotment for Essential Medicines (including Life Saving Medicines) must be increased X
,1
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by atleast
Rs. 25,000/per annum per TATT/-1
PHC. All
Essential
drugs must
be ntavailable
at the
A
PHC at all times.
4. Every PHC must have a working Telephone.
5. Atleast 1000 PHCs in the State must be made fully functional satisfying the above criteria,
within the next 6 months.
x
X
|
A
6. The mobile Health Units and PHCs in Tribal Areas should be made fully functional.
T
7
7. The Urban Family Welfare Centres and Health Centres under India Population Project VIII
should be involved in Comprehensive Primary Health Care.
A
2. Referral Services: Secondary and Tertiary Health Care
::
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X
2. All key staff, including Doctors / Staff Nurses/ANMs, and other essential staff attached to X
the Primary Health Centres must stay in the quarters. Where repairs are necessary they v
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.
X
A
A
¥
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Z
I
x
1. Complete the Secondary Care Institutions in progress under KHSDP (100 Secondary Care
Hospitals) in the next Six months and make them fully functional with adequate human
power, equipments and accessories. The OPEC Hospital in Raichur must be made
functional as early as possible. Work out effective linkages of Primary Health Care
Y
X
Institutions with the referral hospitals.
2. The eight districts in the State which do not have a Blood bank to have atleast one blood
bank each.
A
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xi
X
3. Laboratory Services
X
1. All laboratories must be staffed with trained technicians. Fresh appointees must be given
orientation training before posting and existing staff should be given refresher training.
2. The PHC laboratories must provide prompt and efficient service for the diagnosis of TB,
malaria, leprosy, RTI/UTI and other routine investigations.
3. Rs. 30,000/- per PHC to be initially earmarked for the purchase of Microscopes (about Rs.
15,000/-), equipments, glass ware, other accessories and reagents.
¥
x
I
4. Strengthening the Public Health System
1. A short two week course on Public Health principles and practice for Taluka and District
Health Officers at the State Institute for Health and Family Welfare. Short in-service
orientation courses on public health principles and programmes for PHC Medical Officers.
2. 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 Professional Associations.
II
5. Women and Children
1. The role of Dais in safe deliveries should be supported and training enhanced. Disposable
Delivery Kits of good quality and cost effective components should be provided.
2. Educate and promote personal hygiene especially during menstrual period by the
distribution of subsidised menstrual pads/cloth.
Ensure 24-hour Emergency Obstetrics Care Services at CHCs and Taluka Hospitals.
4. To involve FOGSI in RCH Programme at Bellary District.
5. To cater to the Newborn Care, the Anganwadi Worker to be trained to be the second
functionary.
■■
6. Health Human Resources Development
■
I
•
Y
Y
X
■
1. Moratorium on New medical, Dental, Nursing, Pharmacy and Physiotherapy colleges for
the next three years, (exception: Nursing Colleges in the underserved areas). No more
essentiality certificate or affiliation to be given. Where essentiality certificate or temporary
affiliation has been given but the College has not started functioning, the certificate and
affiliation to be withdrawn immediately.
2. Extend the moratorium on new Ayurvedic, Homoeopathy and Unani Colleges by another 2
years.
xii
?
Y
I
X
I
x
I
The State Institute of Health and Family Welfare to be upgraded. The Institute and RGUHS
together with VOs and experts should take up the training at all levels in Management,
Public Health and Ethics.
1
4. Increase the intake for the training of Auxiliary Nurse Midwives (ANMs) so as to fill the
vaccancies at the earliest. Encourage NGOs with the capacity for training to take up the
training of ANMs.
5. Every Medical and Dental College to adopt a block for service to the people of the area and
training of students.
7. Health Systems Management
X
X
1. All administrative posts to be filled up
I
2. A Vigilance Cell in the Directorate headed by the Commissioner for disciplinary action
y
4
against corruption, absenteeism and for speedy disposal of enquiries.
3. A transfer Policy to be evolved on the basis of well defined criteria, and implemented. Mis
match of professionals and service requirements to be addressed.
4. About 100 Doctors from the Department to be selected through a transparent “search-cumselection” mechanism with the assistance of the Task Force, given intensive training in
management and placed at the Directorate and DHOs Offices as Programme Managers.
5. Care will be exercised in the procurement, supply and making available all essential drugs,
operating the Rate Contract System rationally and effectively.
X
X 8. Health Information Management System
A
Y
1. An integrated Geographical Information System based HMIS to be initiated and
implemented.
I
2. Annual reports and monthly updated programme performance to be placed on website of the
Directorate for information.
¥
I 9. Law and Ethics
1. The legislation introduced in the Legislative Council to regulate the functioning of Health
Care Institutions should be sent to a Select Committee to elicit views from all concerned
(stake-holders, professionals and public).
¥¥
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10. Indian Systems of Medicine and Homeopathy
1. Plan and initiate action to have ISM&H wings in the existing District / Taluka hospitals.
l
I
II
J
xiii
J
X
11. Panchayat Raj and Empowerment of People
1. Training must be imparted to the new Panchayat members regarding their responsibilities
and duties, with respect to Health, Nutrition, Drinking Water and Sanitation, Population and
co-ordination with the health staff and need for monitoring health programmes.
iI
I
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X
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2. The Gram Panchayat should appoint a woman health functionary at Village where there is
no ANM/Anaganwadi Worker for the management of Health, Nutrition, Drinking Water
and Sanitation, Population. This could be initiated atleast in a few districts where Human X
Development Index is low.
¥
12 Strengthening Partnerships
I 1. Introduce a single window Voluntary Organisations Cell at the Health Directorate to co
ordinate the different programmes and simplifying procedures for grant-in-aid avoiding delays.
Commissioner to be the nodal officer.
2. Use the services of private practitioners and specialists where there is lack of such personnel in
the Government sector.
I
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v
¥
X
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l
Y
I
xiv
1.
Introduction
Changes in the Health System are essential to bring about equity and quality in the services,
which must be available and accessible to the people. The services must be cost-effective
and relevant.
For the health system to run efficiently and effectively, there is need for all the stake holders
- the people, the policy and decision makers, the care providers and others - to agree on a set
of fundamental values. We believe that the major value in Health Care is equity with
quality. This was the guiding principle for the call for “health for all”. We have to reflect and
decide upon the changes to be made in the Health System to uphold the values and meet
peoples’ needs. This is best done with the full involvement and participation of the
community.
The Public demands improvements in Health Care. Their dissatisfaction with the existing
system is clear from the large number of depositions by representatives of various
associations and still larger number of letters received by the Task Force. Valuable
suggestions have been received from the Honourable Minister for Health, the Honourable
Minister of State for Medical Education, the Principal Secretary for Health, the Secretary for
Medical Education and the Commissioner for Health. The Director of Health Services and
his senior colleagues who interacted with the Task Force, have brought forth the drawbacks
and problems and suggested changes. Their willingness to change augurs well for
improvement in equity with quality. The suggestions are many. Question: which way to go?
The Health Care System must accept accountability for the health of the people of the State.
The System must accept responsibility for the outcome and health status. How effective has
the system been in meeting the health needs of the people of the State? Has there been a
positive impact on the health of the people? Could it have achieved better results utilising the
same resources? Have we been addressing the Health Care priorities? The health system is
socially accountable for what they do and what they fail to do.
The implementers of the Health System, the 62,000 (sanctioned strength) members of the
Government health sector team, play a critical role, in the Medical and Health care of the 52
million people. Hence, careful attention needs to be paid to developing and improving their
morale, self esteem and self confidence; to inculcate a sense of pride in the quality of their
service. Strategies need to be developed by which their competence is increased. Recognising
that strong social forces of hierarchy, class, caste, gender and ethnicity underlie and cross cut
all technical interventions and health programmes, explicit planned efforts need to be made
so that the health team members, particularly Doctors and Nurses, gain an understanding of
the dynamics of the Indian Society.
-1 -
District Health Plans that are responsive to local health problems should be encouraged. An
integrated bottom up approach to health policy fits into the decentralised approach to
governance being developed through Panchayat Raj systems. It offers a greater opening for
active involvement of people, Community Based Organisations, Voluntary and Private
agencies in the Health Policy process of the State. Thus, we will move towards the goal of
Peoples Health in Peoples Hands and of Health for All, particularly the marginalised.
We need a health care system, which is equitable, need based, culturally acceptable, of good
quality, cost-effective and sustainable. It should benefit all the people of the State. The focus
is on Primary Health Care and Public Health. Improvement in Health Status calls for
committed action on the part of all concerned, both within and outside the health sector. The
Health Sector is to be responsible for Primary Health Care and surveillance for the control of
the outbreak-prone diseases, which forms one aspect of Public Health. Education, Nutrition,
adequate Safe Water and hygienic environment are critical elements of Public Health to
prevent disease and maintain health. These elements are outside the formal Health Sector.
The collaboration and co-ordinated complementary actions among all the relevant sectors are
fundamental to equity and quality in health.
-2-
2..
Disparities
Regional inequalities are said to be the legacy for the State of Karnataka. The Human
Development Index and Gender Related Development Index computed for the first time
(Human Development in Karnataka, 1999) for the 20 districts of the State bring forth the
clustering. This important process of documentation has thrown open the great challenge of
bridging the developmental gaps.
‘‘Uneven development in Health infrastructure and the delivery of the services in the
Northern districts of Gulbarga, Raichur, Bellary, Bijapur, Bidar and Dharwad have led to
poor health indicators for these districts” - Human Development in Karnataka, 1999. The
district Human Development Index, 1991 was lowest in Raichur followed by Gulbarga, Bidar
and Bellary. The Health Index (1991) ranking from the bottom was Bellary, followed by
Tumkur, Chitradurga, Shimoga and Dharwad. It is necessary to work out the various health
indicies disaggregated for the 27 districts, including 7 new ones. The disparities will be
greater if we consider the Talukas. There are also pockets of poor development and health in
the better-developed districts. All such areas need greater attention.
Amongst the principal and classical Health indicators are included Life Expectancy at Birth
(LEB), Infant Mortality Rate (IMR), Crude Birth Rate (CBR), and Crude Death Rate (CDR).
These also show disparities between districts.
In 1991, LEB in Karnataka was 62.07 years (60.6 years for men; 63.61 years for women) In
all districts LEB were higher for women than for men. Differences between LEB for men and
women varied from one district to another. It ranged from 9 years in Kolar and Hassan to
0.62 years in Bangalore Urban district.
In 1991 IMR was down by 7 points to 74 in comparison to 1981 levels At District level it
ranged from 29 in Dakshina Kannada to 79 in Bellary. The decline in CDR has been slow
over the last 3 decades. The districtwise estimates varied from 7 in Dakshina Kannada and
Shimoga to 10.7 in Gulbarga. The Crude Birth Rate in the 22 districts belongiing to the
Bangalore, Belgaum and Mysore divisions varied between 17 and 22, whereas it is between
27 and 30 in the 5 districts belonging to the Gulbarga division (Source: ISEC, Bangalore,
Rapid Household Survey- RCH Project, 1998).
In the eighties, the decadal population growth rate declined in all districts except Bidar,
Bijapur, Gulbarga and Raichur. The annual compound growth rates of these four districts
increased from 1.99% in 1971-1981 to 2.25% in 1981-91 suggesting that decline in mortality
has been more than decline in fertility.
-3 -
Health Care Facilities
There are differences in availability of Health Care facilities in the different districts. In
1996-97 the population per bed in government medical institutions in Karnataka was 1166,
and the ratio varied from 395 in Kodagu to 2330 in Raichur district.
There is a need for improvement in Health management especially in the Northern districts
where poor management is compounded by large number of vacancies and the less aware and
less articulate population.
Facilities and services available in primary level health care institutions are not fully utilised
and secondary and tertiary level hospitals are overcrowded. It is estimated that nearly 1/3 of
the patients who are currently treated at tertiary level hospitals could well be treated at lower
cost in first referral units.
In Bangalore (Urban) District, Belgaum and Dharwad the number of private medical
institutions is higher than the number of public medical institutions. The number of private
hospital beds is less than the number of public hospital beds except in Bijapur, Dharwad and
Dakshina Kannada districts. The number of private hospital beds is quite high when
compared to number of public hospital beds in Dakshina Kannada (7334 against 2787)
Among different social groups, it remains a matter of concern that there has been no
concerted effort at reducing morbidity and mortality rates among the marginalised (scheduled
caste and tribal populations).
In 1995-96, the Couple Protection Rate in Karnataka was about 57%. The proportion varied
from 41% in Raichur to 73% in Mandya. In 1992-93, 6.9% of married women in
reproductive age group were effectively protected by spacing methods (5.8% IUD and 1.1%
Oral pills) and 1.7% of men with wives in childbearing age were using condoms. Between
1956 and 1995-96 the proportion of vasectomies was only 13%.
Gulbarga Division comprising districts of Bellary, Bidar, Gulbarga, Koppal and Raichur,
along with Bijapur in Belgaum division tends to be most backward in terms of Demographic,
Social and Health indicators.
RELATED ISSUES AND CONCERNS
•
An important determinant of health is female literacy. The state average is 44.3%. But it
shows great variation between districts. While Bnaglore (Urban), Dakshina Kannada,
Udipi and Kodagu show female literacy rates above 60%, it is as low as 21.7% in
Raichur, 22.8% in Koppal, 24.5% in Gulbarga and 28.6% in Chamarajanagar. The
differential in literary rates is highest in rural areas. Rural female literacy for the State is
-4-
as low as 35%. The districts of Gulbarga and Raichur have rural female literacy rates
lingering at around 16%. Female literacy in the two remaining districts of Bellary and
Bidar in Gulbarga division is also only marginally above 30%. It is a matter of concern
that the districts of Belgaum, Bangalore Rural, Kolar, Mandya and Mysore too have
female literacy rates below the country average of 39%.
«-
Analysis of the growth of per capita district income in real terms during the eighties
shows that the annual percentage increase, in per capita income was less than 2% in
Bidar, Chitradurga, Kodagu, Mandya, Raichur, Shimoga, and Uttara Kannada whereas it
was between 4 and 7% in Bangalore, Belgaum, Bijapur, Dakshina Kannada and Kolar.
•
76% of workforce is in rural areas. Despite growth in urban job opportunities, the
proportion of the labour force still dependant on low-income-rural-employment is high.
Women appear to be replacing men in rural jobs (low and agricultural) consequent to
migration of men to towns for better paid employment.
®
One of the most important factors is the higher poverty level (lower purchasing power).
The percentages of people below poverty line in some of these districts were Bidar 56%, Dharwad - 50%, Kolar - 48%, Gulbarga - 45.5% and Bellary - 44.5%. Bijapur and
Raichur which are identical to Gulbarga and Bellary in many deprivation indicators seem
to have lower Poverty ratios. The National Sample Survey has found that meeting
expenses for medical care is an important cause of indebtedness. Hence, providing
access to good quality health care services by the government can help to reduce the
poverty spiral and help in development.
GENDER ISSUES
•
Most districts in the State have unfavourable Sex Ratios and these are not necessarily
only in northern divisions of Gulbarga and Belgaum. What is more disturbing is the
decline in the over all Sex Ratio from 963 in 1981 to 960 in 1991.
•
The Infant Mortality Rate for females has only marginally improved for the State from 74
in 1981 to 72 in 1991. The ratio was highest in Dharwad district. Bellary, Bidar and
surprisingly Shimoga were above the State average. The lowest was in Dakshina
Kannada.
•
Age Specific Mortality Rates show that 26% of deaths of women were between ages of
15 and 34 in comparison to 15% amongst men.
•
The mean age at marriage for girls is low in the districts of North Karnataka especially
Bidar, Gulbarga, Raichur, Bijapur and even Belgaum (lower than Bellary)
•
Utilisation of health services by women is poor, and this issue is closely linked to low
status of women, the lack of public health education and the glaring physical inadequacy
of hospital services required by this group of users.
•
The four districts of Hyderabad Karnataka region and Bijapur district in Belgaum
division still have very high fertility rates. The participation of men in birth control is
almost non existent.
•
Lack of access to credit for women particularly from formal financial institutions has
been well documented.
•
Crimes against women including routine violence are heavily underreported. The police
and formal legal system are clearly not seen as useful by women, for justice and
redressal.
-6-
3.
Primary Health Care
The focus of the Task Force has been on Primary Health Care and Public Health. Primary
Health Care is essential health care, universally accessible and acceptable with community
participation and includes health promotion, prevention and rehabilitation and management
of common diseases, at affordable cost.
Primary Health Care can succeed only with involvement and empowerment of the people.
The Panchayat Raj experiment has been ushered in Karnataka to bring about decentralised
governance. This can bring in the much needed Community Participation under Primary
Health Care.
Primary Health Care is channelised mainly through Primary Health Centres (and the sub
centres) and Community Health Centres, which are the first referral Units. A good referral
system is necessary for the success of Primary Health Care. There are a large number of
vacancies of laboratory technicians. Simple laboratory investigations are necessary for
effective Primary Health Care.
It is recognised that the Private practitioners belonging to the different systems of Medicine
are most often the first contact for health care
3.1 RURAL HEALTH
Strengthening Primary Health Centres and Sub centres
Improvement in the functioning of the Primary Health Centre is a must for Primary
Health Care. Though there is sufficiency of the number of centres, according to the
prescribed norms, there is need to improve the efficiency and effectiveness. There is
also a need to ensure proper distribution of these centres.
Recommendations:
All vacancies of Doctors, Laboratory Technicians and A.NMs must be filled up
immediately.
2.
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.
J.
The allotment for Essential Medicines (including Life Saving Medicines) must
be increased by atleast Rs. 25,000/- per annum per PHC. All Essential drugs
must be available at the PHC at all times.
-7-
4.
Every PHC must have a Telephone.
5.
Atleast 1000 PHCs in the State must be made fully functional satisfying the
above criteria, within the next 6 months.
3.2 URBAN HEALTH
Primary Health Care in Urban areas have been neglected. Urban Health is not better
than Rural health, as far as the poor are concerned. Disaggregated health indicies show
that often the health of the Urban poor (in the slums or scattered through the towns and
cities) is often worse; the averages are better because of the health status of the affluent.
There is need for comprehensive health care, especially in the slums, where the people
do not have the social support which is present in the rural areas.
The Urban Family Welfare Centres and the newer health centres under IPPVIII (in
Bangalore City) concentrate on Family Welfare, neglecting Primary Health Care, even
though the job descriptions of the Lady Medical Officers in-charge of these centres
include promotive, preventive and curative care.
Medical care at the First Contact level is provided mainly by Private Practitioners
(present in relatively large numbers) and also by the Teaching and other Hospitals and
Nursing Homes in the Cities and Municipalities. But this is not comprehensive Primary
Health Care.
The different Health Centres within the urban areas under the Municipalities and
Corporations function independently of the Directorate of Health Services. There is
need for better co-ordination for efficiency and effectiveness.
Recommendations:
1. The Urban Family Welfare Centres and Health Centres under India Population
Project VIII should be involved in comprehensive Primary Health Care.
3.3 REFERRAL SERVICES:
Secondary and Tertiary Health Care
Primary Health Care requires the support of Referral Centres (Secondary and Tertiary)
tor its effective functioning. Primary Health Care looks after common ailments. Other
conditions require more specialised care which are provided by Taluka, District,
-8-
i
Teaching and Speciality Hospitals. The success of Primary Health Care depends on the
referral system. This should be made responsive to and responsible for the care of the
referred subjects.
Recommendation:
1. Complete the Secondary Care Institutions in progress under KHSDP (100
Secondary Care Hospitals) in the next six months and make them fully functional
with adequate Human power, equipments and accessories. The OPEC Hospital in
Raich ur must be made functional as early as possible. Work out effective linkages
of Primary Health Care Institutions with the referral hospitals.
3.4 EMERGENCY HEALTH SERVICES
Provision of emergency services can prove to be life saving or avoid life-long misery.
Emergency services
• Provide immediate relief to patients with acute medical, surgical, obstetric or other
emergencies,
® Manage accident and poisoning victims, and
• Attend to medico-legal problems.
Recommendations:
1. Improve the capability of the Health Care Personnel at PHC to attend to
emergencies. The Emergency services should cater to all emergencies, including
Obstetric and Gynaecological cases, poisoning cases and Dog and Snake bites.
Polyvalent anti-Snake Venom Serum must be made available at all PHCs at all
times as a life saving measure.
2. Well-equipped Ambulance Vans with well-trained 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. SGARRC and NIMHANS to be the nodal Centres.
3.5 LABORATORY SERVICES
Health care, at primary and higher levels, depends on diagnostic quality which in turn
requires laboratory tests in specific instances. The tests appropriate for primary and
secondary levels have been defined. Unfortunately most of the laboratories attached to
the Primary Health Centres are non-functional, because of lack of trained laboratory
technicians and equipments, such as Microscopes and reagents. It is essential to ensure
-9-
that every laboratory has a working oil immersion microscope, necessary glass-ware
and accessories and reagents.
Recommendations:
1. Ail laboratories must be staffed with trained technical persons and equipped with
the necessary instruments, accessories and reagents. Fresh appointees must he
given orientation training before posting and existing staff should be given
refresher training.
2. The PHC laboratories must provide prompt and efficient service for the diagnosis
of TB, malaria, leprosy RTI/UTI and other routine investigations must he
available.
3. Rs. 30,000/- per PHC to be initially earmarked for the purchase of Microscopes
(about Rs. 15,000/-), equipment, glassware, other accessories and reagents.
3.6 BLOOD BANKING AND TRANSFUSION SERVICES
The Supreme Court initiative and revision of the Drug Control Act & Rules for blood
banks have sought to ensure blood safety & bring quality in Blood banking &
Transfusion Services. But the sudden transition to stringent norms is a cause for
concern. The lack of access to licensed blood banks especially for patients in remote &
peripheral areas, has resulted in blood not being available and therefore denial of a life
saving intervention.
There is an unequal distribution of blood banks (Bangalore has 40, many districts have
only one each and 8 districts do not have even one). Setting up of and licensing of new
blood banks should address regional disparities.
There is an inadequate voluntary donor base. NGOs have taken a proactive role in the
voluntary blood donation movement.
There is sub-optimal and irrational use of blood.
Recommendations:
1.
The eight districts in the State which do not have a Blood bank to have atleast
one blood bank each.
2.
A study to be initiated and concrete proposal(s) to be developed to ensure and
make available safe blood to the needy in the districts. The proposal to also
review the existing guidelines and their feasibility. A representation to be made
by the State Government to the Government of India in this regard.
- 10-
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1.
Possibility of having doctors of ISM&H to be incharge of some of the PHUs.
2.
Having some selected and willing NGOs to manage the PHCs.
3.
Improving the linkages of Primary Health Care Institutions with Secondary
and Tertiary care institutions.
4.
Study the organisation of Urban Primary Health Care under Corporations and
Municipalities and Integration / Co-ordination with the Directorate of Health
and Family Welfare Services.
5.
Quality Control of Diagnostic Laboratories.
6.
All Health Care Institutions PHCs and above to have Health Advisory
Committee, including representatives of VOs and representatives of Health
Professional bodies (other than the Board of Visitors).
7.
Working hours of the Health Care Institutions to suit community needs.
8.
User fees and their utilisation.
9.
Setting acceptable standards for Primary Health Centres, Community Health
Centres and other Health Care Institutions.
10.
Training in First Aid and Cardio-pulmonary Resuscitation.
11.
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 the help of NGOs.
12.
The medical community should be sensitized to make optimal & rational use
of blood. Every hospital should have a blood transfusion committee to ensure
this.
13.
Pilot projects to study the logistics management and monitoring of the 3-tier
system of - Component Center-District blood bank-blood storage unit should
be initiated.
14.
Establishing Zonal Blood Component Separation Centres.
15.
Round-the-clock Services at PHCs with resident Lady Medical Officers.
- 11 -
4.
Public Health
Public Health is the Health of the Population, achieved by improved life style, good nutrition,
water supply and sanitation, maintenance and improvement of the environment and reduction
and removal of risk or causative factors of diseases and an appropriate and immediate
intervention, should there be an outbreak of the disease.
The government has accepted the responsibility to take measures to improve the health and
well being of its citizens through the Constitution and various Policy measures. Amongst the
sub divisions of Public health are:
• Nutrition
• Drinking water supply
• Sanitation and Waste Management
• Communicable Diseases
• Non-communicable Diseases
The State government adopted the strategy of providing the Basic Health Services through
the Health Centre concept, providing comprehensive preventive, and curative services.
Promotive and rehabilitative services which are an integral part of Comprehensive Health
Care have not yet been adequately addressed.
4.1 STRENGTHENING THE PUBLIC HEALTH SYSTEM
Human Resources for Public Health
A major drawback noticed by the Task Force was the lack of public health
qualifications and expertise among staff managing public health programmes at State,
district and taluka levels. Promotions, too, are based on seniority and not on
competence for the task. There are mismatches between personal qualifications and the
job. For instance a gynaecologist may be a District Malaria Officer, or a surgeon a
District Health Officer. Public Health is mistakenly perceived to be administration
which supposedly any doctor is capable of carrying out. It is essential that the persons
appointed to carry out Public Health activities have the necessary expertise and
experience.
Recommendations:
1. A Short two-week course on Public Health principles and practice for Taluka and
District Health Officers at the State Institute for Health and Family Welfare.
Short in-service orientation courses on public health principles and programmes
for PHC Medical Officers to be run by the State Institute in collaboration with
District Training Centres.
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Structural Issues in the Public Health System
Integrated approaches
For historical reasons a number of vertical national health programmes were developed
to address major public health problems. Each developed their own systems of service
delivery, recording, reporting, supervisory control and resource generation. In the
1960s, the Ministry and Department of Health were split into two, for health and family
welfare respectively.
These factors have resulted in a fragmentation and
compartmentalisation of the health system, with duplication of reporting systems.
Though the Kartar Singh Committee in the 1970s recommended integration, this has
not occurred in spirit or in action. There are still multiple sources of funding and of
systems. Referral systems too are still ineffective.
Recommendations:
1. A review of the Externally Aided Projects to be initiated to facilitate their
absorption into the Health System. Sustainability and consolidating the gains /
achievements to be the primary objective.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Qualifications in Public Health to be a requirement for Taluka, District, Divisional
and State level Health Officers of public health programmes.
2. Health Administration and Management courses for senior health staff.
3. All public health posts to be made full-time posts without private practice. A
suitable allowance equal to one third of basic pay to be given. For good
comprehensive care, including public health care at the Primary Health Centre
level, it is necessary for Primary Health Centre medical officers to also be fulltime with adequate compensation.
4. State level posts for public health programmes to be filled by selection, based on
qualification and competence, and not by promotion on seniority alone.
5. Health manpower planning policies to develop people for senior selection posts.
6. Medical colleges in the State to be made partners in the public health training of
government staff.
7. Evolve a comprehensive health policy.
8. Integration of the departments of Health and Family Welfare.
9. Evolve mechanisms to strengthen integrated functioning of health personnel,
even though they are paid under different programme heads.
10.The referral system to be improved on a district-wide basis and to be renewed
annually, with indicators to be developed.
- 13 -
11. The Department of Health and Family Welfare to collaborate with the Ministry of
Rural Development and Panchayat Raj, Urban Development and with the
Institute for Social and Economic Change and NGOs to
© Develop training modules on water supply, sanitation and health for elected
local body members.
• Organise Training of Trainers on Panchayat Raj and Health for all districts.
® Create IEC materials for the general public on the public health powers and
functions of local bodies. Wide dissemination of this information through mass
media.
12. Special training for building community capacity regarding Panchayat Raj and
Health, including microplanning, for NGOs, CBOs and leaders of community
groups such as Mahila Sanghas, Yuva Sanghas etc.
13. The role of Public Health Institute, Bangalore and State Surveillance Centre,
Bangalore
4.2 NUTRITION
An issue of concern is the continuing high prevalence of mild to moderate malnutrition
among all segments of the population. Under-nutrition affects the growth and
development of the child and the health of all at every age.
Exclusively breast fed infants grow optimally till about 5 months and upon weaning
slacken for weight and height gains in comparison to the nationally accepted norms. At
6 months, about 15% infants are underweight for age and this proportion rises to 65%
by 4 years. Although the prevalence of severe malnutrition in the community is low, the
high prevalence of mild and moderate undemutrition and micronutrient deficiencies,
particularly that of Vitamin A and iron, are of serious concern. Such undernutrition has
long term deleterious consequences for physical and intellectual growth and
development. Girls who have gone through this path tend to give birth to low birth
weight babies, thus perpetuating this adverse cycle.
Undernutrition predisposes to increased severity and increased case fatality of common
infectious diseases including measles, gastroenteritis and lower respiratory tract
infection. In summary, ensuring optimal nutrition during infancy, preschool age,
school age and adolescence is one of the most crucial determinants of the survival,
health, growth and development of individuals in the community. The provision of
food and ensuring food and nutrition security and just distribution of food are concerns
of the Health Sector. One of the defects that requires remedy is the relatively high price
of pulses and oils. For the not-rich population, pulses and oil are the main source of
protein and fat respectively; their deficiencies are the major reason tor calorie
deficiency and undemutrition in general. The Government must take a broad view of
- 14-
these issues and ensure effective and coordinated action to fulfill the nutritional security
of growing children and adolescents. The Health Sector must give critical support in
defining nutritional norms, defining and monitoring norms of nutrition and growth, and
in providing health education.
Recommendations
1.
2.
3.
4.
Define and establish the items of coordination between the Health Sector and
ICDS. These must include
(a) A mechanism to detect, take corrective steps and monitor children with
mild to moderate undernutrition,
(b) Coordination in detecting and treating infectious diseases in children,
especially diarrhea skin and ear infections with appropriate care.
Weaning foods for Infants and children above Six months to be made available
under the ICDS scheme.
Systematic promotion of kitchen gardens supported by seed/seedling supply.
Drumstick, Chakramuni (Chikermane), 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 the Nutrition programmes.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Education of mothers, health check ups of children and training to Anganwadi
teachers regarding Nutrition and Health.
2. Increase supplementary food supply to pregnant women.
3. Create avenues of Nutrition education and awareness creation to all, in particular
to women.
4. Encourage and popularize nutrition mixes for supplementation. Locally available
and familiar food grains (eg. Ragi), pulses, millets, cereals, ground nut, jaggery
and vegetable oils should be used. These may be home mixed, or locally
produced as projects under Mahila Mandal etc. CFTRI advice to be sought.
5. Enhance the production of Ragi, Jowar and Pulses and their distribution through
the Public Distribution System.
4.3 WATER SUPPLY AND SANITATION
The second most crucial determinant of health (by way of absence of disease),
conservation of nutrition (due to prevention of disease) and
prevention of
undernutrition (by way of avoiding the negative energy/nitrogen balance of illness), is
- 15 -
\l
the provision of adequate safe drinking water and sanitation to prevent pathogen
contamination of the environment by avoiding fly menace and mosquito breeding. The
environment, especially water, may act as a vehicle for chemical toxins. Northern
Karnataka has the recognized problem of bone fluorosis, a debilitating disease due to
excess fluoride in well water. Unless specifically tested for, we may not even know
about some toxins (eg. Insecticides, arsenic etc.) The Health Sector must define norms,
develop monitoring techniques and processes and apply them in all communities. The
Government must evolve a coordination mechanism to ensure regular and routine
monitoring and ensuring corrective steps when deficiencies are detected.
Sewerage systems and measures for environmental sanitation are very inadequate
particularly for the rural population and the urban poor.
Recommendations
1. 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
Taiaka Medical Officers should visit all sources of drinking water periodically.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Mechanisms for intersectoral co-ordination between Ministeries/departments for
rural and urban development, water supply and sewerage boards, and pollution
control boards.
2. Gram Panchayats and Municipal Bodies to be activated regarding their
responsibilities and powers for provision of water supply and sanitation.
4.4 WASTE MANAGEMENT
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.
Three waste streams have been identified for better management. They are Industrial
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.
- 16-
Enlightened citizens coupled with Judicial activism have ensured that due attention is
paid towards this neglected issue. 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, modernisation of transport
vehicles.
Efforts are currently on to implement systems for safe management of health care waste
in all the secondary care hospitals under KHSDPas also by private, voluntary and
corporate hospitals. The concern of environmental pollution because of each and every
institution attempting an incinerator system is being addressed. The solutions have been
towards common health care waste management facilities.
Co-operative endeavours need to be proactively encouraged. 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
1. Ensure proper segregation of Waste and total waste management at all health
care institutions,
2. All health care institutions including Primary Health Centres and General
Practitioners Clinic, should develop a policy and action plan for safe
management of waste generated in their premises. The segregated waste
streams should not get mixed up with general solid waste.
3. Initiate orientation and training of Health Care Personnel for proper waste
management practices including practice of Universal Precautions.
4. The government should support initiatives for common waste management
treatment facilities.
5. A Sanitary Landfdl site must be identified for all Towns and Cities by local
bodies, with assistance of the Health Department.
- 17-
II
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Incorporating aspects of Safe Management of Health Care Waste into the
curriculum for all health sciences
2. Safe Management of Health Care Waste to be incorporated into the training
courses at the State Institute of Health and Family Welfare and the District Health
and Family Welfare training Centres
3. An Action Plan for an integrated waste Management plan which incorporates
Segregation as a primary component and includes strategies for Health Care
Waste to be developed in partnership with the Stakeholders and the
Neighbourhood groups.
4. Health Impact Assessment to be part and parcel of Environment Impact
Assessment for all Industrial Projects.
4.5 COMMUNICABLE DISEASES
Due to their importance in affecting the health of the people and causing death, disease
and disability several national programmes have been established to control, eliminate
or eradicate specific Infectious Diseases, namely National Leprosy Eradication,
National Tuberculosis Control, National Anti-malaria, National Filaria Control and
National HIV / AIDS Control, National Guinea worm Eradication and National Polio
Eradication. In addition, the National Immunisation Programme aims to control the
cluster of diseases together called vaccine preventable. The burden of infectious
diseases does not seem to be declining satisfactorily, inspite of our efforts.
A number of Infectious Diseases that were at one time very common in developed
countries but were controlled by the systematic application of public health principles,
actions and interventions, are still prevalent in Karnataka. They include faecal-oral
transmitted via water or food (cholera, typhoid fever, dysentery, hepatitis A, E), vector
borne (Malaria, Filariasis, Japanese Encephalitis, Dengue Fever), animal to human
transmitted (Rabies, Brucellosis, Leptospirosis, Cysticercosis), and person to person
transmitted (tuberculosis, sexually transmitted diseases). We have not been able to
eliminate or even control them, either due to non-application ofpublic health principles
or actions, or in spite of disease specific control programs, which are not being applied
efficiently.
On top of this burden, new (emerging) or resurgent Infectious Diseases are also posing
a threat to the health of the people. The most important among them is HIV / AIDS,
which appeared first in 1987-88 and since then it has been slowly but relentlessly
spreading.
- 18-
|
The occurrence (prevalence) of an exogenously transmitted Infectious Diseases such as
cholera, typhoid fever, malaria is already evidence for the silent phenomena of huge
numbers of the microbial pathogens (amplification) and of patent pathways of
transmission. The occurrence of at least one more epidemiologically linked case is
warning that an outbreak is potentially in the making. Immediate actions (to diagnose
the infection and the transmission pathway, and to prevent further transmission) are
necessary to prevent a larger outbreak. This requires a dynamic disease surveillance
system, the infrastructure to investigate (microbiologically and epidemiologically) and
the skills to define, design, apply and evaluate specific interventions successfully. Such
system / infrastructure, essential for public health, is absent in Karnataka.
4.5.1 Vector Borne Diseases
The heavy burden of malaria could be noted from the documented numbers of cases
in Karnataka. In 1997, under the government health system 7,304,866 fever cases
were tested with blood smear microscopy and 161,775 cases of malaria (including
39,877 Pfalciparum') were diagnosed. In addition, in 8 urban populations 103,671
fever cases were tested in 1997 and 12,548 cases (382 Pf) were detected. In 1988 the
numbers of malaria detected were, rural 107,910 (23,469 Pf) plus, urban 7,521 (598
Pf). Malaria is not under control and unlike in the past, it is prevalent in urban
populations as well as in rural populations.
Kyasanur forest disease is peculiar to Karnataka (Shivmoga, Uttara and Dakshina
Kannada, Chikmagalur). Other vector borne viral diseases include Japanese
encephalitis (JE), dengue fever and dengue haemorrhagic fever / shock syndrome
(DHF/DSS) and West Nile virus disease. During 1999, outbreaks of JE were
confirmed by laboratory confirmation of cases in the districts of Bellary, Raichur, and
Kolar. JE is known to occur in the districts of Chitradurga, Koppal, Mandya,
Bangalore urban and rural. In 1997 there was a large outbreak of DF and DHF / DSS
in Bangalore urban and rural and Kolar. In the same year DHF / DSS became
recognized by the public on account of the media attention of an outbreak in Delhi.
4.5.2 Tuberculosis
In 1998 the estimated target for new TB cases to be detected in Karnataka was 70,284
but the achievement was only 55,557 (79%). Even this figure might be an
overestimate since the number of sputum smears examined was only 236,175 (30%)
against a target of 782,172. In 1999 first quarter, the achievements were even lower
with 11% sputum examination and 26% case detection.
4.5.3 Immunisation
The reported achievements of childhood immunizations in 1997-98 have been above
100% for BCG, DPT, and OPV: for measles vaccine it was 94%, the TT coverage for
- 19-
u
pregnant women was also over 100%. However in the absence of a disease
surveillance system, combining information from govt, sector and private sector
health care systems, the degree of reduction of vaccine preventable diseases cannot be
ascertained. Alternate independent information indicates that the achievement in
childhood immunization in Karnataka is below 80%.
4.5.4 Food and Water Borne Diseases
Karnataka is endemic for cholera / gastroenteritis, with annual seasonal increases
around monsoons. Indeed ‘cholera combat teams’ have been established and located
in Gulbarga, Bijapur, Chitradurga, Bellary and Mysore districts. During 1998, 501
deaths due to gastroenteritis and 2 deaths due to cholera were documented. The
number of reported cases of acute viral hepatitis was 2520 (2 deaths) and typhoid
fever 842 (4 deaths). The above statistics are based on information received from
within the government health care institutions.
4.5.5 Worm infestations
The two principal Helminthic infestations are Round Worm and Hook worm. Their
burden and the impact on health are largely underreported. Their contributions in
accelerating malnutrition (PEM and Nutritional anaemia) is well documented. The
Primary Prevention methods have been successful whenever implemented in full.
There is thus an urgent requirement to provide for Safe Drinking water, Sanitary
disposal of human excreta and health education for better personal hygiene and use of
latrines
4.5.6 HIV/AIDS
The Human Immunodeficiency Virus (HIV) and cnsequent disease of AIDS have
been slowly but steadly speeding in Karnataka since the late 1980’s. The predominant
mosde of transmission is multi partner heterosexual contact. After the intorduction of
Blood safety measures, spread through unscreened transfusion has declined markedly.
Currently, the main concern is the spread of HIV infection to mongamously married
women who get infected from their promiscuous husbands. Mother to infant (vertical)
transmission is now being recognised. The National AIDS Control Organisation and
the Karnataka AIDS Control Society have been mainly responsible for data collection
and programme planning and implementation.
The age spectrum of HIV infection is another cause for concern. Youth are
increasingly seen to be infected. Future interventions need to be addressed at enabling
youth to adopt safe behaviour with regards to STI and HIV.
-20-
4.5.6 Other Infectious Disease
There are a number of other infectious diseases which affect our people, but they do
not get attention from the system. For example Acute respiratory infections including
pneumonia (1,912,650 episodes and 215 deaths reported in 1993 ), rabies (40 deaths
in 1990, 34 deaths in 1993) sexually transmitted diseases (11,949 cases of syphilis
and gonorrhea in 1995 ). Acute rheumatic fever and chronic rheumatic heart disease
are important causes of disability and premature death. The frequency of bacterial
meningitis, leptospirosis, Brucellosis, Rickettsial fevers, melioidosis remain
unrecognized. The extent, nature and pattern of hospital acquired (nosocomial)
Infectious Diseases remain largely unrecognized. Antimicrobial sensitivity and
resistance patterns of major infectious agents are tested in many institutions, but such
information and data are not monitored constantly and the responses and remedial
measures developed and applied are not evaluated.
It is evident that the several of the National Health Programmes are either not
succeeding or are actually faltering. Each programme deserves to be evaluated and
remedial measures identified and applied. In this context, the State must take the lead
and initiate to undertake the endeavour to identify and suggest the remedial measures.
Recommendations
7. 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.
2. 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
Professional Associations.
3. Choose one model of Communicable Disease surveillance (in contra-distinction
to HMIS) after considering the model developed by KHSDP.
4. Every school must have facilities for Safe drinking water and latrines. Proper use
of latrines must be inculcated at the school level itself
5. Periodic deworming and correction of the Nutritional anaemia (by providing
supplementary Iron tablets) for pregnant and lactating mothers, women, children
and adults.
-21 -
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Make all Taluka and District Hospitals fully functional to diagnose and manage all
communicable diseases.
2. Malaria and other Vector Borne Diseases: Review the VCRC Recommendations
for Bangalore City and follow up for implementation.
3. A comprehensive action plan to be prepared within 6 months for Rabies control.
Train relevant personnel on rational use of Anti-Rabies Vaccine. Ensure strict
licensing and immunizing of pet animals in every town and / or city. Public
education is urgent.
4. Establish one Integrated model of Disease Surveillance after examining the
KHSDP Model
5. Develop a proper training system for Taluka Health Officers
6. Computerise every District Health Office and later Taluka Health Officers for
Disease surveillance.
7. Every house must have a mechanism for sanitary disposal of excreta
8. Study the logistics for newer Vaccinces for children
4.6 NON-COMMUNICABLE DISEASES
Non-communicable diseases form a large group. Most of them do not have a cure but
we can alleviate pain and suffering by judicious management.
There is a constant increase in the incidence of non-communicable diseases: longer life
span unhealthy life styles, increasing stress and strain-all lead to increased incidence.
Amongst the diseases to be tackled include diabetes mellitus, hypertensioncardiovascular dieseases and cancer (such as cervical, lung, oral, gastro-intestinal). Others
include goitre or other thyroid disorders, diseases of the lung including asthma and
chronic obstructive pulmonary disease.
4.6.1 Diabetes mellitus
The incidence of diabetes is on the increase. Even taking the incidence as low as one
percent, Karnataka will have as many as five lakh people, suffering from the disease
and its complications leading to kidney, eye and other problems. The disease has to
be detected early to prevent complications.
The State does not have a well-recognised centre to educate, guide and manage the
people problem. Very few the medical colleges have this speciality developed to any
extent.
-22 -
Recommendations
/. A ll PHCs to have facilities to detect and manage / refer patients with Diabetes
2. Secondary Care hospitals should have physicians re-oriented for the
management ofpersons with diabetes and their complications together with the
needed anti-diabetic drugs, including insulin.
4.6.2 Hypertension and Cardio-vascular Diseases
The incidence of high blood pressure is high. It may occur along with diabetes.
Hypertension can cause various complications such as heart disease, kidney disorders,
etc.
Ischaemic Heart Disease is a leading cause of death. Atherosclerosis is the underlying
cause of most of Ishcaemic cardiac events . It can result in Myocardial Infarction,
Congestive Cardiac Failure, Cardiac Arrythmias and sudden Cardiac death. The Risk
increases with age, smoking, hypertension, diabetes and high cholesterol.
Recommendation
1. All PHCs to diagnose hypertension and risk factors for Cardio-vascular
diseases and manage / refer patients as necessary.
4.6.3 Mental Health and Epilepsy
Mental health problems are increasingly being recognised as manageable. Persons
with mental illness can be treated effectively and they can lead a productive life in the
society.
Mental health problems include psychotic problems, depressive disorders, alcohol
related problems (medical and neurological, accidents and sociological) and neurotic
stress related and adjustment problems. People attending the outpatients often have
somatoform disorders and suffer from subjective distress; they come with multiple,
vague symptoms.
While the majority of the persons with mental illness can be managed at the primary
health care level, there is also need for specialised departments and institutions.
Karnataka Institute of Mental Health, Dhanvad is the only State government run
mental hospital. Even this has now become a part of the Karnataka Institute of
Medical Sciences. The conditions there are poor. It is necessary to maintain the
Institute of Mental health as a major State speciality Hospital. Its structure and
functioning need considerable improvement. The Task Force awaits the report of the
review committee set for up for this purpose. The other major institution is the
-23 -
National Institute of Mental Health and Neurosciences, Bangalore. This is an
autonomous institution and is doing very good work. A good proportion of the
patients is from the State.
The departments of Psychiatry in the Medical Colleges are very weak, with the
exception of two or three private medical colleges.
Epilepsy is more common than thought of and can be managed effectively. Hot water
epilepsy is very common in Mysore plateau region and needs special attention. Early
diagnosis based on clinical methods and regular treatment by Primary Care
Physicians using inexpensive drugs like Phenobarbitone and Phenytoin can
effectively control epilepsy. What is required is the need to ensure supply of
medicines without break.
Recommendations
L The Community based Mental Health Programme in Bellary District should be
strenghtened.
2. 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.
3. Improve the facilities and conditions in the Karnataka Institute of Mental
Health, Dharwad, which should continue as the major speciality institute with
autonomy in governance.
4.6.4 Cancer Control
With the increase in Life expectancy, Cancer is becoming a major Public Health
problem. Cancers are said to be the 3rd 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 higher incidence of cancer in female is due to the greater proportion of Cancer
Cervix and Breast cancer. With the increasing trend of using Tobacco in the form of
smoking and Gutka especially by men, oral, oesophageal and lung cancers are more
commonly encountered.
There is a need for looking into the magnitude of the problem of cancer in Karnataka
in a broader perspective of utilisation of existing and available facilities. A
combination of lack of awareness, economic condition, fear of disease, inadequate
diagnostic facility has resulted in presentation of these cancers in advanced stages.
-24-
At present only 1/3 of the Cancer cases are being treated in the different facilities.
There is a need to establish more Cancer treatment facilities with low cost, high
quality care. Involvement of the Non-governmental agencies is very crucial.
Recommendations:
1. Downstaging of Cancer Cervix programme to be initiated on priority,
2. A model comprehensive Cancer Control Pilot Project to be initiated at Mandya
district,
3. Director, Kidwai Memorial Institute of Oncology, Bangalore to be ex-officio
Joint Director (Cancer Control)
4.6.5 ORAL HEALTH
Dental caries, poor peri-odontal health and oral cancer are common in Karnataka. It
is necessary to tackle them for improved health. There are dental clinics in the
district and many of the taluka headquarters.
Community Dental Health Programmes can improve dental health
There are belts of fluoride in drinking water in many districts. These affect the teeth
in addition to the bones.
Recommendations
1.
2.
All Taluka hospitals to have qualified dental surgeons.
Principal, Government Dental College to be ex-officio Joint Director (Dental
Health)
4.6.6 OCCUPATIONAL HEALTH
Every occupation carries with it inherent health hazards. In addition, accidents occur.
These add on to the other common health problems. The occupational health hazards
can be controlled.
The largest number of persons are involved in agriculture. There is increased use of
pesticides to protect the crops. All pesticides are poisonous. With the pests
developing resistance, the dose of pesticides and the harmful effects increase,
affecting the workers directly and indirectly, in the factory and the field. There are
pesticide residues in the food chain, water and soil affecting all the people.
Agricultural workers are often affected by ergonomic problems in the use of tools.
Exposure to biological agents add to the adverse effects.
-25 -
Sericulture is the source of employment for a large number of people in the State.
Karnataka is the leading producer of silk in the country. Allergic manifestations such
as breathing problems and skin disorders are common in those involved in the
industry.
Beedi industry involves large numbers of men, women and children. The tobacco
contained in the beedi affects their health
Silicosis is common in the workers in the granite and related industries
Many people are involved in Poultry rearing. It has a number of health hazards.
There are many large, medium and small factories in manufacture and fabrication.
Many chemicals like Lead, Zinc, Nickel, Cadmium and Chromium are involved.
Many of these industries also produce high levels of noise, which can affect hearing.
There are many laws designed to reduce occupational health hazards but they are
seldom used effectively.
Karnataka has the Regional Occupational Health Centre of the Indian Council of
Medical Research. Its services must be used more effectively to reduce the
occupational health problems.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1.
2.
3.
4.
5.
6.
7.
8.
Health Education to improve Life style, physical exercise and food habits.
Health education to avoid risk factors for primary and secondary prevention of
Hypertension and Ischaemic Heart Disease
Ail doctors must be able to tackle high blood pressure and prevent its
complications and to provide immediate care in cases of Ischaemic heart
disease and refer as necessary.
Sensitise the primary care doctors (PHC doctors and private practitioners) to
mental health problems and issues, and develop a district programmes based
on the learning experience at Bellary District Programme.
A Joint Director at the State level may be given the duties to co-ordinate and
improve mental health activities. A comprehensive Mental Health Programme
for the State to be developed.
Strengthen the facilities for psychiatric service and training in the teaching
hospitals.
The Karnataka State Cancer Control Advisory Board to be reactivated and
made the nodal agency for linking the Cancer treatment centres across the
state
Initiating a rural cancer registry on a Pilot basis
-26-
Proactive discouragement of Tobacco company advertisements and
sponsorships.
10. Banning the sale of Tobacco in any form within 100 metres of school premises
and Banning its use in Office Premises and Public Places
11. Shifting the cultivation of the cash crop of tobacco to food or other crops.
12. Health education for better dental care and reduction of tobacco chewing.
13. Specialist services (Orthodontics and Maxillo-facial services) at district level.
14. Promote Community Dental Programmes with involvement of Dental Colleges.
15. Effective enforcement of the laws controlling pollutants and safety in industries.
16. Periodical health check-up of the workers and follow-up.
9.
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5.
Maternal and Child Health
Shortfalls in staffing requirements, especially lady medical officers and trained birth
attendants has lead to sub-optimal implementation of RCH programs.
The aim of the RCH program to attain 100% institutional deliveries may be a laudable one.
But the "institutions” are inadequate in numbers and in terms of infrastructure. ANMs too are
not always available. So the proportion of institutional deliveries is low. In this context the
role of the Traditional Birth Attendants or Dais is very crucial in providing delivery
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 by the Central Government without insights into its functioning or
the need for alternate measures.
During delivery, while the birth attendant looks after the mother, including the expulsion of
the placenta, meeting the essential needs of the newborn is inadequate. If the baby does
not breathe within 60 seconds, immediate external assistance will be essential to prevent
asphyxia. The throat has to be cleared of secretions by simple suction and the baby may need
physical stimulation to start breathing and prevent brain damage. These simple measures may
make all the difference. Other common complications like hypothermia and feeding
problems, especially in low birth weight babies, are likely to lead to death unless promptly
recognised and remedied. All these skills can be taught to any intelligent adult woman,
especially if she is motivated. She can also be trained to recognise sepsis (including
pneumonia and meningitis) by simple criteria. We can reduce neonatal mortality, which
currently conrtributes about half of the infant mortality, then we can drastically reduce our
IMR. It is currently a matter of concern that the Infant Mortality Rate has become 58 per
1000 live births in 1998, while it was 53 in 1997 and 1996.
Exclusive breast feeding of the infant till 4 to 6 months is very important to maintain the
nutrition and growth of the baby and to prevent diarrheal diseases. Infants tend to falter in the
rate of weight gain from the time of weaning. This is due more to the lack of understanding
of Nutrition than the lack of food items in the household. The worker involved with the
prevention of Neonatal Mortality could also be entrusted with assissting mothers with Breast
feeding and proper weaning as well as Growth Monitoring to detect any deviation from the
normal pattern. The same worker could oversee the full immunisation of the infant. Such a
Village level worker, if present in a population of 1000 people, will have to supervise the
birth and growth of approximately 20 babies per annum. The Anganwadi provides the
necessary food items for weaning as well as Nutritional Supplementation of Preschool
Children. The suggested worker would concentrate in the first year of life.
People are not aware of the facilities that are available for Maternal and Child Health.
Corruption is present at many levels. Money is demanded even when the delivery is
supposed to be free. Unaccounted charges are collected even from the poorest. These are
-28-
u
general issues and are more relevant to delivery of MCH services, especially when we
understand that nearly 65% of our population is women and children.
The quality of sendees is poor due to a lack of discipline, accountability and motivation
among the health care givers at all levels. 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. There is also a need for ensuring the
availability of medicines (example: IFA tablets) at all times especially when the proportion
of Nutritional anaemia is 80%.
People are not necessarily aware of the facilities that are potentially available for Maternal
and Child Health. Corruption is present at many levels. Money is demanded even when the
delivery care is to be free of charge. Unaccounted charges are collected even from the
poorest. These are general issues and are more relevant to the provision of MCH services,
especially when we understand that nearly 65% of our population are women and children.
Recommendations
1. Increasing the skills of ANMs in the CNA methodology. Revision of the existing
training syllabus to incorporate enhanced technical and communication skills.
Sensitisation regarding the importance of the timings spacing and number of
births and exclusive breastfeeding for the first 6 months,
2. The role of Dais in safe deliveries should be supported and training enhanced.
Disposable Delivery Kits of good quality and cost effective components should be
provided.
3. Where services ofANM are not available, the Anganwadi Worker to be trained to
undertake the specified activities till a regular ANM is posted.
4. To cater to the Newborn Care the Anganwadi worker to be trained to be the
secondfunctionary. She may be given additional monetary compensation.
5. Ensure 100°/o registration in the first trimester, proper antenatal, natal, and
postnatal care with involvement of Private sector,
6. Ensure uninterupted supply of IFA at all times at all Health Care Institutions.
7. Ensure 24-hour delivery services at FRUs with involvement of Private sector.
8. A Pilot Project has been taken up in the 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 programs.
-29-
ISSUES AND CONCERNS FOR MEDIUM AND LONGTERM CONSIDERATION
1. Enhance the Mobility of the ANMs. The loan facility to buy a two wheeler may be
made available in districts not covered by India Population Project IX.
2. Accessibility to FRUs for the people may be ensured by supporting the
community funds for emergency transportation.
3. Health Education and Information programs should be systematised. Child care
programs, and immunisations can be promoted with the help of the private sector
(eg. Indian Paediatric Association).
4. The camp methodology for sterilisation operations should be discontinued.
Instead the availability of sterile, hygienic conditions for carrying out the surgical
procedures eg. sterilisations, MTPs etc on specified days (Fixed-Day strategy)
should be ensured at the Health Care Institutions, which are equipped for this
purpose.
5. Provision of cluster services for women and children in one place and at
specified times will ensure better utility of the services. Eg. Nutritional programs,
Health Education, self-help group meetings, Immunization, etc in anganwadi
premises.
6. Integration of RCH programme into the General Health Care Delivery.
7. Procurement / supply of IFA tablets, Vaccines to be reviewed and streamlined.
8. Based on the experience at the Bellary PCH Pilot Project, FOGSI Initiative to be
extended to other Districts.
-30-
6.
Population Stabilisation
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. It would be relevant to note that
the implementation of the population policy would not be the sole responsibility of the
Health and Family Welfare Department and that considerable inter-sectoral coordination is
necessary.
The broad objectives of the State Policy for Stabilisation of Population would be to achieve
the replacement level by 2010. While the latter could be described as attaining a Net
Reproduction Rate of One (NRR=1) by that year, it would conceptually be easier to define
stabilisation as attaining a Total Fertility Rate of 2.1 (TFR). The adoption of a goal of TFR of
2.1 by 2010 would be consistent with the methodology adopted by the Registrar General of
India in arriving at the Population projections for the country and for the State.
The projections made by the RGI, assuming a TFR of 2.1 being the desirable goal (in
substitution of the concept of NRR of 1 previously adopted), for Karnataka indicate that the
State would attain replacement level in 2009. The population of Karnataka in the years ahead
would be as follows:-_____________
Year (as on 1st March)
Population (000s)
2001_
52,720
2006_______
56,181
2011_______
59,615
62,783
2016
The Crude Birth Rate of the State in 1996-2001 is 20.77 and is estimated to be 19.08 by
2006-11. The issue would be the implementation of family planning along with development
variables in order to achieve the CBR by 2006-2011. The fall in the BR would be critically
dependent on meeting the unmet need for contraception services and efficiency of the IEC
and delivery systems. There is an unmet need for family planning services.
The IMR would still be comparatively high - this would imply enhancement in measures for
its reduction.
The proportion in the older age groups would increase - the package of health services,
including geriatric care, would need to be periodically reviewed.
-31 -
PHC-1OO
r
0bZ7c
6c
r
-
A.
Elements of a State Policy • Need to recognise 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
• Identify the important parameters and indices for that could guide such a state policy;
• Suggest any structural changes in the Department with regard to services delivery, IEC
by region (being looked at separately);
• Part of the health package - but it would be necessary to recognise the need for continued
emphasis on family planning - would include encouraging spacing methods, offering
alternatives, combined with RCH;
• Availability, Accessibility, Quality and, if charges are levied, Affordability, of services;
• Role of Panchayat Raj institutions
Recommendations:
L A Population Policy as part of the comprehensive Health Policy will be drafted
for wider discussionsfor eliciting public and professional opinion.
2. Commence a strong IEC Programme regarding the health hazards and social ills
of early marriages, the need to raise the age at marriage and advantages of
postponing the second child.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Set up a Cabinet Committee which would review health services in general and
the elements of the Population - and Health - Policy periodically. This should be
an Empowered Committee whose decisions would be final and not need further
consideration internally within the Departments
2. Consider legislation with regard to registration of marriages - as part of the
attempt to prevent child marriages.
-32-
Focus on Special Groups
7.1 WOMEN AND HEALTH
Poverty coupled with Gender bias and poor social and economic 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. Early childbearing, frequent pregnancies,
unsafe abortion, RTI & STI etc. contributes to the poor health of women. Women’s
empowerment therefore remains the single most important tool in bridging this gap
between Services available and the user.
Work outside the home places an additional demand on the women who are already
burdened with household work; reproduction and child rearing; and family demandsboth physical and mental. Wage earning empowers women in decision making, but non
-wage earners do not have this advantage and their contribution is not even recognized.
The nutritional status of the women is lower and starts with discriminatory trends from
early infancy, through childhood and adolescence and adult life. The woman herself is
partly responsible for this. She considers her nutritional and health needs as the last
priority and does not know the importance of her own health as a contributing factor to
ensure the health of her children. Poor access to health services due to lack of transport
also contributes to this neglect.
RCH looks at the health needs of the woman in the reproductive phase. Her special
needs during adolescence, post reproductive phase and menopause as well as health
problems other than those of the reproductive system are neglected eg. Cancer
(especially cervix and breast) and Unipolar Depression. Another issue is the need for
Hygiene during menstrual period.
TB kills more women annually than all causes of maternal mortality combined. The
impact of TB on women is more intense with the problems of malnutrition, ill health,
HIV infection, repeated child birth, fear, stigma attached to the disease and the delay
and access in seeking medical care. Although the overall prevalence of pulmonary
tuberculosis is lower in women, the progression from infection to disease is higher.
This could be because of the triple burden of house work, child care and employment
leaving very little time for taking care of herself.
RTI / STI and AIDS are supposedly dealt with through the RCH program. But the
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 these eminently preventable diseases
amongst women.
-33-
Violence is a very important factor leading to physical and mental health problems and
a lowering of an already low self image.
There is an increasing adolescent population with specific needs which, have to be
addressed.
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. Health Education will
form part of the empowerment process and therefore will have to be addressed as a
long-term, separate, planned activity.
Recommendations:
1.
2.
3.
4.
5.
Sensitise all Health Care Personnel on issues relating to gender inequalities.
Educate and promote personal hygiene especially during menstrual period by
the distribution of subsidised menstrual pads/cloth through PDS.
Services of Lady Medical Officer to be available at all PHCs.
Improve diagnostic, medical and counselling services for STI & HIV/AIDS for
the women as well as the sexual partner.
Initiate efforts to identify gender related barriers to TB diagnosis and treatment
and integrate into overall efforts to improve programme effectiveness. Identify
sources of inequity.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Activities to enhance empowerment of the women including poverty alleviation.
2. The Adolescent’s needs for health information and services particularly with
regard to nutrition, sexuality and reproduction.
7.2 PERSONS WITH DISABILITIES
Disabilities rob the basic rights of an individual to physical, mental, spiritual and social
well -being. Disabilities include among others, locomotor, visual and learning
disabilities; hearing and speech impairment; Mental Illness, Mental Retardation,
multiple disability etc
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% and the Action Aid surveys showed a rate of 2 to 3%. These figures may
-34-
have included only the severe cases, those that the families and community perceived
as being disabled and needing interventions. 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.
Nearly 10% of disabilities in developing countries are caused by conditions which are
preventable.
Globally programs for the Persons With Disability, which were earlier institution-based
and expensive, have now become Community Based Rehabilitation (CBR). 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 disabled 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, labor, vocational training,
housing, welfare, sports and agriculture. NGOs, Disabled peoples Organizations
(DPOs) and religious leaders within the community therefore 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 a
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.
In India, the Ministry of Welfare is the nodal agency for rehabilitation, which launched
11 District Rehabilitation Centers, one of which is in Talakaadu, 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.
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.
•
Community Based Rehabilitation methodology is still not implemented adequatley;
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.
-35-
•
Networking unsatisfactory.
•
Identification of people with mild disability and 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.
•
There is a need for co-ordination of activities of health, education, vocational
training and welfare sectors.
Recommendations
1. Utilise Media to create awareness and training ofparents and other care-givers
on specific disabilities.
2. Establish the role of the Health department in Disability Prevention, Early
detection, Intervention, corrective surgery and physiotherapy.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Shift from institutional approach to a Community Based Rehabilitation-home(parent) based approach; and from single to a multi-disability approach.
2. Sensitize
health-care workers
on
disability-prevention,
identification,
classification, records of progress and evaluation, referral and home-based
stimulation training. Staff from Leprosy control programs may be trained first.
3. Minimize preventable disability. Identify and minimize sectoral loop-holes in the
RCH & Immunization programs. The Health Department to take responsibility for
Prevention, Physiotherapy and Corrective surgery.
4. Networking initiatives - Get all people, Govt, as well as NGOs, from all sectors to
meet at a common platform and plan out strategies.
5. Implementation of specific training programs.
-36-
7.3 TRIBAL HEALTH
The health infrastructure for the Tribals in Karnataka include 31 PHCs and 10 Mobile
Health Units. The predominant problem associated with this infrastructure is that many
are not located in the identified Tribal areas. Vehicle problems and Vacancies make
these health centers non-functional. Referral services are non-existent
Traditional Medicine being practiced by the Tribals is ignored. There is much difficulty
in accessing the herbs in the forests.
The commonest diseases amongst the Tribals are Tuberculosis, Malaria, Anthrax and
Leptospirosis. Substance abuse of Alchohol, Tobacco and Bhang is common. Sickle
Cell Disease is prevalent.
The Nutrition status is poor. The Anganawadi Centres are not properly functioning. The
Rice supplied through the PDS is not the staple diet of the Tribals. The supply from the
PDS is poorly monitored.
The Drinking Water and Sanitation facilities are not satisfactory.
Child Labour and Bonded Labour are prevalent. The involvement and participation of
the Community in Health and development programmes is poor and there virtually
exists no Health education activities. The Voluntary Organsiations have played an
important role in the health of the Tribals.
The Tribal ANM’s programme under India Population Project 9 has had a positive
effect.
Recommendations:
1.
2.
3.
Strengthen the existing Mobile Health Units and the PHCs in the Tribal areas
and make them allfunctional.
Initiate a systematic documentation of Traditional Medicine with the help of
Voluntary Organisations.
Strengthening of the Tribal ANM project. The current batch of 27 needs to be
posted on priority and a fresh batch of training to be initiated.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. All the Integrated Tribal Development Project (ITDP) Areas, to be covered under
the Tribal ANM Project
-37-
2. The re-organisation and relocation of the Subcentres and PHCs in the Non-Tribal
areas under Tribal Sub plan to be taken up.
3. The referral system to be strengthened.
4. RCH to be a major agenda in these Tribal areas.
5. Promote Traditional Medicine and integrate it into the current Health Care
System.
6. Improve the quality of Health and Growth monitoring under the Tribal Sub Plan.
7. Screening and management of Sickle Cell Anaemia and G6PD Deficiency by
Voluntary Organisations. Disease Surveillance systems to be set up for
Tuberculosis, Malaria, Leptospirosis and Anthrax.
8. Include Ragi, Jowar and Pulses in the Public Distribution System.
9. Setting up of a Community Fund for Emergency and Referral services.
10. Incentives for Health Care Personnel who opt to work in the Tribal Areas.
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8.
Health Education
8.1 HEALTH EDUCATION
Health Education can yield large dividends in improving the health of the people. It
helps the people to attain and maintain health, understand the problems causing death,
disease and disability and take appropriate action to promote health and prevent
disease. But it is a neglected area.
Health Education is concerned with establishing responsible behaviour and in bringing
about changes in the behaviour. It concentrates on developing health practices which
can bring about the best possible state of well-being. Health education is a process that
helps people to find out their health needs and activate them for suitable health related
behaviour.
Health education must take into consideration the customs, beliefs and practices of the
individual, the family and the community*. Programmes need to be developed, which
are suitable to the people of the area.
Kamataka has a rich heritage of folk arts (Yakshagana, Kathakalakshepa, drama, song
and dance, puppet shows, street plays, etc.) which can be effectively used in health
education. They have evolved within the culture of the society.
1
Other media can also be used effectively - the print and newspaper, electronic - AIR,
Doordarshan, movies, posters and others. Face to Face communication and group
discussions are effective. We need well-trained and motivated personnel with good
leadership. They should make optimum use of the services of experts from different
disciplines-sociology, community health, education and communication. Besides the
State health directorate and the central health education bureau, there are voluntary
organizations in Karnataka which can render significant service in carrying out health
education programmes.
Recommendations:
1.
Reorganise and integrate the different IEC programmes in the Directorate of
Health and Family Welfare Services with professional inputs.
-39-
8.2 SCHOOL HEALTH
Many personal habits and lifestyles that have important consequences for health are
formed early in life. Health education in schools can help young people to make
informed choices.
A sound school health education programme, during the formative period of the child,
focuses on the circumstances that affect the health and well being of the child and
through the child in other children, their families and the community, child to child,
child to family and child to community.
School Health is important for education. School attendance is affected by health and
disease among children and their families. Healthy children learn well; learning is
affected if children are ill or malnourished.
School health checkups influence immediate problems, which affect learning: impaired
vision, hearing and nutrition; anaemia due to intestinal parasites or iron deficiency.
Schooling helps children adopt healthy lifestyles, which will then be continued.
Mothers with some schooling take better care of their babies; they are more likely to
seek medical care when needed and have their children immunized.
A health promoting school provides a healthy environment, health and nutrition
education, school health services and physical education and recreation. It helps to
prevent causes for death, disease and disability, such as use of tobacco, sedentary life
style and injuries and accidents.
The curriculum must include all aspects of health, including knowledge of the structure
and function of the human body, nutrition, human sexuality, sexual rights and
responsibilities, reproductive rights and responsibilities, population issues, sexually
transmitted diseases, HIV /AIDS, substance abuse including tobacco and alcohol,
values and life skills, issues in marginalisation, disability and self-esteem.
Recommendations:
1.
Initiate greater coverage of all students in all the schools in the State with
health (including Dental) checkups and health education. Train the students in
first aid.
2.
Use the media, including AIR and DD to promote health (similar to UGC
Programmes).
-40-
J
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION""|
1. Promoting healthy life styles
2. Study the impact of different media of communication in different regions of the
State, in disseminating health messages, so as to utilize the most effective ones.
3. Help the personnel and troupes involved in health education through folk media
to improve the quality of their communication, especially to the rural.
4. Develop health education materials at the regional level suitable to the culture of
the region.
5. Use AIR and DD to impart lessons in health
6. Equip the teachers in skills in effective communication of health principles and
practices, utilising the syllabus in 1 to 10 standards. Revision of School
curriculum from Health point of view and to make health education of the
students effective.
-41 -
9.
Health Human Resources
DEVELOPMENT
Health services require large numbers of qualified and skilled professionals and staff. The
present situation is one of over supply of medical graduates in the various systems.
Karnataka has exceeded the norms for qualified professionals. Too quick expansion in the
number of colleges tells on the quality of education.
There has been a mushrooming of new Colleges. There are at present 23 Medical, 36 Dental,
46 Pharmacy, 38 Physiotherapy, 43 Ayurvedic, 11 Homeopathic, 2 Unani and 3 Naturopathy
and Yoga Colleges. Many of them do not have the necessary infrastructure and teaching
staff as per the norms set by the different councils.
The situation is not better with respect to the Nursing education. There are about 150 schools
of Nursing and 40 Colleges of Nursing. Many of them do not have adequate qualified staff or
training facilities
Expansion may be necessary in some areas of paramedical education. There is need for more
ANMs. The Departments of Health and Family Welfare Services (DHFWS) and Medical
Education (DME) must make a comprehensive study of the requirements. Many of the
Paramedical Job Oriented Courses are not of satisfactory quality.
Round the clock diagnostic (X-ray, Laboratory, etc.,) and blood bank services are not
available in many of the hospitals including the Tertiary.
One felt need was the orientation and training of all health staff in Health Care schemes,
Public Health, Ethics and Management.
Many persons who met the Task Force stated that there is widespread corruption in the
conduct of University Examinations (undergraduate and postgraduate medical) and that the
examiners demand and take money for giving pass.
Recommendations:
1.
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 under-served areas of Karnataka. Where essentiality
certificate or temporary affiliation has been given but the College has not
-42-
2.
3.
4.
5.
6.
7.
8.
9.
10.
started functioning, the certificate and affiliation should be withdrayvn
immediately.
Extend the moratorium on new Ayurvedic, Homoeopathy and Unani Colleges
by another 2 years.
Take up urgently the repairs af the buildings of the Colleges, hospitals and
hostels, equipments and vehicles of the Government teaching institutions and
hospitals. All equipments must be maintained in good working condition.
Redeploy teaching and non-teaching staff according to the needs.
Streamline the working of emergency services like Casualty, Burns and
Accidents and provide round the clock diagnostic (X-ray, laboratory, etc.) and
blood bank services in all Teaching Hospitals. Essential drugs must be
available at all times.
The State Institute of Health and Family Welfare to be upgraded and be made
autonomous. The Institute and RGUHS should take up the training at all levels
in management, public health and ethics along with Voluntary Organisations
and Experts.
Increase the intake for the training of Auxiliary Nurse Midwives (ANMs).
Encourage NGOs with the capacity for training to take up the training of
ANMs
Every Medical and Dental College to adopt a block for service to the people of
the area and training of students
Corruption at the University Examinations to be eliminated.
The teaching programmes in the Government Medical Colleges to be
strengthened by invited teaching faculty and given suitable remuneration; they
will not have clinical responsibility at the hospital.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Every Medical College to be responsible for the health Care of one district in
collaboration with the department of Health and Family Welfare services.
2. Monitoring and evaluation (performance appraisal) of the teaching and other staff
once in 6 months.
3. Heads of Departments, Resident Medical Officers, Medical Superintendents,
Principals and Directors should be given sufficient authority and be made directly
accountable for the quality of the teaching and service. Officers must be made to
follow the Duty Manuals.
Plan training and retraining of the officers in
management.
4. Every professional College to have an education unit to improve the teaching
capability.
-43 -
5. RGUHS to organize teacher training programmes
6. Reorganize the Directorates of Health and Family Welfare and Medical
Education to integrate Health Care Services and Education.
7. Alternate strategies of Health Personnel development to serve in Rural areas.
8. Review of the Paramedical Job Oriented Courses.
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II
10.
Health Systems Management
10.1 ADMINISTRATION
The cadre structure and the corresponding lines of management of health services
have historically evolved on the basis of designated plan schemes and financing
sources such as Centrally Sponsored Schemes, Central Programmes for specific
purposes, Externally Aided Projects and the like. This has resulted in a diffusion of
hierarchies in terms of focal control points and nodal points of responsibilities. It has
also incidentally resulted in independent reporting systems with consequent dilution
of the ability to monitor progress and performance in the activities of the Directorate.
The internal mechanisms to build up the morale of the hierarchies and also enforce
control and discipline have weakened considerably.
The efficiency of the health services has been eroded considerably. The management
of the cadre in terms of filling up vacancies, postings and transfers, matching
qualifications to job requirements and training has been weak. These, and related
issues, need urgent attention. Some issues are capable of being tackled in the short
term, while others would require further examination.
There is lack of co-ordination in the functioning of the Health and Family Welfare
Department and of the associated departments. The systems of monitoring of both
performance and expenditure, based on an efficient reporting system are very weak.
This has to be an integral part of the activities of the department. But, temporarily, in
order to remedy this present situation, a post of the Commissionser, Health and
Family Welfare, has been created. The role, responsibilities and authority of the
Commissioner have to be defined.
There are at present about 100 doctors with Postgraduate qualification in various
disciplines serving at different PHCs, whose services can be better utilised to fill the
vaccancies at Taluka level and above Health Care Institutions.
There are about 950 cases of Doctors on cases of absenteeism, misappropriation, traps
and general complaints. Some of them are long standing.
The need for capable, professional management of the services in the department has
been acutely felt. The department should identify and induct young professional
managerial talent at the district and State level structures to give impetus to the
programmes and services.
-45 -
Recommendations
1.
2.
3.
4.
5.
6.
7.
8,
9.
10.
11.
AU administrative posts in the Directorate to be filled up.
All the posts of Joint Directors and above to be selection posts.
The services of doctors with Postgraduate qualifications in various disciplines
serving at different PHCs to be utilised to fill the vacancies at Taluka level
and above Health Care Institutions
A Vigilance Cell in the Directorate headed by the Commissioner for
disciplinary action against corruption^ absenteeism andfor speedy disposal of
enquiries.
The process of regularisation of the contract Doctors to be commenced.
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 personal responsibilities increase d) transfers ofprimary health
centre (including subcentre) staff should be preferably be within the district.
In making transfers the mismatch between the qualifications of the officer
and those requiredfor the post should be corrected. The principles adopted by
the Education department would provide useful guidelines
About 100 Doctors from the Department to be selected through a transparent
“search-cum-selection” mechanism assisted by the Task Force, given
intensive training in management and placed at the Directorate and DHOs
Offices as Programme Managers.
The selection of Inservice Doctors for Post Graduate courses should be based
on the needs of the Departmentfor specific specialisations and not on the
preferences of the officers. A review of the needs to be made for this purpose.
The practice ofpostings of Officers on OOD should be kept to the bare
essential. This would ensure that postings based on individual preferences or
to avoid transfers are minimised.
The role and responsibilities of the Commissioner, Health and Family
Welfare may be defined as follows - “The Commissioner, Health and Family
Welfare shall be responsible for monitoring, supervising and implementing
all National and State Health and Family Welfare programmes in the State.
The Commissioner shall also be responsible for ensuring coordination among
the various Directorates and Divisions within the Health system and also with
related Departments^9.
The specific responsibilities are indicated in
Annexure 7. Sufficient administrative and financial authority to be delegated
to the Commissioner to perform the responsibilities effectively.
The system of performance appraisal (confidential reports) to be
implemented.
-46-
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
A review of the structure of the health services would be done and all relevant issues
would be included in this review. Some of the issues that would need attention would
be
1. Review of the structure of the Directorate to consider possible and desirable
changes; delegation of authority both financial and administrative, control
mechanisms; training; maintenance of assets, and other relevant issues.
2. Consideration of the reinstitution of a strong Public Health element in health
services. This would include inculcation of an appreciation of the needs of the
rural areas, compulsory rural postings and making rural and public health
experience a condition for career prospects.
3. Consideration of a mechanism for attending to public complaints and complaints
relating to corruption by the establishment of a District Committee with the
Deputy Commissioner as Chairman, the Chief Executive Officer, Superintendent
of Police and DHO as members along with two or three prominent local NGO
representatives.
4. Issues relating to private practice by Government doctors.
5. Issues relating to corruption and associated matters.
6. Consideration of the externally funded projects with reference to sustainability
and institutionalisation of both work culture and performance levels, relationship
with the DHS and connected issues.
7. Preparation of a perspective plan for the Directorate that takes into account
programme needs, staff issues, financing.
8. Any structural changes that may seem necessary, including the creation of a
distinct Public Health Cadre in the Directorate. This would include recognition
and consideration of related issues of cadre formation, cadre options for staff and
the like.
9. Mechanisms for enhancing the participation of the private sector for
augmentation of health / medical services - Induction of private specialists
wherever necessary and induction of lady doctors in rural areas.
10. Developing a possible mechanism for providing support to the DHS through
induction of external expertise for monitoring and providing planning support.
11. Reorganising PHCs, taking into consideration staffing structures, equipment,
future locations and other relevant factors.
12. Establishment of Advisory Board of Health with defined functions, for providing
the necessary support to the system.
13. Citizens Charter for all Health Care Institutions.
14. Review of the existing Cadre and Recruitment Rules.
-47 -
10.2 PLANNING
Health services must meet cunent 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 would, therefore,
be necessary to have an in-built ability for carrying out such reviews and in the
preparation of perspective plans.
A Planning Unit in the Directorate would be needed with this capacity. The unit
should be responsible for preparation of the Five Year Plans and Annual Plans of the
Directorate and for the preparation of the long-term perspective plan. It would also
have to develop the capability to monitor progress in adoption and implementation of
such plans. Expertise in both physical and financial planning would have to be
available in-house. Its importance would have to be recognised by assigning to it an
appropriate place in the administration and management tree. Its staffing and other
features would be studied.
The lack of appropriate health human resources has affected the services provided by
the Health Department. The Health Humanpower requirement should be assessed and
developed to meet the present and future needs also.
The establishment of a Geographical Information System in the Directorate 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 Information
Management System.
Recommendations:
1.
A suitable structure for the Planning Unit in 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.
10.3 FINANCING
In assessing the financing of the health sector, the issues would be (a) adequacy of
funding in relation to the current and possible future scale and responsibilities of the
Department, (b) the adequacy of financial delegations and a review of current
-48-
delegations, (c) operational issues relating to reduction of accounting workload at
field levels and simplification of procedures, and (d) the relationship between the
aided projects and the DHS which has both administrative and financial implications.
In the year 1999 - 2000, the Plan provision under Medical and Public Health was Rs.
3706.45 lakhs of which the expenditure is of the order of 1171.14 lakhs. Even
assuming further expenditure would be booked in the revised estimates, there is a
massive under-utilisation of funds. Under Non-Plan, the provision was Rs. 12098.58
lakhs while the expenditure is of the order of Rs. 6808.96 lakhs. The latter shortfall is
mainly because staff positions have not been filled.
The under-utilisation of funds has serious implications. It would imply that
performance and improvement of health services are inadequate. It is necessary to
improve the mechanisms for periodic review of both physical and financial progress.
Such a review is again dependant on the establishment of an efficient, timely and
adequate reporting system. The Commissioner, Health and Family Welfare, could
carry out such a review.
Elsewhere in this report it has been recommended that all posts should be filled
expeditiously, particularly those at the primary levels such as ANMs, other categories
of health workers, laboratory technicians, etc. If these posts are filled, corresponding
needs for equipment, including kits for Dais, would have to be met. Sufficient
provision would have to be made for the latter.
Recommendations:
7.
2.
Additional Resources to be provided during 2000 - 2001 to carry out the
reforms suggested.
Monitoring of expenditure, specially plan programmes to ensure adequate
utilisation and results must be done.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
The financial needs of the Directorate would be reviewed. The important aspects
that would be considered would include:
1. The long term needs of the Department taking into consideration the perspective
plan that would be formulated and the structural changes that may be considered
necessary.
-49-
2. The internal financial delegations to permit more effective decision making at the
various functional levels.
3. The accounting burden at the field level would appear excessive. These
procedures and the financial reporting systems would also need review.
A comprehensive review of the financial management system is envisaged and a
plan of action would be prepared.
10.4 HEALTH INFORMATION MANAGEMENT SYSTEM
The need for periodic monitoring of performance of the health system scarcely needs
emphasis. At present the monitoring system is not uniform and does not provide the
management information that it should. Different monitoring systems and formats,
dependent on the particular programme they relate to, now exist. There is no
coordination among these vertical reporting systems, resulting in both lack of utility
and waste of internal resources. An efficient monitoring system would have to be
developed and instituted.
There are distinct features of the health system that would need to be monitored.
These would include monitoring of (a) the physical performance of the system in
terms of identified parameters, (b) financial management, and (c) personnel matters.
The monitoring system would also have to provide for management at the micro level
and assist in the sensitive and efficient appraisal of information. It should permit
administrative and technical inputs that would reflect performance so that continuous
internal evaluation is possible. The information system must provide for feedback to
the operational levels.
A complete review of the current systems of reporting is envisaged. Such a review
would take into account the type and content of the information that would be useful,
and its periodicity. It would also specify the reporting formats and the flow of
information. The objective would be to establish a uniform reporting system that
would permit efficient appraisal of performance on the basis of set parameters, and
which would help in better administration of health services.
The integration of the data base with the GIS referred to early would also be ensured.
The information system for management of health services, particularly if it has to
have the added advantage of a GIS overlay, would be enormously enhanced if the
system was computerised. In any case, the GIS is computer based. The advantages of
a computerised system at all levels are well known in terms of maintenance, retrieval
-50-
and analysis of the information. It would be desirable to computerize the health
management system from the PHC upwards at some point of time. However, such
large-scale computerisation would have to be well planned and carried out in stages.
As a beginning, it would be desirable to computerise the offices of the DHO as soon
as possible.
The utility of the information system is dependent on the efficiency of the reporting
mechanisms. Deficiencies in the latter, including late or incomplete receipt of basic
records would seriously reduce its utility. At present, it is noticed that reporting is
weak because, among other reasons, of the inadequate supply of forms of reporting
and registers. It many cases, the staff use odd sheets of paper for reporting and this
increases the difficulties of record maintenance. It should be possible to arrange for
timely printing and supply of all forms and registers in adequate measure, particularly
since the requirements are known and tend to be constant over the years. It is
recommended that this matter be monitored by the Directorate of Health Services and
that arrangements are made for such supply.
Recommendation
1.
2.
3.
4.
An integrated, comprehensive Geographical Information System based HIMS
to be initiated and implemented.
All the District Health Officer should be computerised for efficient
management and control ofHealth System in the district.
The formats / registers needed at various levels to be updated, printed and
supplied in adequate quantities and on-time.
Annual reports and monthly updated programme performance to be placed on
website of the Directorate for information.
10.5 MEDICINES PROCUREMENT AND SUPPLY
The methodology of arriving at Annual Medicinal drug requirements for the health
care Institutions in the State is at best experienced estimates or at worst adhoc. The
Government of Karnataka purchases the Drugs required as per Rate Contract
document. The Government Medical Stores, GMS, Bangalore in the Directorate of
Health Services is the nodal agency for the procurement of these medicinal drugs.
The Rate Contract was not processed in two previous years.
It was noticed that Not all the essential drugs were covered under the Rate Contract
system. The MO (of PHC/ CHC/ Taluka Hospital/ District Hospital) is responsible for
indent. The MO or his representative has to travel all the way to the GMS in
-51 -
OMC
c -- too
poo
fo (
I *<
)
•
Bangalore to procure the indent. The efforts to establish District stores has not been
completely functional.
It was noticed that the available medicines included near expiry date medicines. It
was also reported that Medicines which are not required (either because of available
stock on hand or simply unnecessary) had to be taken. Eg: 300 vials of Fortified
Pencillin with expiry date of February 2000 was supplied to a Health Care Institution
at the end of January 2000; when the monthly requirement did not exceed 20 to 25
vials or maximum 30 vials.
The Rate Contract system provides for the lowest bidder to be contracted first. When
the lowest bidder fails it is expected the next lowest bidder would be approached.
This results in delay in procurement and sometimes loss of money to the exchequer.
A system needs to be set up when the procedural delays would not be at the cost of
the patient.
The Primary Health Centres indent for medicines worth Rs. 50,000 per year. (The
norms for other institutions vary) This stock of Medicines was said to be sufficient for
about only three months. However, it was discovered that there are 13 different
sources from Central and State sources, which the health Care Personnel of the PHC
can obtain the drugs. Not all are perennial and reliable sources. This definitely
warrants a review of the situation in toto.
As noted above, the Central Government also supplies the requirement of some of
these medicines, especially under the Maternal and Child Health programmes. It was
reported that there was no Central supply of IFA tablets for two years. This led to a
situation when IFA tablets were not available for the patients for two whole years.
This is highly deplorable. Remedial and back up systems should be delineated in such
unforeseen (? !!) circumstances.
A preliminary analysis of the previous three year purchase of medicines under the
60% ZP quota was undertaken. It was noted that not all purchases were generic. In
instances it was found difficult to justify the purchase of the drugs. The Task Force
eagerly awaits the report of the special committee constituted to review the situation.
Recommendations
L
The Rate Contract System
a)
to be based on the exhaustive list incorporating the features of the WHO
and the National Essential drug list;
-52-
b)
2.
3.
|
if there is no bidder for any essential drug, suitable alternative
arrangement to be delineated for purchases to be made.
The RC should specify the total requirement of the drugs for the entire State
including that of ZPs and include all sources and not just 40% of the GMS
quota.
The ZP or any other drugs procurement agency for Government Health Care
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.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. The Health Care Institutions should provide the list and quantity of Drugs for the
annual requirement by the end of the year (31st December) based on the
Morbidity load and also previous experience.. The collation successively at the
district and State levels to be the total requirement of the Drugs for the State.
2. The RC should specify the consignee of the drugs and all efforts to be made to
supply the quantum of drugs indented at the door step of the Health Care
Institution. Though costly this system would solve a lot of hassles for the health
care institution.
3. It is necessary that the exercise of processing of the fresh RC should begin by
the month of December and completed by the time the current RC expires.
4. If the Central government supplies are either delayed or not forthcoming
immediate alternate purchases to be made. Reimbursement including the higher
costs incurred if any, to be claimed as matter of right and responsibility.
10.6 LAW AND ETHICS
There are many laws in the State, which regulate the health professionals and health
care institutions. These are scattered widely in many pieces of legislation. Further,
most of the laws are not effectively implemented.
Problems in implementation
An example of non-implementation of the laws because of loopholes is female
foeticide, which is increasing in the State. To prevent female foeticide, the Pre-natal
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). What is
illegal is pre-natal sex determination and sex selective abortion. The person who
conducts the sex determination (usually ultrasonologist) communicates only orally;
- 53 -
|
I 1
there is no written evidence. One doctor identifies the sex of the foetus; another
doctor terminates the pregnancy.
Another example is the Human Organs Transplant Act, 1994. The purpose was to
stop or at least reduce the unethical practice of sale of organs (usually kidneys) by
unrelated donors and to promote cadaver transplants. But the sale of kidneys goes on
within a system of touts and sharing of the booty by all involved.
New Bill, 1999
Karnataka had “the Karnataka Private Nursing Homes (Regulation) Ordinance, 1976
and the rules there under. But this was never implemented. A new Bill, 1999 has
been introduced in the Legislative council. Considerable changes are needed to make
it effective and acceptable. The aim should be quality assurance. This needs
appropriately defined standards relevant to the size, type and location of the health
care institution (hospitals, nursing and maternity homes, blood banks, diagnostic
centres and others), based on social, economic and cultural situation.
Quackery
Unqualified and untrained persons often practice medicine. Such unlawful practice
may take different forms
- Totally unqualified person practising any system of medicine or treating patients
- A person qualified in one system of medicine, practising another system of
medicine, in which he or she is not qualified.
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 and causing complications.
Accreditation
Voluntary process of accreditation of health care institutions can assure quality of
service. Standards are worked out by a recognised body, which carries on an
inspection. Based on the results of the inspection, the health care institution may be
given accreditation. This process is invogue in many countries. It is a process of
self-regulation.
Ethics
All professions have codes of conduct. Thus, there are codes of conduct in Medicine,
Nursing, Dentistry, etc. There are Councils for the health professions with powers of
disciplinary action. But these powers are seldom exercised. There are many
instances of malpractice, negligence and incompetence. Many of the Councils do not
even know the number of the professionals practising in the State, because of lack of
renewal of registration.
-54-
u
Recommendations
1. The legislation introduced in the Legislative Council to regulate the functioning
of Health Care Institutions should be sent to a Select Committee to elicit views
from all concerned (stake-holders, professionals and public).
2. Take steps to renew the registration of health professionals once in 5 years with
the respective State Councils. Initiate steps to register all Health Care
Institutions
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1. Identify the loopholes in the existing laws affecting health professionals and
health care institutions. Initiate measures to plug the loop holes. Implement the
laws effectively
2. Enact a new Public Health Act, based on the Model Public Health Act (1987),
with suitable modifications.
3. Examine in depth the problem of quackery and take steps to stop it.
4. Monitoring by an independent agency of Organ Transplants in cases of unrelated
living donors and promotion of cadaver transplants
5. Make the teaching / learning of ethics as part of health professions education.
6. Have training programmes in medical ethics for all health professionals.
7. The respective State Councils should ensure that the members of the health
professions practise ethically, following the codes of conduct
-55-
11.
Indian Systems of Medicine and
Homeopathy
11.1 AYURVEDA, UNANI AND HOMEOPATHY
The Indian Systems of Medicine have been functioning for thousands of years. The
department of Indian System of Medicine and Homeopathy (ISM&H) was bifurcated
from the Department of Health in 1972. These systems continue to be popular with
the public. The department renders medical relief in Ayurveda, Unani, Siddha,
Naturopathy, Yoga and Homoeopathy and facilitates medical education, drug
manufacturing, publication and practice of medicine in these subjects.
The budget allocation for the Department of ISM&H is less than 1% of the total
health budget. This is very inadequate.
There has been a mushrooming of new Colleges in these systems. At present there
are 43 in Ayurveda, 15 in Homoeopathy, 3 in Unani and 2 in Naturopathy and Yoga
in the State. Many of them do not have the basic infrastructure and faculty.
There is a disparity in the scales of pay between those qualified in ISM&H and those
qualified in Modem Medicine, so also there is disparity in the stipends for house
surgeons and postgraduate students.
Many Ayurvedic medicines have short shelf-life (6 months); the supply to
government dispensaries is once a year; the potency of medicines will be lost. The
amount for the dispensaries is Rs. 18,000/- per annum. This is too meagre to meet the
requirements.
The existing buildings of hospitals and dispensaries require repairs and renovation.
There are many vacancies of the post of physicians. 8 districts do not have ISMH
hospitals. Cities and municipal towns do not have enough dispensaries in ISMH.
There is no well-equipped drug-testing laboratory to identify spurious and adulterated
drugs.
Recommendations:
L
2.
Plan and initiate action to have ISM&H wings in the existing District/Taluka
hospitals.
The drug licensing authority should ensure the printing of the date of
manufacture and date of expiry of drugs on the containers.
-56-
ll
3.
4,
5.
6.
The supply of medicines to hospitals and dispensaries must be quarterly to
avoid loss ofpotency.
The budget allocation per dispensary should be increased to Rs. 36,000/- per
annum.
The stipendfor the Interns and Postgraduates to be enhanced.
Steps to be taken to conduct Entrance Tests for selection to Postgraduate
courses
ISSUES AND CONCERNS FOR MEDIUM AND LONG-TERM CONSIDERATION
1. Reducing the disparity in the pay scales of Doctors in ISM&H and Modern
medicine
11.2 FOLK MEDICINE AND TRADITIONAL MEDICINE
Karnataka has a rich tradition of folk medicine / traditional medicine. We have both
codified and oral tradition. There are a large number of folk medicine people
(Carriers of oral tradition) who treat chronic and common illnesses. Traditional birth
attendants are an important health resource in our country.
Folk medicine is community supported. It is decentralised, locally available and
culturally acceptable.
Hundreds of different species of plants are used for medicinal purposes in Karnataka.
The prime need is to conserve the plants growing in the natural state. Cultivation of
the identified plants in situations similar to the natural habitat needs to be urgently
addressed.
ISSUES AND CONCERNS FOR MEDIUM AND LONG-TERM CONSIDERATION
1. Steps to be initiated to document and conserve the plants used by the folk
medicine people.
2. Cultivate the medicinal plants on a large scale so that they do not become extinct
with their increased use.
3. The rights and access to procure medicinal plants to be safeguarded.
-57-
12.
Panchayat Raj and
Empowerment of People
12.1 PANCHAYAT RAJ INSTITUTIONS AND HEALTH
Health care 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.
The advantages of involvement of the panchayat institutions in implementation and
management of health services are that focus on vulnerable and special groups would
be enhanced, preventive measures would get emphasised 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.
The temporary difficulties in doing so are recognised but these are not
insurmountable. These include problems of perception of mutual roles of the
panchayat body and the technical officials, likely emphasis on creation of physical
assets, etc. However, with training of the members in their duties and responsibilities
not merely under the Act but to the community, these issues should be capable of
being sorted out.
The Karnataka Panchayat Raj Act, 1993 specifies the responsibilities of these bodies
regarding health services. It also prescribes the mechanisms, through Committees, for
performance of these duties. However, for increasing involvement of these
institutions in the management of health services at the community level, it would
seem essential to create further awareness in the community of their entitlements and
how they can access these entitlements through their representative organisations.
At present there is no full-time trained health functionary at the Village level. The
Gram 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 Gram Panchayat. This Village health functionary would
undertake the necessary field activities relating to Health, Nutrition, Water supply and
Sanitation and Population within the each village and bring about co-ordination
between Gram Panchayat and Health Care Services.
- 58 -
Recommendations:
1. Training must be imparted to the new Panchayat members regarding their
responsibilities and duties, with respect to Health, Nutrition, Drinking Water
and Sanitation, Population and co-ordination with the health staff and needfor
monitoring health programmes.
2. Women members of Panchayats should be separately oriented to the RCH,
ICDS and similar programmes. They should be motivated to take on the role of
community leaders in health and health-related issues.
3. The Gram Panchayat should appoint a woman health functionary at Villages
where there is no ANM or Anganwadi worker for assistance to the ANM/Dai to
look after the new born at the time of delivery and in 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.
12.2 PEOPLES EMPOWERMENT FOR HEALTH
“Peoples Health in Peoples Hands” could be achieved through Health awareness and
education, enabling the Community to understand their health situation in their
Villages, make them prioritise their health needs and prepare Village Health Action
Plans. This could be done through Health campaigns, Participatory techniques like
PRA, PLA and Micro-planning exercises.
Village communities who are enthusiastic could form Village Health Committees.
The Village Health Committees should consist of Gram Panchayat member, Health
Worker, Anganwadi Worker, School teacher, leaders of the community,
Representatives of self help groups, Village education committees, Mahila Swasthya
sanghas and Youth Clubs. Atleast 50% of the members should be from the
marginalised people (SC & STs) and 50% of the members should be Women
members. Similarly “Sub-centre Health Committees” and “PHC Health Committees”
also could be formed.
Village health Committees must meet every month. It should review the activities
undertaken during the month and also review the subsequent Monthly plan. The
Village Health Committees will help the Health Worker to undertake the planned
activities and make the services accessible and available to the people. They also
make the Health worker accountable to people.
-59-
Recommendation:
1.
A pilot project in one district to have health committees at Village, Subcentre
and PHC levels.
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATIONS
1. Amendments to the Panchayat Act to provide for greater attention to health and
related social sectors.
2. Social issues such as need to raise the age at marriage, personal hygiene should
receive emphasis in training and later, in the Committees;
3. Institutions such as ISEC could be requested to prepare model plans of
development, including health, which would facilitate planning by these bodies.
4. The Pilot Project learning to be extended to the entire State.
-60-
13.
Strengthening Partnerships
We have a mix of health Care providers: Public, Voluntary and private. The NonGovernmental Organizations comprise of two large groups:
♦ Voluntary (not-for-profit) organisations;
♦ Private / Corporate (for-profit) sector.
They constitute a sizable number, whether it be in relation with the care provided, the
number of persons attended to, the number of personnel or the number of institutions or beds
or the expenditure by the people.
The government has the responsibility, as per the Constitution, to provide for the health care
of the people. Voluntary Organisations have been playing a significant role in providing
health care services. They are often supported by International Orgnaisations. Sometimes
International Orgnaisations may be directly involved in health care. The health care needs of
the people are met largely by private practitioners. Often they are the first level of contact.
They are involved almost exclusively in curative acre. There are private Nursing Homes and
corporate hospitals. They also provide mostly curative care.
The attitude so far has been generally one of confrontation, or at best, one of co-existence.
Can we change it to one of collaboration and co-operation? Each one can learn form the
others. The government is involved in Primary Health Care and Public Health. Can the
Voluntary and private Sector be motivated to get involved to a greater extent in Primary
Health Care and Public Health? The Voluntary sector is well motivated. Can their example
be used to make the Public and Private Sectors better motivated?. The private sector is good
in management. Can the Public and Voluntary Sectors learn better management (personnel,
materials, money, time and information) form the Private sector? The government must take
the initiative to bring about the changes.
Many corporate organisations are now willing to contribute a small percentage of their profit
to meet the social and community needs. These sources need to be tapped and channelised to
meet the health needs of the people. One method is to build trusts for funds on a district basis
to which these organisations and others can contribute. The trustees of these funds should be
public persons of known integrity from the district and willing and able to devote time to
ensure proper utilisation of the funds for the Primary Health Care in the district. The
members of the Parliament and legislators, hailing form the district, can play a key role in
mobilising funds, without strings attached.
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13.1 VOLUNTARY ORGANISATIONS
There are a large number of Voluntary Agencies working in the field of Health and
Family Welfare in Karnataka. There are two types
• National / State Voluntary Agencies
• International Voluntary Agencies;
The Voluntary Organizations work at different levels :
• Grass-roots level in health, education, environment, etc.
• Training, networking, supporting other organizations
• Focussing on advocacy, lobbying, policy issues, etc.
The Voluntary Organizations are scattered throughout the State but are more
concentrated in the Southern districts and based more in the cities.
Many Voluntary Organizations work with the Government. There has to be clear
understanding of partnership between the Government and the Voluntary
Organizations.
Strengths of Voluntary Organizations
Voluntary organizations have greater freedom to implement the programmes than the
Governmental agencies
The workers in the Voluntary Organizations are generally more dedicated.
The programmes handled by Voluntary Organizations are mainly localised.
Implementation of programmes is easier and quicker.
There is less hierarchy, making the functioning smoother
Weaknesses
There is often a lack of second line leadership, which can affect sustainability.
Voluntary agencies may suffer from lack of funds at times. Those Voluntary
agencies, depending on external funding may have to stop the programme, if funding
is stopped.
Recommendations
1.
2.
A Directory of Voluntary Organizations working in Health and Healthrelated work in Karnataka should be brought out immediately and updated
periodically.
Introduce a single window Voluntary Organizations Cell at the Health
Directorate to co-ordinate the different programmes and simplifying
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procedures for grant-in-aid avoiding delays. Commissioner to be the nodal
officer.
13.2 PRIVATE AND CORPORATE SECTOR
The private sector (general practitioners, nursing homes and corporate hospitals) play
a large role in the health care (mostly curative) of the people of the State. Their role
must be understood and encouraged to provide holistic services.
Recommendations
1)
2)
3)
4)
Use the services of private practitioners and specialists where there is lack of
such personnel in the Government sector, paying for their services on
mutually agreed terms. In case of deficiency of doctors in PHCs Private
Practitioners may be appointed on "adhoc" basis
Involve organizations of doctors in IEC activities and national programmes.
Provide drugs and vaccines in the national programmes to the private
practitionerfor the benefit of the economically poor.
Tertiary hospitals in Private sectors may provide training programmes for the
government doctors
ISSUES AND CONCERNS FOR MEDIUM AND LONG TERM CONSIDERATION
1) Work out the logistics of partnership concept between Government and Voluntary
Organizations.
2) Involve Voluntary Organsiations in planning, implementation and monitoring of
Health Programmes.
3) Enactment of Nursing Home Bill with necessary changes
4) Have the hospitals owned by the private / corporate sector to reserve 10% of the
beds for people below the poverty line.
5) Family and group Insurance schemes for all including villages to be worked out
and encouraged
6) Formation of Quality Assurance committee with the help of professional bodies
for self-regulation.
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14.
Short term recommendations
AND PLAN OF ACTION
The Task Force on Health and Family Welfare has identified certain recommendations that
demand immediate attention keeping with the thrust of the Task Force, Terms of Reference
and deliberations, to strengthen health care in Karnataka with special focus on Primary
Health Care and Public Health. These recommendations are implementable in the short term.
The overall thrust of the recommendations is to strengthen Equity with Quality in Health
Care Services in the State i.e., to focus on those who need services most and to provide them
with services which are of the best possible quality, within the limitations of resources and
other constraints, under which the health sector functions today.
As the process of review proceeds, we hope to evolve a framework of Comprehensive State
Health Policy that will make a functional Primary Health Care and a strong Public Health
System, a reality of the State of Karnataka.
1. Primary Health Care
1.1. RURAL HEALTH
1.1.1. All vacancies of Doctors, Laboratory Technicians and ANMs at PHCs and
Subcentres must be filled up immediately.
ACTION: Government, DHFWS
1.1.2. 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;
ACTION: DHFWS
1.1.3. The allotment for Essential Medicines (including Life Saving Medicines)
must be increased by atleast Rs. 25,000/- per annum per PHC. All Essential
drugs must be available at the PHC at all times.
ACTION; Government, DHFWS
1.1.4. Every PHC must have a Telephone.
ACTION: DHFWS
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1.1.5. Atleast 1000 PHCs in the Seate must be made fully functional satisfying the
above criteria, within the next 6 months
ACTION: DHFWS
1.2. URBAN HEALTH
1.2.1. The Urban Family Welfare Centres and Health centres under India Population
Project VIII should be involved in Comprehensive Primary Health Care.
ACTION: DHFWS, Banga/^re Maltanagara Palike, Department of Urban
Development
1.3. REFERRAL SERVICES: Secondary and Tertiary Health Care
1.3.1.Complete the Secondary Care Institutions in progress under KHSDP (100
Secondary Care Hospitals) in the next Six months and make them fully
functional with adequate Human power, equipments and accessories. The
OPEC Hospital in Raichur must be made functional as early as possible. Work
out effective linkages of Primary Health Care Institutions with the referral
hospitals.
ACTION: Government, PA-KHSDP
1.4. EMERGENCY HEALTH SERVICES
1.4.1. Improve the capability of the Health Care Personnel at PHC to attend to
emergencies. The Emergency services should also cater to all emergencies,
including Obstetric and Gynaecological cases, poisoning cases and Dog and
Snake bites. Polyvalent anti-Snake Venom Serum must be made available at
all PHCs at all times as a life saving measure.
ACTION: DHFWS
1.4.2. Well-equipped Ambulance Vans with well-trained 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. SGARRC and NIMHANS to be the nodal
Centres.
ACTION: DHFWS, PA-KHSDP
1.5. LABORATORY SERVICES
1.5.1. All laboratories must be staffed with trained technical persons and equipped
with the necessary instruments, accessories and reagents. Fresh appointees
must be given orientation training before posting and existing staff should be
given refresher training.
ACTION: DHFWS
65
1.5.2. 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.
ACTION: DHFWS
1.5.3. Rs. 30,000/- per PHC to be initially earmarked for the purchase of
Microscopes (about Rs. 15.000/-), glass ware, equipment, other accessories
and reagents.
ACTION: Government, DHFWS
1.6. BLOOD BANKING AND TRANSFUSION SERVICES
1.6.1.The eight districts in the State which do not have a Blood bank to have atleast
one blood bank each
ACTION: Government, DHFWS
\.62A study to be initiated and concrete proposal(s) to be developed to ensure and
make available safe blood to the needy in the districts. The proposal to also
review the existing guidelines and their feasibility. A representation to be
made by the State Government to the Government of India in this regard.
ACTION: Government, DHFWS, Drugs Controller
2. Public Health
2.1. STRENGTHENING THE PUBLIC HEALTH SYSTEM
Human Resources for Public Health
2.1.1. A short two week course on Public Health principles and practice for Taluka
and District Health Officers at the State Institute for Health and Family
Welfare. Short in-service orientation courses on public health principles and
programmes for PHC Medical Officers.
ACTION: DHFWS, Director-SIHFW, RGUHS, All Medical Colleges,
Experts
Structural Issues in the Public Health System
2.1.2. A review of the Externally Aided Projects to be initiated to facilitate their
absorption into the Health System. Sustainability and consolidating the gains/
achievements to be the primary objective.
ACTION: Government, DHFWS, VOs
2.2. NUTRITION
2.2.1. Define and establish the items of coordination between the Health Sector and
ICDS. These must include:
(a) A mechanism to detect, take corrective steps and monitor children with
mild to moderate undemutrition.
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(b) Coordination in detecting and treating infectious diseases in children,
especially diarrhoea, skin and ear infections with appropriate care.
ACTION: DHFWS, Department of Women and Child Welfare
2.2.2. Weaning foods for Infants and children above six months to be made available
under the ICDS scheme.
ACTION; Government, Department of Women and Child Welfare,
DHFWS
2.2.3. Systematic promotion of kitchen gardens supported by seed/seedling supply.
Drumstick, Chakramuni (Chikermane), Amaranthus, Papaya, local beans, are
some examples.
ACTION: DHFWS, Forest and Horticulture department
2.2.4. 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.
ACTION: Government, DHFWS
2.3. WATER SUPPLY AND SANITATION
2.3.1. 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.
ACTION: DHFWS, RDPR
2.4. WASTE MANAGEMENT
2.4.1. Ensure proper segregation of Waste and total waste management at all health
care institutions.
ACTION: Health Care Institutions, Government, DHFWS
2.4.2. All health care institutions including Primary Health Centres and General
Practitioners Clinic, should develop a policy and action plan for safe
management of waste generated in their premises. The segregated waste
streams should not get mixed up with general solid waste.
ACTION: Health Care Institutions, Government, DHFWS
2.4.3. Initiate orientation and training of Health Care Personnel for proper waste
management practices including practice of Universal Precautions.
ACTION: Health Care Institutions, DHFWS
2.4.4. The government should support initiatives for common waste management
treatment facilities.
ACTION: Government, Local Self Governments
67
2.4.5. A Sanitary Landfill site must be identified for all Towns and Cities by local
bodies, with assistance of the Health Department.
ACTION: DHFWS, Urban Development, Local self Government, VOs,
2.5. COMMUNICABLE DISEASES
2.5.1. 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: DHFWS
2.5.2. 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 Professional Associations.
ACTION: DHFWS, NTI, MRC, ROHFW, DME, NGOs,
2.5.3. Choose one model of Communicable Disease surveillance (in contra
distinction to HMIS) after considering the model developed by KHSDP.
ACTION: DHFWS
2.5.4. Every school must have facilities for Safe drinking water and latrines; proper
use of the latrine must be inculcated at the school level.
ACTION; DHFWS, Education Department, NGOs.
2.5.5. Periodic deworming and correction of the Nutritional anaemia (by providing
supplementary Iron tablets) for pregnant and lactating mothers, women,
children and adults.
ACTION: DHFWS, Government (Central and State)
2.6 NON COMMUNICABLE DISEASES
2.6.1 Diabetes mellitus
2.6.1.1. All PHCs to have facilities to detect and manage / refer patients with
Diabetes.
ACTION: DHFWS, NGOs
2.6.1.2. Secondary Care hospitals should have physicians re-oriented for the
management of persons with diabetes and their complications
together with the needed anti-diabetic drugs, including Insulin.
ACTION: DHFWS
68
I
2.6.2 Hypertension and Cardio-vascular Diseases
2.6.2.1. All PHCs to be able to diagnose hypertension and risk factors for
cardiovascular diseases and to manage/refer patients, as necessary.
ACTION: DHFWS, Professional Bodies
2.6.3 Mental Health and Epilepsy
2.6.3.1. The Community based Mental Health Programme in Bellary District
should be strengthened.
ACTION: DHFWS, NIMHANS
2.6.3.2. 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.
ACTION: DHFWS, NGOs
2.6.3.3. Improve the facilities and conditions in the Karnataka Institute of
Mental Health, Dharwad which should continue as the major
speciality institute with autonomy in governance.
ACTION: DHFWS,Government, DME
2.6.4 Cancer Control
2.6.4.1. Downstaging of Cancer Cervix programme to be initiated on
priority.
ACTION: DHFWS, KMIO, Government
2.6.4.2. A model comprehensive Cancer Control Pilot Project to be initiated
at Mandya district.
ACTION: DHFWS, KMIO
2.6.4.3. Director, Kidwai Memorial Institute of Oncology, Bangalore to be
ex-officio Joint Director (Cancer Control).
ACTION: DHFWS, Government
2.6.5 Oral Health
2.6.5.1. All Taluka hospitals to have qualified dental surgeons.
ACTION: DHFWS, Government, NGOs
'1.6.52. Principal, Government Dental College to be ex-officio Joint Director
(Dental Health).
ACTION: DHFWS, Government
69
3.
Maternal and Child Health
3.1.Increasing the skills of ANMs in the CNA methodology. Revision of the existing
training syllabus to incorporate enhanced technical and communication skills.
Sensitisation regarding the importance of the timing, spacing and number of births,
and exclusive breast feeding for the first 6 months.
ACTION: DHFWS, PD-RCH
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.
ACTION: DHFWS, PD-RCH, Government
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: DHFWS, PD-RCH
3.4. To cater to the Newborn Care the Anganwadi worker to be trained to be the second
functionary. She may be given additional monetary compensation.
ACTION: DHFWS, Department of Women and Child Welfare
3.5. Ensure 100% registration in the first trimester, proper antenatal, natal, and postnatal
care with involvement of Private Sector.
ACTION: DHFWS, NGOs
3.6. Ensure 24-hour delivery services at FRUs. with involvement of Private Sector.
ACTION: Government, DHFWS, NGOs
3.7. Ensure uninterupted supply of IFA at all times at all Health Care Institutions.
ACTION: Government, DHFWS
3.8. A Pilot Project has been taken up in the 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.
ACTION: DHFWS; PD-RCH; FOGSI and VOs
70
4. Population Stabilisation
4.1. A Population Policy as part of the comprehensive Health Policy will be drafted
for wider discussions for eliciting public and professional opinion.
ACTION: Government, DHFWS, NGOs
4.2. Commence a strong IEC programme regarding the health hazards and social ills
of early marriages, the need to raise the age at marriage and advantages of
postponing the second child.
ACTION: DHFWS, Media(Electronic, Cultural, Print)
5. Focus on Special groups
5.1 WOMEN AND HEALTH
5.1.1. Sensitise all Health Care Personnel on issues relating to gender inequalities.
ACTION: DHFWS, NGOs
5.1.2. Educate and promote personal hygiene especially during menstrual period by
the distribution of subsidised menstrual pads/cloth.
ACTION: DHFWS, NGOs, Government
5.1.3. Services of Lady Medical Officer to be available at al Primary Health
Centres..
ACTION: DHFWS
5.1.4. Improve diagnostic, medical and counselling services for STI & HIV/AIDS
for women as well as the sexual partner.
ACTION: DHFWS, SIHFW
5.1.5. Initiate efforts to identify gender related barriers to TB diagnosis and
treatment; integrate into overall efforts to improve programme effectiveness.
Identify sources of inequity.
ACTION; DHFWS, NTI
5.2 PERSONS WITH DISABILITIES
5.2.1. Utilise Media to create awareness and training of parents and other care-givers
on specific disabilities.
ACTION: DHFWS, NGOs9 Media (Print, Electronic, Cultural)
5.2.2. Reestablish the role of the Health department in Disability Prevention, Early
detection, Intervention, corrective surgery and physiotherapy.
ACTION: DHFWS, Disabled Welfare Department.
5.3 TRIBAL HEALTH
5.3.1.
Strengthen the Mobile Health Units and the PHCs in the Tribal areas and
make them all functional.
ACTION: DHFWS, NGOs
71
5.3.2. Initiate a systematic documentation of Traditional Medicine with the help of
Voluntary Organisations.
ACTION: DHFWS, VOs
5.3.3. Strengthening of the Tribal ANM project. The current batch of 27 needs to be
posted on priority and a fresh batch of training to be initiated.
ACTION: DHFl^S
6. Health Education
6.1 HEALTH EDUCATION
6.1.1.Reorganise and integrate the different IEC programmes in the Directorate of
Health and Family Welfare Services with professional inputs.
ACTION: DHFWS, NGOs
6.2 SCHOOL HEALTH
6.2.1. Initiate action for greater coverage of all students in all the schools in the
state with health (including Dental) checkups and health education. Train
students in First Aid.
ACTION DHFWSf NGOs
6.2.2. Use AIR / DD to impart lessons in Health (similar to UGC programmes).
ACTION: DHFWS, Media (Electronic), NGOs
7. Health Human Resources Development
7.1.
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 underserved areas of Karnataka. Where essentiality certificate or
temporary affiliation has been given but the College has not started functioning,
the certificate and affiliation should be withdrawn immediately.
ACTION: Government, DME, RGUHS
'll.
Extend the moratorium on new Ayurvedic, Homoeopathy and Unani Colleges by
another 2 years.
ACTION: Government, DME, RGUHS
7.3.
Take up urgently the repairs of the buildings of the Colleges, hospitals and
hostels, equipment and vehicles of the Government teaching institutions and
hospitals. All equipment must be maintained in good working condition.
ACTION: Government, DHFWS, RGUHS, DME
7.4.
Redeploy teaching and non-teaching staff according to the needs.
ACTION: DME
72
7.5.
7.6.
7.7.
7.8.
7.9.
7.10.
Streamline the working of emergency services like Casualty, Bums, and
Accidents. Round the clock diagnostic (X-ray, laboratory, etc.) and blood bank
services in all teaching Hospitals. Essential drugs must be available at all times.
ACTION: DME
The State Institute of Health and Family Welfare to be upgraded and be made
autonomous. The Institute and RGUHS together with VOs and experts should
take up the training at all levels in management, public health and ethics.
ACTION: Government, DHFWS, SIHFW, RGUHS, VOs, Experts, Task Force
Increase the intake for the training of Auxiliary Nurse Midwives (ANMs)
Encourage NGOs with the capacity for training to take up the training of ANMs.
ACTION: Government. DHFWS, NGOs
Every Medical and Dental College to adopt a block for service to the people of
the area and training of students.
ACTION: Government, DME, DHFWS, RGUHS, All Medical and Dental
Colleges
Corruption in the examination system to be eliminated.
ACTION: Government, DME, RGUHS, All Colleges
The teaching programmes in the Government Medical Colleges to be
strengthened by invited teaching faculty and given suitable remuneration; they
will not have clinical responsibility at the hospital.
ACTION: Government, DME, RGUHS
8. Health Systems Management
8.1 ADMINISTRATION
8.1.1. All administrative posts in the Directorate to be filled up.
ACTION: Government. DHFWS
8.1.2. All the posts of Joint Directors and above to be selection posts.
ACTION: Government. DHFWS
8.1.3. The services of doctors with Postgraduate qualifications in various disciplines
serving at different PHCs to be utilised to fill the vacancies at Taluka level
and above Health Care Institutions.
ACTION: Government. DHFWS
8.1.4. A Vigilance Cell in the Directorate headed by the Commissioner for
disciplinary action against corruption, absenteeism and for speedy disposal of
enquiries.
ACTION: Government
8.1.5. The process of regularisation of the contract doctors to be commenced.
ACTION: Government. DHFWS
73
8.1.6. A transfer Policy to be evolved on the basis of well defined criteria, and
implemented. Mis-match of professionals and service requirements to be
addressed.
ACTION: Government, DHFWS, Task Force
8.1.7. About 100 Doctors from the Department to be selected through a transparent
“search-cum-selection” mechanism assisted by Task Force, given intensive
training in management and placed at the Directorate and DHOs Offices as
Programme managers.
ACTION; DHFWS; SIHFW
8.1.8. The selection of In-service Doctors for postgraduate courses to be based on
the needs of the Department for quality health care.
ACTION: DHFWS, Government
8.1.9. The practice of postings of officers OOD should be kept to the bare essential.
ACTION: Government, DHFWS
8.1.10. The role, responsibility and authority of Commissioner, Health and Family
Welfare to be defined enabling to function effectively. Suggestion in
Annexure. Sufficient administrative and financial powers to be delegated
ACTION: Government
8.1.11. The system of performance appraisal (confidential reports) to be implemented.
ACTION: DHFWS
8.2 PLANNING
8.2.1. A suitable structure for the Planning Unit in 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.
ACTION: Government, DHFWS, Task Force
8.3 FINANCING
8.3.1. Additional resources to be provided during 2000
reforms suggested.
ACTION: Government
2001 to carry out the
8.3.2. Monitoring of expenditure, especially plan programmes to ensure adequate
utilisation and results must be done.
ACTION: Commissioner, Health and Family Welfare
8.4 HEALTH INFORMATION MANAGEMENT SYSTEM
8.4.1. An integrated Geographical Information System based HMIS to be initiated
and implemented.
ACTION: Government^ DHFWS, Task Force
74
u
8.4.2. All the District Health Officer should be computerised for efficient
management and control of Health System in the district.
ACTION: Government, DHFWS, Task Force
8.4.3. The formats / registers needed at various levels to be updated, printed and
supplied in adequate quantities and on-time.
ACTION: DHFWS, Task Force
8.4.4. Annual reports and monthly updated programme performance to be placed on
website of the Directorate.
ACTION: Government, DHFWS, Task Force
8.5 MEDICINES PROCUREMENT AND SUPPLY
8.5.1. The Rate Contract System
(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.
ACTION: Government, DHFWS, Drugs Controller
8.5.2. The RC should specify the total requirement of the drugs for the entire State
including that of ZPs and include all sources and not just 40% of the GMS
quota.
ACTION: Government, DHFWS
8.5.3. The ZP or any other drugs procurement agency for Government Health Care
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.
ACTION: Government, DHFWS, ZP
8.6 LAW AND ETHICS
8.6.1. The legislation introduced in the Legislative Council to regulate the
functioning of Health Care Institutions should be sent to a Select Committee
to elicit views from all concerned (stake-holders, professionals and public).
ACTION: Government
8.6.2. Take steps to renew the registration of health professionals once in 5 years
with the respective State Councils. Initiate steps to register all Health Care
Institutions.
ACTION: Government, DHFWS, State Councils for Medicine, Dentistry,
Nursing,Ph armacy.
75
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9. Indian Systems of Medicine and Homeopathy
9.1 AYURVEDA, UNANI AND HOMEOPATHY
9.1.1. Plan and initiate planning to have ISM&H wings in the existing District /
Taluka hospitals.
ACTION: Government, DHFWS,DISM&H
9.1.2. The drug licensing authority should ensure the printing of the date of
manufacture and date of expiry of drugs on the containers.
ACTION: DISM&H, Drugs Controller
9.1.3. The supply of medicines to hospitals and dispensaries must be quarterly to
avoid loss of potency.
ACTION: Government, DISM&H
9.1.4. The budget allocation per dispensary should be increased to Rs. 36,000/- per
annum.
ACTION: Government, DISM&H,
9.1.5. The stipend for the Interns and Postgraduates to be enhanced.
ACTION: Government, DISM&H
9.1.6. Steps to be taken to conduct Entrance Tests for selection to Postgraduate
courses.
ACTION: DISM&H
10. Panchayat Raj and Empowerment of People
10.1 PANCHAYAT RAJ INSTITUTIONS AND HEALTH
10.1.1. Training must be imparted to the new Panchayat members regarding their
responsibilities and duties, with particular regard to health and other social
sectors; relationship with the health staff and need for monitoring health
programmes to be emphasised.
ACTION: NGOs, Government
10.1.2. Women members of Panchayats should be separately oriented to the RCH,
ICDS and similar programmes. They should be motivated to take on the role
of community leaders in health and health-related issues.
ACTION: Government, DHFWS, ISEC
10.1.3. The Gram Panchayat should appoint a woman health functionary at Villages,
where there is no ANM or Anganwadi 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.
ACTION: Government, DHFWS, RDPR
76
10.2 PEOPLES EMPOWERMENT FOR HEALTH
10.2.1. A pilot project in one District to have Health Committees at Village, Sub
centre and Primary Health Centre levels.
ACTION: Government, DHFWS, DPRD, NGOs
11. Strengthening Partnerships
11.1 VOLUNTARY ORGANISATIONS
11.1.1. A Directory of Voluntary Organizations working in Health and Healthrelated work in Karnataka should be brought out immediately and updated
periodically.
ACTION: Government, DHFWS,
11.1.2. Introduce a single window Voluntary Organisations Cell at the Health
Directorate to co-ordinate the different programmes and simplifying
procedures for grant-in-aid avoiding delays. Commissioner to be the nodal
officer.
ACTION: Government, DHFWS, NGOs
11.2 PRIVATE AND CORPORATE SECTOR
11.2.1. Use the services of private practitioners and specialists where there is lack
of such personnel in the Government sector, paying for their services on
mutually agreed terms. In case of deficiency of doctors in PHCs, Private
Practitioners may be appointed on "adhoc" basis.
ACTION: Government, DHFWS, NGOs
11.2.2. Involve organisations of doctors in IEC activities and national programmes.
ACTION: Government, DHFWS, NGOs
11.2.3. Provide drugs and vaccines in the national programmes to the private
practitioner for the benefit of the economically poor.
ACTION: Government, DHFWS, NGOs
11.2.4. Tertiary hospitals in Private sectors to also provide training programmes for
the government doctors.
ACTION: Government, DHFWS, NGOs
77
Annexures
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. HEW 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.
Dr. H. Sudarshan, Kanina 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
Interegrated Rural Health Centre, Pavagada, Tumkur
Dr. M. Maiya, Physician, Bangalore
Dr. S. Subramanya, Project Administrator, Karnataka
Health Systems Development Project
4.
5.
6.
7.
8.
9.
10.
11.
12..
Chairman
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member
Member Convenor
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.
78
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
79
ANNEXURE IB
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 COM 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 Convenor, 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.AtoP.S-l&2
80
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 Convenor.
In the Notification read at (2) above on returing 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
Convenor 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 are pleased to nominate The Project
Administrator, Karnataka Health System Development Project and Special Secretary to
Government, Health and Family Welfare Services Department as Member Convenor of Task force
of 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,
BTore.
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
81
u
8. The Accountant General in Karnataka, Bangalore
9. The Commissioner, Health & Family Welfare, Bangalore
10. The Director, Heath & 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.
82
ANNEXURE 2
________ Schedules of the Meetings and Consultations (Entire Group)
_______ Month
Dates
1. December 1999
2. January 2000
3. February 2000
4. March 2000
5. April 2000
21st
3rd, 4ttl 5th, IO111, 11th, 12th, 27th, 28ttl, 29^
8111, 14111, IS01,16th 21st 25th, 28th, 29th
1st, b01, 7th, 8th, 11th, 13th, 20th
6th, 14th
Total = 28 full working days.
83
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
ANNEXURE3
_______________________ Sub Groups and Members
_________________ TOPICS_______________
____________ MEMBERS_________
Health Systems and Services in Rural Areas.
Dr. C. M. Francis (Team Leader)
Health Systems and Services in Urban Areas.
Sri. P. Padmanabha.
Emergency Health Care.
Dr. M. Maiya.
Panchayat Raj and Health Care.___________
Swami Japananda.________________
Communicable Diseases.
Dr. Jacob John. (Team Leader)
Dr. Latha Jagannathan.
Dr. S. Nagalotimath.
Swami Japananda.________________
Population Stabilisation (RCH).
Sri. P Padmanabha. (Team Leader)
Dr. Latha Jagannathan.
Dr. Suresh. B. Kulkarni.___________
Human Resource Development
Dr. Chandrashekar Shettycream Leader).
Medical Education.
Dr. C. M. Francis.
Health Education.
Dr. Jacob John.
Dr. S. Nagalotimath.______________
Health Financing.
Sri P Padmanabha (Team Leader).
Dr. S. Subramanya._______________
Indigenous / Alternate Systems of Medicine.
Dr. Jayaprakash Narayan. (Team Leader)
Dr. Chandrashekar Shetty._________
Non Communicable Diseases,
Dr. S Nagalotimath(Tearn Leader).
Dental Health,
Dr. C. M. Francis.
Mental Health and Epilepsy.
Nutrition.
Dr. C M Francis (Team Leader).
Dr. P. Padmanabha.__________
Health of Special Groups.
Dr. Jacob John.
Dr Latha Jagannathan(Team Leader)
Voluntary Sector in Health Care.
Swamy Japananda (Team Leader).
Dr. Chandrashekar Shetty.
Dr. M. Maiya.________________
Private / Corporate Sector in Health Care.
Dr. M. Maiya. (Team Leader)
Dr. Suresh. B. Kulkarni.
Dr. Latha Jagannathan.________
Law and Ethics.
Dr. C. M. FranciS(Team Leader)
Dr. Latha Jagannathan.
Health Policy.
Dr. C. M. Francis. (Team Leader)
Inter Sectoral Co-ordination.
Dr. Thelma Narayan
External aided Projects.________________
Health Management Information Systems.
Dr. Latha Jagannathan (Team Leader).
Sri. P. Padmanabha.____________
Administration and Planning
Sri P Padmanabha______________
Maternal and Child Health
Dr. Kamini RaO (Team Leader).
Dr. Thelma Narayan
Dr. Lata Jagannathan
84
ANNEXURE4
List of Individuals / Organisations / Associations who interacted with the
Task Force
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 Principal Secretary,
4. Sri A K M Nayak, ias Formerly Health Commissioner
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 Project Director, IPP IX
Directorate
Health and Family Welfare Services:
1. Dr. P N Halagi, Director of Health and Family Welfare,
2. Dr. Makapur, Director, State Institute of Health and Family Welfare
3. Dr. Shivaratna Savadi, Formerly Director of Medical Education
4. Dr. Nagaraj G V, Project Director, RCH
5. Dr. Murugendrappa, Additional Director, Primary Health
6. Dr. Kurthkoti, Additional Director, Health Education and Training
7. Dr. K. Sharadamma, Additional Director (SPC), KHSDP
8. Dr. Bhattacharjee, Director, Population Centre
9. Dr. Kumaraswamy, Joint Director, Ophthalmology
10. Dr. Janguay, Joint Director, Leprosy
11. Dr. Narayana Murthy, Joint Director, Tuberculosis
12. Dr. Jayadev, Joint Director, HET
13. Dr. Jalaja Sundaram, Joint Director, Nutrition
14. Smt. H.S. Susheela, Joint Director (IEC)
15. Sri Prakasham, Joint Director, Demography
16. Dr.V. S. Rajamma (HMIS), Deputy Director, KHSDP
17. Dr. K R Kamath, Deputy director, PHI
18. Dr. M. Dhananjaya Reddy (CMD), Deputy Director
19. All the District Health Officers
20. All District Surgeons
21. Dr. D.M. Koradhanyamath, Training Officer, IPP-IX
22. Shri P. Mahadev, Asst. Leprosy Officer,
23. Smt. D. R. Jayashri, Systems Analyst,
24. Sri Veeranna, Assistant Director, Nursing Services
85
Indian Systems of Medicine and Homoeopathy
25. Dr. S M Angadi, Director of Indian Systems of Medicne,
26. Dr. Malini, Principal, Govemmem Ayurvedic College,
27. Dr. Prakash, Principal, Government Homeopathic Medical College
Drugs Control Department
28. Dr. Ananada Rajashekar, Drugs Controller
29. Mr. Prabha Chandra, Deputy Drugs Controller
30. The Chief Pharmacist, Government Medical Stores
3] 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
4] 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. Ramesh Bilimagga, Dr. Sheela Bhanumathy, Dr V C Shanmuganandan, Indian
Medical Association
7. Dr. Mallikaijunaiah, 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. Malikaijuna R, Dr. Veerabhadraiah, Dr. Sanath Kumar, Dr. Ravishankar,
Karnataka Government Contract Doctors Association
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)
86
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
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
Interaction with Press
1. Sri Chennakrishna, Reporter, Samyukta Karnataka
2. Sri. G.D. Yatish Kumar, Reporter, Janavahani
3. Sri. B. S. Satish Kumar, Deccan Herald
4. Reporter, Asian Age
5. Smt. Padmini, The Hindu
6. Sri B N Chandrakumar, Programme Officer, Doordarshan Kendra
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
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.
87
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, AV AS
Peoples Organisations
1. Sri Sridhar and Sri Basavaraju, Bharatiya Gnana Vignana Samiti
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
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
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
Autonomous Hospitals
1. Dr. Ballal, Sanjay Gandhi Accident Relief and Rehabilation Center
2. Dr. Benakappa, Indira Gandhi Institute of Child Health
Invited Guests / Experts
1. Dr. Phadke, St. John’s Medical College Hospital, FORTE
2. Dr. Philip Thomas, St. John’s Medical College Hospital, FORTE
3. Dr. Venkatesh, Bangalore Kidney Foundation.
4.Sri. D.K. Bhatt, Consultant Health System Management
5.Sri. P.V. Bhat, Principal System Analyst; Smt. K. Padmavathi, Secretary Systems
Analyst, National Informatics Centre
88
6.Sri Manjot Deol, Manager, Sri S Mani, Business Manager; Sri Sanjeev, Vice
President, Wipro GE Medical System
7. Justice D.M. Chandrashekar
8. Dr. Hema Reddy, Formerly Director of Health Services
9. Dr. Vinod Vyasulu and Dr. Indira, Centre for Budget and Policy Studies
10. Dr. Sathyanarayana, Centre for Symbiosis of Technology, Environment and
Management
11. Dr. Darshan Shankar, Foundation for Revitalisation of Local Health Tradition
12. Dr. R.M. Varma, Consultant Neuro Surgeon
13. Dr. R L Kapoor, Consultant Psychologist
14. Sri P G R Sindhia, MLA and Formerly Health Minister of Karnataka
15. Sri Suryanarayana Rao, Trade Union Leader, CPI (M)
16. Sri Nagaraj G N, Secretariat member, CPI (M),
17. Dr. N.H. Antia, The Foundation for Research in Community Health, Pune
18. Dr. Rajaratnam Abel, RUSHA, Christian Medical College and Hospital, Tamil
Nadu
19. Dr. Muraleedharan, Indian Institute of Technology, Chennai
20. Dr. Sridhar, SEWA, Wardha
21. Dr. Almas Ali, Project Officer, South Asia Poverty Alleviation Programme, UNDP
22. Sri Srinivasan, Formerly Health Secretary, Government of India
89
ANNEXURE 5
List of Invited Suggestions / Comments
Invitations sent to
A]
All the members of the
• The Karnataka Legislative Assembly
• The Karnataka Legislative Council
S]
• The Health Secretaries of the States and Union Territories in India
C]
All the
• District Health Officers, Directorate of Health and Family Welfare Services,
Government of Karantaka
• Taluka Health Officers, Directorate of Health and Family Welfare Services,
Government of Karantaka
• District Surgeons, Directorate of Health and Family Welfare Services, Government
of Karantaka
D] Citizens who responded to the request
Sri Kariyanna,
Sri. Chaluvarayaswamy N______
Sri. ChikkamadaNayaka________
Sri. NeelakanthaRao Deshmukh
Garmpalli_________________
Dr. R Srinivasa Murthy_______
Dr. Vasundhara M K
Dr. Mani K S_______
Dr, Munichoodappa C
Dr. Parameshwara V
Dr. Hegde B M_____
Dr. Basappa K
Dr. Pruthvish S
Dr. Shivaram C
Dr. Nagesh______
Dr. Rama Rao S V
Dr. Ramakrishna V
Prof. Joga Rao S V
Dr. Sudarshan M K
MLA and Chairman, Scheduled Castes and Scheduled Tribes
Welfare Committee________________________
Member, Karanataka legislative Assembly Nagamangala_______
Member, Karanataka legislative Assembly Bannur____________
President, Zilla Panchayat, Gulbarga
Professor of Psychiatry, NIMHANS__________________
Professor and Head of Community Medicine, Dr. B R
Ambedkar Medical College______________________ __
Formerly Director, NIMHANS______________________
Consultant Diabetologist, Bangalore__________________
Consultant Physician and Cardiologist, Bangalore_______
Vice-chancellor, Manipal Academy of Higher Education
Professor of Preventive and Social Medicine and formerly
Dean,________________________________ __________
Co-ordinator, Disability Training and Research Unit,
ACTIQNAID- India_______________________________
Emeritus Professor in Community Medicine, M S Ramaiah
Medical College_____________________________ _
Principal, R V Dental College_______________________
Consultant in Health______________________________
Health Education Consultant, IUPHE_______________ __
Director, TILEM, National Law School of India University
Professor and HOD, Community Medicine, KIMS
90
Sri A N Yellappa Reddy
Sr. Anne Marie_______
Mrs Sudha Tewari_____
Dr. N Shantaram______
Dr. Padma Rao
Formerly Secretary to Government of Karnataka_____
Principal, College of Nursing, St. Martha’s Hospital
Managing Director, Parivar Sewa Sanstha, New delhi
President, Karnataka Association of Community Health
Kasturba Medical College, Manipal
91
ANNEXURE 6a
List of Suggestions by Post Kannada
Name of the Individual
Organisation
1. Abdul Mujeeb S
2. Administrative Medical General Hospital, Soraba
Officer
3. Anjanappa
4. Anonymous
5. Anonymous
6. Asthulekhan E Lodi
7. Dr. bi. Ashoka Reddy
Karnataka State Government Doctor’s
Association ®
8. N.Y. Badager
9. Bahubali
10. Banada S S
11. Basava Raju
12. BhatGS
FPAI
13. Dr. Chandrappa Gowda
14. Chandrika S Y
15. Dakappa Muddhol
16.
District Health and Family Welfare
17. Deputy Medical Director District Cholera Controlled Team
18. Dr. Dharwad S C
District Malaria Office
19. Eerappa M Hulihalli
20. Guruswamy
21. Health Officer
*Mobile Doctor’s Unit
22. Heggade V S
Taluka Industrial Centre
23. Hony Secretary
Teachers Association, Government Polytechnic
24. Kaashivappa A Thotagi
25. Karyadarshi
Taluk Soliga Abhivruddi Sangha (Regd.)
26. Keshvappa M G
27. Krishnamurthy B R
28. M.D. Krishnayya
Karnataka State Yaadhava Vani Sangha
29. Dr. Kulakarni S S
30. Kumari Shwetha M
Revalkar
31. Laksmana Rao T K
32. Dr. M B Rudrappa
Health and family Welfare Training Centre
33. Mahadeva Shetty K M
34. Dr. S.B. Maheshwara
Dudee Organisation for Rural Reconstruction
(Regd.)
35. Dr. Muralidhar
Karnataka State Government Indian Health and
Homoeopathy Contract Doctor’s Association
(Regd.,)
36. Nagappa R Tiger
Karnatak Dalita Sangharsha Samiti
37. Nagaraja. A
*Jai Bheem Youth Union (Regd)
38. M.S. Nagaraj
Karnataka State Pharmacist’s (Allopathy)
Association
92
Place
Tumkur
Shivamogga
Bangalore
Bangalore
Bangalore
Gadag
Chitradurga
Belgaum
Belagaum
Bidar
Tumkur
Mysore
Shivamogga
Davanagere
Belagaum
Chamarajanagar
Gulbarga
Dharwad
Haveri
Bellary
Kollegal
Bidar
Bidar
Belagaum
Chamarajanagar
Shivamogga
Bangalore
Bangalore
Belgaum
Davanagere
Bangalore
Hubli
Mysore
Gundlupet
Bellary
Gulbarga
Bangalore
Bangalore
J
List of Suggestions by Post Kannada (continued)
39. Nanjundaiah
FEDINA - VIKASA
Mysore
40. Nataraj
Sri Guruboodhi Swamigala Vidhyathi Nilaya Hunusur
41. Nirvani Gowda
Hassan
42. Patil N S and 40 others
Belgaum
Chalakulu, Mattanuru, Malkama and Shosa
43. Smt. Philomena Joy
Mysore
Rural Literacy and Health Programme
44. Prabhakar N P
Bidar
45. Prabhakar Rao and 6 others
Bidar
46. Dr. Raju
Shivamogga
47. Ramachandra I. Pavar
Belagaum
48. Dr. Ramachandra K.
Mandya
49. Dr. S B Maheshwara.
Dudee Organisation for Rural Reconstruction Gundlupet
50. Sanga N R
Bagalkot
51. Dr. Sangamesh Kalahal
Bangalore
Karnataka State Govt. Indian Systems’
Medical Officers’ Association
52. Sattar S A and 6 others
Bhalki
53. Secretary
Kollegal
Taluk Soliga Abhivridhha Sangha
54. Seetharamaiah and
Bangalore
Government Nurses Association, Karnataka
Dasegowda
55. Shashikala
Belagaum
56. Shabbir Ahmad Athaar
Gokak
57. Shena Shetty
Aadhivaasi shikshana kendra
Bantwal
58. Sidharameshwar Guruji
Revansidheshwar Prasanna Education Society Bidar
59. Sidheshwaran G.N.
Chitradurga
Chitradurga District Health Supervisor
Association
60. Srinath. N. Navale
Belgaum
61. Dr. P. S. Upaadhyaaya
Taluka Medical Office
Shivamogga
62. H. Venkataramanayya
Shri venkateshwara kendra Trust ®
Bangalore
63. Sheena Shetty
Adivasi Sikshana Kendra
Bantwala
64. Shettar M S
Gadag
65. Siddappa Haralenneyavar
Kunsi
66. Siddarameshwara Guruji
Bidar
Revanasiddeshwara Prasanna Education
Society
67. Siddramappa and 20 others Ajjampura, Singtagere, Sakhrayapatna
Chikkamagalur
68. Dr. P.K. Srinivas
District Malaria Officer
Mysore
69. Srinivas Murthy
Bangalore
70. Subramanya R
Bangalore
71. Subramanya R
Bangalore
72. Taluka Health Officer,
General Hospital
Chintamani
73. Taluka Health Officer
yadhagiri
74. The President
Bangalore
RamaMurthynagar Welfare Association
75. Thimmiah H D
Chitradurga
76. ThyaraMallesh S M
Chitradurga
77. Venkatesh K R
K. R Pete General Hospital
Mandya
78. Venkatesh R
Bangalore
79. Verrabhadrappa H
Bhadravathy
80. Vijayalakshmi Yelia
Chitaguppa
81. Dr. Yamanur Saheb B P
Karnataka Rajya Nadaf / Pingara Sangha
Bellary
82. G.R. Yogendra Nayak
Shimoga
83.
Taluka Health Officer,
Udipi
93
84. Dr. R Venkatesh
85. Smt Vatsaia
86. Dr. M Chandrashekar
87.
C/o T S Sridhar
Ex Chief Judge
94
T Narsipura
Yelahanka
Mangalore
ANNEXURE 6b
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. E. Basavaraju
6. Dr.Chandrashekar N M .
• 7.
8. Farooqui MAH
9. Ganagmalliah
10. Giri ATS
11. Dr.Govindaraju
12. GuttalMC
13. Dr.Hanumanthappa T.
14. Health Officer
15. The Head Master
16. Dr.Jayanth G Paraki.
17. Dr.K Taranath Shetty
18. Krishna Murthy G
19. Kumari Sandhya
20. G.Krishna Swamy
21. MHBaigDr.
22. Dr.Mahendranath K M
23. Dr.Maliyappa G H
24. Dr.Marekannavar S N
25. Murthy SN S
26. Narayana H S
27. Mrs Nassema Banu
28. Dr.Prakash C Rao
29. Rangaswamy K.L.
30. Raj anna N
31. Rajarama K E T
32. Rajesh
33. Dr. S.V. Rama Rao
34. Ramesh Kumar Pande
35. Dr.Ranganath T
36. Reddy C R
37. Roy David V S
38. Sagar K S
Organisation
Associate Prof. K.I.M.S.
Bharath Cyan Vigyan Samithi
Homepathic Forum
DHO, Health & Family Welfare Dept.
Bangalore City District Youth Congress (I)
K R Hospital
Directorate of Health and Family Welfare
services
PHC
Manikappa Bandeppa Khashapura Higher
Primary and High School
NIMHANS
President, Garuda Seva Samaj
District Hospital
Indian Rheumatism Association, Karnataka
State
Shoba Nursing Home
HAL II Stage Civic Amenities and Cultural
Association
Government Urdu Middle and Higher Primary
School
Drugs Action Forum, Karnataka
Formerly Member, Karnataka Legislative
Assembly
Population Research Centre
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
Prof, of Community Medicine & Director (Rtd.) Bangalore
Member, Karnataka Legislative Assembly
Bidar
Mysore
Bidar
Kodagu
Coorg Organisation for Rural Development
Bangalore
Citizens Forum
95
List of Suggestions by Post English (continued)
39. Sangeeta C M
40. Dr.Sanjeevi Shayana
41. Shakeel Ahmed
42. Sharshchandra H D
43. Dr.Shivarama Shastry
44. Shivasharanappa Chitta
45. Srinath P L
46. Srinivasa Rao
47. Students
48. Dr.Sumanth Goel
49. Dr.UdayaKumar
50. Varadaraj B K
51. Dr. U.S. Vanahalli
52. Venkatesh
53. Vishwanath Ashturey
and others
54. Dr. R.S. Wali
55. Yogesh G
56. Ziauudin Alvi
57. Dr. Jagadish
PHC Savalanga
Akkamahadevi Womens College
Diploma Physiotherapist Youth Forum
President, Dr. Hahnemann’s Rural Homeo
Medical Practitioner’s Associtation ®
Humnabad
Raichur
Tumkur
Bangalore
Dhunnali
Bidar
Mysore
Mysore
Bangalore
Bagalkot
Bangalore
Bangalore
Mahalingpur
Chamarajanagar
Bidar
Assoc. Prof., B.L.D.E.A’s Medical College
CEO, Consulting Engineering Services India
Ltd.
58. Dr. Shashikala M
Community health Specialist, ST Marthas
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 Officer, CHC
62. Dr. B N Brahmacharya
Hony Secy. Prakruti Jeevana Kendra ® Trust
63. Dr. Ramkrishna B Goud, PG in Community Medicine, MSRMC
96
Bijapur
Bangalore
Bidar
Hubli
Bangalore
Mulki
Bangalore
Banglore
ANNEXURE 7
Suggested Role and Responsibilities of the Commissioner (Health and Family
Welfare)
Commissioner (Health and Family Welfare) shall be responsible for monitoring,
supervising and implementing all National and State Health and Family Welfare
programmes in the State. He shall also perform coordinating functions among the
various directorates and divisions both within the Health System as well among related
departments.
In specific terms, Commissioner (HFW) shall
1. monitor and supervise the implementation of RCH, National Health Programmes of
TB control, Blindness control, Leprosy eradication, Anti Malaria, Women’s Health,
and such other programmes as Government may determine from to time;
2. coordinate health related programme activities with the Directorate of Medical
Education, Drug Controller, Indian Systems of Medicine, as also with the Directorate
of Women and Child Development, Commissioner for Public Instruction, and the
Directorate for Disabled Welfare; and Urban local bodies:
3. ensure proper integration and coordination in respect of various divisions within the
Department of Health and Family Welfare including with the externally assisted
project divisions;
4. facilitate the designing and implementing of a convergent MIS for the Health System
as a whole;
5. prepare sustainability plans for the externally assisted projects as well as prepare
projects for future external funding;
6. guide to prepare all policy and plan^proposals relating to health and family welfare
before their submission to Government;
7. be responsible for matters relating to cadre and recruitment rules in respect of
personnel of the health and welfare department and look after all correspondence in
the Directorate of Health and Family Welfare with Government in respect of posting
and disciplinary matters of Class 1 officers;
8. shall serve as a member on all State programme implementation Committees, as well
as a member on the Governing Councils of the autonomous health institutions.
9. help the Task Force and the Department in the preparation of a ten year perspective
plan for the department taking into consideration appropriate parameters so as to
ensure that health services are maintained at an optimum level of adequacy and
efficiency.
In addition, Commissioner (HFW) shall perform all functions and discharge such duties
and responsibilities as may be assigned to him by Government from time to time.
97
ANNEXURE 8
Information on Karnataka
HDI and GDI Ranks for Major States:
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_
__£
__ £
__£
__ 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
Karnataka - A comparison
6.97
Tamil
Nadu
14.27
202.18
36.98
86.27
136.22
774.88
1303.93
443.76
1720.58
1,154.82
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
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
J.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
3,837
4466
4748
4305
4,707
Sub Centre
23.03
Andhra
Pradesh
25.54
PHC
117.13
CHC
Particulars
Average Rural
Area (Sq. KM)
covered by a
Average Radial
Distance (KM)
covered by a
Average Number
of Villages
covered by a
Karnataka
Kerala
All India
22.89
Source: Rural Health Statistics in India , June, 1998: Bureau of Health Intelligence, Government of India
98
RURAL HEALTH Infrastructure in Karnataka:
Health Centres
1999-2000
(upto Dec 99)______
__________ 249
__________ 1676
___________ 583
__________ 8143
16212
Community Health Centres
Primary Health Centres
Primary Health Units____
Sub-centres____________
Beds__________________
Source: Annual Report, 1999-2000, Department of Health and Family Welfare, Government of
Karnataka
URBAN HEALTH Infrastructure in Karnataka:
_____________ Hospitals___________
District Hospitals_________________
Teaching Hospitals________________
Major Hospitals__________________
Specialised Hospitals______________
General Hospitals / Maternity Hospitals
______________ Total_____________
Urban Primary Health Centres_______
Institutions (number)
_____________ 24
________________ 9
________________ 8
_______________ 16
______________ 120
______________ 177
9
Beds
7616
5907
1521
3330
4899
23273
54
Source: Annual Report, 1999-2000, Department of Health and Family Welfare, Government of
Karnataka
Some selected Health Indicators of Karnataka - a comparison:
___________Parameter__________
Crude Birth Rate________________
Crude Death Rate_______________
Infant Mortality Rate____________
Total Fertility Rate______________
Effective Couple Protection Rate (%)
Annual Growth Rate (%)
Male
Life Expectancy at Birth
Female
Karnataka
22.01
All India
25.9*
S57
63.01
Z?
1?
HFA /2000
_______ 21
________ 9
SO7
60
58.31
M7
61.7'
6157
60
45.S'5
L7t
62.41
63.41
1= 1998; 2= 1994; 3= 1995
Source: Annual Report, 1999-2000, Department of Health and Family Welfare, Government of
Karnataka; Handbook of Statistics,
99
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